Should the food intake of patients admitted to acute hospital services be routinely supplemented? A randomized placebo controlled trial

BACKGROUND

Many patients admitted to acute hospital services are underweight or harbour vitamin deficiencies.

OBJECTIVES

To determine the effect on patient throughput of a policy of routine vitamin supplementation, and of early routine sipfeed supplementation in 'thin' patients (5-10% weight loss or body mass index 18-22).

DESIGN

Factorial randomized placebo controlled trial of oral multivitamins from the first day of admission, and, after nutritional screening, of a nutritionally complete sipfeed from the second day in 'thin' patients.

SETTING

Acute medical, surgical and orthopaedic hospital services of a London teaching hospital.

PARTICIPANTS

1561 patients admitted as emergencies were included in the vitamin study of which 549 were included in the sipfeed study.

MAIN OUTCOME MEASURE

Length of hospital stay (LOS).

RESULTS

Offering multivitamins to acute admissions resulted in a mean change (reduction) in LOS of -0.4 days 95% CI (-2-1.2days). The results suggest greater reductions for those discharged after 10 days: mean change=-2.3 days 95% CI (-5.7 to 1.2). Sipfeed supplementation was associated with an increased mean length of stay 2.8 days 95% CI (-0.8-6.3). 18% of acute admissions were classified undernourished on the basis of BMI, MUAC or percent weight loss combined.

CONCLUSIONS

No benefit was observed for sipfeed intervention although a small benefit of less than one day is not excluded. Vitamin supplementation may have slight but economically important benefit.

Prevalence of thiamin deficiency in anorexia nervosa

OBJECTIVE

Deficiency of thiamin (vitamin B1) causes a range of neuropsychiatric symptoms that resemble those reported in patients with anorexia nervosa (AN) but the prevalence of thiamin deficiency in AN has not been reliably established. This study was designed to investigate the prevalence of thiamin deficiency in AN.

METHOD

Thirty-seven patients attending a specialist eating disorders unit and meeting all or some of the DSM-IV criteria for AN were compared with 50 blood donor controls. All subjects underwent measurement of erythrocyte transketolase activation following the addition of thiamin pyrophosphate, the standard biochemical test for thiamin deficiency. Deficiency was defined as a result more than 2 SD above the mean of the control population.

RESULTS

Fourteen patients (38%) had results in the deficient range; 7 (19%) met the most stringent published criterion for deficiency. Deficiency was not related to duration of eating restraint, frequency of vomiting, or alcohol consumption.

DISCUSSION

Thiamin deficiency may account for some of the neuropsychiatric symptoms of AN and routine screening or supplementation may be indicated.

A double blind, randomised, controlled trial of glutamine supplementation in parenteral nutrition

BACKGROUND AND AIMS

To determine whether the inclusion of 20 g free glutamine as part of the nitrogen source of parenteral feeds reduces length of hospital stay or mortality.

METHODS

In a randomised, double blind, controlled trial in 168 patients clinically accepted for parenteral nutrition, standard feeds were compared with feeds in which 3.8 g of the total nitrogen was replaced with the equivalent 20 g glutamine. A minimum of 11 g nitrogen/day was used in all patients. Daily intakes of energy and nitrogen were determined using a validated computer protocol and were similar for the two groups. All feeds included trace elements, vitamins, electrolytes, and minerals.

RESULTS

A total of 85 patients received a median of eight (interquartile range 5-13) daily feeds containing glutamine while 83 received a median of eight (5-15) standard feeds. No difference between groups was detected for infective complications. Twenty control patients and 14 who had received glutamine died during their hospital stay (NS). Median length of stay was 32 (23-52) days on glutamine, which was not significantly different from the control value of 35 (25-55) days. Glutamine was associated with a significant (p<0.03) reduction in length of stay in surgical patients (45 days (range 29-81) versus 30 days (range 19-54)).

CONCLUSION

The benefit from glutamine supplementation of parenteral feeds as used in this trial has not been proved. Supplementation may have advantages in surgical patients and in haematological malignancy. Further trials are required.

The thiamin, riboflavin and pyridoxine status of patients on emergency admission to hospital

The aim of this study was to assess the prevalence of thiamin, riboflavin and pyridoxine deficiencies at admission to an acute hospital. One hundred and twenty adult patients were selected at random from those admitted via the Accident and Emergency department over 3 days. Comparisons were made with a group of 80 healthy blood donors sequentially attending a local transfusion centre. The alcohol intake of 500 patients admitted sequentially via the same Accident and Emergency department was also assessed. Erythrocyte transketolase (ETK), glutathione reductase (EGR) and aspartate aminotransferase (EAA) coenzyme activation assays were used to determine thiamin, riboflavin and pyridoxine deficiencies. The prevalences of deficiency states in the inpatient group were 21, 2.7 and 32% for thiamin, riboflavin and pyridoxine deficiencies respectively with 49.2% being deficient in one or more vitamin. The mean alcohol intake in the group of patients in whom this was assessed was 9.7 units per week compared with 10 units per week amongst blood donors.

Do gastroenterologists want to be trained in ultrasound? A national survey of trainees in gastroenterology

AIMS

(1) To establish whether gastroenterologists wish to train in abdominal ultrasound according to the Royal College of Radiologists' document, Guidance for the training in ultrasound of medical non-radiologists. (2) To determine whether the ultrasound workload generated by gastroenterologists differs from that by other clinicians.

METHODS

A postal questionnaire was sent to all 278 gastroenterology trainees. The indications and findings of 100 consecutive gastroenterologist requested scans were compared with 100 scans requested sequentially by other clinicians through a teaching hospital radiology department.

RESULTS

82% of the survey forms were returned. 77% of trainees wished to train in abdominal ultrasound and 68% were prepared to train in the manner outlined in the guideline document. However, 86% felt that they would ideally prefer not to assess renal or pelvic pathology, restricting to hepatobiliary diagnosis only. 73% of trainees did not anticipate that a further scan by a radiologist would be required. Comparison of gastroenterology scans with those requested by other clinicians revealed a relative excess of hepatobiliary indications and findings, and a notable paucity of renal and pelvic pathology in gastroenterology practice.

CONCLUSIONS

There is general interest in abdominal ultrasound training among gastroenterology trainees and broad acceptance of the guideline document. However, most trainees perceive a focus of training restricted to hepatobiliary disease to be most appropriate. The case mix study provides support for this viewpoint. It is suggested that a more focused ultrasound training for gastroenterologists be considered.

Gastrointestinal bleeding and obstruction due to giant gallstone impaction in the duodenal bulb

Images

Case report: abscess of the adductor muscles of the thigh--an unusual complication of Crohn's disease

The occurrence of a Crohn's abscess involving the hamstring muscle group has not been reported previously. We report this diagnosis in a patient with ileocolonic Crohn's disease who had presented earlier with a presacral abscess.

Reversible jaundice in primary biliary cirrhosis due to hyperthyroidism

A patient with primary biliary cirrhosis had a dramatic deterioration in liver function with jaundice over 2 months as a result of development of Graves' disease. Clinical examination and radiological and cardiovascular investigations excluded heart failure and biliary obstruction as the cause of this deterioration. The patient's jaundice entirely reversed with treatment of hyperthyroidism, with bilirubin levels decreasing from 244 to 16 mumol/L (14.35 to 0.94 mg/dL). Deterioration in liver function in a patient with primary biliary cirrhosis as a result of hyperthyroidism has not previously been described.