A survey of staffing levels in paediatric diabetes services throughout the UK

AIMS

To assess staffing levels of healthcare professionals involved in the care of children and young people with diabetes in the UK.

METHODS

A web-based questionnaire was distributed to lead consultant paediatricians from all paediatric diabetes services in the UK between October and December 2014. Data on staffing levels and other aspects of diabetes services were collected and differences between the four nations of the UK and across the 10 English diabetes networks were explored.

RESULTS

Some 175 services (93%) caring for 29 711 children and young people aged ≤ 24 years with diabetes participated in the survey. Northern Ireland and Wales had the lowest ratio of total staff to patient population. Nursing caseloads per one whole-time equivalent (WTE) nurse ranged from 71 patients in England to 110 patients in Northern Ireland with only 52% of the UK services meeting the Royal College of Nursing recommended nurse-to-patient ratio of > 1 : 70. Scotland and Northern Ireland had the highest ratio of consultants and fully trained doctors per 1000 patients (3.5 WTE). Overall, 17% of consultants had a Certificate of Completion of Training in Endocrinology and Diabetes. Some 44% of dietitians were able to adjust insulin dose. Only 43% of services provided 24-h access to advice from the diabetes team and 82% of services had access to a psychologist. Staffing levels adjusted for volume were not directly related to glycaemic performance of services in England and Wales.

CONCLUSIONS

Wide variations in staffing levels existed across the four nations of the UK and important gaps were present in key areas.

Clinic variation in glycaemic control for children with Type 1 diabetes in England and Wales: a population-based, multilevel analysis

AIM

To understand the scope for improving children's glycaemic outcomes by reducing variation between clinics and examine the role of insulin regimen and clinic characteristics.

METHODS

Cross-sectional analysis of 2012-2013 National Paediatric Diabetes Audit data from 21 773 children aged < 19 years with Type 1 diabetes cared for at 176 clinics organized into 11 regional diabetes networks in England and Wales. Variation in HbA_1c was explored by multilevel models with a random effect for clinic. The impact of clinic context was quantified by computing the per cent of total variation in HbA_1c which occurs between clinics (intraclass correlation coefficient; ICC).

RESULTS

Overall, 69 of the 176 diabetes clinics (39%) had a glycaemic performance that differed significantly from the national average after adjusting for patient case-mix with respect to age, gender, diabetes duration, deprivation and ethnicity. However, differences between clinics accounted for 4.7% of the total variation in HbA_1c . Inclusion of within-clinic HbA_1c standard deviation led to a substantial reduction in ICC to 2.4%. Insulin regimen, clinic volume and diabetes networks had a small or moderate impact on ICC.

CONCLUSIONS

Differences between diabetes clinics accounted for only a small portion of the total variation in glycaemic control because most of the variation was within clinics. This implies that national glycaemic improvements might best be achieved not only by targeting poor centres but also by shifting the whole distribution of clinics to higher levels of quality.

Effect of food models and low-temperature storage on the adhesion of Lactobacillus rhamnosus GG to Caco-2 cells

This study evaluated the effects of fat and sugar levels on the surface properties of Lactobacillus rhamnosus GG during storage in food model systems, simulating yogurt and ice cream, and related them with the ability of the bacterial cells to adhere to Caco-2 cells. Freeze-dried L. rhamnosus GG cells were added to the model food systems and stored for 7 days. The bacterial cells were analyzed for cell viability, hydrophobicity, ζ potential, and their ability to adhere to Caco-2 cells. The results indicated that the food type and its composition affected the surface and adhesion properties of the bacterial cells during storage, with yogurt being a better delivery vehicle than ice cream in terms of bacterial adhesion to Caco-2 cells. The most important factor influencing bacterial adhesion was the storage time rather than the levels of fats and sugars, indicating that conformational changes were taking place on the surface of the bacterial cells during storage.

Surface and adhesion properties of lactobacilli

The surface properties of lactobacilli are of significant technological importance as they determine the interaction of the bacterial cells with the gastrointestinal mucosa, and therefore influence their location in the gut and their functionality. Studying the surface of the bacteria is critical for understanding the adhesion process better. This review compiles the knowledge from studies on the characterization Lactobacillus surfaces and evaluates the potential relationship between the cells' physicochemical characteristics and their adhesive abilities. It also discusses the effect that the production processes, such as fermentation and drying, can exert on the surface properties and adhesion abilities of lactobacilli.

Evaluation of the effect of malt, wheat and barley extracts on the viability of potentially probiotic lactic acid bacteria under acidic conditions

In this work, the effect of cereal extracts, used as delivery vehicles for potentially probiotic lactic acid bacteria (LAB), on the acid tolerance of the cells was evaluated under conditions that simulate the gastric tract. More specifically, the effect of malt, barley and wheat extracts on the viability of Lactobacillus plantarum, Lactobacillus acidophilus and Lactobacillus reuteri during exposure for 4 h in a phosphate buffer acidified at pH 2.5 was investigated. In the absence of cereal extracts all strains demonstrated a significant reduction in their cell population, particularly L. plantarum. The viability of L. plantarum was improved by approximately 4 log(10) cycles in the presence of malt and 3 log(10) cycles in the presence of wheat and barley. The survival of L. acidophilus and L. reuteri was increased by more than 1.5 and 0.7 log(10) cycle, respectively, upon addition of cereal extracts. In order to evaluate the contribution of the cereal constituents on cell survival, the individual effect of glucose, maltose and free amino nitrogen (FAN), which were added at concentrations that correlated to the reducing sugar and FAN content of the cereal extracts, was examined. The viability of L. plantarum was progressively improved as the maltose or glucose concentration increased; an increase by approximately 2 log(10) cycles was observed in the presence of 8.33 g/l sugar. The survival of L. acidophilus increased by more than 1 log(10) cycle, even at very low concentrations of maltose and glucose (e.g., 0.67 g/l), while L. reuteri stability was enhanced in the presence of maltose but no appreciable effect was demonstrated in the presence of glucose. Sugar analysis indicated that glycolysis was inhibited in all cases. Addition of tryptone and yeast extract, used as sources of FAN, enhanced L. acidophilus acid tolerance, but did not affect L. reuteri and L. plantarum. The results presented in this study indicate that malt, wheat and barley extracts exhibit a significant protective effect on the viability of L. plantarum, L. acidophilus and L. reuteri under acidic conditions, which could be mainly attributed to the amount of sugar present in the cereal extracts.

Application of cereals and cereal components in functional foods: a review

The food industry is directing new product development towards the area of functional foods and functional food ingredients due to consumers' demand for healthier foods. In this respect, probiotic dairy foods containing human-derived Lactobacillus and Bifidobacterium species and prebiotic food formulations containing ingredients that cannot be digested by the human host in the upper gastrointestinal tract and can selectively stimulate the growth of one or a limited number of colonic bacteria have been recently introduced into the market. The aim of these products is to affect beneficially the gut microbial composition and activities. Cereals offer another alternative for the production of functional foods. The multiple beneficial effects of cereals can be exploited in different ways leading to the design of novel cereal foods or cereal ingredients that can target specific populations. Cereals can be used as fermentable substrates for the growth of probiotic microorganisms. The main parameters that have to be considered are the composition and processing of the cereal grains, the substrate formulation, the growth capability and productivity of the starter culture, the stability of the probiotic strain during storage, the organoleptic properties and the nutritional value of the final product. Additionally, cereals can be used as sources of nondigestible carbohydrates that besides promoting several beneficial physiological effects can also selectively stimulate the growth of lactobacilli and bifidobacteria present in the colon and act as prebiotics. Cereals contain water-soluble fibre, such as beta-glucan and arabinoxylan, oilgosaccharides, such as galacto- and fructo-oligosaccharides and resistant starch, which have been suggested to fulfil the prebiotic concept. Separation of specific fractions of fibre from different cereal varieties or cereal by-products, according to the knowledge of fibre distribution in cereal grains, could be achieved through processing technologies, such as milling, sieving, and debranning or pearling. Finally, cereal constituents, such as starch, can be used as encapsulation materials for probiotics in order to improve their stability during storage and enhance their viability during their passage through the adverse conditions of the gastrointestinal tract. It could be concluded that functional foods based on cereals is a challenging perspective, however, the development of new technologies of cereal processing that enhance their health potential and the acceptability of the food product are of primary importance.

Growth studies of potentially probiotic lactic acid bacteria in cereal-based substrates

AIMS

The overall growth kinetics of four potentially probiotic strains (Lactobacillus fermentum, Lact. reuteri, Lact. acidophilus and Lact. plantarum) cultured in malt, barley and wheat media were investigated. The objectives were to identify the main factors influencing the growth and metabolic activity of each strain in association with the cereal substrate.

METHODS AND RESULTS

All fermentations were performed without pH control. A logistic-type equation, which included a growth inhibition term, was used to describe the experimental data. In the malt medium, all strains attained high maximum cell populations (8.10-10.11 log10 cfu ml(-1), depending on the strain), probably due to the availability of maltose, sucrose, glucose, fructose (approx. 15 g l(-1) total fermentable sugars) and free amino nitrogen (approx. 80 mg l(-1)). The consumption of sugars during the exponential phase (10-12 h) resulted in the accumulation of lactic acid (1.06-1.99 g l(-1)) and acetic acid (0.29-0.59 g l(-1)), which progressively decreased the pH of the medium. Each strain demonstrated a specific preference for one or more sugars. Since small amounts of sugars were consumed by the end of the exponential phase (17-43%), the decisive growth-limiting factor was probably the pH, which at that time ranged between 3.40 and 3.77 for all of the strains. Analysis of the metabolic products confirmed the heterofermentative or homofermentative nature of the strains used, except in the case of Lact. acidophilus which demonstrated a shift towards the heterofermentative pathway. All strains produced acetic acid during the exponential phase, which could be attributed to the presence of oxygen. Lactobacillus plantarum, Lact. reuteri and Lact. fermentum continued to consume the remaining sugars and accumulate metabolic products in the medium, probably due to energy requirements for cell viability, while Lact. acidophilus entered directly into the decline phase. In the barley and wheat media all strains, especially Lact. acidophilus and Lact. reuteri, attained lower maximum cell populations (7.20-9.43 log10 cfu ml(-1)) than in the malt medium. This could be attributed to the low sugar content (3-4 g l(-1) total fermentable sugar for each medium) and the low free amino nitrogen concentration (15.3-26.6 mg l(-1)). In all fermentations, the microbial growth ceased at pH values (3.73-4.88, depending on the strain) lower than those observed for malt fermentations, which suggests that substrate deficiency in sugars and free amino nitrogen contributed to growth limitation.

CONCLUSIONS

The malt medium supported the growth of all strains more than barley and wheat media due to its chemical composition, while Lact. plantarum and Lact. fermentum appeared to be less fastidious and more resistant to acidic conditions than Lact. acidophilus and Lact. reuteri.

SIGNIFICANCE AND IMPACT OF THE STUDY

Cereals are suitable substrates for the growth of potentially probiotic lactic acid bacteria.