Do guidelines influence breathlessness management in advanced lung diseases? A multinational survey of respiratory medicine and palliative care physicians

Background: Respiratory medicine (RM) and palliative care (PC) physicians’ management of chronic breathlessness in advanced chronic obstructive pulmonary disease (COPD), fibrotic interstitial lung disease (fILD) and lung cancer (LC), and the influence of practice guidelines was explored via an online survey. Methods: A voluntary, online survey was distributed to RM and PC physicians via society newsletter mailing lists. Results: 450 evaluable questionnaires (348 (77%) RM and 102 (23%) PC) were analysed. Significantly more PC physicians indicated routine use (often/always) of opioids across conditions (COPD: 92% vs. 39%, fILD: 83% vs. 36%, LC: 95% vs. 76%; all p < 0.001) and significantly more PC physicians indicated routine use of benzodiazepines for COPD (33% vs. 10%) and fILD (25% vs. 12%) (both p < 0.001). Significantly more RM physicians reported routine use of a breathlessness score (62% vs. 13%, p < 0.001) and prioritised exercise training/rehabilitation for COPD (49% vs. 7%) and fILD (30% vs. 18%) (both p < 0.001). Overall, 40% of all respondents reported reading non-cancer palliative care guidelines (either carefully or looked at them briefly). Respondents who reported reading these guidelines were more likely to: routinely use a breathlessness score (χ2 = 13.8; p < 0.001), use opioids (χ2 = 12.58, p < 0.001) and refer to pulmonary rehabilitation (χ2 = 6.41, p = 0.011) in COPD; use antidepressants (χ2 = 6.25; p = 0.044) and refer to PC (χ2 = 5.83; p = 0.016) in fILD; and use a handheld fan in COPD (χ2 = 8.75, p = 0.003), fILD (χ2 = 4.85, p = 0.028) and LC (χ2 = 5.63; p = 0.018). Conclusions: These findings suggest a need for improved dissemination and uptake of jointly developed breathlessness management guidelines in order to encourage appropriate use of existing, evidence-based therapies. The lack of opioid use by RM, and continued benzodiazepine use in PC, suggest that a wider range of acceptable therapies need to be developed and trialled

Bioavailability of a novel form of microencapsulated bovine lactoferrin and its effect on inflammatory markers and the gut microbiome: a pilot study

Bovine lactoferrin, extracted from milk or whey, is used in a range of products to enhance immunity and support digestive health, iron absorption, and homeostasis. This study examined the absorption and effect of Progel (Brisbane, Queensland, Australia) microencapsulated bovine lactoferrin (Inferrin™, Bega Bionutrients, Victoria, Australia) on immune markers and the microbiome. A double-blind randomised, cross-over trial was conducted with 12 healthy males randomised to one of two doses, equivalent to 200 mg or 600 mg lactoferrin, for two four-week supplementation arms, with a two-week washout period. Subjects received either standard bovine lactoferrin or Inferrin™ for each arm. Baseline and post each trial arm, CD69+ activation on CD4+ and CD8+ cells was analysed, bovine and human lactoferrin contents of faecal and serum samples were reported, and the gut microbiome was analysed using 16S sequencing and metagenomic sequencing. The mean level of CD69+ activation on the CD4+ cells was lower after supplementation regardless of the form or dose of lactoferrin. This was statistically significant for the 200 mg dose. A higher level of bovine lactoferrin was found post-supplementation in those taking Inferrin™, although this was not statistically significant. Changes in phylum-level microbial community profiling were detected post-supplementation in the second trial arm, particularly in those receiving Inferrin™. Metagenomic sequencing showed changes in the volumes of the top 100 species of bacteria present before and after all treatment arms. Results suggest that lactoferrin supplementation may have beneficial effects on the microbiome and immune system, and that the use of Inferrin™ improves absorption. Larger detailed studies are needed to ascertain the potential positive effects of bovine lactoferrin supplementation

Australian dietitians’ knowledge and practices regarding vitamin D

Vitamin D deficiency has been identified as a worldwide issue with potential to adversely affect an individual's health. To date, no research has been conducted into the Vitamin D knowledge and practices of Australian Dietitians. The purpose of this study was to survey Dietitians on their knowledge and practices regarding Vitamin D intake, sources, supplementation, and affect on disease state. An online survey was disseminated to members of the Dietitians Association Australia (responses n = 134) via online national newsletters. Descriptive statistics were used to analyse the results. Where respondents made comments, answers were coded and placed into corresponding categories. Z‐scores were used to compare between responses. 29% of respondents identified that endogenous production contributes 90–100% of total Vitamin D. 42% of respondents correctly identified the recommendation of 10–15 minutes of sun exposure at low UV times to prevent deficiency. 31% of respondents correctly identified the cut‐off for mild deficiency, 20% for moderate deficiency, and 16% for severe deficiency. Approximately a third of respondents were unsure of the forms of Vitamin D supplements available or whether there were differences in potency. When asked about what their first‐line treatment for deficiency would be, 84% said supplements, 71% said increased sun exposure. Actual cases seen by respondents were treated by supplements (88%), and only 4% used increased sun exposure. Dietitians are well positioned to provide patients with advice on Vitamin D supplementation and sun exposure practices, but there is a need for clear and well‐disseminated guidelines for Vitamin D management by Dietitians

A systematic review: vitamin D status and sleeve gastrectomy

Background: Bariatric patients regularly present with insufficient vitamin D status before and after surgery, which requires substantial supplementation to treat. This review aims to assess the effect of sleeve gastrectomy on vitamin D status and the effectiveness of vitamin D supplementation. Methods: This review was conducted in accordance with the Guidelines for Meta-Analyses and Systematic Reviews of Observational Studies. Results: The current guidelines recommend initial vitamin D supplementation of at least 3000 IU/day post-operatively, with no need for follow-up testing after sleeve gastrectomy. Only one study has trialled a dose in line with the recommendations for this patient group. They found that it was effective in improving VitD status. Conclusions: On-going monitoring of vitamin D status is necessary, as the recommended level is not often reached

The role of vitamin D in adipogenesis

Vitamin D, a secosteroid predominately obtained by endogenous production, has in recent years been linked to obesity and its comorbidities. The purpose of this review is to draw conclusions from animal and human studies on the effects of vitamin D on adipogenesis to identify the molecular links between vitamin D and obesity. The information presented herein was obtained from 4 databases (PubMed, CINAHL, Cochrane Library, Scopus) using predefined search terms, as well as research literature and other reviews. The effects of vitamin D on adipogenesis have been researched in several animal models, and the majority of these studies suggest vitamin D plays an inhibitory role in adipogenesis. Studies into vitamin D status and obesity in humans are limited, with the majority being observational epidemiological studies that provide no conclusions on cause and effect or clear links on the molecular mechanisms. The few cell culture and supplementation studies that have investigated adipogenesis in human cells indicate that, in contrast to findings from rodent studies, vitamin D is proadipogenic. There is insufficient evidence to determine whether 1) vitamin D deficiency is associated with a lean or obese phenotype, 2) vitamin D deficiency is a consequence of obesity, or (3) the effects of vitamin D on fat tissue are due to interactions with calcium

Vitamin D: Australian dietitian's knowledge and practices

Aim: To survey dietitians on their knowledge and practices regarding vitamin D (VitD) intake, sources, supplementation and effect on disease state

Association of sun exposure, skin colour and body mass index with vitamin D status in individuals who are morbidly obese

Vitamin D deficiency is a common issue, particularly in obese populations, and is tested by assessing serum 25(OH)D concentrations. This study aimed to identify factors that contribute to the vitamin D status in fifty morbidly obese individuals recruited prior to bariatric surgery. Data collected included serum 25(OH)D concentrations, dietary and supplement intake of vitamin D, sun exposure measures, skin colour via spectrophotometry, and genotype analysis of several single nucleotide polymorphisms in the vitamin D metabolism pathway. Results showed a significant correlation between serum 25(OH)D concentrations and age, and serum 25(OH)D and ITAC score (natural skin colour). Natural skin colour accounted for 13.5% of variation in serum 25(OH)D, with every 10 degrees increase in ITAC score (i.e., lighter skin) leading to a 9 nmol/L decrease in serum 25(OH)D. Multiple linear regression using age, ITAC score, and average UV index in the three months prior to testing, significantly predicted serum 25(OH)D concentrations (R-2 = 29.7%). Single nucleotide polymorphisms for all vitamin D genes tested, showed lower serum 25(OH)D for those with the rare genotype compared to the common genotype; this was most pronounced for fok1 and rs4588, where those with the rare genotype were insufficient (= 50 nmol/L). Assessing vitamin D status in individuals with morbid obesity requires testing of 25(OH)D, but potential risk factors for this population include natural skin colour and age

Substantial between-country differences in organising community care for older people in Europe—a review

BACKGROUND: The European population is aging. The main drivers of public spending on health care for people of 65 years and older are hospital admission and admission to long-term care facilities. High quality community care can be a cost-effective and quality solution to respond to the impact of ageing populations on health-care systems. It is unclear how well countries are equipped to provide affordable and quality community care. The aim of this article is to describe and compare community care delivery with care-dependent older people in Europe.  METHODS: This study is conducted within the European Union-financed IBenC project [Identifying best practices for care-dependent elderly byBenchmarkingCosts and outcomes of community care (FP7)] in which six European countries are involved. To compare the community care delivery with care-dependent older people in these countries, we performed a systematic comparison of macro indicators using metadata complemented with data from multinational surveys.  RESULTS: Data on the following dimensions are described and compared: population of the country, governmental expenditures on health, sources of community health services funding, governmental vision and regulation on community care, community care organisations and care professionals, eligibility criteria for and equity in receiving care and the involvement of informal care.  CONCLUSION: : Because of the variations in the European community care contexts, the growing demand for community care as a cost-effective and quality solution to the care burden of aging populations will have country-specific impacts. When learning from other countries' best practices, in addition to researchers, policy makers should take full account of local and national care contexts.status: publishe