Nutritional and Post-Transplantation Outcomes of Enteral versus Parenteral Nutrition in Pediatric Hematopoietic Stem Cell Transplantation: A Systematic Review of Randomized and Nonrandomized Studies

Hematopoietic stem cell transplantation (HSCT) involves the administration of chemotherapy followed by the infusion of donor stem cells. After treatment, children can consequently experience nausea, vomiting, diarrhea, anorexia, and mucositis, which negatively impact oral intake, leading to rapid deterioration in nutritional status and risk of malnutrition. Nutrition support therefore becomes necessary to circumvent these adverse effects. This has traditionally been provided via parenteral nutrition (PN), but pediatric evidence is increasingly advocating enteral nutrition (EN) as a preferential alternative. The objective of this review is to determine the efficacy of any forms of EN versus PN provided during admission to children aged ≤ 18 years undergoing HSCT. Primary outcomes considered efficacy in relation to various nutritional parameters, and secondary outcomes included a range of post-transplantation parameters. Data sources included English and non-English articles from the start date of MEDLINE, EMBASE, AMED, CINAHL and Cochrane Controlled Trials register, up to July 2018. Key journals were also hand searched, reference lists scanned, clinical experts contacted, and gray literature searched using EThOS and Open Grey. Randomized and observational studies comparing any forms of EN versus PN in children aged ≤ 18 years undergoing HSCT investigating nutritional or post-transplantation outcomes were eligible. Data were extracted from included studies using a custom extraction form that had previously been piloted. Because included studies were observational, risk of bias was assessed using Risk of Bias in Non-randomised Studies of Interventions. Because only a small number of heterogenous studies reporting a wide range of differently defined outcomes were included, meta-analyses were not performed and data were presented in narrative form. Conflicting results in favor of either method of nutrition support or no difference between methods were seen for duration of interventions, nutritional intakes, biochemical and anthropometric changes, mortality, infections, length of admission, and neutrophil engraftment. EN may provide favorable benefits over PN regarding acute graft-versus-host-disease (aGVHD) and platelet engraftment. A paucity of studies was found investigating the question posed by this review. Included studies were clinically heterogenous regarding populations, interventions, and outcomes, at moderate to serious risk of bias due to the absence of randomization, confounding parameters, statistical control, retrospective designs, and participant selection. Some studies were more than 15 years old. Despite the limited number and poor quality of identified studies, results support the growing body of pediatric evidence that EN is feasible during HSCT. Similar differences regarding many nutritional and post-transplantation outcomes were seen in both forms of nutrition support, but EN could provide benefits above PN including reduced incidence of aGVHD and faster platelet engraftment

ભારતના કાગળ ઉદ્યોગની નફાકારકતાનું વિશ્ર્લેષણ

માનવજાતિ એ હંમેશાં આદાન-પ્રદાન માટે પત્રવ્યવહાર અને વિચારોને મુદ્રિત કરવાની પ્રવૃત્તિ વિષે શોધ કરી સતત સંશોધન પ્રવૃત્તિમાં સુધારો કરવાની દિશામાં જ આગળ વધી છે. આ દિશામાં આગળ વધી મીણ કે લાખના બોર્ડ (તક્તીઓ), ભૂર્જપત્રો, તાડપત્રો, કાંસ્યપત્રો, રેશમ અને માટીની પાટીઓ વગેરે શોધ્યા ત્યાર સુધીમાં કાગળની શોધ કરી ન હતી ભૂતકાળની નોંધવા લાયક બાબતો સરળતાથી લખી શકાય તેવી વિગતો, માહિતીઓ વગેરે સસ્તા દરે અને વ્યાપક પ્રમાણમાં લખવાની દિશામાં કોઈ જ શોધ આદરી ન હતી. ઇ. પૂર્વે ૪૦૦૦માં પ્રાચીન ઇજીપ્તવાસીઓએ સૌ પ્રથમ કોઈ પદાર્થ-કાગળ જેવો જેને કહી શકીએ એની શોધ કરી પેપીરસ (Papyrus) એક વણેલી – ગૂંથેલી સાદડી હતી કે જેમાં બરુ કે નેતરની છાલ વાપરી એક સખત પતરાં જેવું બનાવ્યુ એ પેપીરસમાંથી પેપર અસ્તિત્વમાં આવ્યું આગળ જતાં ઇતિહાસ કહે છે તે મુજબ પ્રાચીન ગ્રીક લોકો આવી સાદડીઓ બનાવતા કે જેમાં પ્રાણીઓની છાલનો લખવા માટે ઉપયોગ થતો અન્ય એક માન્યતા એવી છે કે કાગળ કે જેને માટે અંગ્રેજીમાં પેપર શબ્દ છે તે મૂળ ફ્રેંચ ભાષામાં પેપીઅર પરથી પડેલ છે, તેમાંથી ગ્રીક ભાષામાં પેપ્યરોઝ છે તેમાંથી આ શબ્દની વ્યુત્પત્તિ થઈ. ઇ.સ. ૧૦૫માં કાગળ અસ્તિત્વમાં આવ્યો. ટીસાઈ બન ચીની કોર્ટ અધિકારીએ આ શરૂઆત કરી એમ માનવામાં આવે છે. ઇ.સ. ૧૦૦૯નો ઇતિહાસ લખે છે કે છેલ્લા ૪૦૦ વર્ષ સુધીમાં કાગળની શોધ ક્રમશઃ પ્રવાસ કરીને યુરોપ સુધી પહોંચી. યુરોપમાં કાગળની પ્રથમ મીલ આરબોએ શરૂ કરી

Investigation Of Risk Factors That Precede Primary Open Angle Glacoma

Primary open angle glaucoma (POAG) is characterized by progressive degeneration of the retinal ganglion cells, resulting in optic nerve atrophy with visual field defects. The biological basis of POAG is not fully understood. This thesis covers two studies. The aims for Study 1 were to investigate the risk factors of glaucoma in a population aged 18 years to 40 years. These were investigated by a retrospective study of intraocular pressure measurements and optic nerve assessments (cup to disc ratio) in two groups. One group had a family history of glaucoma and a second group was without a family history of glaucoma. The aims for Study 2 were to investigate whether the risk factors for primary open angle glaucoma were present many years before glaucoma develops. These were investigated with a retrospective review of intraocular pressure measurements and optic nerve measurements in participants who subsequently developed primary open angle glaucoma. Each study collected anonymised retrospective data from community optometry clinics for extraction and analysis of data on intraocular pressure measurements and optic nerve assessments. Study 1 collected one data entry per case. Study 2 collected ten years of historical data from each clinical visit from clinical records of participants prior to their diagnosis/treatment of glaucoma. This data spanned 33 years. For each glaucoma record, data for a similar period were obtained from a case-matched control record. The results for Study 1 are that mean intraocular pressure measurements and optic nerve head assessments in young adults aged between 18 years and 40 years did not differ significantly in cases with a family history of glaucoma compared with a group without. For Study 2, the correlations of intraocular pressure and optic nerve cup to disc ratio indicate an increase in values over a 10-year duration for cases that subsequently developed glaucoma as compared to case-matched controls. Analyses conducted at 5 and 10-year time points for mean intraocular pressure and median optic nerve cup to disc ratios prior to POAG diagnosis were statistically significantly different (p<0.05). Visual field data were collected for all the cases and descriptive data showed that pre-diagnosed cases had more reported suspicious visual field defects. The principle findings of this thesis are that there are pre-glaucomatous changes up to ten years before glaucoma diagnosis and that this may have considerable relevance for models of glaucoma aetiology. It also highlights the important role that community optometrists play in guarding the borders between pre-glaucoma and glaucoma

An examination of factors influencing the choice of therapy for patients with coronary artery disease

Background A diverse range of factors influence clinicians' decisions regarding the allocation of patients to different treatments for coronary artery disease in routine cardiology clinics. These include demographic measures, risk factors, co-morbidities, measures of objective cardiac disease, symptom reports and functional limitations. This study examined which of these factors differentiated patients receiving angioplasty from medication; bypass surgery from medication; and bypass surgery from angioplasty. Methods Univariate and multivariate logistic regression analyses were conducted on patient data from 214 coronary artery disease patients who at the time of recruitment had been received a clinical assessment and were reviewed by their cardiologist in order to determine the form of treatment they were to undergo: 70 would receive/continue medication, 71 were to undergo angioplasty and 73 were to undergo bypass surgery. Results Analyses differentiating patients receiving angioplasty from medication produced 9 significant univariate predictors, of which 5 were also multivariately significant (left anterior descending artery disease, previous coronary interventions, age, hypertension and frequency of angina). The analyses differentiating patients receiving surgery from angioplasty produced 12 significant univariate predictors, of which 4 were multivariately significant (limitations in mobility range, circumflex artery disease, previous coronary interventions and educational level). The analyses differentiating patients receiving surgery from medication produced 14 significant univariate predictors, of which 4 were multivariately significant (left anterior descending artery disease, previous cerebral events, limitations in mobility range and circumflex artery disease). Conclusion Variables emphasised in clinical guidelines are clearly involved in coronary artery disease treatment decisions. However, variables beyond these may also be important factors when therapy decisions are undertaken thus their roles require further investigation

Effectiveness of adult community-based physical activity interventions with objective physical activity measurements and long-term follow-up: a systematic review and meta-analysis.

OBJECTIVE: To identify randomised controlled trials (RCTs) of physical activity (PA) interventions with objective PA outcomes in adults and to evaluate whether intervention effects were sustained beyond 12 months. DESIGN: Systematic review and meta-analysis. DATA SOURCES: Seven databases (Medline, Embase, PsycINFO, Web of Science, Cochrane library, CINAHL (Cumulative Index of Nursing and Allied Health Literature) and ASSIA (Applied Social Sciences Index and Abstracts)) were searched from January 2000 until December 2019. ELIGIBILITY CRITERIA: RCTs reporting objective PA outcomes beyond 12 months with community-based participants aged ≥18 years were included; those where controls received active interventions, including advice to increase PA levels, were excluded. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers completed extraction of aggregate data and assessed risk of bias. Meta-analyses used random-effects models at different follow-up points. Primary outcomes were daily steps and weekly minutes of moderate-to-vigorous PA (MVPA). RESULTS: Of 33 282 records identified, nine studies (at generally low risk of bias) were included, five in meta-analyses with 12 months to 4 year follow-up. We observed 12 month increases for intervention vs control participants in steps/day (mean difference (MD)=554 (95% CIs: 384 to 724) p<0.0001, I2=0%; 2446 participants; four studies) and weekly MVPA minutes (MD=35 (95% CI: 27 to 43) p<0.0001, I2=0%; 2647 participants; four studies). Effects were sustained up to 4 years for steps/day (MD=494 (95% CI: 251 to 738) p<0.0001, I2=0%; 1944 participants; four studies) and weekly MVPA minutes (MD=25 (95% CI: 13 to 37) p<0.0001, I2=0%; 1458 participants; three studies). CONCLUSIONS: There are few PA interventions with objective follow-up beyond 12 months, more studies are needed. However, this review provided evidence of PA intervention effects beyond 12 months and sustained up to 4 years for both steps/day and MVPA. These findings have important implications for potential long-term health benefits. PROSPERO REGISTRATION NUMBER: CRD42017075753

Challenges in Patient Recruitment, Implementation, and Fidelity in a Mobile Telehealth Study

Introduction: Mobile telehealth (MTH) evaluations in diabetes have been conducted, but few report details and issues related to recruitment, implementation (intervention delivery), fidelity, and context. These have important implications on the interpretation of the findings and effectiveness of the intervention. This article reports these data from an MTH study and describes the challenges experienced in running an intervention such as this in an active clinical environment. Materials and Methods: We conducted a mixed-methods MTH study that included a 9-month randomized controlled trial in people with poorly controlled diabetes. Detailed recruitment data were recorded during the study. Data on contacts between MTH participants and the MTH team were collected and used to report on intervention delivery and fidelity. Meeting and field notes, as well as communications between research team members during the study, were used to report on the contextual factors that affected recruitment, implementation, and fidelity. Results: The recruited sample size represented 6% of the total clinic population (n = 1,360) and 10.7% of the number of potentially eligible people at the clinic (n = 802) identified at the beginning of the study. Contextual factors related to patients, healthcare providers, the institution, or the recruitment protocol contributed to influence access to study participants and the number of participants randomized (n = 81). Technical and device-related aspects of the MTH intervention were delivered successfully, but the expected education and clinical feedback by the MTH nurse were not delivered according to the protocol. Although 92.5% of introductory calls were made by the MTH nurses, only 13.3% of expected educational calls were performed. Changes to the MTH nursing staff affected intervention participants differently and contributed to the low fidelity of intervention delivery. Conclusions: The current article presents data on the influence of contextual factors on the conduct of this MTH study and underlines the need for these processes to be assessed and reported adequately in future MTH research

A randomised, controlled trial of the effects of a mobile telehealth intervention on clinical and patient-reported outcomes in people with poorly controlled diabetes

Objective The objective of this research is to determine the effects of mobile telehealth (MTH) on glycosylated haemoglobin (HbA1c) and other clinical and patient-reported outcomes in insulin-requiring people with diabetes. Methods A nine-month randomised, controlled trial compared standard care to standard care supplemented with MTH (self-monitoring, mobile-phone data transmissions, graphical and nurse-initiated feedback, and educational calls). Clinical (HbA1c, blood pressure, daily insulin dose, diabetes outpatient appointments (DOAs)) and questionnaire data (health-related quality of life, depression, anxiety) were collected. Mean group changes over time were compared using hierarchical linear models and Mann-Whitney tests. Results Eighty-one participants with a baseline HbA1c of 8.98% ± 1.82 were randomised to the intervention ( n = 45) and standard care ( n = 36). The Group by Time effect revealed MTH did not significantly influence HbA1c ( p = 0.228), but p values were borderline significant for blood pressure ( p = 0.054) and mental-health related quality of life ( p = 0.057). Examination of effect sizes and 95% confidence intervals for mean group differences at nine months supported the existence of a protective effect of MTH on mental health-related quality of life as well as depression. None of the other measured outcomes were found to be affected by the MTH intervention. Conclusions Findings from this study must be interpreted with caution given the small sample size, but they do not support the widespread adoption of MTH to achieve clinically significant changes in HbA1c. MTH may, however, have positive effects on blood pressure and protective effects on some aspects of mental health

Knowledge, attitudes and practices of medical staff towards obesity management in patients with spinal cord injuries: an International survey of four western European countries

Objective: To (1) examine the opinions of medical staff working in spinal cord injury (SCI) centres (SCICs); (2) evaluate their knowledge, attitudes and practices towards obesity prevention and management; (3) report the number of beds and dietitians available at each SCIC. Methods: A 37-item questionnaire was sent to 23 SCICs in the UK, the Netherlands, Belgium and the Republic of Ireland between September 2012 and January 2013. Results: Eighteen SCICs returned the questionnaires for analysis. All respondents stated that they had an interest in obesity treatment but only 2.3% of the respondents received training in obesity management. Sixty-one percent of staff did not consider body mass index (BMI) to be appropriate for use in SCI patients and subsequently less than half of the respondents use BMI routinely. The majority of respondents reported that they are confident in dealing with overweight (74.5%) and obese (66.1%) SCI adults, less than half (44.1%) are confident in treating overweight and obese SCI children. Respondents also indicated the need for nationally adopted guidelines and a lack of physical activity provision. There were 17.5 whole-time equivalent (WTE) dietitians recorded in 22 SCICs, equivalent to 47.8 beds per WTE dietitians (range 10–420). Non-UK SCIC dietitians are significantly better resourced than in UK SCICs (beds per WTE dietitian: 36 vs 124, P=0.035). Conclusion: Medical staff expressed the need to participate in obesity prevention and management. Appropriate training should be considered for all medical staff and the development of specific weight management guidelines and dietetic provision should be considered