Trevor R. Smith

University Hospital Southampton NHS Foundation Trust · Gastroenterology & Clinical Nutrition

Introduction Nutrition is an essential part of gastroenterology specialist training. There is limited evidence of trainee experience in this area. The shorter training programme introduced in 2022 may lead to reduced exposure to this subspecialty. We aimed to explore and describe current nutrition training experiences, confidence and satisfaction t...

Introduction Filgotinib was licensed for use in ulcerative colitis in the UK in January 2022 and NICE approved in June 2022. We reviewed our patients treated with filgotinib following the additional measures recommended by the EMA to identify those at increased risk of side effects with JAK inhibitors. The position of filgotinib in therapeutic path...

Introduction University Hospital Southampton (UHS) receives more than 8000 patient contacts via its IBD help line/online portal each year many with symptom relapse. Enteric infections mimicking an IBD flare are common with studies reporting up to 17% of symptomatic IBD patients returning positive tests.¹ The aim of this project was to determine the...

The impact of oral nutritional supplements (ONS) on patients with complications (disease related morbidity) requires further exploration. This systematic review included 44 randomised controlled trials (RCT) (29 RCT surgical, 15 RCT medical patients) examining the effect of ONS in community settings on the incidence of complications (n5716, mean ag...

Background & aims: The United Kingdom (UK) nutrition database monitors the changing landscape of adult home parenteral nutrition support (HPS) to inform clinicians and policy makers of the need for this life saving treatment. Methods: The UK database is administered by the British Association for Parenteral and Enteral Nutrition (BAPEN). Data fo...

Background The success of early dexamethasone therapy for hospitalised COVID-19 cases in treatment of Sars-CoV-2 infection may predominantly reflect its anti-inflammatory action against a hyperinflammation (HI) response. It is likely that there is substantial heterogeneity in HI responses in COVID-19. Methods Blood CRP, ferritin, neutrophil, lymph...

Introduction In the management of acute hospital admissions during the COVID‐19 pandemic, safe patient cohorting depends on robust admission diagnostic strategies. It is essential that screening strategies are sensitive and rapid, to prevent nosocomial transmission of COVID‐19 and maintain patient flow. Methods We retrospectively identified all CO...

Introduction Patients on home parenteral nutrition (HPN) are recognised to be at high risk of metabolic bone disease (MBD). ESPEN guidelines recommend screening with annual DEXA (Dual-energy X-ray absorptiometry) scans for all patients on HPN. The National Institute for Health and Care Excellence states that DEXA scans should not routinely be perfo...

Introduction Nasojejunal tube (NJT) insertion using the Cortrak® enteral access system (CEAS) has been reported to be a simple technique for placing postpyloric feeding tubes. CEAS uses an electromagnetic sensing device that tracks and displays the path of the feeding tube during placement at the bedside and avoids the need for endoscopic or radiol...

Introduction Patients with suspected inflammatory bowel disease (IBD) referred from primary care often face diagnostic and treatment delays. This study aimed to compare a novel direct-access IBD endoscopy pathway with the traditional care model. Method Single centre real-world study analysing primary care referrals with suspected IBD. Group A: pat...

Objectives Risk of hospital-acquired COVID-19 (HA-COVID-19) infection is increased by cohorting infected and non-infected patients together in assessment areas, whist awaiting laboratory PCR results. Molecular point-of-care tests (mPOCT) reduce time to results and improve patient flow but the impact on HA-COVID-19 is unknown. Methods In this pre a...

Background and Aims Subcutaneous (SC) vedolizumab presents the opportunity for inflammatory bowel disease (IBD) patients to manage their treatment at home. There is currently no data on the process of transitioning patients established on intravenous (IV) to SC as part of routine clinical care. The aim of this programme is to evaluate the clinical...

Introduction In May 2020, subcutaneous (SC) vedolizumab was approved for use in Inflammatory Bowel Disease (IBD). Patients with IBD have a number of risk factors for a poor outcome from SARS-CoV-2 infection and managing this risk by reducing hospital visits is crucial. Currently there is no information on the process or outcomes of transitioning pa...

Objectives: The provision of high-quality personal protective equipment (PPE) has been a critical challenge during the COVID-19 pandemic. We evaluated an alternative strategy, mass deployment of a powered air-purifying respirator (PeRSo), in a large university hospital. Methods: We performed prospective user feedback via questionnaires sent to heal...

Objectives: provision of high quality personal protective equipment (PPE) has been a critical challenge during the COVID-19 pandemic. We evaluated an alternative strategy, mass deployment of a powered air purifying respirator (PeRSo) in a large university hospital. Methods: we performed prospective user feedback via questionnaires sent to healthc...

Eating and drinking are essential for maintenance of nutrition and hydration, but are also important for pleasure and social interactions. The ability to eat and drink hinges on a complex and coordinated system, resulting in significant potential for things to go wrong.The Royal College of Physicians (RCP) has published updated guidance on how to s...

Background and aims The case-mix of patients with intestinal failure due to short bowel syndrome (SBS-IF) can differ among centres and may also be affected by the timeframe of data collection. Therefore, the ESPEN international multicenter cross-sectional survey was analyzed to compare the characteristics of SBS-IF cohorts collected within the same...

Background: the success of early dexamethasone therapy for hospitalised COVID-19 cases in treatment of Sars-CoV-2 infection may predominantly reflect its anti-inflammatory action against a hyperinflammation (HI) response. It is likely that there is substantial heterogeneity in HI responses in COVID-19. Methods: blood CRP, ferritin, neutrophil, lym...

Background The success of early dexamethasone therapy for hospitalised COVID-19 cases in treatment of Sars-CoV-2 infection may predominantly reflect its anti-inflammatory action against a hyperinflammation (HI) response. It is likely that there is substantial heterogeneity in HI responses in COVID-19. Methods Blood CRP, ferritin, neutrophil, lympho...

A significant proportion of COVID-19 patients show evidence of hyperinflammation (HI) of which secondary haemophagocytic lymphohistiocytosis (sHLH) is the most severe manifestation and diagnosed with HScore. Using a COVID relevant modification of the HScore (%HScore), we set out to determine the prevalence of sHLH in 567 COVID-19 inpatient cases. T...

A significant proportion of COVID-19 patients show evidence of hyperinflammation (HI), of which secondary haemophagocytic lymphohistiocytosis (sHLH) is the most severe manifestation and diagnosed with HScore. Using a COVID-relevant modification of the HScore (%HScore), we set out to determine the prevalence of sHLH in 567 COVID-19 inpatient cases....

Abstract Introduction Patients with Intestinal failure (IF) are at risk of malnourishment and altered body composition particularly at times of acute illness. Loss of muscle mass and poor functional ability are risk factors for deconditioning, extended length of stay and surgical complications. Funding a dedicated physiotherapist for our IF unit w...

Introduction Intestinal failure associated liver disease (IFALD) is a complication in patients with intestinal failure (IF) on home parenteral nutrition (HPN). It can progress to cirrhosis requiring a combined liver-intestinal transplant which carries a higher morbidity and mortality than isolated intestinal transplant. Early assessment for liver f...

Introduction The landscape of medical therapies for severe ulcerative colitis is widening. Tofacitinib, the first oral therapy and Janus kinase (JAK) inhibitor to be approved for this indication, was licensed in the EU in August 2018 and was approved for use in the NHS by NICE in November of that year. This is a description of the real-world experi...

Background/aims Refeeding syndrome can result following excessive feeding of malnourished patients. The syndrome remains poorly defined but encompasses a range of adverse effects including electrolyte shifts, hyperglycaemia and other less well-defined phenomena. There are additional risks of underfeeding malnourished individuals. Studies of refeedi...

Introduction Patients with suspected IBD referred by primary care (GP) are traditionally seen in gastroenterology outpatient clinics followed by endoscopic investigations. This 2 phase model leads to delay in diagnosis and treatment, increasing pressure on gastroenterology outpatient services while still requiring endoscopic intervention. Our novel...

Introduction Intestinal failure associated liver disease (IFALD) refers to liver injury due to intestinal failure (IF) and parenteral nutrition (PN). This presents as steatosis and cholestasis which can lead to fibrosis and cirrhosis. ESPEN recommends that IFALD should be diagnosed by the presence of abnormal liver function tests (LFTs) with radiol...

Background Glucocorticosteroids (GC) are long-established, widely used agents for induction of remission in inflammatory bowel disease (IBD). Hyperglycaemia is a known complication of GC treatment with implications for morbidity and mortality. Published data on prevalence and risk factors for GC-induced hyperglycaemia in the IBD population are limi...

Objective COVID-19 has disrupted the normal way of life in the UK, but for some patients with inflammatory bowel disease (IBD), the impact of this unprecedented global emergency was far greater. We aimed to assess the experience of patients with IBD during the COVID-19 lockdown. Design We designed a survey focused on the impact of COVID-19 on IBD...

COVID-19 negatively impacts nutritional status and as such identification of nutritional risk and consideration of the need for nutrition support should be fundamental in this patient group. In recent months, clinical nutrition professional organisations across the world have published nutrition support recommendations for health care professionals...

Objective It has been assumed that a significant proportion of COVID-19 patients show evidence of hyperinflammation of which secondary haemophagocytic lymphohistiocytosis (sHLH) is the most severe manifestation. To facilitate diagnosis of sHLH the HScore has been developed and validated. We set out to examine the prevalence of sHLH-like hyperinflam...

Background Glucocorticosteroids (GC) are long-established, widely used agents for induction of remission in inflammatory bowel disease (IBD). Hyperglycaemia is a known complication of GC treatment with implications for morbidity and mortality. Published data on prevalence and risk factors for GC-induced hyperglycaemia in the IBD population are limi...

Large trials assessing oral nutritional supplements (ONS) and dietary advice (DA) in primary care are lacking. This study examined effects of ONS + DA versus DA on intake, weight, QoL, healthcare use and satisfaction in malnourished free-living older people. Three hundred and eight people (71.5 ± 10.7y) were randomised to receive ONS + DA (n154) or...

Sarcopenia is a progressive and generalised disorder of skeletal muscle strength, function and mass, that is most commonly associated with the normal ageing process. It is increasingly recognised that sarcopenia can also develop as a consequence of malabsorptive and inflammatory conditions, such as those seen by gastroenterologists and hepatologist...

Objective: Since nutritional screening is not routinely and accurately performed by busy care workers, the aim of this study was to evaluate a self-screening electronic measuring station that includes sonic height measurements. Methods: In all, 114 patients, 18 to 85 y of age and attending gastrointestinal outpatient clinics, followed automatica...

Introduction Type 2 intestinal failure (IF) is a prolonged (>28 days), acute condition requiring complex multi-disciplinary (MDT) care and intravenous (IV) supplementation, either in hospital or through the provision of home parenteral nutrition (HPN). Without careful MDT management, these patients can progress to type 3 IF, requiring lifelong IV s...

Introduction Buried bumper syndrome (BBS) represents a rare, but potentially serious complication in percutaneous endoscopic gastrostomy (PEG) tubes. In BBS there is a growth of the gastric mucosa over the inner bumper of the PEG tube, affecting 0.–% of PEG tubes.Options for the management of BBS include the insertion of a jejunal extension, surgic...

Introduction Gastrocutaneous fistulae (GF) are a rare, but difficult to manage complication after percutaneous endoscopic gastrostomy (PEG) tube removal. In cases, refractory to conventional medical management various approaches have been used for their treatment including; surgical closure, through the scope clipping and endoscopic suturing with v...

Catheter-related bloodstream infections (CRBSIs) commonly arise from a parenteral nutrition catheter hub. A target for a Nutrition Support Team is to have a CRBSI rate of less than 1 per 1000. The diagnosis of CRBSI is suspected clinically by a temperature shortly after setting up a feed, general malaise or raised blood inflammatory markers. It is...

The term ‘malnutrition’ is used to describe a deficiency, excess or imbalance of a wide range of nutrients, resulting in measurable adverse effects on body composition, function and clinical outcome. As such, it can refer to individuals who are either over- or under-nourished, although it is usually used synonymously with undernutrition, as here. A...

Abstract Introduction The importance of presence of a nutrition support team (NST) and a nutrition steering committee (NSC) were recognised in 1994 by BAPEN with the recommendation that all major UK hospitals should appoint a NSC and at least one NST. It was recognised that delivering excellent nutritional care within hospitals required the co-ordi...

Aim This project aimed to evaluate the time taken for formal reporting of blood culture results, the associated impact of this on prescribing appropriate antibiotic therapy and defining the period of starvation whilst PN is withheld for patients with catheter related bloodstream infections (CRBSI) Method Clinical data were retrospectively collecte...

Purpose: Disease-related malnutrition continues to be a common and costly public health problem especially in older community based adults, with 90% of malnutrition orginating in the community and older adults accounting for 52% of the total costs of malnutrition1. There remains a lack of large randomised trials in free living older people assessin...

Introduction Nasogastric (NG) tube feeding is an important component of nutritional care. However it has risks and introducing feed or medicines into the respiratory tract through a misplaced NG tube is categorised as a ‘never event’ by NHS England. If confirmation of safe NG tube placement requires a chest x-ray (CXR), this must be interpreted by...

Background & aims: Malnutrition is common in care home residents, but information on the cost-effectiveness of nutritional interventions is lacking. This study, involving a randomised trial in care home residents, aimed to examine whether oral nutritional supplements (ONS) are cost-effective relative to dietary advice. Methods: An incremental co...

Introduction Home parenteral nutrition (HPN) for palliative malignancy is increasing and optimal selection of patients remains challenging. A nomogram predicting survival length1 based on Glasgow prognostic score (CRP and albumin), primary cancer, metastases & Karnofski performance status has recently been developed. In the nomogram survival was ca...

Background & aims: Few trials have explored the effect of nutrition support on quality of life (QoL). This study examined the effects of oral nutritional supplements (ONS) vs dietary advice on QoL in malnourished care home residents. Methods: 104 malnourished, care home residents (medium + high risk), identified using the Malnutrition Universal...

Aims: In recent years, there have been a number of case reports of severe hypomagnesaemia associated with proton pump inhibitor (PPI) use, such that both the FDA and MHRA have issued drug safety warnings. They have recommended periodic serum magnesium testing in patients prescribed PPIs but provide no guidance on timing of these measurements. Met...

Background and aims Inoperable bowel obstruction is the most common and judicious indication for long term parenteral nutrition in patients with palliative malignancy. Considerable uncertainty exists about the survival length, quality of life (QOL) and associated health economics of home parenteral nutrition (HPN) for this patient group. Methods A...

Introduction Survival following Intestinal transplantation (ITX) has improved, approaching that of home parenteral nutrition (HPN) at 5 years. We describe quality of life (QOL) and performance status (PS) on uncomplicated HPN, those with criteria for ITX due to complicated HPN (CHPN) and those after ITX. Methods SF36 was used to assess QOL. Perform...

Emerging evidence suggests taurolidine reduces the risk of repeated episodes of catheter related blood stream infections (CRBSI) in a subgroup of patients receiving home parenteral nutrition (HPN). We defined 3 indications where taurolidine could be considered and retrospectively analysed data from patients who were treated over a 10 year period to...

Oedema is observed frequently following surgery and may be associated with worse outcomes. To date, no study has investigated the role of oedema in the emergency surgical patient. This study assesses the incidence of oedema following emergency abdominal surgery and the value of early postoperative oedema measurement in predicting clinical outcome....

Introduction IBD patients are at risk of micronutrient deficiency including vitamin D. There is evidence that vitamin D deficiency is associated with poor disease activity. Aims/Background To determine the vitamin D status and evaluate the effectiveness of oral vitamin D treatment in a sub-set of IBD patients at a University Hospital. Method All IB...

Introduction Inflammatory bowel disease (IBD) patients are at risk of micronutrient deficiencies, including vitamin D. There is increasing evidence that vitamin D deficiency has a negative impact on disease activity. This study aims to determine the vitamin D status of a sub-set of IBD patients at a University Hospital and to evaluate the effective...

Background & aims Type 2 intestinal failure (IF) is a specific disease entity, the management of which requires multidisciplinary clinical expertise combined with appropriate infrastructure. Accurate UK costs for providing such services are unavailable. We made an assessment of these costs at our hospital, categorising patients according to whether...

Information relating to the provision of HPN in New Zealand and Scotland has been published.1 This paper expands that benchmarking exercise to examine the organisation, prevalence and referral pathways across several countries of the world.Methods The ESPEN Home Artificial Nutrition Chronic Intestinal Failure working group agreed a pro forma and ci...

Introduction Catheter related blood stream infections (CRBSI) in patients receiving home parenteral nutrition (HPN) cause significant morbidity, are potentially life-threatening and through repeated line replacements may compromise venous access. We introduced products containing taurolidine as preventative antimicrobial line locks in 2006 for HPN...

Introduction Some enterally fed patients require placement of a nasojejunal tube (NJT) which is often considered to need time-consuming, costly radiological or endoscopic input which can delay feeding commencement. This study examined the feasibility and accuracy of bedside NJT placement. Methods As part of a study comparing nasogastric tube (NGT)...

Introduction Malnourished Surgical patients are at a significantly greater risk of post-operative complications and death than well-nourished patients. The “Malnutrition Universal Screening Tool” (MUST) is a validated tool for identifying at-risk patients. This paper studies the application of MUST in patients undergoing emergency abdominal surgery...