Background: Not only does IBD lead to nutritional deficiencies, but also nutrients influence its pathophysiology: exclusive enteral nutrition (EEN) is an effective primary treatment in Crohn's disease; and vitamin D (VitD) is involved in its pathogenesis and course. Aims: We hypothesised that nutrients impact on the course of IBD. We therefore studied the effect of EEN i) on long term clinical course in children; ii) on CD58, a costimulatory molecule at the intestinal epithelial cell (IEC) lines, iii) adults with Crohn's disease. We examined the possible effect of serum vitamin D levels on the course of IBD and also the possible role of ethnicity in our paediatric and adult populations that were treated with EEN but also in our general adult population. Results Chapter II: 56 paediatric patients with Crohn's disesase were followed up for 5 years. 57% of patients achieved remission after 6 weeks of EEN. Achievement of clinical remission within 6 weeks of EEN was significantly associated with a longer time to relapse and to treatment escalation. VitD deficiency was common; and those patients who were deficient were significantly more likely to require corticosteroids and also needed thiopurines sooner. Chapter III: CD58 was expressed in the IEC isolated from IBD patients and healthy controls. EN down-regulated the expression of CD58 on IEC lines. Chapter IV: 22 adult patients with Crohn's disease with a mean age of 30.8 years were given EEN and followed up for a mean time of 1.9 years. 22.7% of patients went into clinical remission and 77.3% experienced a clinical response. By the end of follow up 63.6% (14/22) of patients had clinically relapsed and 36.4% required surgery during their follow up. There was no difference between South Asian and Caucasian patients in the disease outcomes after administration of EEN. Chapter V: Bangladeshis were more often vitamin D deficient than white Caucasian patients; however vitamin D status was not associated with the course of IBD. Bangladeshis developed perianal disease and required thiopurines earlier in their disease course. Bangladeshi patients with UC had more extensive disease. Conclusions: EEN, when successful, improves the long term outcome of Crohn's disease in children, possibly in part, by down-regulating CD58 on the IEC. VitD deficiency may influence the clinical course of IBD; however our results were contradictory between children and adults and significantly limited by the assessment of the vitamin D level at a single time point.

Behandling med enteral nutrition erbjuds de patienter som har tugg- och sväljsvårigheter främst av neurologiska orsaker. Behandling kan därför ske med nasogastrisk eller gastrostomisk sond. Gastrostomisk sond väljs då behandlingen planeras vara ett långvarigt alternativ. Forskning visar att enteral nutrition medför ökat oberoende och lättnad över att inte behöva vara orolig över sitt näringsintag. Sociala tillfällen som inkluderar mat och dryck upplevs dock som svåra. Det saknas tillräcklig uppföljning av hur behandlingen fungerar för dessa patienter i det dagliga livet, vilket kan medföra att patientens nutritionsbehov inte ses över.Syftet är att beskriva patienters upplevelser av behandling med enteral. Åtta personer med enteral nutrition har intervjuats och analyserats utifrån kvalitativ innehållsanalys. Resultatet av denna studie visar att upplevelsen av att inte kunna äta normalt skiljer sig åt beroende på patienternas utgångsläge, att förskrivningen av material har förbättrats sedan SÄRNÄR- teamet tagit över, men distributionen är däremot bristfällig. Vidare visar studien att information oftast är tillräcklig på specialistenheten, men sämre om patienten vårdas på annan enhet än den som är specialiserade på enteral nutrition. Att vänja sig vid nackdelar och se fördelar med enteral nutrition framkommer som betydelsefullt för dessa patienter och är avgörande för att gå vidare i livet. Patienterna upplever att omgivningen inte förstår deras situation. På grund av att inte kunna äta normalt saknar dessa patienter den sociala samvaron i samband med matsituationen och upplever ett utanförskap. Genom att patienters egna berättelser och livshistoria förs fram, kan det bidra till att utveckla och förbättra vården av enteral nutrition. Vår förhoppning är att resultatet från denna studie ska komma till nytta för SÄRNÄR – teamet i deras arbete med att följa upp patienter med enteral nutrition. / Program: Specialistsjuksköterskeutbildning med inriktning mot distriktssköterska

Doctor of Philosophy (PhD) / Although registered nurses have a plethora of information sources available to assist them in making clinical decisions, how this information informs such decisions is not well understood. Through the work undertaken in this thesis a deeper understanding of information use in clinical practice is developed. Information use in clinical uncertainty is explored, specifically in the context of making decisions about enteral feeding practices within critical care environments. Instrumental case studies were used to access the information use processes of registered nurses working in an intensive care unit. Two case sites (a Level III intensive care unit in metropolitan teaching hospital and a Level II intensive care unit in a district hospital) were selected for the purpose of theoretical replication. Data were collected to inform specific issues. Concurrent verbal protocols (think aloud), observation and retrospective probing were used to explore documented clinical decisions and the information used to inform those decisions. Q sorting was used to determine the accessibility and usefulness of information available to participants and focus groups were used to explore senior nurse clinician’s perceptions of the authority of the identified information sources. A synthesis of findings from the two case sites highlighted three key issues. First, natural testimony (the use of personal communication to obtain information) was privileged over other, more formal sources of information however the veracity of the information obtained through natural testimony was not explicitly assessed. Registered nurses relied on the credibility of the person providing the information, leaving the information itself unchallenged. The clear reliance on information accessed through natural testimony, but the evident lack of critical evaluation of information obtained in this way, indicates a need for the development of strategies for the critical assessment of the accuracy of this clinical information. Second, the findings highlighted nurses’ use of clinical inquiry. Nurses used clinical inquiry to resolve clinical uncertainty as well as for logistic reasons. Participant’s use of inquiry was influenced by their approach to work, the impact of both organisational and personal perspectives on the perceived value of their work; and by models of clinical leadership where an investment in relational capital was considered a strategy to positively influence a culture of inquiry. Although organisational documents which are designed to ensure quality and consistency of patient care as required by current clinical governance strategies were considered useful, these document were not widely used as a primary source of information. The use of organisational documents, as well as the need to practice in concert with such documents, was identified as a factor negatively impacting on the development and support of nurses’ use of clinical inquiry. Third, findings addressed the usefulness of information for clinical decisions and the resolution of clinical uncertainty. The usefulness of information was influenced by its relevance to a clinical question or information deficit, and by the media used to convey the information. In general, print based media was considered more useful than other forms such as electronic documents. While original research was not considered useful, nurses valued research-based practice and responded positively to incorporating research into practice, particularly if research was pre-appraised by colleagues who were able to disseminate research findings to the clinical area and facilitate its use in clinical practice. This case study indicates that information use is less about individuals and the clinical context in which they are making decisions, and more about the social, cultural and organisational influences that shape decision making, and the information selected to support those decisions. The preference for natural testimony as information in decision making may, on first consideration, be viewed as undesirable in a work context that relies on accurate and consistent documentation. Determining the credibility of the information provider and the accuracy of the information itself is also challenging in an environment where this type of information and the approach to accessing it is selected for its ease of accessibility and the speed at which it can be applied. Yet, the pervasiveness with which nurses rely on others for information suggests verbal testimony is important in the context of clinical practice and highlights the need to develop a clearer understanding of why nurses privilege this information. Therefore verbal testimony must be considered carefully as a strategy for providing information, particularly research-based information and this study therefore highlights the need to develop strategies that enable those providing information to convey their expertise as a clinician as well as a user and provider of information. The organisational culture and work structures currently in place in Australia are unlikely to undergo significant change in the coming years, therefore their impact on information use warrants careful consideration. The nursing profession and the higher education sector aim to foster through inquiry, the independent, evidence-based practice of registered nurses. Health care organisations also highly value independent, evidence-based practice but also promote patient safety through use of current clinical governance strategies. While these two goals can be complimentary they also create tension when clinical governance strategies stifle inquiry and independent decision making of registered nurses. Ultimately, the current health care system in Australia and the wider community expect an evidence base for practice together with clinical governance strategies that promote safe practice. Nurses, as part, of this system must be accountable for both in the context of their clinical practice. We therefore need with some urgency to determine how to best balance these complementary and simultaneously competing ideals.

La recolección de los datos se realizo en 191 pacientes que recibían nutrición enteral de la unidad de soporte nutricional del Hospital Edgardo Rebagliati Martins durante Junio-Agosto del 2003. En este período se observó que el 28.80% de estos pacientes recibieron Osmolite HN (NET) y medicación por sonda nasogástrica. Para el estudio In Vitro de diseño prospectivo y experimental se seleccionaron 15 medicamentos de acuerdo a la frecuencia de administración y al potencial riesgo farmacológico. Se observó para cada parámetro, la relación lineal entre las variables al adicionar NET a las suspensiones. Se evidenció un incremento en el valor de la viscosidad para el caso de la suspensión de Ciprofloxacino de 21 y 26.1 cps debido a la formación de gránulos densos en presencia del NET. La osmolalidad mostró la relación lineal entre la suspensión con la adición del NET (F=8.15, µ:0.05) a los 12, 36 y 60 minutos de infusión; no alcanzando valores máximos de 200mOsm/Kg, obteniéndose como máximo valor el de la Ranitidina con 186mOsm/Kg a los 60 minutos. Se evidenció que la adición del NET a la suspensión del Omeprazol disminuyó su acidez de 5.89 a 6.83, para el caso de la suspensión de Fenitoína el cual en presencia del NET y el aspirado gástrico se observo una disminución de su alcalinidad de 10.07 a 7.92 (µ:0.05). El valor medio de los valores de velocidad de caída para las suspensiones fue de 6”28 y con la adición del NET de 12”01 (µ:0.05), evidenciándose la ||obstrucción de la sonda para el caso de la suspensión de Ranitidina. La adsorción de Fenitoína de las proteínas del NET mostró que el mayor grado de unión se produjo a la 1:30 h (91.33%) y 3:00 h (89.10%); siendo 68.62% Fenitoína recuperada durante las 4 horas de infusión (µ:0.05). De acuerdo al estudio realizado se concluye que no todas las formas farmacéuticas pueden administrase con el nutriente enteral total por sonda nasogástrica por los cambios fisicoquímicos que la trituración genera. / The collection of the data was made in 191 patients that received nutrition enteral of the unit of supports nutritional of Hospital Edgardo Rebagliati Martins during June-August of the 2003. In this period we were observed that 28.80% of these patients received Osmolite HN and medication for nasogastric tube. For the study In Vitro of prospective and experimental design, 15 medications were selected according to the administration frequency and to the potential pharmacological risk. We were observed for each parameter, that lineal relationship among the variables when adding NET to the suspensions. The increment was evidenced in the value of the viscosity for the case of the suspension of Ciprofloxacino from 21 to 26.1 cps due to the formation of dense granules in presence of the NET. The osmolalidad showed the lineal relationship among the suspension with the addition of the NET (F=8.15, µ:0.05) to the 12, 36 and 60 minutes of infusion; not reaching maximum values of 200mOsm/Kg, obtaining the maximum value the Ranitidina with 186mOsm/Kg to the 60 minutes. We were evidenced with the addition of the NET to the suspension of the Omeprazol diminished its acidity from 5.89 to 6.83, for the case of the suspension of Fenitoina which in presence of the NET and aspired gastric observed a decrease of its alkalinity from 10.07 to 7.92 (µ:0.05). been evidenced the obstruction of the tube in the case of the suspension of Ranitidina. The adsorption of Fenitoína of the proteins of the NET evidenced that the biggest grade of union at the 1:30 h (91.33%) and 3:00 h (89.10%); being 68.62% Fenitoína recovered during the 4 hours of infusion (µ:0.05). According to the carried out study we concluded that not all the pharmaceutical forms can administers with the nutritious total enteral for nasogastric tube for the physiochemical changes that its trituration generates.

Enteral feeding is commonly used in paedaitric patients. It helps to improve the digestive, absorptive, immunologic and nutrition status. However, poor handling in enteral feeding can lead to bacterial contaminations and severe consequences resulting in significant morbidity and mortality. At present, there are no definite guidelines on the handling of enteral feeding in local setting, therefore developing evidence based guideline on enteral feeding is critically important to eliminate inconsistent practices and prevent nosocomial infections related to enteral feeding. This dissertation is a translational nursing research that aims at developing evidence based guideline on enteral feeding in infants. The objectives of this thesis are to search for existing literatures on enteral feeding; perform a critical appraisal on the literatures; develop guideline on enteral feeding in infants; assess the implementation potential of the proposed guidelines, and develop the implementation and evaluation plans. The ultimate goal is to reduce the nosocomial infections in infants with enteral feeding in an acute hospital. A systemic search for relevant and valid evidence was performed using three electronic databases and nine relevant studies were retrieved. Critical appraisals on the nine studies were performed and the level of evidence for each study was graded according to the Scottish Intercollegiate Guidelines Network (SIGN). By synthesizing the data from nine studies, it is concluded that optimal hang time and proper hand hygiene appeared to have significant effect in reducing nosocomial infections related to enteral feeding. The implementation potential of the innovation was assessed in terms of the transferability, feasibility and cost benefit ratio. After assessing the implementation potential, it is found that the evidence is transferable and feasible to implement the proposed guideline in the target paeditaric setting. An evidence based guideline on enteral feeding in infants was developed. An implementation plan of the new guideline included a comprehensive communication plan with both administration and nurses and a pilot test were developed to ensure a smooth implementation and optimize the transferability and effectiveness of the evidence based guideline in the target population. A systematic evaluation plan on patient outcomes, health care provider outcomes and systemic outcomes was developed. The evidence based guideline on enteral feeding was expected to be implemented in the long run to reduce the risk of nosocomial infections in infants with enteral feeding. / published_or_final_version / Nursing Studies / Master / Master of Nursing

Doctor of Philosophy (PhD) / Although registered nurses have a plethora of information sources available to assist them in making clinical decisions, how this information informs such decisions is not well understood. Through the work undertaken in this thesis a deeper understanding of information use in clinical practice is developed. Information use in clinical uncertainty is explored, specifically in the context of making decisions about enteral feeding practices within critical care environments. Instrumental case studies were used to access the information use processes of registered nurses working in an intensive care unit. Two case sites (a Level III intensive care unit in metropolitan teaching hospital and a Level II intensive care unit in a district hospital) were selected for the purpose of theoretical replication. Data were collected to inform specific issues. Concurrent verbal protocols (think aloud), observation and retrospective probing were used to explore documented clinical decisions and the information used to inform those decisions. Q sorting was used to determine the accessibility and usefulness of information available to participants and focus groups were used to explore senior nurse clinician’s perceptions of the authority of the identified information sources. A synthesis of findings from the two case sites highlighted three key issues. First, natural testimony (the use of personal communication to obtain information) was privileged over other, more formal sources of information however the veracity of the information obtained through natural testimony was not explicitly assessed. Registered nurses relied on the credibility of the person providing the information, leaving the information itself unchallenged. The clear reliance on information accessed through natural testimony, but the evident lack of critical evaluation of information obtained in this way, indicates a need for the development of strategies for the critical assessment of the accuracy of this clinical information. Second, the findings highlighted nurses’ use of clinical inquiry. Nurses used clinical inquiry to resolve clinical uncertainty as well as for logistic reasons. Participant’s use of inquiry was influenced by their approach to work, the impact of both organisational and personal perspectives on the perceived value of their work; and by models of clinical leadership where an investment in relational capital was considered a strategy to positively influence a culture of inquiry. Although organisational documents which are designed to ensure quality and consistency of patient care as required by current clinical governance strategies were considered useful, these document were not widely used as a primary source of information. The use of organisational documents, as well as the need to practice in concert with such documents, was identified as a factor negatively impacting on the development and support of nurses’ use of clinical inquiry. Third, findings addressed the usefulness of information for clinical decisions and the resolution of clinical uncertainty. The usefulness of information was influenced by its relevance to a clinical question or information deficit, and by the media used to convey the information. In general, print based media was considered more useful than other forms such as electronic documents. While original research was not considered useful, nurses valued research-based practice and responded positively to incorporating research into practice, particularly if research was pre-appraised by colleagues who were able to disseminate research findings to the clinical area and facilitate its use in clinical practice. This case study indicates that information use is less about individuals and the clinical context in which they are making decisions, and more about the social, cultural and organisational influences that shape decision making, and the information selected to support those decisions. The preference for natural testimony as information in decision making may, on first consideration, be viewed as undesirable in a work context that relies on accurate and consistent documentation. Determining the credibility of the information provider and the accuracy of the information itself is also challenging in an environment where this type of information and the approach to accessing it is selected for its ease of accessibility and the speed at which it can be applied. Yet, the pervasiveness with which nurses rely on others for information suggests verbal testimony is important in the context of clinical practice and highlights the need to develop a clearer understanding of why nurses privilege this information. Therefore verbal testimony must be considered carefully as a strategy for providing information, particularly research-based information and this study therefore highlights the need to develop strategies that enable those providing information to convey their expertise as a clinician as well as a user and provider of information. The organisational culture and work structures currently in place in Australia are unlikely to undergo significant change in the coming years, therefore their impact on information use warrants careful consideration. The nursing profession and the higher education sector aim to foster through inquiry, the independent, evidence-based practice of registered nurses. Health care organisations also highly value independent, evidence-based practice but also promote patient safety through use of current clinical governance strategies. While these two goals can be complimentary they also create tension when clinical governance strategies stifle inquiry and independent decision making of registered nurses. Ultimately, the current health care system in Australia and the wider community expect an evidence base for practice together with clinical governance strategies that promote safe practice. Nurses, as part, of this system must be accountable for both in the context of their clinical practice. We therefore need with some urgency to determine how to best balance these complementary and simultaneously competing ideals.

Thesis (Ph. D.)--University of Sydney, 2008. / Title from title screen (viewed 11 February 2009). Submitted in fulfilment of the requirements for the degree of Doctor of Philosophy to the Faculty of Nursing And Midwifery. Includes bibliographical references. Also available in print form.

Thesis (Ph. D.)--Case Western Reserve University, 2005. / Frances Payne Bolton School of Nursing. Includes bibliographical references. Available online via OhioLINK's ETD Center.

El documento digital no refiere un asesor / Publicación a texto completo no autorizada por el autor / Da a conocer el manejo de la nutrición enteral mínima (NEM) mediante la descripción de sus características, en los recién nacidos pretérmino con peso menor a 1500 gr hospitalizados en la UCI Neonatal del Hospital Nacional Alberto Sabogal Sologuren durante el período de Julio 2011 a Julio 2012. Estudio descriptivo, retrospectivo de corte transversal. Se incluye 74 recién nacidos pre término menores a 1500 gramos atendidos en UCI del Hospital Nacional Alberto Sologuren durante el periodo de 2011 a 2012. Para las variables cuantitativas se determina medidas de tendencia central y medidas de dispersión. Para las variables cualitativas se elabora frecuencias absolutas y relativas. Además para relacionar las variables cualitativas se usa la prueba de Chi-cuadrado y para variables numéricas la prueba T de Student a un nivel de significancia del 5%. El peso promedio de los recién nacidos pretérmino < de 1500 gr con nutrición enteral mínima (NEM) fue 1150±213 gr y la edad gestacional media es 29±2 semanas. El sexo femenino es el más frecuente (54,1%). Las características de la nutrición enteral mínima tienen un promedio de volumen de inicio de 9,1 cc/kg y frecuencia inicial de administración 7 tomas /día. Además el tiempo de vida de los RN al prescribir la NEM es en su mayoría un día (60,8%) mientras para efectivizarse este procedimiento es más de 2 días (59,5%). La forma de administración de la NEM es mayormente en bolo (93,2%), seguido de infusión (4,1%) y por ambos métodos (2,7%), además el tiempo promedio de hospitalización es 41 días. A las dos semanas de recibir alimentación enteral el 51,4% tiene una ganancia de peso de hasta 250 gr, sin embargo el 43,2% tiene pérdida de peso de hasta 308 gr luego de 2 semanas de tratamiento. Asimismo las causas de suspensión de NEM son principalmente por no contar con leche materna (66,7%), intolerancia oral (53,3%) y en menores frecuencias comorbilidades como sepsis y hemorragia digestiva. Además en el 75,7% de RN se observa 2 causas de suspensión a la vez. Por otro lado se observa que hubo más complicaciones cuando el tiempo de duración es mayor a 4 días. Asimismo se encuentra asociación significativa entre la mortalidad y el tiempo de duración de la NEM (p=0.022), la edad gestacional (p=0,003) y el tiempo de vida al NEM (p=0,031) en los RN pretermino < de 1 500 gr. Además el 96,4% de RN que presentan sepsis usaban catéter percutáneo mientras que el tiempo promedio de hospitalización es mayor en los RN que no presentan sepsis. Concluye que las características de la nutrición enteral mínima en recién nacidos con peso menor a 1500 gr hospitalizados en la UCI Neonatal tienen un promedio de volumen de inicio de 9,1 cc/kg y frecuencia inicial de administración 7 tomas en un día; el tiempo de vida al prescribir la NEM es frecuentemente un día mientras para efectivizarse este procedimiento es más de dos días. La principal forma de administración de la NEM es mayormente en bolo y la causa más importante de suspensión es la ausencia de leche materna. Además la mortalidad está asociada al tiempo de duración de NEM ≤4 días. / Trabajo académico

El soporte nutricional en el paciente crítico es de vital importancia por su impacto en la morbimortalidad, estancia y preservación de la masa tisular entre otros. Se debe garantizar a todos los pacientes críticos soporte nutricional idealmente por vía enteral por la disminución de la traslocación bacteriana y la estimulación de la función de las vellosidades intestinales; es así, que el objetivo de la presente investigación es describir qué aspectos debe considerar el profesional de enfermería para brindar nutricional enteral a un paciente en estado crítico. Se trata de una investigación secundaria, la misma que utiliza la metodología de la investigación basada en la evidencia, se tomó en cuenta 08 artículos científicos relacionados con el tema, los que fueron buscados en bases de datos reconocidas en comunidad científica, como: scielo, redalyc, dialnet y google académico. Se seleccionó una guía de procedimientos clínicos, que se evaluó con el instrumento AGREE, el nivel de evidencia y potencia de las recomendaciones se ajustó siguiendo la propuesta del grupo GRADE. La respuesta a la pregunta clínica refiere: Lavado de manos con agua y jabón (A), Colocación de guantes de látex descartables. (A), Posición del paciente semifowler o Fowler. (B), Identificar posición de la sonda en cada turno. (A), Higiene bucal y limpieza del ostoma en cada turno. (B), Control diario del aspecto de la sonda, los sistemas de infusión deben cambiarse cada 24 horas. (B), Verificar residuo gástrico antes de cada administración de la fórmula en caso de administración intermitente, o cada 6 hs en caso de administración continua. (A), Preparación de la fórmula a administrar siguiendo normas de bioseguridad (B). / Trabajo académico