2023 Annual BAPEN Conference Review

Pete Turner, Programmes Committee Chair

The BAPEN 2023 Programmes Committee, led by Pete Turner, are pleased to report on an enormously successful 2023 Annual Conference, held in Edinburgh in November.

As part of BAPEN’s commitment to being inclusive across the four nations, we were delighted to take the 2023 Annual Conference to Edinburgh. Attracting record numbers – over 700 attendees – the Conference offered delegates a varied programme of clinical and scientific sessions to meet the needs of a multidisciplinary audience of healthcare professionals (HCPs) working within the field of nutritional care.

We delivered 14 parallel symposia, as well as the Pennington and Keynote Lectures. These scientific sessions were also interspersed with our Nutrition Village sessions, which were incredibly popular, as well as oral and poster presentations and three unopposed industry satellite symposia from Abbott, Nutricia and Takeda.

The Conference enabled us to share the latest cutting-edge and innovative practice with an abundance of practical take home messages and gave delegates the opportunity to network with colleagues and our industry partners in the exhibition.

With our ongoing commitment to sustainability, delegates had access to an interactive Conference app, sponsored by Fresenius Kabi and Calea, to review the programme and speakers biographies, as well as being able to view a PDF of the abstracts/posters, and network with sponsors and colleagues throughout the Conference.

Whilst it is not possible to describe all of the sessions in detail, we hope this gives an insight into the many Conference highlights over the two days. If any of the sessions spark your interest, you can also view recordings of all the sessions online via the BAPEN website. Access to all on-demand content is free to BAPEN members and non-members who attended the conference and for a small fee for any non-members who were not able to attend.

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Day 1

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Trevor Smith, BAPEN President, opened the Conference with a brief summary of activities, followed by an update on the activities of the COVID Airborne Alliance and the Public Enquiry from Barry Jones. We then heard from four of our top scoring abstracts before ending the session with excellent talks from Martin Sinclair on care received by patients undergoing surgery for Crohn’s disease and from Richard Smith on the challenges of sustainability within the NHS.

Simon Gabe and Priya Mistry chaired one of our first parallel sessions, looking at High Output Stomas. Jeremy Nightingale gave a detailed overview to help us understand pathological and physiological reasons behind why a high output stoma occurs and its implications. This was followed by the second presentation by Alison Culkin which looked at individualised management plans, including dietary advice and salt rehydration solutions. This raised lots of questions from the audience and interesting discussions about palatability of oral salt rehydration solutions and the kind of flavouring that could be added. The key message was to avoid some artificial sweeteners that may have a laxative effect, such as sorbitol. The final presentation of the symposium looked specifically at the medical management of high output stomas and was given by Ashley Bond. High output stomas require careful medical management to reduce loss of electrolytes and fluids and may need parenteral support if all else fails. If left untreated it can lead to hospitalisation with acute kidney injury. The final part of this symposium was an oral abstract presentation by Jack Eaton, sharing a meta-analysis of real-world evidence compared to the data for teduglutide in clinical trials. As a relatively new drug on the intestinal failure (IF) scene, teduglutide has been able to help some patients come off or reduce frequency of parenteral support. We look forward to more evidence on practical experiences of teduglutide at future BAPEN events.

Representing PENG, Rebekah Smith and Linda Cantwell brought us their symposium on jejunal feeding. This session featured 3 expert speakers, Alex Miras, Claire Campbell and Ester Fry. It was followed by one of the PENG award-winning top scoring abstract presentations presented by Emma Noble.

Alex Miras presented a summary of the physiology of gut hormones that control appetite, hunger and nausea, also including the gut and brain interaction and the response of hormones to nutrients when received by the jejunum compared to the stomach. He provided a physiological understanding for reasons for the symptoms that patients may experience with jejunal feeding due to the hormone response. One of the key messages to take away was that over time the hormone response and associated symptoms with jejunal feeding can reduce/resolve.

Claire Campbell, Nutrition Nurse Lead, Enteral Nutrition Team Guys and St Thomas’ Hospital spoke on ‘Jejunal feeding: more questions than answers’. Claire provided a very comprehensive overview the of indications, challenges and troubleshooting when it comes to considering, continuing, discontinuing and managing jejunal feeding and jejunal feeding tubes. This opened up a good conversation and highlighted the lack of evidence and limitations in tube type availability that we have in this area. Research opportunities everyone!?

Esther Fry, an Upper GI Dietitian from Nottingham University Hospitals NHS Trust, presented on ‘Long-term nutritional issues with jejunal feeding’. Do you routinely undertake micronutrient and mineral screening in your gastrectomy patients and/or those that are long-term fed via jejunum? Esther presented convincing data from an audit and case reviews of upper gastrointestinal (GI) patients at Nottingham Hospital of the risk of copper, selenium and B12 deficiency with a focus on severe copper deficiency and shares their guidelines and management plan. This promoted several delegates in the room to think about changing practice.

Emma Noble, Clinical Lead Dietitian (IF), Leeds Teaching Hospitals NHS Trust, and one of our top abstract selections, presented on ‘The vitamin and trace element status of IF patients receiving long-term home parenteral nutrition and home parenteral fluids’.

Emma presented the results of a service review assessing the micronutrient status of patients receiving home parental nutrition (HPN). This highlighted another patient group at risk of potential micronutrient deficiencies, including copper and selenium, in addition to zinc and vitamin A. However, high vitamin E levels in some patients were noted. This has led to amongst others, the consideration of home IV micronutrient supplementation for patients receiving home parenteral fluids with chronic micronutrient deficiencies, despite receiving high dose oral supplementation.

Irena Grecu Chaired a BAPEN Medical session on ‘Making the EFFORT to Optimise Nutrition on the ICU’. Delivering optimum nutrition at the right time to the critically ill patients remains one of the more controversial topics in clinical nutrition. More recently, a whole new debate started around the optimum protein intake and the narrative shifted towards different phases of critical illness and appropriate nutrition intake and composition for each of these phases. Three international experts in the field, Danni Bear from London, Elisabeth de Waele from Brussels and Judith Merriweather from Edinburgh, presented the most recent evidence available and further answered questions and comments from the audience.

The key take home messages were that higher protein delivery in the acute, catabolic phase of critical illness is not beneficial and may potentially be harmful in some categories, like in patients with acute kidney injury or sicker patients with multi-organ failure. The ‘million-dollar’ question ‘How to identify, in practice, the ‘metabolic switch’ from catabolism to anabolism?’ may soon be answered by AI and precision medicine. Meanwhile, clinicians can use more indirect calorimetry (starting on day 3 from ICU admission and every time the clinical condition changes thereafter), combined with more traditional measures like nitrogen balance, or inflammatory markers trend. At the moment, there is little evidence regarding nutrition target and composition in the recovery phase. However, it is clear that the patient’s journey of recovery after critical illness from the ICU – ward – community should be better managed, by increasing collaboration between secondary and primary care teams.

Representing BIFA, Kirstine Farrer and Jeremy Nightingale chaired a session on ‘Prevention and treatment of metabolic problems in IF)’. Phillip Allen spoke first on ‘bone disease’, reminding us that the BIFA guidelines on this will be published in early 2024. He pointed out that there are patient (e.g. weight, illness, medication) and lifestyle factors (e.g. smoking, exercise, alcohol) affecting bone density. He recommended an annual Frax^® assessment with bone density measurements every 3-5 years depending upon their risk. The importance of sodium and vitamin K was discussed.

Lisa Sharkey gave a live remote presentation on liver problems. Lisa drew attention to the fact that liver disease (with fibrosis) in IF sometimes involves a second liver insult (e.g. NAFLD, viral hepatitis, or excessive alcohol intake). If an IF patient becomes jaundiced due to IFALD, they are likely to die within 11 months, hence liver disease needs to be detected early, usually with a liver biopsy and, if found, an intestinal transplant assessment needs to be considered.

Sheldon Cooper bravely tackled the problem of acid base balance in IF patients, showing that metabolic acidosis and metabolic alkalosis are the problems most commonly encountered. Regular measurements of serum chloride and bicarbonate should be made. The importance of the chloride-acetate ratio in a parenteral support bag was discussed.

Graeme Doherty addressed glycaemic control and parenteral nutrition. He told us that if insulin is injected into a parenteral support bag 30% will bind to bag/tubing, hence he did not recommend this. For most patients feeding at night a soluble and isophane insulin (2 injections) will suffice, with one dose being given 5 minutes after the infusion begins. There will be new BIFA guidelines about this this year.

After an interesting first day, which included a satellite symposium sponsored by Abbott and two extremely popular Nutrition Village sessions supported by Eitan Medical, the Insides Company and Avanos, delegates donned their kilts and took to the dance floor at the Ghillie Dhu for a traditional Scottish Ceilidh lead by a Scottish Ceilidh band.

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Day 2

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Following a fun evening, delegates rose early to support this year’s Breakfast Symposium, sponsored by Nutricia, before we heard from our other Core Groups during day two’s excellent range of sessions.

The BPNG symposium, chaired by Ruth Newton, covered a wide range of issues that may arise when treating a surgical patient. Robbie Cord presented a surgical case that covered areas, not just relating to managing nutritional support, but also how to deliver, physically administer and monitor parameters relating to the patients’ other co-existing conditions. These included steroids, analgesia and thyroid disease. In considering the administration of PN in such a complex patient, it highlighted the need to factor in changes of route of other medications in case access was a problem. Factors to consider are the transdermal/enteral routes available and also changes of absorption, as well as cost and, in the current climate, availability of the alternative product recommended. Compatibility is also to be reviewed if the last resort of the parenteral route is required.

Emma Wilkinson also provided a session that looked at drug administration via enteral tubes. Despite there being several resources available, there is still little evidence to support this route change in some of the more specialist areas. This talk focused upon the intricacies of administration, taking into account changes in legislation, formulation, as well as practicalities and monitoring for not just side effects (e.g. diarrhoea), but also clinical changes in order to optimise patient outcomes.

Priya Mistry closed the symposium with a talk around the experiences of being a non-medical prescriber in the field of nutrition support. An introduction of the timeline of the legislative changes implemented was then followed up with some personal reflection of the pressures and challenges of being a non-clinician prescriber. This also included factors that need to be considered when prescribing a product that is not just safe for the patient but also physically stable to be manufactured. A comparison was also made to the role of a supplementary prescribing as well, which is still the qualification of some of our multi-disciplinary colleagues in the field of nutrition. In having the experience of a clinical pharmacist, as well as a qualified prescriber, the pharmacist is ideally placed to look at the whole prescription, holistically, to ensure that all medication prescribed elsewhere is not affected.

The session closed after a lively panel debate with questions from the audience. PENG were also proud to work with the British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN) developing the ‘Blended diet via enteral feeding tube’ symposium. Rebekah Smith chaired this session, where we heard from Sarah Duran who helped to develop the BDA Blended Diet Toolkit, alongside PENG members, around the evidence behind blended diets following a review of the literature. Sarah discussed the continuum of how blended diets were used from patients dependent on homemade blended diet to patients taking a hybrid approach of blended diet and commercial feed. Sarah also highlighted the benefits and challenges that faced patients on a blended diet.

Katie Angell, a Nurse and advocate for blended diets via feeding tubes, discussed the importance of teamworking and the practicalities of how the blended diet works for children and parents in the community, particularly in schools, and the training that is required to provide a blended diet to children in the community.

The symposium’s last presentation was from a patient expert Rataporn Deesomsak, a mum giving her perspective on feeding her son a blended diet via his feeding tube. Rataporn touched on the reality of making and storing the blends and what she felt the benefits were for her son. This was a powerful presentation and PENG would like to thank PINNT for helping to organise our last speaker.

Our Four Nations session chaired by Sarah-Jane Nelson and Ben Shandro focused on ‘Nutrition Support in Patients with Motor Neurone Disease (MND)’. This very well attended session was commenced by Scotland’s Lead MND Nurse Consultant Judith Newton. Judith presented ‘A national approach to weighing up options for nutritional support in MND’. She outlined the very impressive set up for MND in Scotland, the goal to double the number of MND nurses in Scotland, and decision making around enteral feeding decisions.

The session continued with ‘Development of a collaborative pathway for gastrostomy insertion in MND: The NHS Grampian experience’ by Francesca Moroni. Describing the NHS Grampian experience from a Gastroenterologist point of view, Francesca outlined that, on occasions, the gastroenterologist placing the tube is not necessarily involved in the decision making process, and the challenges and risks that this may hold.

Sean White then gave his presentation on ‘Gastrostomy placement in MND: a complex decision distributed over time and people’ in which he described his doctorate work to date on patient decision making around many aspects of the MND course, including nutrition support.

Recognising the excellent MND nurse set up in Scotland to be a gold-standard, many dietitians in the audience were seeing patients without this type of support outside of tertiary care and found the patient decision making conversations regarding nutrition support highlighted by Sean very helpful and empowering. Another important discussion was around nutrition support teams and gastroenterologists and careful decision making and appropriate patient selection.

The BAPEN 2023 Annual Conference concluded with the final symposium which, following its success last year, saw the return of ‘Clinical Nutrition Room 101’ ably chaired, once again, by our esteemed Chair of the Programmes Committee, Pete Turner. Pete aimed to provide a light-hearted end to the Conference with some important take home messages from the panel, which included: Alison Culkin, Fiona Leitch, Trevor Smith, Natalie Welsh and Becky White.

BAPEN Programmes would like to extend sincere thanks to all those involved in organising symposia for this year’s BAPEN 2023 Conference with multi-disciplinary representation from each of the following organisations:

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BAPEN Awards and Recognitions

Presented by Dr Trevor Smith, President and Dr Barry Jones, IAC Chair

John Lennard-Jones Medal

The John Lennard Jones Medal is the highest accolade that the Association can bestow. Presented by Dr Trevor Smith, President and Dr Barry Jones, IAC Chair, it was awarded to Rebecca Stratton for her significant and consistent contribution to BAPEN over many years.

BAPEN also formally recognised previous recipients of the John Lennard-Jones Medal from 2021 and 2022 whose awards had previously been presented virtually during the webinar series.

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The Roll of Honour

This was introduced in 2008 and is the gift of the Council for any member who has given “over and above” for BAPEN in the preceding year. The 2023 Roll of Honour was presented to Wendy-Ling Relph.

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BAPEN’s Best Oral Award

Alison Culkin for the presentation of: ‘A randomised controlled crossover trial comparing polymeric and semi-elemental oral nutritional supplements (ONS) in patients with short bowel’.

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Posters

The Professor RG Clark Best Poster Prize went to Lia Garden for the poster entitled: ‘Specialist dietetic input prevents further weight loss for patients requiring regular paracentesis’.

Highly commended posters were also recognised and awarded to:

• Sally Stojic: ‘Case report of a post bariatric, type 2 intestinal failure, home distal feeding patient'
• Fiona Leitch: ‘Can a Standard Operating Procedure (SOP) be used to simultaneously convert continuous intravenous to bolus subcutaneous insulin, and continuous PN to cyclic?’
• Colette Kirk: ‘A cross sectional study of quality of life of adult patients treated with home parenteral nutrition in North East England and Cumbria’ and her work on ‘Assessment of health-related quality of life and health utility in patients on home parenteral nutrition’.

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The Pamela Harris Medal Lecture

Awarded to Kirsty Hall for the presentation of her abstract ‘Efficiency of a Nurse led Service in the Management of Central Venous Catheter Repairs for Patients Receiving Home Parenteral Support’.

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Powell-Tuck Prize

BAPEN Medical awarded two Powell-Tuck Prizes for the best abstract submitted by a doctor in training to:

• Daniel Ashmorel: ‘Case report of a post bariatric, type 2 intestinal failure, home distal feeding patient'
• Ayodele Sasegbon: ‘The relationships between SARC-F, the Rockwood clinical frailty scale, bioelectrical impedance analysis, and anthropometry in patients with type two intestinal failure’.

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The PENG Award

The PENG Award is an annual suportive educational grant supported by Abbott, Fresenius Kabi and Nutricia. Many clinicians are implementing fabulous initiatives in their local hospitals, but don't ever think to share their great work. To encourage more clinicians to publish work this year the PENG Award was given to the highest scoring abstract accepted for the BAPEN Conference, where the first author is a PENG member and has not previously had an abstract accepted for the BAPEN Conference. This year PENG Awarded 3 winners:

• Alison Culkin: ‘A randomised controlled crossover trial comparing polymeric and semi-elemental oral nutritional supplements (ONS) in patients with short bowel’
• Emma Noble: ‘The vitamin and trace element status of intestinal failure patients receiving long-term home parenteral nutrition and home parenteral fluids’.
• Hayley Williams: ‘PN use post cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) – preliminary results’.