Grace Black

Requirements for iron and docosahexaenoic acid (DHA) content of infant formula varies by country. Powdered full-term infant formula purchase data from all major physical stores in the US between 2017-2019 were obtained from CIRCANA, Inc. Iron and DHA composition and scoop sizes for each formula were obtained from manufacturers. The equivalent liquid ounces of prepared formula were calculated. Average iron and DHA content were compared between formula types and to both US and European formula composition requirements. These data represent 55.8 billion ounces of formula. The average iron content of all formula purchased was: 1.80 mg/100 kcal. This iron concentration is within the FDA regulations. However, it exceeds the maximum allowable iron concentration of infant formula (Stage 1) set by the European Commission of 1.3 mg/100 kcal. A total of 96% of formula purchased had an iron concentration of >1.3 mg/100 kcal. DHA is not a required ingredient in US formulas. The average DHA content of all formula purchased was: 12.6 mg/100 kcal. This DHA concentration is far below the minimum required DHA concentrations of infant formula (Stage 1) and follow-on formula (Stage 2) set by the European Commission of 20 mg/100 kcal. These are novel insights into the iron and DHA intake of formula-fed infants in the US. As international infant formulas have entered the US market due to the formula shortage, parents and providers need to be aware of regulatory differences in formula nutrient composition.

Background Accurate and detailed endoscopy reporting in ulcerative colitis (UC) is critical for clinical decision-making. High-quality reporting involves inclusion of several criteria, previously identified by an independent group of experts (Building Research in IBD Globally (BRIDGe) group). Few studies have evaluated UC reporting quality. Our aim was to evaluate the impact of an intervention bundle designed to standardise and improve UC endoscopy reporting. Methods This intervention bundle included: integration of a template into reporting software; endoscopist training; instructional posters in endoscopy rooms; cohorting patients onto specific lists. Reporting quality was judged against 10 criteria recommended by BRIDGe. In phase one, UC endoscopy reports were retrospectively evaluated at a centre with prior implementation of the intervention bundle and compared to six centres without. In phase two, the intervention bundle was prospectively implemented and evaluated at a single centre. Results In phase one, the intervention was associated with greater inclusion of BRIDGe reporting criteria from median 5 (IQR 5-7) to 7 (5-8), P < 0.0001. This was replicated in phase two, with improved reporting after the intervention from 5 (4-6) to 6 (5-8), P < 0.0001. Reporting of endoscopic indices was more frequent in the centre with prior intervention (77.7% (202/260) vs 44.4% (400/900), OR 4.35 95%CI 3.16-6.00, P < 0.0001). In phase two, implementation of the bundle increased the use of endoscopic indices pre-intervention vs post-intervention (57.7% (131/190) vs 69.6% (117/168), OR 1.68 95%CI 1.1-2.56, P = 0.02). Conclusion This is the first study to demonstrate that an intervention bundle can achieve greater standardisation and improve UC endoscopy reporting.

<h3>Introduction</h3> The importance of endoscopic evaluation as part of the management of ulcerative colitis (UC) is becoming increasingly appreciated. However, the quality and completeness of UC endoscopy reports is variable. Previous studies have demonstrated that standardisation of reporting can optimise practice and there now exists expert consensus on which items should be included in a high quality UC endoscopy report. Our aim was to identify areas of suboptimal practice which could inform the design of an intervention bundle to improve reporting. We also aimed to identify any groups of endoscopists to whom the interventions should be specifically directed. <h3>Methods</h3> Reports of 227 lower GI endoscopies (103 flexible sigmoidoscopies, 124 colonoscopies) performed on UC patients at UCLH between April-October 2018 were reviewed. Reports were evaluated against 10 endoscopic reporting items recommended by the Building Research in Inflammatory Bowel Disease Globally (BRIDGe) groups expert consensus exercise¹, as well as documentation of UCEIS scores. Thus, each report was given a mark out of 11. Subgroup analyses were carried using Mann-Whitney (continuous) or Fishers exact (categorical) tests. <h3>Results</h3> The rate at which each reporting item was documented is shown in table 1. Description of previous disease extent (3%), UC therapy (10%) and symptoms (9%) at the time of the procedure were all infrequently reported. However, perhaps the most clinically relevant finding was that an objective measure of disease activity was missing in nearly half of reports. Subgroup analysis demonstrated that non-consultants (trainees and nurse endoscopists) were significantly more likely to report UC therapies (p=0.045) and biopsy location (p=0.031). No other significant differences were observed for individual reporting items or overall score (median 5/11 in both groups, p=0.07). <h3>Conclusions</h3> Our data demonstrates that many endoscopic UC reports are not consistent with optimal practice based on expert consensus. We identified areas that could potentially be optimised using an interventional bundle. Most importantly, the use of an endoscopic index. The interventional bundle should involve all endoscopists and could include such measures as local training sessions, hard-copy and online training materials, pooling of UC procedures on dedicated lists and integration of template reports into reporting software. <h3>Reference</h3> Devlin SM, Melmed GY, Irving PM, et al. Recommendations for Quality Colonoscopy Reporting for Patients with Inflammatory Bowel Disease: Results from a RAND Appropriateness Panel. <i>Inflamm Bowel Dis</i> 2016;22:1418–24.