BackgroundMalnutrition is a problem in advanced cancer, particularly ovarian cancer where malignant bowel obstruction (MBO) is a frequent complication. Parenteral nutrition is the only way these patients can received adequate nutrition and is a principal indication for palliative home parenteral nutrition (HPN). Giving HPN is contentious as it may increase the burden on patients. This study investigates patients’ and family caregivers’ experiences of HPN, alongside nutritional status and survival in patients with ovarian cancer and MBO.MethodsThis mixed methods study collected data on participant characteristics, clinical details and body composition using computed tomography (CT) combined with longitudinal in-depth interviews underpinned by phenomenological principles. The cohort comprised 38 women with ovarian cancer and inoperable MBO admitted (10/2016 to 12/ 2017) to a tertiary referral hospital. Longitudinal interviews (n = 57) were carried out with 20 women considered for HPN and 13 of their family caregivers.ResultsOf the 38 women, 32 received parenteral nutrition (PN) in hospital and 17 were discharged on HPN. Nutritional status was poor with 31 of 33 women who had a CT scan having low muscle mass, although 10 were obese. Median overall survival from admission with MBO for all 38 women was 70 days (range 8–506) and for those 17 on HPN was 156 days (range 46–506).Women experienced HPN as one facet of their illness, but viewed it as a “lifeline” that allowed them to live outside hospital. Nevertheless, HPN treatment came with losses including erosion of normality through an impact on activities of daily living and dealing with the bureaucracy surrounding the process. Family caregivers coped but were often left in an emotionally vulnerable state.ConclusionsWomen and family caregivers reported that the inconvenience and disruption caused by HPN was worth the extended time they had at home.

Increasingly, patients with advanced ovarian cancer in bowel obstruction are receiving home parenteral nutrition (HPN). Little is known about making and implementing the decision. This study explored the decision-making process for HPN and investigated the barriers and facilitators to implementation. This was a qualitative study underpinned by phenomenology involving 93 longitudinal in-depth interviews with 20 patients, their relatives and healthcare professionals, over 15 months. Participants were interviewed a maximum of four times. Interview transcripts were analysed thematically as per the techniques of Van Manen. We found variance between oncologists and patients regarding ownership of the HPN decision. The oncologists believed they were engaging in a shared decision-making process. However, patients felt that the decision was oncologist-driven. Nevertheless, they were content to have the treatment, when viewing the choice as either HPN or death. In implementing the decision, the principal mutable barrier to a timely discharge was communication difficulties across professional disciplines and organisations. Facilitators included developing a single point-of-contact between organisations, improving communication and implementing standardised processes. Oncologists and patients differ in their perceptions of how treatment decisions are made. Although patients are satisfied with the process, it might be beneficial for healthcare professionals to check patients’ understanding of treatment.

We are very uncertain whether HPN improves survival or quality of life in people with MBO as the certainty of evidence was very low for both outcomes. As the evidence base is limited and at high risk of bias, further higher-quality prospective studies are required.

High-quality evidence on the effect of ketogenic diets on anthropometry, metabolism, QoL and tumour effects is currently lacking in oncology patients. Heterogeneity between studies and low adherence to diet affects the current evidence. There is an obvious gap in the evidence, highlighting the need for controlled trials to fully evaluate the intervention.

Analysis 2.3. Comparison 2 Dietary changes, Outcome 3 Subgroup analysis energy intake (kcal) BMI > 25 kg/m at 3 months...... Analysis 2.4. Comparison 2 Dietary changes, Outcome 4 Subgroup analysis energy intake (kcal) BMI > 25 kg/m at 6 months...... Analysis 2.5. Comparison 2 Dietary changes, Outcome 5 Mean fruit servings (per day

The lead author affirms that this manuscript is an honest, accurate and transparent account of the study being reported. The lead author affirms that no important aspects of the study have been omitted and that any discrepancies from the study as planned have been explained.

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the effectiveness and safety of home parenteral nutrition in people with inoperable malignant bowel obstruction.

Background: Malnutrition in patients hospitalised with a stroke have been assessed using different nutritional screening methods but there is a paucity of data linking risk of malnutrition to clinical outcomes using a validated tool. Aims:To identify the prevalence of malnutrition risk in patients after a stroke and assess the predictive value of the Malnutrition Universal Screening Tool on clinical outcomes.Patients and methods: Using data from electronic records and the Sentinel Stroke National Audit Programme (January 2013 and March 2016), patients aged > 18 years with confirmed stroke admitted to a tertiary care stroke unit were assessed for risk of malnutrition. The association between malnutrition risk and clinical outcomes was investigated and adjusted for confounding variables.Results: Of 1101 patients, 66% were screened at admission. Most patients (n= 571, 78.5%) were identified as being at low risk, 4.1% (n=30) at medium risk and 17.4% (n=126) at high risk of malnutrition. Compared with low risk, patients with medium or high risk of malnutrition were more likely to have a longer hospital stay (IRR 1.30, 95% CI 1.07, 1.58), and had greater risk of mortality (10.9% versus 3.5%, 95% CI 0.03, 0.13).Conclusions: Prevalence of malnutrition assessed by Malnutrition Universal Screening Tool in patients after a stroke was relatively low, but nearly a third of patients were not screened. Patients classified as being at medium or high risk of malnutrition were more likely to experience negative outcomes. Early identification of this population may improve outcome if appropriate care is provided.