BACKGROUND:Biologically based complementary and alternative medicine (BBCAM) includes special diets, dietary supplement and herbal remedies, not prescribed by a doctor or dietitian. The use of BBCAM is common among cancer survivors. BBCAM can interact with conventional treatments and unregulated products may cause harm. This study aimed to determine the prevalence, types, and motivations for BBCAM use among cancer survivors. METHODS:A survey assessed clinical characteristics and BBCAM use in participants >18 yrs who had received cancer treatment in Ireland from 2018 to 2022. RESULTS:Amongst 295 respondents (77% female, mean age 53 yrs), BBCAM use increased from 28% pre-diagnosis to 34% post-diagnosis (p < 0.001). For BBCAM users (n = 97, 33%), "daily-use" increased from 38% to 72% (p < 0.001) post-diagnosis. Common types included: mineral/vitamin supplements (84%), dietary supplements (e.g. turmeric, coenzyme-Q10) (78%), herbal remedies/botanicals (e.g. mistletoe, St. John's Wort, echinacea, ginseng) (50%), cannabis (21%), and other natural products (laetrile, shark cartilage, apricot kernels) (19%). Biological medicines (GcMAF, immuno-augmentative therapy) were used by 12% of BBCAM users. Special diets including dairy free (32%), gluten-free (19%), intermittent fasting (17%), ketogenic diet (15%), juicing/detox (10%) were also common. Perceived benefits included: improved well-being (63%) and reduced psychological stress (59%). CONCLUSION:BBCAM use increases after a cancer diagnosis. Patient perceived benefits highlight potential gaps in the current healthcare model, indicating a need for greater emphasis on safe survivorship care.

Malnutrition is highly prevalent among oncology patients, with large-scale studies reporting involuntary weight loss in 31-87%, depending on tumour site and disease stage. A combination of nutrition-impact symptoms, reduced oral intake and systemic inflammation lead to poor tolerance to treatment, diminished quality of life and reduced survival. Systemic inflammation is a hallmark of cancer-associated malnutrition and contributes to loss of lean mass and abnormal body composition phenotypes (sarcopenia, cachexia and low muscle density) which may coexist with overweight and obesity. Malnutrition screening tools are widely used to identify patients at risk; however, traditional weight and BMI-based instruments such as the Malnutrition Screening Tool (MST) and Malnutrition Universal Screening Tool (MUST) frequently misclassify patients with cancer as well-nourished. These tools fail to account for nutrition-impact symptoms, inflammation and muscle wasting. Although obesity is an established cancer risk factor, 40-60% of patients with metastatic disease remain overweight or obese during treatment. When screening tools are BMI-based, high fat stores mask muscle wasting, leading to misclassification of nutritional risk and delayed dietetic referrals. To improve detection, screening tools should incorporate patient-reported symptoms, inflammatory markers and body composition assessment, enabling earlier, proactive nutritional care. Alternatively, it may be time to acknowledge that all cancer patients are inherently 'at-risk' of malnutrition and to prioritise universal access to dietetic support from diagnosis through treatment. This review summarises current malnutrition screening and assessment practices in oncology and outlines key considerations for future research and clinical practice.

Identification of reliable biomarkers in Hepato-pancreatico-biliary (HPBC) and gastric cancers (GC) has been extremely challenging, and no effective screening modality is currently available. There is an increasing appreciation that the gut microbiome may be altered in these diseases and act as a predictor of disease or disease outcome. To examine the gut microbiota in a cohort of treatment naïve, newly diagnosed pancreatic, biliary and gastric cancer patients and age matched controls. Stool samples from 37 treatment naïve, newly diagnosed HPBC and GC patients and 47 age-matched non-cancer controls were prospectively collected. Microbiota composition was determined by 16 S rRNA amplicon sequencing. Differences in the microbial composition of HC and HPBC patients were assessed using linear discriminant analysis effect size. Predictive functional profiling of microbial communities was obtained with PICRUSt. The gut microbiota of HPBC patients was significantly different compared to the non-cancer controls. Enterococcus, Enterobacter, Streptococcus and Lactobacillus, were significantly increased in HPBC, while numerous Lachnospiraceae, Ruminococcaceae_UCG014, Bacteroides and Faecalibacterium were significantly reduced in HPBC. Enterobacter and Enterococcus best discriminated the HPBC samples, while Butyrivibrio and Lachnospira best discriminated the non-cancer controls. There was a trend towards decreased diversity and richness in cancer patients with increasing severity of cancer stage. We report a significant difference in microbial composition in patients with pancreatic and biliary cancer compared to non-cancer controls, which is associated with an increase in pathogens and a decrease in potential beneficial bacteria. Our results support the potential for the gut microbiota to act as an early biomarker for these highly fatal and poorly diagnosed gastrointestinal cancers.

The identification of food-grade bioactives with proven orexigenic effects would mark significant progress in the treatment of disease-related malnutrition. To investigate the effects of two milk-derived hydrolysates (UL-2-141 (whey hydrolysate) and MF1145 (casein hydrolysate)) on appetite and energy intake in healthy humans, a single-blind, placebo-controlled, 3-arm cross-over feeding trial was conducted in 22 fasted, cannulated healthy male volunteers. Participants received 26 mg kg-1 of both hydrolysates and placebo and were observed from morning to afternoon with a set breakfast and ad libitum lunch. Mean total daily energy and protein intakes when treated with placebo were 2673 kcal (95% CI: 2247-3100 kcal) and 128 g (95% CI: 105-152 g), respectively. Energy intake for either treatment was not significantly different from that for placebo (p = 0.266 for UL-2-141 and p = 0.796 for MF1145). Protein intake significantly increased in the UL-2-141 arm compared with that in placebo (+23 g, p = 0.044), but it did not significantly increase in the MF1145 arm (+13 g, p = 0.189). Appetite, hunger and satiety responses on VAS for either treatment were not significantly different from those obtained for placebo. GLP-1 was significantly higher pre-lunch in the UL-2-141 arm than in placebo (+8 pmol L-1, p = 0.01) and in the MF1145 arm (+7 pmol L-1, p = 0.039). GH was significantly lower pre-lunch only in the UL-2-141 arm than in placebo (-133 pg mL-1, p = 0.027). Protein intake was significantly increased in the UL-2-141 arm, demonstrating appetite modulation, potentially via indirect or delayed stimulation of the ghrelin receptor. Since healthy adults are often not in tune with their physiological hunger, repeating the study in subjects with established anorexia may be prudent.

BACKGROUND:The Global Leadership Initiative on Malnutrition (GLIM) criteria provides a framework for assessing cachexia in cancer patients. However, the role of systemic inflammation in this framework needs further exploration. METHODS:This study analyzed a cohort of 388 advanced cancer patients from 18 oncological care settings. C-reactive protein (CRP), the modified Glasgow Prognostic Score (mGPS) and Neutrophil-to-Lymphocyte Ratio (NLR) were used to assess systemic inflammation. Associations between these inflammatory markers and Weight Loss (WL), Body Mass Index (BMI), Skeletal Muscle Index (SMI), and survival outcomes (OS) were evaluated using Chi-square and Kaplan-Meier survival analyses. RESULTS:CRP was significantly associated with ECOG-PS (p < 0.01), and WL (p < 0.05). mGPS was significantly associated with ECOG-PS (p < 0.001), WL (p < 0.001), and BMI (p < 0.05). NLR was significantly associated with ECOG-PS (p < 0.05), WL (p < 0.001), and BMI (p < 0.05). CRP (p < 0.001), mGPS (p < 0.001), NLR (p < 0.001), WL (p < 0.001), and SMI (p < 0.05) were significantly associated with OS, but not BMI (p = 0.23). Combining CRP, mGPS, NLR, with WL, BMI, and SMI significantly improved OS prediction. WL was significantly associated with OS in patients with NLR<3 (p < 0.05) but not in CRP≤10 mg/L or mGPS = 0. SMI was significantly associated with OS in patients with mGPS = 0 (p < 0.05). CONCLUSION:Systemic inflammation, as assessed by CRP, mGPS and NLR, significantly improves the relationship between phenotypic criteria and OS. These findings support the GLIM framework's inclusion of systemic inflammation as a critical factor. Given its strong predictive value, systemic inflammation should be prioritized in routine clinical assessments of cancer patients, with mGPS having greater prognostic value within the GLIM framework.

Introduction: Successful breast cancer outcomes can be jeopardised by adverse events. Understanding and integrating patients' and doctors' perspectives into care trajectories could improve patient safety. This study assessed their views on, and experiences of, medical error and patient safety. Methods: A cross-sectional, quantitative 20-40 item questionnaire for patients attending Cork University Hospital Cancer Centre and breast cancer doctors in the Republic of Ireland was developed. Domains included demographics, medical error experience, patient safety opinions and concerns. Results: 184 patients and 116 doctors completed the survey. Of the doctors, 41.4% felt patient safety had deteriorated over the previous five years and 54.3% felt patient safety measures were inadequate compared to 13.0% and 27.7% of patients respectively. Of the 30 patients who experienced medical errors/negligence claims, 18 reported permanent or long-term physical and emotional effects. Forty-two of 48 (87.5%) doctors who experienced medical errors/negligence claims reported emotional health impacts. Almost half of doctors involved in negligence claims considered early retirement. Forty-four patients and 154 doctors didn't experience errors but reported their patient safety concerns. Doctors were more concerned about communication and administrative errors, staffing and organisational factors compared to patients. Multiple barriers to error reporting were highlighted. Conclusion: This is the first study to assess patients' and doctors' patient safety views and medical error/negligence claims experiences in breast cancer care in Ireland. Experience of medical error/negligence claims had long-lasting implications for both groups. Doctors were concerned about a multitude of errors and causative factors. Failure to embed these findings is a missed opportunity to improve safety.

Women diagnosed with a hormone-receptor positive (HR+) breast or gynaecological cancer are not routinely prescribed hormone replacement therapy to alleviate menopausal symptoms due to the risk of causing cancer recurrence. Many of these women use herbal or botanical supplements, diet and lifestyle interventions to provide relief. Through an extensive literature review, national focus groups with menopausal female cancer survivors, consultation with an established public and patient involvement panel, and the creation of a national review panel of medical and healthcare professionals, Ireland’s first evidence-based resource is in development for female menopausal cancer survivors.

Rationale: Cachexia (CC) management is challenging due to the multifactorial aetiology of the syndrome. Studies evaluating the efficacy of nutrition interventions often recruit patients who already have CC and whose prognosis is poor and in whom simple interventions may not be as effective. Pragmatic, multimodal trials are required to target the complex aetiology and demonstrate efficacy in real-world settings. As efficacy is reportedly poor in advanced CC, a validated means of identifying suitable patients early in the CC trajectory is also required.

Study design: Multicentre cluster randomised clinical trial. Setting: 26 hospitals in Australia (n=20) and New Zealand (n=6). 13 hospitals were randomised to the intervention group and 13 to control in the 2017 bronchiolitis season (with representation of secondary and tertiary hospitals from each country within both groups following stratification). Retrospective data from three bronchiolitis seasons prior to the trial (2014–2016) were additionally collected. Interventions: Targeted interventions were developed based on behaviour change theories (specifically the ’Theoretical Domains Framework’), following a qualitative study which identified local barriers and enablers to evidencebased bronchiolitis care. Interventions included: appointment of medical and nursing clinical leads, stakeholder meetings, trainthetrainer workshops, focused educational delivery (via PowerPoint presentation conveying scripted messages specifically designed to promote behavioural change), supplemental educational materials (clinician training videos, parent/caregiver information sheets), audit and feedback. Control: Hospitals disseminated the relevant (2016) Australasian Bronchiolitis Guideline as they wished; no other suggestions made as to management of bronchiolitis. Primary outcome: The proportion of infants who complied with all five of the Australasian Bronchiolitis Guideline recommendations known to have no benefit (avoidance of chest radiography, alongside no salbutamol, corticosteroid, epinephrine or antibiotic use) in the first 24 hours of hospitalisation. Secondary outcomes: Duration of hospitalisation, intensive care admission, death. Main results: Authors demonstrated an improved guideline compliance rate during the first 24 hours of hospitalisation in the intervention hospitals (85%) versus control (73%; p<0.001), with no statistically significant difference in duration of hospitalisation or intensive care admission. Improvements were consistent across both emergency department (p=0.002) and inpatient (p=0.004) phases of care.

Rationale: Patients with incurable cancer may survive for significant periods of time, however determinants of this are not clear. Elucidation of factors which adversely influence survival may allow for better prognostic estimates. The aim of this study was to investigate predictors of survival in a cohort of patients with incurable cancer.

804 Background: The CT-derived sarcopenia score (CT-SS) is thought to capture the nutritional and functional reserve of the cancer patient. However, it is unknown whether the CT-SS is associated with measures of physical function in patients with advanced cancer. Furthermore, has complimentary prognostic value when utilised as a phenotypic criterion in the GLIM cachexia framework. Methods: Prospectively collected data from patients with advanced cancer, undergoing anti-cancer therapy with palliative intent, across nine sites in the UK and Ireland between 2011–2016, was retrospectively analysed. Relationships between the CT-SS, ECOG-PS, measures of physical function and aetiological GLIM criterion (mGPS and metastatic disease) were examined using χ 2 test for linear-by-linear association. Results: 518 patients met the inclusion criteria. 55 % (n=286) were male and 51% (n=266) were 65 years of age. The majority of patients had either GI (47%, n=242) or lung (25%, n=129) tumours. 46% (n=241) were CT-SS ≥1. 53% (n=274) of patients were inflamed (mGPS≥1). 63% (n=325) had an ECOG-PS>0/1. Of the 192 patients who underwent timed up-and-go testing and two-minute walk testing, 72% (n=138) and 96% (n=185) were categorised as a failure, respectively. Median survival from entry to the study was 8.7 months (4.2-18.3). 84% (n=433), 64% (n=339) and 38% (n=194) of patients were alive at 3-, 6- and 12-months, respectively. The CT-SS was significantly associated with ECOG-PS (p<0.001), timed up-and-go test failure (p<0.05), two-minute walk test failure (p<0.05), 3-month survival (p<0.05), 6-month survival (p<0.05) and 12-month survival (p<0.05). Furthermore, was significantly associated with 3-, 6- and 12-month survival in patients who were mGPS 0 and did not have metastatic disease (p<0.05 and p<0.05, respectively). Conclusions: The CT-SS is associated with physical function and survival in patients with advanced cancer. Furthermore, has complementary prognostic value to the aetiological criterion of the GLIM framework.

3-year-old Susie has been referred to the medical paediatric clinic by her general practitioner with sweating at night; her parents change Susie’s pillowcase whilst she is asleep at around 11pm as her hair looks wet with sweat. Her mother has searched ‘ sweating overnight ’ on the internet and is worried that her child has cancer. What should you do? Night sweats are a common complaint in young children in the general paediatric clinic, either as the presenting complaint or as a symptom mentioned in the context of other concerns. Despite this, available literature on the subject is scarce.1 2 How do we limit over-investigating these children and mitigate parental anxiety, while ensuring timely detection of serious pathologies such as malignancy or infection? This article aims to provide a structured approach to the management of paediatric night sweats. ### How are night sweats defined? Night sweats are subjective reports (often parental) involving an exaggeration of the normal circadian temperature rhythm. They are defined as sweating that occurs solely or predominantly at night.1 The clinical significance of night sweats, particularly within the paediatric population, remains controversial. Although severe night sweats can be both distressing and disruptive to sleep, in most cases the child is completely unaffected, apyrexial, and awoken by a worried parent.3 4 Conversely, night sweats may be the presenting clinical manifestation of certain serious medical conditions (including malignancy, infection, autoimmune disease and obstructive sleep apnoea).1 It is important to be aware of the red flag features to look out for. ### What are the underlying physiological mechanisms responsible for sweating? The autonomic nervous system has an essential role in human thermoregulation. The skin’s blood vessels and sweat glands are innervated by sympathetic nerve fibres.2 Regulation of sweating involves both complex thermoregulatory and non-thermoregulatory mechanisms.5 Core body temperature (Tc) decreases as a result of sweating. The preoptic anterior hypothalamic region …

To cite: Ryan A, Kelly A. Arch Dis Child Educ Pract Ed Epub ahead of print: [please include Day Month Year]. doi:10.1136/archdischild2022324836 © Author(s) (or their employer(s)) 2023. No commercial reuse. See rights and permissions. Published by BMJ. Increasing numbers of refugees have entered Europe over recent years, reflective of international crises caused by conflict in Afghanistan, Syria and the Horn of Africa. Approximately onethird are children and young people aged under 18 years, many unaccompanied. These individuals often arrive at their most vulnerable following hazardous journeys with complex healthcare needs. 2 In 2019, more than twothirds of the global refugee population originated from just five countries: Syria, Venezuela, Afghanistan, South Sudan and Myanmar. In the same year, only 0.5% of the world’s refugees had successfully resettled elsewhere. By 2020, around 82.4 million people worldwide were forcibly displaced from their homes. Of these, 26.4 million were refugees, while 48 million were internally displaced within their country of origin. Eightysix per cent of the world’s refugees are hosted within lowincome countries. The UK is home to roughly 1% of global refugees. Nearly 7.7 million Ukrainians (ie, one in six) have been internally displaced since the Russian invasion of the country began in February 2022. As of October 2022, almost 14 million refugees have fled Ukraine, twothirds of whom are children. Unaccompanied children arriving in the UK should be offered an initial health assessment through the statutory requirement for lookedafter children. However, accompanied children and young people may present to a range of services (including general, community or acute paediatric services); it is therefore imperative that all paediatricians are equipped to identify and manage the unmet health needs of these children and young people. Table 1 delineates the terminology used to describe such individuals. This article aims to highlight the important initial issues to consider when assessing a child or young person with unmet health needs while directing them to useful resources and appropriate services. A comprehensive health assessment is a lengthy process which is usually undertaken by paediatricians with expertise in reviewing health needs in vulnerable children; however, any paediatrician may be presented with issues related to refugee and migrant health.

Background Although suggestive of dysregulated metabolism, the relationship between serum LDH level, phenotypic/aetiologic diagnostic Global Leadership Initiative on Malnutrition (GLIM) criteria and survival in patients with advanced cancer has yet to examined. Methods Prospectively collected data from patients with advanced cancer, undergoing anti-cancer therapy with palliative intent, across nine sites in the UK and Ireland between 2011–2016, was retrospectively analysed. LDH values were grouped as <250/250–500/>500 Units/L. Relationships were examined using χ 2 test for linear-by-linear association and binary logistics regression analysis. Results A total of 436 patients met the inclusion criteria. 46% ( n = 200) were male and 59% ( n = 259) were ≥65 years of age. The median serum LDH was 394 Units/L and 33.5% ( n = 146) had an LDH > 500 Units/L. LDH was significantly associated with ECOG-PS ( p < 0.001), NLR ( p < 0.05), mGPS ( p < 0.05) and 3-month survival ( p < 0.001). LDH was significantly associated with 3-month survival independent of weight loss ( p < 0.01), BMI ( p < 0.05), skeletal muscle mass ( p < 0.01), metastatic disease ( p < 0.05), NLR ( p < 0.05) and mGPS ( p < 0.01). Discussion LDH was associated with performance status, systemic inflammation and survival in patients with advanced cancer. LDH measurement may be considered as an aetiologic criteria and become a potential therapeutic target in the treatment of cancer cachexia.

Rationale: International studies have shown a high prevalence of malnutrition & muscle wasting in oncology patients, which increase risk of poor tolerance to chemotherapy, decreased quality of life & poorer survival. Currently the prevalence of cachexia (CC), sarcopenia & weight loss (WL) in Irish patients with cancer has not been described.

The present study examined the relationships between CT-derived muscle measurements, systemic inflammation, and survival in advanced cancer patients with good performance status (ECOG-PS 0/1). Data was collected prospectively from patients with advanced cancer undergoing anti-cancer therapy with palliative intent. The CT Sarcopenia score (CT-SS) was calculated by combining the CT-derived skeletal muscle index (SMI) and density (SMD). The systemic inflammatory status was determined using the modified Glasgow Prognostic Score (mGPS). The primary outcome of interest was overall survival (OS). Univariate and multivariate Cox regressions were used for survival analysis. Three hundred and seven patients met the inclusion criteria, out of which 62% (n = 109) were male and 47% (n = 144) were ≥65 years of age, while 38% (n = 118) were CT-SS ≥ 1 and 47% (n = 112) of patients with pre-study blood were inflamed (mGPS ≥ 1). The median survival from entry to the study was 11.1 months (1-68.1). On univariate analysis, cancer type (p < 0.05) and mGPS (p < 0.001) were significantly associated with OS. On multivariate analysis, only mGPS (p < 0.001) remained significantly associated with OS. In patients who were ECOG-PS 0, mGPS was significantly associated with CT-SS (p < 0.05). mGPS may dominate the prognostic value of CT-derived sarcopenia in good-performance-status patients with advanced cancer.