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D'Eusebio C, Merlo FD, Ossola M, Bioletto F, Ippolito M, Locatelli M, De Francesco A, Anrò M, Romagnoli R, Strignano P, Bo S, Aimasso U. Mortality and parenteral nutrition weaning in patients with chronic intestinal failure on home parenteral nutrition: A 30-year retrospective cohort study. Nutrition 2023; 107:111915. [PMID: 36566610 DOI: 10.1016/j.nut.2022.111915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 11/06/2022] [Accepted: 11/13/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Home parenteral nutrition (HPN) is the standard treatment for patients with chronic intestinal failure (CIF). Mortality and weaning rates of these patients differ widely among cohorts; however, these outcomes were often considered independent-rather than competing-events, leading to an upward bias of the retrieved estimates. OBJECTIVES The aim of this retrospective cohort study was to evaluate, evaluating through a competing risk analysis, the rates and predictors of mortality and weaning in CIF patients from an Italian referral center. METHODS All adult patients with CIF receiving > 3 mo HPN from 1985 until 2016 were enrolled. Clinical information was collected from the database of the Intestinal Failure Unit of Torino, Italy. Patients were stratified according to the presence or not of short bowel syndrome (SBS). RESULTS The cumulative incidences of death and weaning were 27.3% and 32.3% and 39.0% and 33.7% at 5 and 10 y from HPN initiation, respectively. At multivariable competing risk analyses, mortality was predicted by age (sub-distribution hazard ratio [SHR] = 1.65 per 10-y increase; 95% CI, 1.35-2.01), type 3 SBS (SHR = 0.38; 0.15-0.94), small bowel length ≥ 100 cm (SHR = 0.42; 0.22-0.83), and reconstructive surgery (SHR = 0.11; 0.02-0.64) in SBS patients, and by age (SHR = 1.38 per 10-y increase; 1.16-1.64) and presence of stoma (SHR = 0.30; 0.12-0.78) in non-SBS patients. In the same model, weaning was predicted by type 3 SBS (SHR = 6.86; 3.10-15.16), small bowel length ≥ 100 cm (SHR = 3.54; 1.99-6.30), and reconstructive surgery (SHR = 2.86; 1.44-5.71) in SBS patients, and by age (SHR = 0.79 per 10-y increase; 0.66-0.94) and presence of stoma (SHR = 2.64; 1.38-5.07) in non-SBS patients. CONCLUSIONS Surgical procedures strongly affected mortality and weaning risk in CIF patients.
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Affiliation(s)
- Chiara D'Eusebio
- Department of Medical Science, University of Torino, 10124 Torino, Italy
| | - Fabio Dario Merlo
- Unit of Dietetic and Clinical Nutrition, Città della Salute e della Scienza Hospital, 10126 Torino, Italy.
| | - Marta Ossola
- Unit of Dietetic and Clinical Nutrition, Città della Salute e della Scienza Hospital, 10126 Torino, Italy
| | - Fabio Bioletto
- Department of Medical Science, University of Torino, 10124 Torino, Italy
| | - Mirko Ippolito
- Department of Medical Science, University of Torino, 10124 Torino, Italy
| | - Monica Locatelli
- Food Chemistry, Biotechnology and Nutrition Unit, University of Piemonte Orientale, 28100 Novara, Italy
| | - Antonella De Francesco
- Unit of Dietetic and Clinical Nutrition, Città della Salute e della Scienza Hospital, 10126 Torino, Italy
| | - Marta Anrò
- Unit of Dietetic and Clinical Nutrition, Città della Salute e della Scienza Hospital, 10126 Torino, Italy
| | - Renato Romagnoli
- General Surgery 2U, Liver Transplantation Unit, Città della Salute e della Scienza Hospital, 10126 Torino, Italy
| | - Paolo Strignano
- General Surgery 2U, Liver Transplantation Unit, Città della Salute e della Scienza Hospital, 10126 Torino, Italy
| | - Simona Bo
- Unit of Dietetic and Clinical Nutrition, Città della Salute e della Scienza Hospital, 10126 Torino, Italy.
| | - Umberto Aimasso
- Unit of Dietetic and Clinical Nutrition, Città della Salute e della Scienza Hospital, 10126 Torino, Italy
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Oke SM, Nightingale JM, Donnelly SC, Naghibi M, Willsmore J, Lloyd DAJ, Gabe SM. Outcome of adult patients receiving parenteral support at home: 36 years' experience at a tertiary referral centre. Clin Nutr 2021; 40:5639-5647. [PMID: 34662849 DOI: 10.1016/j.clnu.2021.08.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 08/27/2021] [Accepted: 08/28/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIMS Patients with intestinal failure often need long-term home parenteral support (PS). We aimed to determine how the underlying diagnosis, complications and survival had changed over the last 36 years in the UK's largest IF centre. METHODS 978 adult home PS patient records were analysed from January 1979 until October 2016. The age, sex, underlying aetiology, complications and survival was compared over 5-year periods. RESULTS Pre-1990 to 2011-2016, numbers increased from 29 to 451, the mean age of patients increased from 31 ± 16.5 to 52 ± 17.6 years. The percentage of patients with IF due to surgical complications increased (3.4%-28.8%, p < 0.001)), while those with inflammatory bowel disease decreased (37.9%-22.6%, p < 0.001). Complication of home PS reduced: catheter related blood stream infections (CRBSI) 71.4% to 42,2%, CVC thrombosis 34.5%-5.3%. Intestinal failure associated liver disease (IFLAD) 10.3%-1.8%. Patients with dysmotility, scleroderma and a congenital aetiology had the highest incidence of CRBSI and CVC Thrombosis. Overall survival was greater pre-1995 [HR 0.2-0.4 (p = 0.02)] most likely associated with an increase in mean age. Survival for patients without malignancy was 90%, 66%, 55%, 45%, 33% and 25% at 1,5, 10, 15, 20 and 30 years respectively. Multivariate analysis demonstrated a relationship between survival and age of starting home PS; type of home PS; presence or absence of the colon in continuity; and underlying aetiology. CONCLUSION Demand for home PS is increasing in particular for advanced malignancy, post-surgical complications and older more co-morbid patients. Complications of home PS are reducing over the last 30 years and 10-year survival for non-malignant aetiologies improving. Survival and changes in aetiology in intestinal failure.
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Affiliation(s)
- Siddhartha M Oke
- St. Mark's Hospital, Harrow, United Kingdom; Department of Metabolism, Digestion and Reproduction Imperial College London, United Kingdom.
| | | | | | | | - James Willsmore
- St. Mark's Hospital, Harrow, United Kingdom; Department of Metabolism, Digestion and Reproduction Imperial College London, United Kingdom
| | | | - Simon M Gabe
- St. Mark's Hospital, Harrow, United Kingdom; Department of Metabolism, Digestion and Reproduction Imperial College London, United Kingdom
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Noguchi K, Ochiai R, Imazu Y, Tokunaga-Nakawatase Y, Watabe S. Incidence and Prevalence of Infectious Diseases and Their Risk Factors among Patients Who Use Visiting Nursing Services in Japan. J Community Health Nurs 2021; 37:115-128. [PMID: 32820980 DOI: 10.1080/07370016.2020.1780047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This study aimed to clarify the incidence of infectious diseases and the associated risk factors among patients who use visiting nursing services in Japan. We conducted a one-year follow up cohort study with 419 participants. The incidence and period prevalence rate of infectious diseases were 0.63 and 15.0%, respectively. In the multiple logistic regression analysis, the presence of chronic respiratory failure, Parkinson's disease, dermatosis other than pressure ulcers, and the inability to perform oral self-care were significantly related to the contraction of an infectious disease.
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Affiliation(s)
- Kyoko Noguchi
- Infection Control Nursing, Department of Nursing, Graduate School of Medicine, Yokohama City University , Yokohama, Japan
| | - Ryota Ochiai
- Nursing Course, School of Medicine, Yokohama City University , Yokohama, Japan
| | - Yoko Imazu
- Nursing Course, School of Medicine, Yokohama City University , Yokohama, Japan
| | | | - Setsuko Watabe
- Nursing Course, School of Medicine, Yokohama City University , Yokohama, Japan
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Fuglsang KA, Brandt CF, Scheike T, Jeppesen PB. Differences in methodology impact estimates of survival and dependence on home parenteral support of patients with nonmalignant short bowel syndrome. Am J Clin Nutr 2020; 111:161-169. [PMID: 31562502 DOI: 10.1093/ajcn/nqz242] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 08/29/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In patients with intestinal failure (IF), who are receiving home parenteral support (HPS), variations between centers in estimates of survival and HPS dependency often reflect differences in population characteristics. However, variations in methodology and adherence to model assumptions may further contribute. OBJECTIVES We investigated how differences in methodology affect estimates of outcomes in IF patients. METHODS We applied different model assumptions and statistical methods to real-life outcome data from a well-characterized cohort of nonmalignant short bowel syndrome (SBS) patients. This retrospective study was based on extracts from the Copenhagen IF database and from the Danish death registry. RESULTS Estimates of mortality varied substantially, depending on the study design and statistical method. The 5-y mortality rate obtained with the Kaplan-Meier (KM) method was estimated to be 10.1% higher if patients were only followed during HPS treatment, compared with follow-up regardless of HPS treatment. The 5-y cumulative incidence of weaning off HPS was overestimated by 4.4% when inappropriately using the KM method, instead of the cumulative incidence function. The 5-y survival rates in nonmalignant SBS-IF patients who initiated HPS were 89.1% for those aged younger than 40 y, 74.8% for patients aged 40-60 y, and 52.1% for those older than 60 y. A Cox regression analysis identified age and diagnoses other than inflammatory bowel disease as significant risk factors for mortality. For HPS dependency, bowel anatomy was significantly associated with the ability to wean off, and no patients without a colon and less than 100 cm remnant of the small bowel remained continuously weaned off and alive for one year. CONCLUSIONS The large variations in outcomes illustrated in this study emphasize the importance of the appropriate selection of statistical methods. A comparison between studies is problematic, due to differences in the methods employed.
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Affiliation(s)
- Kristian Asp Fuglsang
- Department of Medical Gastroenterology and Hepatology, Rigshospitalet, Copenhagen, Denmark
| | | | - Thomas Scheike
- Department of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Palle Bekker Jeppesen
- Department of Medical Gastroenterology and Hepatology, Rigshospitalet, Copenhagen, Denmark
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Singh K, Bestgen AN, Dugan A, Singh A, Kirby DF. Challenges to Delivering Home Parenteral Nutrition in Adult Patients With Limited English Proficiency. Nutr Clin Pract 2019; 34:850-857. [PMID: 31553083 DOI: 10.1002/ncp.10409] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Failure to properly administer parenteral nutrition (PN) solutions can have deleterious effects on patients prescribed such therapies. The last few decades have seen diversification of the general population in the United States and elsewhere, with healthcare systems serving an increasing number of non-English-speaking patients and a more ethnically diverse population. Clinicians who provide care to this patient population encounter challenges in ensuring compliance and safe use of PN because of cultural and language barriers. Here we describe our experience of treating patients with limited English proficiency with respect to the barriers that prevent compliant and safe use of PN, especially in those discharged with home PN. We also describe the methods that we use to navigate these common issues to help clinicians provide the safest level of care to patients regardless of the patient's English proficiency.
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Affiliation(s)
- Kevin Singh
- Center for Human Nutrition, Digestive Disease and Surgery Institute, The Cleveland Clinic, Cleveland, Ohio, USA
| | - Ashley N Bestgen
- Center for Human Nutrition, Digestive Disease and Surgery Institute, The Cleveland Clinic, Cleveland, Ohio, USA
| | - Ann Dugan
- Center for Human Nutrition, Digestive Disease and Surgery Institute, The Cleveland Clinic, Cleveland, Ohio, USA
| | - Amandeep Singh
- Center for Human Nutrition, Digestive Disease and Surgery Institute, The Cleveland Clinic, Cleveland, Ohio, USA
| | - Donald F Kirby
- Center for Human Nutrition, Digestive Disease and Surgery Institute, The Cleveland Clinic, Cleveland, Ohio, USA
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Oke SM, Rye B, Malietzis G, Baldwin-Cleland R, Bottle A, Gabe SM, Lung PFC. Survival and CT defined sarcopenia in patients with intestinal failure on home parenteral support. Clin Nutr 2019; 39:829-836. [PMID: 30962104 DOI: 10.1016/j.clnu.2019.03.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 11/21/2018] [Accepted: 03/12/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Sarcopenia occurs in patients with intestinal failure (IF) and has been associated with poorer survival in several chronic diseases. CT can measure sarcopenia through a L3 skeletal muscle index (LSMI). We aim to describe the prevalence of sarcopenia in a section of our IF population using LSMI, & evaluate the effect of home parenteral support (PS) on LSMI & survival. Additionally, we aim to assess any association between LSMI, BMI & other anthropometric measurements. METHODS IF patients on PS treated at St Mark's Hospital between 1/1/2006-1/10/2016 were identified from a prospectively maintained database. Patients were included if they were on PS & had 2 CTs: the first ≤30 days before start of HPN (pre-PS); the second ≥100 days from PS start (post-PS). Patient records were reviewed to obtain clinical & demographic information & date of death. Anthropometric measurements & BMI contemporaneous to CT scans were recorded. RESULTS 64 patients met inclusion criteria (M:F 1:1). 83% of our cohort had LSMI below previously published thresholds for sarcopenia. Mean (SD) pre-PS LSMI was 36.5 (6.8)cm2/m2. Mean BMI pre-PS was 22.1 (4.8) kg/m2. Both BMI (22.1 kg/m2 to 23.5 kg/m2) p < 0.001) & LSMI (36.5 cm2/m2 to 38.4 cm2/m2) (p = 0.003) increased post-PS. A positive correlation was seen between BMI & LSMI pre (r = 0.47 p < 0.001) & post-PS (r = 0.37 p = 0.003). No correlation was seen between LSMI & anthropometric measurements pre-PS (p = 0.78) or post-PS (p = 0.96). 11 (17%) patients died during the study period; a low LSMI pre-PS was not a risk factor for mortality (HR 0.97 p = 0.55). CONCLUSIONS This study is the first to look at sarcopenia & survival using CT defined LSMI (CT-LSMI) in the IF population. 83% of our cohort had a pre-PS LSMI below previously published thresholds, yet we found no relationship between lower baseline LSMI & survival. This may reflect the heterogeneity of the prognoses of the IF population, or that parenteral nutrition itself affects survival. Our study showed that LSMI & BMI improved following PS but demonstrated that other anthropometric measurements had poor correlation with LSMI & showed no significant improvement overall after PS, confirming the known problems of inter-operator & patient variability of these measurements. Whilst we found significant correlation between LSMI & BMI, BMI significantly underestimated the presence & degree of sarcopenia. LSMI has the potential to provide an objective & reproducible measure of sarcopenia in IF. Future larger studies should be performed to evaluate associations with patient outcomes & utility in clinical decision making.
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Affiliation(s)
- Siddhartha M Oke
- St. Mark's Hospital, Harrow, United Kingdom; Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Beth Rye
- St. Mark's Hospital, Harrow, United Kingdom
| | - George Malietzis
- St. Mark's Hospital, Harrow, United Kingdom; Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | | | - Alex Bottle
- Department of Primary Care and Public Health, United Kingdom
| | - Simon M Gabe
- St. Mark's Hospital, Harrow, United Kingdom; Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Phillip F C Lung
- St. Mark's Hospital, Harrow, United Kingdom; Department of Surgery and Cancer, Imperial College, London, United Kingdom.
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Santarpia L, Viceconte G, Foggia M, Alfonsi L, Tosone G, Camera L, Pagano MC, De Simone G, Contaldo F, Pasanisi F. Home Parenteral Nutrition in Patients with Intestinal Failure: Possible Undetected Complications. Nutrients 2019; 11:nu11030581. [PMID: 30857281 PMCID: PMC6471421 DOI: 10.3390/nu11030581] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 03/02/2019] [Accepted: 03/05/2019] [Indexed: 11/27/2022] Open
Abstract
Background: Septic pulmonary embolism (SPE) may be a frequently undetected complication of central venous catheter (CVC)-related bloodstream infections (CRBSIs). Materials and Methods: The incidence of SPE was evaluated in a cohort of non-oncological patients on home parenteral nutrition (HPN) who were hospitalized for a CRBSI from January 2013 to December 2017. The main clinical, microbiological, and radiological features and the therapeutic approach were also described. Results: Twenty-three infections over 51,563 days of HPN therapy were observed, corresponding to an infection rate of 0.45/1000. In 10 out of the 23 cases (43.5%), pulmonary lesions compatible with SPE were identified. Conclusion: Our results demonstrated that a CRBSI can produce asymptomatic SPE with lung infiltrates in 43.5% of the cases, suggesting the need to check for secondary lung infections to choose the most appropriate antimicrobial therapy.
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Affiliation(s)
- Lidia Santarpia
- Internal Medicine and Clinical Nutrition, Department of Clinical Medicine and Surgery, Federico II University of Naples, 80131 Naples, Italy.
| | - Giulio Viceconte
- Infectious Disease, Department of Clinical Medicine and Surgery, Federico II University of Naples, 80131 Naples, Italy.
| | - Maria Foggia
- Infectious Disease, Department of Clinical Medicine and Surgery, Federico II University of Naples, 80131 Naples, Italy.
| | - Lucia Alfonsi
- Internal Medicine and Clinical Nutrition, Department of Clinical Medicine and Surgery, Federico II University of Naples, 80131 Naples, Italy.
| | - Grazia Tosone
- Infectious Disease, Department of Clinical Medicine and Surgery, Federico II University of Naples, 80131 Naples, Italy.
| | - Luigi Camera
- Radiology, Department of Advanced Biomedical Sciences, Federico II University of Naples, 80131 Naples, Italy.
| | - Maria Carmen Pagano
- Internal Medicine and Clinical Nutrition, Department of Clinical Medicine and Surgery, Federico II University of Naples, 80131 Naples, Italy.
| | - Giuseppe De Simone
- Anesthesiology and Intensive Care Unit, Department of Neurosciences, Federico II University, 80131 Naples, Italy.
| | - Franco Contaldo
- Internal Medicine and Clinical Nutrition, Department of Clinical Medicine and Surgery, Federico II University of Naples, 80131 Naples, Italy.
| | - Fabrizio Pasanisi
- Internal Medicine and Clinical Nutrition, Department of Clinical Medicine and Surgery, Federico II University of Naples, 80131 Naples, Italy.
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Abstract
Intestinal failure (IF) is the inability of the gut to absorb necessary water, macronutrients (carbohydrate, protein, and fat), micronutrients, and electrolytes sufficient to sustain life and requiring intravenous supplementation or replacement. Acute IF (types 1 and 2) is the initial phase of the illness and may last for weeks to a few months, and chronic IF (type 3) from months to years. The challenge of caring for patients with IF is not merely the management of the underlying condition leading to IF or the correct provision of appropriate nutrition or both but also the prevention of complications, whether thromboembolic phenomenon (for example, venous occlusion), central venous catheter-related bloodstream infection, IF-associated liver disease, or metabolic bone disease. This review looks at recent questions regarding chronic IF (type 3), its diagnosis and management, the role of the multidisciplinary team, and novel therapies, including hormonal treatment for short bowel syndrome but also surgical options for intestinal lengthening and intestinal transplant.
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Affiliation(s)
- Philip Allan
- Translational Gastroenterology Department, University Hospitals Oxford NHS Foundation Trust, Oxford, UK
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
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Dibb M, Lal S. Home Parenteral Nutrition: Vascular Access and Related Complications. Nutr Clin Pract 2017; 32:769-776. [DOI: 10.1177/0884533617734788] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Affiliation(s)
- Martyn Dibb
- Royal Liverpool University Hospital, Liverpool, Merseyside, UK
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Santarpia L, Buonomo A, Pagano MC, Alfonsi L, Foggia M, Mottola M, Marinosci GZ, Contaldo F, Pasanisi F. Central venous catheter related bloodstream infections in adult patients on home parenteral nutrition: Prevalence, predictive factors, therapeutic outcome. Clin Nutr 2016; 35:1394-1398. [DOI: 10.1016/j.clnu.2016.03.009] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 03/10/2016] [Accepted: 03/14/2016] [Indexed: 02/07/2023]
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Adaba F, Uppara M, Iqbal F, Mallappa S, Vaizey CJ, Gabe SM, Warusavitarne J, Nightingale JMD. Chronic cholestasis in patients on parenteral nutrition: the influence of restoring bowel continuity after mesenteric infarction. Eur J Clin Nutr 2015; 70:189-93. [DOI: 10.1038/ejcn.2015.147] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Revised: 07/18/2015] [Accepted: 07/25/2015] [Indexed: 01/03/2023]
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Catheter-related complications in long-term home parenteral nutrition patients with chronic intestinal failure. J Vasc Access 2015; 13:490-7. [PMID: 23258588 DOI: 10.5301/jva.5000133] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2012] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Home Parenteral Nutrition is a therapeutic option to improve quality of life in chronic intestinal failure. AIMS To describe frequency of complications both in cancer and noncancer patients. METHODS This study was performed on 270 adult patients (52% with cancer, 48% without cancer) followed for a total of 371 years of treatment. Mean duration of therapy was 191±181 for cancer and 830±1168 days/patient for noncancer. The treatment was administered by a competent, dedicated provider. Patients received our prescribed "all-in-one admixtures" at their homes. RESULTS Catheter-related complications/1000-days-catheter was 1.40; mechanical complications were comparable in cancer (0.82) and noncancer (0.91) patients while a statistically significant difference was observed between cancer (0.71) and noncancer (0.46) patients for sepsis. Bacterial infections were more frequent in noncancer, mycotic infections primarily affected cancer patients. In our experience 49% of the patients were readmitted, with a low incidence rate of 0.89/1000 days-catheter. The incidence of hepatobiliary complications in our population was 65%. The degree of liver damage was related to short bowel syndrome and to length of treatment. CONCLUSIONS This study indicated that cancer patients are more vulnerable to CVC-related infections during Home Parenteral Nutrition and that a safer Home Parenteral Nutrition protocol should be adopted in order to contain CVC-related complications.
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Buchman AL, Opilla M, Kwasny M, Diamantidis TG, Okamoto R. Risk factors for the development of catheter-related bloodstream infections in patients receiving home parenteral nutrition. JPEN J Parenter Enteral Nutr 2013; 38:744-9. [PMID: 23744839 DOI: 10.1177/0148607113491783] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Accepted: 05/06/2013] [Indexed: 12/28/2022]
Abstract
BACKGROUND Risk factors for development of catheter-related bloodstream infections (CRBSI) were studied in 125 adults and 18 children who received home parenteral nutrition (HPN). METHODS Medical records from a national home care pharmacy were reviewed for all patients that had HPN infused at least twice weekly for a minimum of two years from January 1, 2006-December 31, 2011. Infection and risk factor data were collected during this time period on all patients although those patients who received HPN for a longer period had data collected since initiation of HPN. RESULTS In adults, 331 central venous catheters (CVCs) were placed. Total catheter years were 1157. Median CVC dwell time was 730 days. In children, there were 53 CVCs placed. Total catheter years were 113.1. Median CVC dwell time was 515 days. There were 147 CRBSIs (0.13/catheter year;0.35/1000 catheter days). In children there were 33 CRBSIs (0.29/catheter year;0.80/1000 days; P < .001 versus adults). In adults, univariate analysis showed use of subcutaneous infusion ports instead of tunneled catheters (P = .001), multiple lumen catheters (P = .001), increased frequency of lipid emulsion infusion (P = .001), obtaining blood from the CVC (P < 0.001), and infusion of non-PN medications via the CVC (P < .001) were significant risk factors for CRBSI. Increased PN frequency was associated with increased risk of CRBSI (P = .001) in children, but not in adults. Catheter disinfection with povidone-iodine was more effective than isopropyl alcohol alone. There were insufficient patients to evaluate chlorhexidine-containing regimens. CONCLUSION Numerous risk factors for CRBSI were identified for which simple and current countermeasures already exist.
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Affiliation(s)
| | | | - Mary Kwasny
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Nielsen XC, Chen M, Hellesøe AMB, Jeppesen PB, Gyldenlykke J, Tvede M, Andersen LP. Etiology and epidemiology of catheter related bloodstream infections in patients receiving home parenteral nutrition in a gastromedical center at a tertiary hospital in denmark. Open Microbiol J 2012; 6:98-101. [PMID: 23248717 PMCID: PMC3520033 DOI: 10.2174/1874285801206010098] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 09/18/2012] [Accepted: 10/05/2012] [Indexed: 11/22/2022] Open
Abstract
We conducted a retrospective epidemiologic study of catheter related bloodstream infections (CRBSI) in patients receiving long-term home parenteral nutrition (HPN) from January 2002 to December 2005. Our results showed that coagulase negative staphylococci (CoNS) were the most prevalent pathogens (44.7% of all CRBSI episodes), followed by Enterobacteriaceae (33.2%). Prevalence for candidemia and Enterococcus bacteremia was relatively high (14.4% and 10.8%, respectively). Cefuroxime resistance was observed in 65.4% CoNS and 31.5% Enterobacteriaceae. Based on the results from the study, a new empiric antimicrobial treatment regiment was suggested.
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Affiliation(s)
- Xiaohui Chen Nielsen
- Department of Clinical Microbiology, Slagelse Hospital, Slagelse, Denmark ; Department of Clinical Microbiology, University Hospital of Copenhagen, Denmark
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Epidemiology of catheter-related infections in adult patients receiving home parenteral nutrition: a systematic review. Clin Nutr 2012; 32:16-26. [PMID: 22959630 DOI: 10.1016/j.clnu.2012.08.004] [Citation(s) in RCA: 129] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Revised: 07/09/2012] [Accepted: 08/13/2012] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS Catheter-related infection (CRI) is the most common and serious complication for adult patients receiving home parenteral nutrition (HPN). Our aim is to provide epidemiological data on infection incidence, infecting pathogens and contributing risk factors. METHODS Four electronic databases (Embase, Medline, IPA, CINAHL) were screened for eligible studies published between 1970 and March 2012. Methodological quality was evaluated and terminology/definitions were re-categorized. RESULTS Thirty-nine studies were included. Extensive variability was observed in terminology/definitions as well as in expression of CRI rate. After correct interpretation of definitions, overall catheter-related bloodstream infection rate (CRBSI) ranged between 0.38 and 4.58 episodes/1000 catheter days (median 1.31). Gram-positive bacteria of human skin flora caused more than half of infections. An analysis of the reported risk factors showed that the origin of a CRBSI is often multifactorial. The risk factors were related to the patient, the venous access device, the education, HPN therapy and follow-up. CONCLUSIONS This review on CRI in adult HPN patients revealed that included studies are of low quality and used poorly described risk factors and different definitions. The human skin flora caused most of infections; therefore, hand hygiene and training remain essential.
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Harrison E, Herrick AL, McLaughlin JT, Lal S. Malnutrition in systemic sclerosis. Rheumatology (Oxford) 2012; 51:1747-56. [PMID: 22850183 DOI: 10.1093/rheumatology/kes160] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
SSc is a chronic multi-system disease with wide-reaching consequences. Gastrointestinal features are present in over 90% of cases and these, together with other disease manifestations, may lead to nutritional decline. This produces substantial morbidity, including reliance on enteral support and even parenteral nutrition-dependent intestinal failure. These complications carry an associated mortality. Up to 18% of patients with SSc are reported to be at high risk of malnutrition [as assessed by Malnutrition Universal Screening Tool (MUST) criteria], with risk increasing with disease severity. Little is known about this decline, its rate of progression and how it affects the individual. Few case series report on nutritional interventions. Most current interventions are based on experience in other diseases. The development of specialist knowledge of SSc-related gastrointestinal disease management and nutritional screening and interventions is required. This paper reviews current knowledge relating to malnutrition and its management in SSc.
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Affiliation(s)
- Elizabeth Harrison
- Department of Gastroenterology, Salford Royal NHS Foundation Trust, Salford, UK.
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Outcome on home parenteral nutrition for benign intestinal failure: a review of the literature and benchmarking with the European prospective survey of ESPEN. Clin Nutr 2012; 31:831-45. [PMID: 22658443 DOI: 10.1016/j.clnu.2012.05.004] [Citation(s) in RCA: 147] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2011] [Revised: 04/12/2012] [Accepted: 05/07/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Indications and timing for referral for intestinal transplantation (ITx) were investigated through a review of the literature on home parenteral nutrition (HPN) for benign intestinal failure and a benchmarking to the results of a prospective European survey which evaluated the appropriateness of the current indications for ITx. METHODS Manuscripts reporting outcomes of adults and children on HPN were retrieved through a PubMed search. Data from the European survey were compared with those on HPN reported in the literature, and with those on ITx reported by the USA registry and by the Pittsburgh center. RESULTS HPN is a safe treatment with a high probability of survival. The risk of death during HPN is increased by the absence of a specialist team, and appears greater during the early period of treatment. Survival probability is decreased in patients with: age >40 or <2 years, very short bowel remnant, presence of a stoma, chronic intestinal pseudo-obstruction of myopathic origin, systemic sclerosis, radiation enteritis, intra-abdominal desmoids, necrotizing enterocolitis, congenital mucosal diseases. Liver failure is the HPN-related complication with the greatest risk of death. Death related to venous catheter complications is rare. The benchmarking supported the results of the European survey.
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Hamilton C, Dasari V, Shatnawei A, Lopez R, Steiger E, Seidner D. Hypocaloric home parenteral nutrition and nutrition parameters in patients following bariatric surgery. Nutr Clin Pract 2012; 26:577-82. [PMID: 21947640 DOI: 10.1177/0884533611416125] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Surgical intervention is considered an acceptable treatment for morbid obesity. Complications following bariatric surgery procedures (BSPs) may necessitate home parenteral nutrition (HPN). No studies have been published on patients receiving HPN following BSP complications. The study aim was to determine if hypocaloric HPN has an effect on body mass index (BMI), albumin, and HPN complications. METHODS A historic cohort of patients was identified from a clinical database. Obese patients (BMI ≥35 kg/m(2)) who underwent BSP and received HPN for an anastomotic leak/fistula or bowel obstruction were included. Comparisons for start and end of therapy were made for calorie and protein intake, BMI, white blood cell count, and serum albumin level. Readmissions and metabolic and infectious complications were recorded. Obese patients received hypocaloric feeds to promote weight loss and protein for wound healing. RESULTS Twenty-three patients were included for an average study length of 1.5 months. Patients received an average of 1.2 g of protein and a median of 13.6 kcal per kg actual body weight (ABW) per day. BMI decreased by 7.1% ± 5.2%, from a median of 39.8 to 37.1, and serum albumin increased by 12.5%, from 2.8 ± 0.5 to 3.2 ± 0.6 g/dL. Readmissions occurred in 52.2% of patients with 40.0% of complications related to HPN. CONCLUSIONS Hypocaloric HPN is efficacious in maintaining adequate nutrition while allowing for weight loss in morbidly obese patients following complications of bariatric surgery. Frequency of HPN complications was comparable to those reported in the literature.
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Affiliation(s)
- Cynthia Hamilton
- Center for Human Nutrition, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH 44195, USA.
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Santarpia L, Alfonsi L, Tiseo D, Creti R, Baldassarri L, Pasanisi F, Contaldo F. Central venous catheter infections and antibiotic therapy during long-term home parenteral nutrition: an 11-year follow-up study. JPEN J Parenter Enteral Nutr 2010; 34:254-62. [PMID: 20467007 DOI: 10.1177/0148607110362900] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Catheter-related bloodstream infections are a serious and common complication in patients receiving home parenteral nutrition (HPN). METHODS Prevalence of infections, type of agents, and effectiveness of antibiotic therapy were evaluated in 296 patients (133 males, 163 females; mean age 58.2 +/- 13.5 years) receiving HPN for at least 3 months, from January 1995 to December 2006. Patients underwent 99,969 (331 +/- 552; minimum 91, maximum 4353) days of catheterization, corresponding to 93,236 (311 +/- 489; minimum 52, maximum 4353) days of HPN. RESULTS Fifty-two patients (24 males and 28 females; 35 oncological and 17 nononcological) were diagnosed with 169 infections. The overall corresponding infection rate was 2.0 per 1000 days of catheterization, with a progressive, regular decrease with time. In 30 cases, immediate central venous catheter removal was necessary. Infections were eradicated in 103 of 139 (74%) cases. As to the most common causative agent, 86 (51%) infections were due to Staphylococcus epidermidis. Of these, 64 were treated from 1995 to 2004, 57 of them (89%) successfully; 22 were treated from 2005 onward, only 7 of them (32%) successfully. CONCLUSIONS Although the global infection rate has progressively decreased over the years, S epidermidis has shown an alarming increase in resistance to antibiotic treatment in the last 2 years, suggesting the need for strategies to prevent central venous catheter infection.
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Affiliation(s)
- Lidia Santarpia
- Department of Clinical and Experimental Medicine, Federico II University, Naples, Italy.
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Tomasik PJ, Sztefko K. The effect of enteral and parenteral feeding on secretion of orexigenic peptides in infants. BMC Gastroenterol 2009; 9:92. [PMID: 20003268 PMCID: PMC2803482 DOI: 10.1186/1471-230x-9-92] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2009] [Accepted: 12/10/2009] [Indexed: 12/15/2022] Open
Abstract
Background The feeding in the first months of the life seems to influence the risks of obesity and affinity to some diseases including atherosclerosis. The mechanisms of these relations are unknown, however, the modification of hormonal action can likely be taken into account. Therefore, in this study the levels of ghrelin and orexin A - peripheral and central peptide from the orexigenic gut-brain axis were determined. Methods Fasting and one hour after the meal plasma concentrations of ghrelin and orexin were measured in breast-fed (group I; n = 17), milk formula-fed (group II; n = 16) and highly hydrolyzed, hypoallergic formula-fed (group III; n = 14) groups, age matched infants (mean 4 months) as well as in children with iv provision of nutrients (glucose - group IV; n = 15; total parenteral nutrition - group V; n = 14). Peptides were determined using EIA commercial kits. Results Despite the similar caloric intake in orally fed children the fasting ghrelin and orexin levels were significantly lower in the breast-fed children (0.37 ± 0.17 and 1.24 ± 0.29 ng/ml, respectively) than in the remaining groups (0.5 ± 0.27 and 1.64 ± 0.52 ng/ml, respectively in group II and 0.77 ± 0.27 and 2.04 ± 1.1 ng/ml, respectively, in group III). The postprandial concentrations of ghrelin increased to 0.87 ± 0.29 ng/ml, p < 0.002 and 0.76 ± 0.26 ng/ml, p < 0.01 in groups I and II, respectively as compared to fasting values. The decrease in concentration of ghrelin after the meal was observed only in group III (0.47 ± 0.24 ng/ml). The feeding did not influence the orexin concentration. In groups IV and V the ghrelin and orexin levels resembled those in milk formula-fed children. Conclusion The highly hydrolyzed diet strongly affects fasting and postprandial ghrelin and orexin plasma concentrations with possible negative effect on short- and long-time effects on development. Also total parenteral nutrition with the continuous stimulation and lack of fasting/postprandial modulation might be responsible for disturbed development in children fed this way.
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Affiliation(s)
- Przemyslaw J Tomasik
- Department of Clinical Biochemistry, Polish-American Children's Hospital, Jagiellonian University, Krakow, Poland.
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Futó J, Harsányi L, Sahin P, Dárdai E, Aradán A, Darvas K. Home parenteral nutrition. May it be performed in Hungary, too? Orv Hetil 2009; 150:225-30. [DOI: 10.1556/oh.2009.28525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
A bélelégtelenségben szenvedő betegek az 1960-as évek vége óta részesülhetnek tartós otthoni parenteralis táplálásban a világ számos országában. Hazánkban a jelenleg is érvényben lévő jogi szabályozás és finanszírozási rendszer a bélelégtelenségben szenvedő, de családi körben élni tudó, sőt megfelelő körülmények között akár munkaképes betegeknek ez az ellátása kizárólag fekvőbeteg-ellátási körben lehetséges. A rendszer ezért rendkívül gazdaságtalan, szükségtelenül foglal le kórházi ágyakat, és ellentétes az európai gyakorlattal. Az elmúlt évek publikációi alapján a szerzők áttekintik a tartós otthoni parenteralis táplálásban részesülő betegek várható élettartamát, életminőségét, a parenteralis tápláláshoz kapcsolódó szövődményeket, illetve a világszerte alkalmazott rendszereket. A tartós táplálás költségeit a nemzetközi adatok alapján magyar viszonyokra vetítve becsülik meg. Az otthoni parenteralis tápláláshoz szükséges szaktudás Magyarországon is maradéktalanul rendelkezésre áll; a szükséges készítmények, technikai felszerelések a magyar piacon is hozzáférhetők. A táplálásterápia iránt elkötelezett hazai szakemberek ezért hivatalos szakmaközi együttműködést kezdeményeztek a tartós otthoni parenteralis táplálás eddig mostohán kezelt kérdésének rendezése érdekében, a rutinszerű otthoni parenteralis táplálás rendszerének kialakítására.
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Affiliation(s)
- Judit Futó
- 1 Fővárosi Önkormányzat Szent Imre Kórház, Sürgősségi Betegellátási Centrum Központi Műtő és Aneszteziológiai Szolgálat Budapest Tétényi út 12–15. 1115
| | - László Harsányi
- 2 Semmelweis Egyetem, Általános Orvostudományi Kar I. Sebészeti Klinika Budapest
| | - Péter Sahin
- 3 Fővárosi Önkormányzat Szent Imre Kórház Belgyógyászati Szakmák Mátrix Szervezete, Gasztroenterológiai Profil Budapest
| | - Ernő Dárdai
- 4 Fővárosi Önkormányzat Egyesített Szent István és Szent László Kórház és Rendelőintézet Központi Aneszteziológiai és Intenzív Betegellátó Osztály Budapest
| | - Attiláné Aradán
- 3 Fővárosi Önkormányzat Szent Imre Kórház Belgyógyászati Szakmák Mátrix Szervezete, Gasztroenterológiai Profil Budapest
| | - Katalin Darvas
- 2 Semmelweis Egyetem, Általános Orvostudományi Kar I. Sebészeti Klinika Budapest
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