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Fuglsang KA, Brandt CF, Jeppesen PB. Survival In Patients Initiating Home Parenteral Support Due To Nonmalignant Short Bowel Syndrome Compared With Background Population. Clin Nutr ESPEN 2022; 50:170-177. [DOI: 10.1016/j.clnesp.2022.05.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 05/09/2022] [Accepted: 05/25/2022] [Indexed: 12/25/2022]
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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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Pironi L, Konrad D, Brandt C, Joly F, Wanten G, Agostini F, Chambrier C, Aimasso U, Zeraschi S, Kelly D, Szczepanek K, Jukes A, Di Caro S, Theilla M, Kunecki M, Daniels J, Serlie M, Poullenot F, Wu J, Cooper SC, Rasmussen HH, Compher C, Seguy D, Crivelli A, Pagano MC, Hughes SJ, Guglielmi FW, Kozjek NR, Schneider SM, Gillanders L, Ellegard L, Thibault R, Matras P, Zmarzly A, Matysiak K, Van Gossum A, Forbes A, Wyer N, Taus M, Virgili NM, O'Callaghan M, Chapman B, Osland E, Cuerda C, Sahin P, Jones L, Lee ADW, Bertasi V, Orlandoni P, Izbéki F, Spaggiari C, Díez MB, Doitchinova-Simeonova M, Garde C, Serralde-Zúñiga AE, Olveira G, Krznaric Z, Czako L, Kekstas G, Sanz-Paris A, Jáuregui EP, Murillo AZ, Schafer E, Arends J, Suárez-Llanos JP, Shaffer J, Lal S. Clinical classification of adult patients with chronic intestinal failure due to benign disease: An international multicenter cross-sectional survey. Clin Nutr 2017; 37:728-738. [PMID: 28483328 DOI: 10.1016/j.clnu.2017.04.013] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 03/19/2017] [Accepted: 04/11/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS The aim of the study was to evaluate the applicability of the ESPEN 16-category clinical classification of chronic intestinal failure, based on patients' intravenous supplementation (IVS) requirements for energy and fluids, and to evaluate factors associated with those requirements. METHODS ESPEN members were invited to participate through ESPEN Council representatives. Participating centers enrolled adult patients requiring home parenteral nutrition for chronic intestinal failure on March 1st 2015. The following patient data were recorded though a structured database: sex, age, body weight and height, intestinal failure mechanism, underlying disease, IVS volume and energy need. RESULTS Sixty-five centers from 22 countries enrolled 2919 patients with benign disease. One half of the patients were distributed in 3 categories of the ESPEN clinical classification. 9% of patients required only fluid and electrolyte supplementation. IVS requirement varied considerably according to the pathophysiological mechanism of intestinal failure. Notably, IVS volume requirement represented loss of intestinal function better than IVS energy requirement. A simplified 8 category classification of chronic intestinal failure was devised, based on two types of IVS (either fluid and electrolyte alone or parenteral nutrition admixture containing energy) and four categories of volume. CONCLUSIONS Patients' IVS requirements varied widely, supporting the need for a tool to homogenize patient categorization. This study has devised a novel, simplified eight category IVS classification for chronic intestinal failure that will prove useful in both the clinical and research setting when applied together with the underlying pathophysiological mechanism of the patient's intestinal failure.
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Affiliation(s)
- Loris Pironi
- Center for Chronic Intestinal Failure, Department of Digestive System, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Denise Konrad
- Home Nutrition Support, Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Francisca Joly
- Centre for Intestinal Failure, Department of Gastroenterology and Nutritional Support, Hôpital Beaujon, Clichy, France
| | - Geert Wanten
- Intestinal Failure Unit, Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Federica Agostini
- Center for Chronic Intestinal Failure, Department of Digestive System, St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Cecile Chambrier
- Unité de Nutrition Clinique Intensive, Hospices Civils de Lyon, Hôpital de la Croix Rousse, Lyon, France
| | | | - Sarah Zeraschi
- Nutrition Team Office, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Darlene Kelly
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Kinga Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | - Amelia Jukes
- University Hospital of Wales, Cardiff, United Kingdom
| | | | | | | | - Joanne Daniels
- Nottingham University Hospital NHS Trust, Nottingham, United Kingdom
| | | | - Florian Poullenot
- Service de Gastroentérologie, Hôpital Haut-Lévêque, CHU de Bordeaux, Pessac, France
| | - Jian Wu
- Intestinal Failure Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Sheldon C Cooper
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Henrik H Rasmussen
- Centre for Nutrition and Bowel Disease, Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
| | - Charlene Compher
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - David Seguy
- Service de Nutrition, CHRU de Lille, Lille, France
| | - Adriana Crivelli
- Unidad de Soporte Nutricional, Rehabilitación y Trasplante de Intestino, Hospital Universitario Fundacion Favaloro, Buenos Aires, Argentina
| | | | - Sarah-Jane Hughes
- Belfast Health and Social Care Trust, Belfast, Northern Ireland, United Kingdom
| | | | | | - Stéphane M Schneider
- Gastroenterology and Clinical Nutrition, CHU of Nice, University of Nice Sophia Antipolis, Nice, France
| | - Lyn Gillanders
- National Intestinal Failure Service, Auckland City Hospital, Auckland, New Zealand
| | - Lars Ellegard
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Ronan Thibault
- Gastrointestinal and Nutritional Rehabilitation Medicine, Clinique Saint Yves, Rennes Cedex, France
| | - Przemysław Matras
- Department of General and Transplant Surgery and Clinical Nutrition, Medical University of Lublin, Lublin, Poland
| | - Anna Zmarzly
- Department of Clinical Nutrition, J. Gromkowski City Hospital, Wroclaw, Poland
| | - Konrad Matysiak
- Centre for Intestinal Failure, Department of General, Endocrinological and Gastroenterological Surgery, Poznan University of Medical Science, Poznań, Poland
| | - Andrè Van Gossum
- Medico-Surgical Department of Gastroenterology, Hôpital Erasme, Free University of Brussels, Belgium
| | - Alastair Forbes
- Norfolk and Norwich University Hospital, University of East Anglia, Norwich, United Kingdom
| | - Nicola Wyer
- University Hospital, Coventry, United Kingdom
| | - Marina Taus
- Centro di Riferimento Regionale NAD Ospedali Riuniti Ancona, Ancona, Italy
| | - Nuria M Virgili
- Unitat Nutrició i Dietética, Servei Endocrinologia i Nutrició, Hospital Universitari de Bellvitge, Barcelona, Spain
| | | | | | - Emma Osland
- Royal Brisbane and Women's Hospital, Herston, Australia
| | - Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | | | - Lynn Jones
- Royal Prince Alfred Hospital, Camperdown, Australia
| | - Andre D W Lee
- Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Paolo Orlandoni
- Centro di Riferimento Regionale NAD, INRCA -IRCCS, Ancona, Italy
| | - Ferenc Izbéki
- Szent György Teaching Hospital of County Fejér, Székesfehérvár, Hungary
| | | | - Marta Bueno Díez
- Servei d'Endocrinologia i Nutrició, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | | | - Carmen Garde
- Hospital Universitario Donostia, San Sebastian, Spain
| | | | | | - Zeljko Krznaric
- Centre of Clinical Nutrition, Department of Medicine, University Hospital Centre, Zagreb, Croatia
| | - Laszlo Czako
- First Department of Internal Medicine, Szeged, Hungary
| | | | | | | | | | - Eszter Schafer
- Magyar Honvedseg Egészségügyi Központ (MHEK), Budapest, Hungary
| | - Jann Arends
- Department of Medicine, Oncology and Hematology, University of Freiburg, Germany
| | - José P Suárez-Llanos
- Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Jon Shaffer
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
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Kim H, Spaulding R, Werkowitch M, Yadrich D, Piamjariyakul U, Gilroy R, Smith CE. Costs of multidisciplinary parenteral nutrition care provided at a distance via mobile tablets. JPEN J Parenter Enteral Nutr 2014; 38:50S-7S. [PMID: 25245253 PMCID: PMC4231785 DOI: 10.1177/0148607114550692] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Determining the costs of healthcare delivery is a key step for providing efficient nutrition-based care. This analysis tabulates the costs of delivering home parenteral nutrition (HPN) interventions and clinical assessments through encrypted mobile technologies to increase patients' access to healthcare providers, reduce their travel expenses, and allow early detection of infection and other complications. METHODS A traditional cost-accounting method was used to tabulate all expenses related to mobile distance HPN clinic appointments, including (1) personnel time of multidisciplinary healthcare professionals, (2) supply of HPN intervention materials, and (3) equipment, connection, and delivery expenses. RESULTS A total of 20 mobile distance clinic appointments were conducted for an average of 56 minutes each with 45 patients who required HPN infusion care. The initial setup costs included mobile tablet devices, 4G data plans, and personnel's time as well as intervention materials. The initial costs were on average $916.64 per patient, while the follow-up clinic appointments required $361.63 a month, with these costs continuing to decline as the equipment was used by multiple patients more frequently over time. Patients reported high levels of satisfaction with cost savings in travel expenses and rated the quality of care comparable to traditional in-person examinations. CONCLUSION This study provides important aspects of the initial cost tabulation for visual assessment for HPN appointments. These findings will be used to generate a decision algorithm for scheduling mobile distance clinic appointments intermittent with in-person visits to determine how to lower costs of nutrition assessments. To maximize the cost benefits, clinical trials must continue to collect clinical outcomes.
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Affiliation(s)
- Heejung Kim
- University of Kansas School of Nursing, Kansas City, Kansas
| | - Ryan Spaulding
- University of Kansas School of Medicine, Kansas City, Kansas
| | | | - Donna Yadrich
- University of Kansas School of Nursing, Kansas City, Kansas
| | | | - Richard Gilroy
- University of Kansas School of Medicine, Kansas City, Kansas
| | - Carol E Smith
- University of Kansas School of Nursing and Preventive Medicine & Public Health, Kansas City, Kansas
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Snowden JA, Ansari A, Sachchithanantham S, Jackson G, Thompson N, Lobo A, Sanderson J, Kazmi M. Autologous stem cell transplantation in severe treatment-resistant Crohn's disease: long-term follow-up of UK patients treated on compassionate basis. QJM 2014; 107:871-7. [PMID: 24803477 DOI: 10.1093/qjmed/hcu095] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Although autologous stem cell transplantation (ASCT) may achieve disease control in severe treatment-resistant Crohn's disease (CD), relapse is frequent, and there is little information regarding long-term outcomes in terms of response to subsequent treatments and complications of ASCT. DESIGN Retrospective evaluation of UK patients treated on a compassionate basis from three UK tertiary centres. METHODS We summarize long-term outcomes of six previously unreported patients with severe treatment-resistant CD treated with ASCT according to international guidelines between 2003 and 2009. Median duration of CD before ASCT was 14 (7-22) years. Following stem cell mobilization, patients were treated with high-dose cyclophosphamide (200 mg/kg) and rabbit anti-thymocyte globulin (7.5 mg/kg) followed by ASCT. RESULTS All patients tolerated ASCT with routine toxicities and no treatment-related mortality and are alive at 50-123 months post-ASCT. Clinical and endoscopic remissions of CD were confirmed at 3 months post-ASCT in five patients, although median time to next treatment for inflammatory disease was 10 months (range: 3-16 months). Subsequently, disease control was achieved with previously ineffective and newer treatments, with surgery performed predominantly for pre-existing fibrotic strictures. Two patients became independent of home total parenteral nutrition (TPN). Reported late complications of ASCT included hypothyroidism and ovarian failure. CONCLUSION Long-term follow-up supports the safety and feasibility of ASCT as a means of achieving short-term control of severe CD whilst potentially re-sensitizing the disease to medical therapy and reducing requirements for surgery and TPN. Given the inevitability of relapse, pre-emptive salvage and/or maintenance treatments post-ASCT should be the focus of future trials.
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Affiliation(s)
- J A Snowden
- From the Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Department of Oncology, University of Sheffield, Department of Gastroenterology, East Surrey Hospitals NHS Trust, Redhill, RH1 5RH Department of Haematology, Guy's and St. Thomas' NHS Foundation Trust, London SE1 9RT Department of Haematology, Newcastle University, Newcastle-Upon-Tyne, NE1 7RU Department of Gastroenterology, Freeman Hospital, Newcastle-Upon-Tyne, NE7 7DN Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF and Department of Gastroenterology, Guy's and St. Thomas' NHS Foundation Trust, London, SE1 9RT UK From the Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Department of Oncology, University of Sheffield, Department of Gastroenterology, East Surrey Hospitals NHS Trust, Redhill, RH1 5RH Department of Haematology, Guy's and St. Thomas' NHS Foundation Trust, London SE1 9RT Department of Haematology, Newcastle University, Newcastle-Upon-Tyne, NE1 7RU Department of Gastroenterology, Freeman Hospital, Newcastle-Upon-Tyne, NE7 7DN Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF and Department of Gastroenterology, Guy's and St. Thomas' NHS Foundation Trust, London, SE1 9RT UK
| | - A Ansari
- From the Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Department of Oncology, University of Sheffield, Department of Gastroenterology, East Surrey Hospitals NHS Trust, Redhill, RH1 5RH Department of Haematology, Guy's and St. Thomas' NHS Foundation Trust, London SE1 9RT Department of Haematology, Newcastle University, Newcastle-Upon-Tyne, NE1 7RU Department of Gastroenterology, Freeman Hospital, Newcastle-Upon-Tyne, NE7 7DN Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF and Department of Gastroenterology, Guy's and St. Thomas' NHS Foundation Trust, London, SE1 9RT UK
| | - S Sachchithanantham
- From the Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Department of Oncology, University of Sheffield, Department of Gastroenterology, East Surrey Hospitals NHS Trust, Redhill, RH1 5RH Department of Haematology, Guy's and St. Thomas' NHS Foundation Trust, London SE1 9RT Department of Haematology, Newcastle University, Newcastle-Upon-Tyne, NE1 7RU Department of Gastroenterology, Freeman Hospital, Newcastle-Upon-Tyne, NE7 7DN Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF and Department of Gastroenterology, Guy's and St. Thomas' NHS Foundation Trust, London, SE1 9RT UK
| | - G Jackson
- From the Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Department of Oncology, University of Sheffield, Department of Gastroenterology, East Surrey Hospitals NHS Trust, Redhill, RH1 5RH Department of Haematology, Guy's and St. Thomas' NHS Foundation Trust, London SE1 9RT Department of Haematology, Newcastle University, Newcastle-Upon-Tyne, NE1 7RU Department of Gastroenterology, Freeman Hospital, Newcastle-Upon-Tyne, NE7 7DN Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF and Department of Gastroenterology, Guy's and St. Thomas' NHS Foundation Trust, London, SE1 9RT UK
| | - N Thompson
- From the Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Department of Oncology, University of Sheffield, Department of Gastroenterology, East Surrey Hospitals NHS Trust, Redhill, RH1 5RH Department of Haematology, Guy's and St. Thomas' NHS Foundation Trust, London SE1 9RT Department of Haematology, Newcastle University, Newcastle-Upon-Tyne, NE1 7RU Department of Gastroenterology, Freeman Hospital, Newcastle-Upon-Tyne, NE7 7DN Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF and Department of Gastroenterology, Guy's and St. Thomas' NHS Foundation Trust, London, SE1 9RT UK
| | - A Lobo
- From the Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Department of Oncology, University of Sheffield, Department of Gastroenterology, East Surrey Hospitals NHS Trust, Redhill, RH1 5RH Department of Haematology, Guy's and St. Thomas' NHS Foundation Trust, London SE1 9RT Department of Haematology, Newcastle University, Newcastle-Upon-Tyne, NE1 7RU Department of Gastroenterology, Freeman Hospital, Newcastle-Upon-Tyne, NE7 7DN Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF and Department of Gastroenterology, Guy's and St. Thomas' NHS Foundation Trust, London, SE1 9RT UK
| | - J Sanderson
- From the Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Department of Oncology, University of Sheffield, Department of Gastroenterology, East Surrey Hospitals NHS Trust, Redhill, RH1 5RH Department of Haematology, Guy's and St. Thomas' NHS Foundation Trust, London SE1 9RT Department of Haematology, Newcastle University, Newcastle-Upon-Tyne, NE1 7RU Department of Gastroenterology, Freeman Hospital, Newcastle-Upon-Tyne, NE7 7DN Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF and Department of Gastroenterology, Guy's and St. Thomas' NHS Foundation Trust, London, SE1 9RT UK
| | - M Kazmi
- From the Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Department of Oncology, University of Sheffield, Department of Gastroenterology, East Surrey Hospitals NHS Trust, Redhill, RH1 5RH Department of Haematology, Guy's and St. Thomas' NHS Foundation Trust, London SE1 9RT Department of Haematology, Newcastle University, Newcastle-Upon-Tyne, NE1 7RU Department of Gastroenterology, Freeman Hospital, Newcastle-Upon-Tyne, NE7 7DN Department of Gastroenterology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF and Department of Gastroenterology, Guy's and St. Thomas' NHS Foundation Trust, London, SE1 9RT 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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Affiliation(s)
- M Miglioli
- Institute of Internal Medicine and Gastroenterology, University of Bologna, St. Orsola Hospital, Via Massarenti 9, 40138 Bologna, Italy
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Abstract
PURPOSE OF REVIEW To highlight the most important and salient articles regarding home parenteral nutrition and quality of life published within the last 3 years. RECENT FINDINGS In recent years, quality of life research in home parenteral nutrition has highlighted the need for a therapy-specific validated questionnaire. Several papers suggest a greater psychological input is required to better understand and evaluate this patient population. Issues surrounding the use of home parenteral nutrition in malignancy have arisen, prompting discussion on ideal timing and candidacy for home parenteral nutrition. Intestinal transplantation is evolving and improving, making it a possible alternative to home parenteral nutrition. Earlier referral is suggested as late referral can result in poorer outcome. SUMMARY Home parenteral nutrition is a life-sustaining therapy for individuals with intestinal failure. There is now a relatively large amount of research into the quality of life in this population, but more focused measurements (in the form of validated therapy-specific questionnaires) are required to answer questions relating to cancer and intestinal transplantation.
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Affiliation(s)
- Alison Chambers
- Department of Human Nutrition, Bart's and The London School of Medicine and Dentistry, Queen Mary University of London, The Wingate Institute, 26 Ashfield Street, London, UK.
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Baxter JP, Fayers PM, McKinlay AW. A review of the instruments used to assess the quality of life of adult patients with chronic intestinal failure receiving parenteral nutrition at home. Br J Nutr 2007; 94:633-8. [PMID: 16277762 DOI: 10.1079/bjn20051533] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Home parenteral nutrition is an established method of supporting patients with intestinal failure, but this treatment may be life long and imposes severe restrictions on daily life. Impact on quality of life is an important outcome when considering the management of home parenteral nutrition patients. This paper reviews studies in which the quality of life of patients receiving home parenteral nutrition has been assessed. A systematic search of electronic databases and relevant publications was undertaken to identify generic or treatment-specific questionnaires used with home parenteral nutrition patients. Many of the thirty-four reports discovered were small studies. Nineteen used non-specific generic instruments, eight used non-validated questionnaires, four used a combination of both, and three did not use any formal tool. Few systematic patterns emerged. There are few available data on the quality of life of home parenteral nutrition patients, and there is a need for standardised, scientifically validated, treatment-specific instruments to measure quality of life in this population.
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Affiliation(s)
- Janet P Baxter
- Department of Digestive Disease and Clinical Nutrition, Ninewells Hospital and Medical School, Dundee, UK.
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Ugur A, Marashdeh BHS, Gottschalck I, Brøbech Mortensen P, Staun M, Bekker Jeppesen P. Home parenteral nutrition in Denmark in the period from 1996 to 2001. Scand J Gastroenterol 2006; 41:401-7. [PMID: 16635907 DOI: 10.1080/00365520500441247] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Home parenteral nutrition (HPN) has been provided to patients with intestinal failure in Denmark since 1970. The results of a national survey comprising a well-defined cohort receiving treatment with HPN in Denmark in the period from 1996 to the end of 2000 are presented, including data on incidence, prevalence, patient characteristics and complications of HPN treatment. MATERIAL AND METHODS HPN was given to 202 patients (115 F, 87 M) 34% with short-bowel syndrome due to inflammatory bowel disease, 26% with cancer, 22% with surgical complications and 19% with other causes, for a total of 410 catheter years. RESULTS At the end of 2000, the prevalence of HPN in Denmark was 19.2 per million, and the average annual incidence was 5.0 per million per year over the 5-year period. The incidence rates of catheter-related bacteraemia and thrombosis were 0.48 and 0.02 episodes per catheter year, respectively. The average catheter lasted 1.5 years. Venous inaccessibility was never encountered. The 5-year mortality was 25% (n = 51). However, only six deaths were related to HPN. Three patients died of HPN-related liver failure, two died of catheter-related sepsis and one patient died of an embolus induced by a catheter thrombus. CONCLUSIONS Since its introduction in 1970 in Denmark, HPN has evolved from an experimental approach to a standardized therapy for patients with intestinal failure. Although HPN morbidity is increasing slightly compared with that reported in earlier surveys, HPN-induced mortality is still less than 1% per year.
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Affiliation(s)
- Asiya Ugur
- Department of Medicine CA-2121, Division of Gastroenterology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Williams N, Shanbhogue LKR, Molenaar JC. Short bowel syndrome: Metabolic and surgical management. Br J Surg 2005. [DOI: 10.1002/bjs.1800811058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- N Williams
- Department of Surgery, Victoria Hospital, Blackpool FY3 8NR UK
| | - L K R Shanbhogue
- Sophia Children's Hospital, Dr Molewaterplein 60, 3015-GJ Rotterdam, The Netherlands
| | - J C Molenaar
- Sophia Children's Hospital, Dr Molewaterplein 60, 3015-GJ Rotterdam, The Netherlands
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de la Cuerda Compés C, Bretón Lesmes I, Bonada Sanjaume A, Planas Vila M. [Protocol for the diagnosis and treatment of catheter related infections in patients with home parenteral nutrition]. Rev Clin Esp 2005; 205:386-91. [PMID: 16143087 DOI: 10.1157/13078251] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
One of the most frequent complications of home parenteral nutrition is parenteral nutrition catheter infection. Prevention of these complications by adequate protocols on the catheter cares manages to decrease significantly the number of infections. Diagnosis and treatment of these infections should be done early to avoid loss of central venous accesses that may affect the treatment with this nutritional support modality in the long term. The existence of a protocol for the diagnosis and treatment of infections related with the catheter is, thus, of great value in the treatment of these patients.
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Affiliation(s)
- C de la Cuerda Compés
- Unidad de Nutrición Clínica y Dietética, Hospital General Universitario Gregorio Marañón, C./Doctor Esquerdo 46, 28007 Madrid, Spain.
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Pironi L, Paganelli F, Labate AMM, Merli C, Guidetti C, Spinucci G, Miglioli M. Safety and efficacy of home parenteral nutrition for chronic intestinal failure: a 16-year experience at a single centre. Dig Liver Dis 2003; 35:314-24. [PMID: 12846403 DOI: 10.1016/s1590-8658(03)00074-4] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Comparisons between safety and efficacy of home parenteral nutrition and of intestinal transplantation for treatment of chronic intestinal failure derived from observational studies. AIMS To present the 16-year experience of home parenteral nutrition by the Chronic Intestinal Failure Centre of Bologna University. PATIENTS A total of 40 adult patients were enrolled between 1986 and 2001. METHODS Safety indices: survival and cause of death, catheter-related bloodstream infection, deep vein thrombosis, liver disease. Efficacy indices: nutritional and rehabilitation status, quality of life (SF36 instrument), re-hospitalisation rate. STATISTICS Kaplan-Maier analysis and Cox model for survival probability and risk factors; logistic regression for catheter-related bloodstream infection risk factors. RESULTS Survival rates at 1, 3 and 5 years were 97, 82 and 67% respectively. Survival was higher in patients < or = 40 years. One death was home parenteral nutrition-related. Incidence of catheter-related bloodstream infection: 0.30/year home parenteral nutrition, was lower in patients treated by a specialized nursing protocol. Incidence of deep vein thrombosis was 0.05/year home parenteral nutrition. Hepatosteatosis occurred in 55%. Body weight remained stable or increased in 80%. Rehabilitation was total or partial in 74%. Re-hospitalisation rate was 0.70/year home parenteral nutrition. Quality of life scored significantly lower than in healthy populations in six out of eight domains. CONCLUSIONS Home parenteral nutrition is a safe and efficacious therapy for chronic intestinal failure. Survival compares favourably with survival after intestinal transplantation.
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Affiliation(s)
- L Pironi
- Department of Internal Medicine and Gastroenterology, University of Bologna, Bologna, Italy.
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15
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Clark RG. Effect of nutrition support on clinical outcome. Clin Nutr 2003; 22 Suppl 2:S69-71. [PMID: 14512059 DOI: 10.1016/s0261-5614(03)00153-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- R G Clark
- Centre for Human Nutrition, University of Sheffield, Northern General Hospital, Sheffield, UK
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16
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Luman W, Shaffer JL. Prevalence, outcome and associated factors of deranged liver function tests in patients on home parenteral nutrition. Clin Nutr 2002; 21:337-43. [PMID: 12135595 DOI: 10.1054/clnu.2002.0554] [Citation(s) in RCA: 85] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION The prevalence of deranged liver function tests (LFT) in patients on long-term home parenteral nutrition (HPN) is poorly documented. The aim of our study was to document the prevalence of this complication and possible associated factors. METHOD Retrospective analysis of case notes of 107 patients on HPN was performed. Deranged LFT was defined as any biochemical parameter of LFT that is 1.5 times above the reference range. RESULTS There were 39 males and the median age was 51 (range 20-73) years old. Median duration of HPN was 40 (range 6-252) months. Underlying diagnoses were Crohn's disease (40%), ischaemic bowel disease in 28.1% (arterial or venous), post-surgical intestinal adhesion and fistula (16.9%) and others (21.7%). The mean energy intake from HPN was 1003+/-544(SD) kcal/day with 845+/-474 kcal/day from glucose, 157+/-127 kcal/day from fat and mean nitrogen intake was 6.2+/-3.6 g/day. Raised alkaline phosphatase (mean 197+/-143(SD)U/L) was the most common abnormality (40 patients). Two patients had hyperbilirubinaemia; one patient had hereditary spherocytosis and in the other patient, the cause could be attributed to HPN with bilirubin of 54 micromol/l. Fifty-one patients (47.7%) had deranged LFT as judged from raised parameters on LFT. Abnormality in LFT was transient in nine patients. For the other 42 patients (39%), abnormalities in LFT remained stable for median duration of follow-up of 18.5 (range 3-180) months. No patients developed decompensated liver disease. On univariate analysis, length of small bowel of less than 100 cm, a higher total caloric intake from HPN (mean 1117+/-486 kcal against 907+/-576 kcal, P<0.05), and higher daily caloric intake from HPN in relation to calculated daily energy requirement (70+/-32% against 57+/-36%) were noted to be significantly associated with deranged LFT. However, on multivariate analysis, length of small bowel of less than 100 cm was the only significant variable for deranged LFT. CONCLUSION Our finding showed the prevalence of deranged LFT to be 39% and raised alkaline phosphatase was the most common abnormality. Length of small bowel of less than 100 cm was found to be a significant independent variable for deranged LFT and the reason for this observation could be due to higher parenteral caloric intake. In our experience, LFT abnormalities are associated with a good prognosis as none of the patients developed decompensated liver disease.
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Affiliation(s)
- W Luman
- Intestinal Failure Unit, Hope Hospital, Salford, Manchester, M6 8HD, UK
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17
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Bozzetti F, Cozzaglio L, Biganzoli E, Chiavenna G, De Cicco M, Donati D, Gilli G, Percolla S, Pironi L. Quality of life and length of survival in advanced cancer patients on home parenteral nutrition. Clin Nutr 2002; 21:281-8. [PMID: 12135587 DOI: 10.1054/clnu.2002.0560] [Citation(s) in RCA: 136] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The use of home parenteral nutrition (HPN) in patients with advanced cancer is controversial because survival is usually short and there are no data regarding the quality of life (QoL). METHODS Sixty-nine advanced cancer patients enrolled in a program of HPN in six different Italian centers were prospectively studied as regards nutritional status (body weight, serum albumin, serum transferrin and total lymphocyte count), length of survival and QoL through the Rotterdam Symptom Checklist questionnaire. These variables were collected at the start of HPN and then at monthly intervals. All these patients were severely malnourished, almost aphagic and beyond any possibility of cure. RESULTS Nutritional indices maintained stable until death. Median survival was 4 months (range 1-14) and about one-third of patients survived more than 7 months. QoL parameters remained stable till 2-3 months before death. CONCLUSIONS HPN may benefit a limited percentage of patients who may survive longer than the time allowed by a condition of starvation and depletion. Provided that these patients survive longer than 3 months, there is some evidence that QoL remains stable for some months and acceptable for the patients.
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Affiliation(s)
- F Bozzetti
- Italian Society for Parenteral and Enteral Nutrition, Milan, Italy
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18
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Complications of long-term home total parenteral nutrition: their identification, prevention and treatment. Dig Dis Sci 2001. [PMID: 11270772 DOI: 10.1023/a: 1005628121546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/17/2023]
Abstract
The purpose of this review is to describe the most common complications of home total parenteral nutrition, their identification, treatment and prevention. Data sources were manuscripts and abstracts published in the English literature since 1968. Studies were selected for summarization in this review on the basis of clinical relevance to the practicing clinician. Home total parenteral nutrition is a relatively safe, life-saving method for nutrient delivery in patients with compromised gastrointestinal function. However, numerous complications, with associated morbidity and mortality, involving the delivery system and the gastrointestinal, renal, and skeletal systems may develop. Catheter-related complications are often preventable and treatable when they occur, although renal and bone abnormalities have elusive etiologies.
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Gonzalez F, Boulétreau P, Bryssine S, Saudin F, Chambrier C. Nutrition parentérale à domicile : bilan de 14 ans d'activité d'un centre agréé. NUTR CLIN METAB 2001. [DOI: 10.1016/s0985-0562(00)00038-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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20
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Pilling M, Walley T. Contracting for high-tech health care for patients at home: a survey of purchaser responses. JOURNAL OF MANAGEMENT IN MEDICINE 1999; 10:17-23, 2. [PMID: 10538028 DOI: 10.1108/02689239610153168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Points out that the Department of Health's Executive Letter: EL(95)5 moved the finance of high technology treatment provided at home for chronically ill patients from the NHS prescribing budget onto a defined and consistent framework. The aim was to obtain better value for money by encouraging competition between potential homecare providers. Reports on a survey of prescribing advisers of purchasing health authorities, which focused on their response to these developments, and discusses the issues identified by purchasers in their implementation of EL(95)5. Notes that, although most purchasers chose to contract directly with a single commercial homecare organization in 1995-1996, there was no consensus about where contracts should be placed in the future, and that the purchasers identified inefficiencies in contracting for such care. Discusses methods of improving the purchasers' response to contracting.
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Affiliation(s)
- M Pilling
- Department of Pharmacology and Therapeutics, University of Liverpool, UK
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21
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Richards DM, Scott NA, Shaffer JL, Irving M. Opiate and sedative dependence predicts a poor outcome for patients receiving home parenteral nutrition. JPEN J Parenter Enteral Nutr 1997; 21:336-8. [PMID: 9406130 DOI: 10.1177/0148607197021006336] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Home parenteral nutrition (HPN) is used to treat intestinal failure. A minority of HPN patients are dependent on opiates and benzodiazepines to control pain and anxiety. The aim of this study was to determine what effects such drug dependence had on patient outcomes. METHODS Ten dependent patients were prospectively compared with 10 well-matched, nondependent HPN patients for the same 12-month period. Episodes of line sepsis and other complications were documented and the cost of treatment estimated. Health status was measured using the SF36 and EuroQol instruments. RESULTS The dependent group had significantly more episodes of central line sepsis (p = .0007) as well as other complications (p = .0002). This led to significantly longer periods of inpatient care (p = .0004) and therefore higher costs of treatment. Health status was lower in the dependent group; they reported more pain (p = .04) and less energy (p = .04). CONCLUSIONS The complication rate and increased cost of treatment for opiate- and sedative-dependent patients receiving HPN significantly detract from the overall outcome of this therapy.
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Affiliation(s)
- D M Richards
- Intestinal Failure Unit, Hope Hospital (University of Manchester School of Medicine), Salford, United Kingdom
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22
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Cozzaglio L, Balzola F, Cosentino F, DeCicco M, Fellagara P, Gaggiotti G, Gallitelli L, Giacosa A, Orban A, Fadda M, Gavazzi C, Pirovano F, Bozzetti F. Outcome of cancer patients receiving home parenteral nutrition. Italian Society of Parenteral and Enteral Nutrition (S.I.N.P.E.). JPEN J Parenter Enteral Nutr 1997; 21:339-42. [PMID: 9406131 DOI: 10.1177/0148607197021006339] [Citation(s) in RCA: 78] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Indication for home parenteral nutrition (HPN) in cancer patients is controversial because intestinal failure and malnutrition are often only two of the many problems found in such patients that may deserve priority of treatment. METHODS This was a retrospective study of 75 cancer patients from nine institutions included in the Italian HPN Registry. The patients had a mean weight loss of 12.5%, serum albumin of 3.1 g/dL, lymphocyte count of 1150/mm3, and serum total iron-binding capacity of 190 micrograms/dL. The main indication for HPN was intestinal obstruction (66%); 72% of the patients had metastatic disease. A series of demographic, oncologic, and nutritional characteristics were analyzed in an attempt to predict a possible benefit of HPN. RESULTS A total of 9897 days of HPN were delivered to 75 cancer patients, for a median of 4 months (range 1 to 15 months) per patient. Sixty-nine patients died while receiving HPN, five had a remission of their intestinal failure, and one chose to stop the treatment. Complications related to parenteral nutrition were as follows: 19 cases of sepsis, 6 catheter occlusions, 4 catheter dislocations, and 2 metabolic imbalances. HPN preserved nutritional status and slightly improved weight, lymphocyte count, serum albumin, and Karnofsky performance status in patients who survived > 3 months. Quality of life during HPN was judged by the clinicians to have improved in only 9% of those who survived < 3 months, but in 68% of the patients who survived for > 3 months. Karnofsky performance status > 50 at the start of HPN was correlated with longer survival (p = .02). CONCLUSIONS Our study demonstrated a positive effect of HPN on nutritional status and quality of life in patients who survived > 3 months and suggests that HPN should be avoided when Karnofsky performance status is < 50.
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Affiliation(s)
- L Cozzaglio
- Department of Surgical Oncology of the Gastrointestinal Tract, Istituto Nazionale per lo Studio e la Cura dei Tumori, Milan, Italy
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Van Gossum A, Bakker H, de Francesco A, Ladefoged K, Leon-Sanz M, Messing B, Pironi L, Pertkiewicz M, Shaffer J, Thul P, Wood S. Nutrition parentérale à domicile chez l'adulte : enquête multicentrique en Europe en 1993 ESPEN — Home Artificial Nutrition Working Group. NUTR CLIN METAB 1997. [DOI: 10.1016/s0985-0562(97)80091-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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24
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Abstract
Treatable malnutrition may occur in up to 25% of hospital patients, depending on the specialty concerned. Nutritional status may also deteriorate during a prolonged hospital stay. The management and prevention of malnutrition requires a climate in which hospital managers have a positive policy towards nutritional care, a screening system to identify the patients at risk, and appropriate protocols for action. Catering services need to be reorganized to address the problems of the sick, so that appropriate food is not only prepared but delivered in a way which makes it likely to be consumed. For the optimal management of artificial nutrition by the enteral or parenteral route, a skilled nutrition team is both necessary and cost-effective.
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Abstract
An economic evaluation of home parenteral nutrition (HPN) for intestinal failure is presented. The cost-utility of HPN and factors affecting the cost-utility ratio were examined to determine whether current practice is the most efficient way of treating intestinal failure. Quality-adjusted life-years (QALYs) gained were measured using a validated health status questionnaire. The cost of treating a patient with intestinal failure was calculated, and marginal cost per QALY gained ratios were obtained. The cost per QALY for an average patient was approximately 68,975 pounds, but the value for patients over 55 years of age of about 126,865 pounds compared with approximately 58,233 pounds for those under 44 years. Treating a patient in hospital rather than at home increased the estimated cost per QALY to approximately 190,000 pounds. The current practice of home care is about 65 per cent more cost-effective than hospital care.
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Affiliation(s)
- D M Richards
- Hope Hospital, University of Manchester Intestinal Failure Unit, Salford, UK
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26
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Shields PL, Field J, Rawlings J, Kendall J, Allison SP. Long-term outcome and cost-effectiveness of parenteral nutrition for acute gastrointestinal failure. Clin Nutr 1996; 15:64-8. [PMID: 16844000 DOI: 10.1016/s0261-5614(96)80021-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/1995] [Accepted: 12/11/1995] [Indexed: 10/26/2022]
Abstract
Although there are several published audits of long-term home parenteral nutrition for chronic gastrointestinal failure, there is little data concerning the long-term outcome following prolonged in-patient parenteral nutrition for an episode of acute gastrointestinal failure. Between 1983 and 1 July 1993, 162 patients received total parenteral nutrition (TPN) in our unit for acute gastrointestinal failure for a total of 4997 patient days and using 192 central venous catheters. Over the 10 years there were 11 mechanical complications resulting in one death. Although the overall catheter infection rate was 5.7%, in the last 4 years it was 0%, associated with a reduction in the frequency of site dressing and change of giving set from three times to once weekly. All patients had lost more than 10% of their body weight before TPN. In the non-malignant group, fed for more than 21 days (mean 50 days), the 10-year survival was 74% at a cost of 4723 pounds sterling per year of life saved. In the malignant group, the 5-year survival was 27% at a cost of 8351 pounds sterling per year of life saved. These costs compare favourably with other technologies, such as dialysis for acute renal failure. Better patient selection, fewer complications and lower costs are obtained when this treatment is carried out by an expert team.
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Affiliation(s)
- P L Shields
- University Hospital, Queen's Medical Centre, Clifton Blvd, Nottingham N67 2UH, UK
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28
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Van Gossum A, Bakker H, De Francesco A, Ladefoged K, Leon-Sanz M, Messing B, Pironi L, Pertkiewicz M, Shaffer J, Thul P, Wood S. Home parenteral nutrition in adults: a multicentre surveyin Europe in 1993. Clin Nutr 1996; 15:53-9. [PMID: 16843998 DOI: 10.1016/s0261-5614(96)80019-7] [Citation(s) in RCA: 77] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/1995] [Accepted: 12/19/1995] [Indexed: 11/18/2022]
Abstract
A retrospective survey was performed in 1994, involving 496 adult home parenteral nutrition (HPN) cases, newly enrolled in the year 1993 from 13 European countries from 75 centres. From the 8 countries having registered more than 80% of cases (423 patients), incidence and prevalence ranged from 0.2 to 4.6 and 0.3 to 12.2 patients/10(6) population/year. In the patients studied, the diagnosis was cancer (42%), Crohn's disease (15%), vascular diseases (13%), radiation enteritis (8%), AIDS (4%) and other nonmalignant non-AIDS diseases (18%). Short bowel syndrome and intestinal obstruction were the two major indications for HPN in 31% and 22%, respectively. Seventy-three percent of the centres had a nutrition team. HPN was administered through a tunnelled venous central catheter in 73%, cyclical nocturnal infusions were used in 90% of patients, and intravenous feeding was the sole source of nutrition in 33%. Only 44% undertook HPN unaided. The present report indicates that cancer has now become the main indication for HPN in Europe; there was, however, a heterogeneous distribution of diseases amongst the reporting countries. The observed 9 (6-12)-month probability of survival was poor in AIDS (n = 8; 12%) and cancer patients (n = 78; 29%) but better for the other HPN indications (n = 115; 92%).
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Ladefoged K, Hessov I, Jarnum S. Nutrition in short-bowel syndrome. SCANDINAVIAN JOURNAL OF GASTROENTEROLOGY. SUPPLEMENT 1996; 216:122-31. [PMID: 8726285 DOI: 10.3109/00365529609094567] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Short-bowel syndrome is a state of severe malabsorption secondary to extensive bowel resection. The most common reasons for extensive bowel resection are Crohn's disease and mesenteric infarction. The pathophysiological consequences depend on extent and site of resection, integrity and adaptation of the remaining bowel, and secondary effects on other organs. Most extensively bowel resected patients can be adequately nourished by mouth, especially since they develop compensatory hyperphagia. For patients with colon in function a high-carbohydrate low-fat diet is beneficial compared to a diet with a normal fat content, because it results in decreased diarrhoea, decreased faecal mineral losses, and increased energy assimilation. The relative amount of dietary fat does not influence stool mass or energy assimilation in jejunostomy patients. Patients with jejunostomy have a high faecal output of water, sodium, and divalent cations, and they often need permanent parenteral supply of saline as well as calcium and magnesium if their small intestinal remnant is < 200 cm and parenteral nutritional support if they retain < 100 cm small bowel. In contrast, 50 cm of the jejunum often suffices for adequate oral nutrition if most of the colon is preserved. The majority of patients needing long-term intravenous supply are trained to administer parenteral nutrition at home (HPN). Most patients on HPN obtain a good or fair quality of life with hospital readmissions corresponding to an average of 10% of the HPN duration and an overall HPN related mortality of about 4%.
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Affiliation(s)
- K Ladefoged
- Medical Dept., Roskilde County Hospital, Koege, Denmark
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31
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Pilling M, Walley T. Effective contracting of high-tech health care for patients at home. JOURNAL OF MANAGEMENT IN MEDICINE 1995; 10:6-14. [PMID: 10162936 DOI: 10.1108/02689239610122261] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
High-technology treatments such as total parenteral nutrition or intravenous antibiotics may increasingly be provided to patients at home. In the past, these services have been funded by the NHS prescribing budget. The aim of the Department of Health's Executive letter EL(95)5, Purchasing High Tech Healthcare for Patients at Home was to ensure that contracts placed by health authority purchasers maintain effective patient services and obtain better value for money by encouraging competition between potential homecare providers. Examines contracting for high-tech health care for patients at home and suggests that efficiency could be improved when contracting with commercial home-care organizations by lead purchasing arrangements. In the long-term, contracting with NHS tertiary centres is most likely to ensure continuity of care and appropriate clinical monitoring of patients.
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Affiliation(s)
- M Pilling
- Department of Pharmacology and Therapeutics, University of Liverpool, UK
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32
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Pennington CR, Powell-Tuck J, Shaffer J. Review article: artificial nutritional support for improved patient care. Aliment Pharmacol Ther 1995; 9:471-81. [PMID: 8580266 DOI: 10.1111/j.1365-2036.1995.tb00409.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Malnutrition is common and undiagnosed in the majority of affected hospital patients; it is associated with impaired organ function, morbidity, and increased length of hospital stay. Artificial nutritional support in malnourished patients leads to improvement in nutritional status and clinical outcome. Nutritional support is required in malnourished patients, patients who are unable to take normal diet and patients with intestinal failure. Gastroenterologists are required to supervise patients with intestinal failure, to insert endoscopic feeding devices, and increasingly to participate in, or lead, nutritional support teams. Major developments in nutrient delivery have included percutaneous endoscopic feeding devices, the recognition that enteral feeding is possible in patients with gastric stasis, and that nutrient needs can be met by peripheral parenteral nutrition. There is much interest in the use of new substrates, or substrates delivered in pharmacological doses such as glutamine and arginine, to manipulate the response to disease. Many hospitals lack an organized approach to artificial nutritional support. Patients continue to suffer from a lack of treatment or the consequences of inappropriate or inadequate treatment. This article reviews the current status of artificial nutritional support and provides guidelines for patient management.
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Howard L, Ament M, Fleming CR, Shike M, Steiger E. Current use and clinical outcome of home parenteral and enteral nutrition therapies in the United States. Gastroenterology 1995; 109:355-65. [PMID: 7615183 DOI: 10.1016/0016-5085(95)90321-6] [Citation(s) in RCA: 380] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND & AIMS Home nutrition support, especially when delivered parenterally, is very costly. The aim of this study is to examine current usage of home parenteral and enteral nutrition (HPEN) in the United States and the quality of therapy outcome. METHODS Medicare HPEN use from 1989 to 1992 was analyzed to assess use, growth, and costs. National Registry information collected on 9288 patients treated with HPEN from 1985 to 1992 was used to assess disease distribution and therapy outcome. RESULTS In the United States, there were approximately 40,000 parenteral and 152,000 enteral home patients in 1992. The usage of HPEN doubled between 1989 and 1992, and a large proportion was in patients with short survival. The prevalence of HPEN in the United States was 4-10 times higher than in other Western countries. Outcome data showed both therapies were relatively safe. The primary disease strongly influenced survival and rehabilitation, and age, per se, was not a reason to deny HPEN. CONCLUSIONS Predicted quality survival at home for several months, rather than a specific diagnosis, seems to be the soundest justification for HPEN. Its role in terminal conditions and patients without primary gastrointestinal diseases needs further evaluations.
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Affiliation(s)
- L Howard
- Department of Medicine, Albany Medical College, New York, USA
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34
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Affiliation(s)
- C R Pennington
- Department of Clinical Pharmacology, Ninewells Hospital and Medical School, Dundee, UK
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35
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Messing B. Long-term outcome and quality of life of adult patients on home parenteral nutrition. Clin Nutr 1995; 14 Suppl 1:24-7. [PMID: 16843969 DOI: 10.1016/s0261-5614(95)80278-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The outcome and prognosis of home parenteral nutrition (HPN) patients may depend on their age and underlying disease and on HPN techniques. Results in the literature are confounded by mixing child and adult populations, short- and long-term HPN treatments and malignant and non-malignant cases. Only four papers have reported the probability of survival and only one of these used multivariate analysis. The quality of life of HPN patients, focusing on community and social rehabilitation, has been reported. The aspects of treatment differ depending upon the circumstances under which HPN is started (acute vs chronic) and the nature of the disease, facts which have to be taken into account in patient management. Prognosis of the underlying disease obviously has a major influence on how rehabilitation is viewed. Patients should be informed of the objectives of HPN by the nutrition team and family circumstances taken into account, before time-consuming and expensive HPN treatment is started.
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Affiliation(s)
- B Messing
- Hôpital Saint-Lazare, Service d'Hépato-Gastro-Entérologie et de Nutrition, Centre agréé de Nutrition Parentérale á Domicile, INSERM U290, 107 bis rue du Faubourg Saint-Denis, 75010 Paris, France
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36
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Boulétreau P. The optimal infusion line for home parenteralnutrition. Clin Nutr 1995; 14 Suppl 1:56-8. [PMID: 16843976 DOI: 10.1016/s0261-5614(95)80285-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- P Boulétreau
- Centre Agréé de Nutrition Parentérale à Domicile, Hotel Dieu-Lyon, France
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Pironi L, Tognoni G. Cost-benefit and cost-effectiveness analysis ofhome artificial nutrition: reappraisal of available data. Clin Nutr 1995; 14 Suppl 1:87-91. [PMID: 16843983 DOI: 10.1016/s0261-5614(95)80292-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- L Pironi
- Institute of Internal Medicine and Gastroenterology, University of Bologna, St. Orsola Hospital, Bologna, Italy
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Abstract
Catheter-related sepsis (CRS) in patients receiving home parenteral nutrition (HPN) is the most frequent complication, with an annual incidence rate of 0.30-0.50 in investigative/approved centres. CRS is responsible for patient deaths in 2.5% of cases which represent 50% of HPN-related deaths. A detailed and strictly applied protocol is the basis of prevention; therefore a low rate of CRS can be used as a marker of quality of care. Skin and hub cultures are used to rule out CRS since their predictive negative value assessed against (semi) quantitative cultures of cannulae were reported to be almost 100%. In the absence of catheter removal, clinical assessment plus quantitative blood cultures with a threshold ratio of 4:1 in central and peripheral blood is a reasonable basis of established CRS. Removal of the infected external cannula is necessary and immediate in cases of tunnel infection, virulent bacteria (e.g. Candida, Staph aureus or pseudomonas species) and for all occurrences of CRS on implantable chambers since conventional treatment fails to sterilise such devices. Thus standard antibiotic treatment may be effective in the absence of tunnel sepsis in the majority of CRS cases due to non-virulent bacteria (mainly Staph coagulase negative species). In these cases of CRS, our experience suggests that the antibiotic-lock technique offers definite advantages over conventional systemic antibiotic treatment, since external catheters were sterilised without recurrent sepsis in more than 85% of cases.
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Affiliation(s)
- B Messing
- Hôpital Saint-Lazare, Service d'Hépato-Gastro-Entérologie et de Nutrition, Centre agréé de Nutrition Parentérale á Domicile, INSERM U290, 107 bis rue du Faubourg Saint-Denis, 75010 Paris, France
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Balzola F, De Francesco A, Malfi G, Boggio Bertinet D, Avagnina S, Massarenti P. Small bowel transplantation: when should it be considered? Clin Nutr 1995; 14 Suppl 1:33-5. [PMID: 16843971 DOI: 10.1016/s0261-5614(95)80280-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- F Balzola
- Department of Gastroenterology and Clinical Nutrition, Molinette Hospital, C. So Bramante, 88-10126 Turin, Italy
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Affiliation(s)
- M Elia
- Dunn Clinical Nutrition Centre, Cambridge, UK
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Messing B, Lémann M, Landais P, Gouttebel MC, Gérard-Boncompain M, Saudin F, Vangossum A, Beau P, Guédon C, Barnoud D. Prognosis of patients with nonmalignant chronic intestinal failure receiving long-term home parenteral nutrition. Gastroenterology 1995; 108:1005-10. [PMID: 7698566 DOI: 10.1016/0016-5085(95)90196-5] [Citation(s) in RCA: 151] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND/AIMS Long-term survival of patients with intestinal failure requiring home parenteral nutrition (HPN) has been only partly shown. Therefore, we described the survival of these patients and explored prognosis factors. METHODS Two hundred seventeen noncancer non-acquired immunodeficiency syndrome adult patients presenting with chronic intestinal failure enrolled from January 1980 to December 1989 in approved HPN programs in Belgium and France; prognosis factors of survival were explored using multivariate analysis. Data were updated in March 1991; not one of the patients was lost to follow-up. RESULTS Seventy-three patients died during the survey, and the mortality rate related to HPN complications accounted for 11% of deaths. Probabilities of survival at 1, 3, and 5 years were 91%, 70%, and 62%, respectively. Three independent variables were associated with a decreased risk of death: age of patients younger than 40 years, start of HPN after 1987, and absence of chronic intestinal obstruction. In patients younger than 60 years of age included after 1983 with a very short bowel, who could represent suitable candidates for small bowel transplantation, the 2-year survival rate was 90%, a prognosis that compared favorably with recent reports of survival after small bowel transplantation. CONCLUSIONS HPN prognosis compares favorably with recent reports of survival after small bowel transplantation.
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Johnston DA, Richards J, Pennington CR. Auditing the effect of experience and change on home parenteral nutrition related complications. Clin Nutr 1994; 13:341-4. [PMID: 16843411 DOI: 10.1016/0261-5614(94)90022-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/1994] [Accepted: 07/08/1994] [Indexed: 10/26/2022]
Abstract
A prospective record of all patients receiving home parenteral nutrition (HPN) in Tayside since 1980 has been used to audit the effect of experience and specific policy changes on HPN related complications. Total HPN related complications fell significantly over the years from 1.59 complications per treatment year during the initial 5 years of HPN experience to the current rate of 0.36 complications per treatment year. Specific policy changes, such as modification of the glucose concentration of feed, could also be shown to produce a significant benefit in the reduction of complications. Increasing experience with HPN results in a fall in complication rates, however, continuous audit of HPN is essential to determine the effect of policy changes on complication rates.
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Affiliation(s)
- D A Johnston
- Gastroenterology Unit, Department of Clinical Pharmacology, Ninewells Hospipal & Medical School, Dundee, UK
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44
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Messing B. [Not Available]. Clin Nutr 1994; 13:192. [PMID: 16843382 DOI: 10.1016/0261-5614(94)90100-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
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Williams NM, Wales S, Scott NA, Irving MH. The incidence and management of catheter occlusion in patients on home parenteral nutrition. Clin Nutr 1993; 12:344-9. [PMID: 16843336 DOI: 10.1016/0261-5614(93)90030-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/1993] [Accepted: 08/24/1993] [Indexed: 11/24/2022]
Abstract
For patients on Home parenteral nutrition (HPN), catheter-related problems are the major source of morbidity and occlusion of the central venous catheter is one of these. We have managed 17 episodes of catheter occlusion in 10 patients on HPN. The median time from insertion to occlusive episode was 23 months. 10 catheters (59%) were saved by the used of thrombolytics (one by thrombolytics and ethanol) and 7 were replaced. The recent incidence of catheter occlusion in this cohort was one episode per 150 patient-months of HPN (0.08 episodes per year). Patients with Crohns disease appear to be at greater risk of developing catheter occlusion (p = <0.05).
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Affiliation(s)
- N M Williams
- Nutrition Unit, University of Manchester, Hope Hospital, Eccles Old Road, Salford, M6 8HD, UK
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Abstract
The experience of Home Parenteral Nutrition (HPN) in Tayside over the last 13 years has been reviewed with particular reference to the indications for, complications of, and quality of life whilst receiving HPN. The observed complication rate has been compared with that of the UK experience, and the observed complication rate for the first seven years of HPN experience has been compared with the subsequent six years. The Tayside experience equates broadly with that of the UK, although there was a different pattern of complications. Increasing experience with HPN has resulted in a fall in HPN related complications to 1 per 3.4 treatment years in Tayside, a rate as low as that of the most experienced HPN centre in the UK.
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Affiliation(s)
- D A Johnston
- Department of Clinical Pharmacology, Ninewells Hospital and Medical School, Dundee
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Carter DM, Wheatley C, Payne-James JJ, Pick A. Home nutrition survey in the UK: The patient's perspective. Clin Nutr 1993; 12:208-12. [PMID: 16843313 DOI: 10.1016/0261-5614(93)90016-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/1993] [Accepted: 04/01/1993] [Indexed: 11/25/2022]
Abstract
A detailed survey questionnaire compiled by the executive committee of Patients on Intravenous and Nasogastric Nutrition Therapy (PINNT) was circulated in November 1991 to the postal addresses of all full (patient) members of PINNT in the UK. The objective of the survey was to identify current practices and problems of home nutrition support as seen from the patients perspective. 128 questionnaires were distributed. 87 (68%) analysable questionnaires were completed and returned. 77 were for parenteral nutrition (HPN) patients and 10 for patients on enteral nutrition (HEN). Areas of concern for patients include the practicalities of administration of lipid and additives, and problems associated with the appearance of air in infusion bags. Although most patients appeared happy with the home nutrition support services 18% commented on particular negative aspects. This survey highlights such areas which may not be identified during routine patient/clinician contact.
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Affiliation(s)
- D M Carter
- PINNT, 258 Wennington Road, Rainham, Essex, RM13 9UU, UK
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