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Lal S, Paine P, Tack J, Aziz Q, Barazzoni R, Cuerda C, Jeppesen P, Joly F, Lamprecht G, Mundi M, Schneider S, Szczepanek K, Van Gossum A, Wanten G, Vanuytsel T, Pironi L. Avoiding the use of long-term parenteral support in patients without intestinal failure: A position paper from the European Society of Clinical Nutrition & Metabolism, the European Society of Neurogastroenterology and Motility and the Rome Foundation for Disorders of Gut-Brain Interaction. Clin Nutr 2024; 43:2279-2282. [PMID: 38824102 DOI: 10.1016/j.clnu.2024.05.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 05/15/2024] [Indexed: 06/03/2024]
Abstract
The role of long-term parenteral support in patients with underlying benign conditions who do not have intestinal failure (IF) is contentious, not least since there are clear benefits in utilising the oral or enteral route for nutritional support. Furthermore, the risks of long-term home parenteral nutrition (HPN) are significant, with significant impacts on morbidity and mortality. There has, however, been a recent upsurge of the use of HPN in patients with conditions such as gastro-intestinal neuromuscular disorders, opioid bowel dysfunction, disorders of gut-brain interaction and possibly eating disorders, who do not have IF. As a result, the European Society of Clinical Nutrition and Metabolism (ESPEN), the European Society of Neuro-gastroenterology and Motility (ESNM) and the Rome Foundation for Disorders of Gut Brain Interaction felt that a position statement is required to clarify - and hopefully reduce the potential for harm associated with - the use of long-term parenteral support in patients without IF. Consensus opinion is that HPN should not be prescribed for patients without IF, where the oral and/or enteral route can be utilised. On the rare occasions that PN commencement is required to treat life-threatening malnutrition in conditions such as those listed above, it should only be prescribed for a time-limited period to achieve nutritional safety, while the wider multi-disciplinary team focus on more appropriate biopsychosocial holistic and rehabilitative approaches to manage the patient's primary underlying condition.
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Affiliation(s)
- S Lal
- National Intestinal Failure Reference Centre, Northern Care Alliance and University of Manchester, Stott Lane, Salford, Manchester, M6 8HD, UK.
| | - P Paine
- Department of Gastroenterology, Northern Care Alliance and University of Manchester, Stott Lane, Salford, Manchester, M6 8HD, UK
| | - J Tack
- Translational Research Center for Gastrointestinal Disorders, KU Leuven, Herestraat 49, 3000, Leuven, Belgium; Rome Foundation, Raleigh, North Caroline, USA
| | - Q Aziz
- Blizard Institute, Wingate Institute for Neurogastroenterology, Centre for Neuroscience, Surgery and Trauma, Queen Mary University of London, London, UK
| | - R Barazzoni
- Department of Medical, Surgical and Health Sciences, University of Trieste, Italy
| | - C Cuerda
- Departamento de Medicina, Universidad Complutense de Madrid, Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - P Jeppesen
- Rigshospitalet, Department of Gastroenterology, Copenhagen, Denmark
| | - F Joly
- Department of Gastroenterology and Nutritional Support, Center for Intestinal Failure, Reference Centre of Rare Disease MarDI, AP-HP Beaujon Hospital, University of Paris Inserm UMR, 1149, Paris, France
| | - G Lamprecht
- Division of Gastroenterology and Endocrinology, Department of Medicine II, Rostock University Medical Center, Rostock, Germany
| | - M Mundi
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - S Schneider
- Gastroenterology and Nutrition, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, Nice, France
| | - K Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | - A Van Gossum
- Medico-Surgical Department of Gastroenterology, Hôpital Erasme, Free University of Brussels, Belgium
| | - G Wanten
- Intestinal Failure Unit, Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - T Vanuytsel
- Translational Research Center for Gastrointestinal Disorders, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - L Pironi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; Centre for Chronic Intestinal Failure, IRCCS AOUBO, Bologna, Italy
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Lal S, Paine P, Tack J, Aziz Q, Barazzoni R, Cuerda C, Jeppesen P, Joly F, Lamprecht G, Mundi M, Schneider S, Szczepanek K, Van Gossum A, Wanten G, Vanuytsel T, Pironi L. Avoiding the use of long-term parenteral support in patients without intestinal failure: A position paper from the European Society of Clinical Nutrition & Metabolism, the European Society of Neurogastroenterology and Motility and the Rome Foundation for Disorders of Gut-Brain Interaction. Neurogastroenterol Motil 2024; 36:e14853. [PMID: 38973248 DOI: 10.1111/nmo.14853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 05/15/2024] [Indexed: 07/09/2024]
Abstract
The role of long-term parenteral support in patients with underlying benign conditions who do not have intestinal failure (IF) is contentious, not least since there are clear benefits in utilising the oral or enteral route for nutritional support. Furthermore, the risks of long-term home parenteral nutrition (HPN) are significant, with significant impacts on morbidity and mortality. There has, however, been a recent upsurge of the use of HPN in patients with conditions such as gastro-intestinal neuromuscular disorders, opioid bowel dysfunction, disorders of gut-brain interaction and possibly eating disorders, who do not have IF. As a result, the European Society of Clinical Nutrition and Metabolism (ESPEN), the European Society of Neuro-gastroenterology and Motility (ESNM) and the Rome Foundation for Disorders of Gut Brain Interaction felt that a position statement is required to clarify - and hopefully reduce the potential for harm associated with - the use of long-term parenteral support in patients without IF. Consensus opinion is that HPN should not be prescribed for patients without IF, where the oral and/or enteral route can be utilised. On the rare occasions that PN commencement is required to treat life-threatening malnutrition in conditions such as those listed above, it should only be prescribed for a time-limited period to achieve nutritional safety, while the wider multi-disciplinary team focus on more appropriate biopsychosocial holistic and rehabilitative approaches to manage the patient's primary underlying condition.
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Affiliation(s)
- S Lal
- National Intestinal Failure Reference Centre, Northern Care Alliance and University of Manchester, Salford, Manchester, UK
| | - P Paine
- Department of Gastroenterology, Northern Care Alliance and University of Manchester, Salford, Manchester, UK
| | - J Tack
- Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
- Rome Foundation, Raleigh, North Carolina, USA
| | - Q Aziz
- Blizard Institute, Wingate Institute for Neurogastroenterology, Centre for Neuroscience, Surgery and Trauma, Queen Mary University of London, London, UK
| | - R Barazzoni
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - C Cuerda
- Departamento de Medicina, Universidad Complutense de Madrid, Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - P Jeppesen
- Department of Gastroenterology, Rigshospitalet, Copenhagen, Denmark
| | - F Joly
- Department of Gastroenterology and Nutritional Support, Center for Intestinal Failure, Reference Centre of Rare Disease MarDI, AP-HP Beaujon Hospital, University of Paris Inserm UMR, Paris, France
| | - G Lamprecht
- Division of Gastroenterology and Endocrinology, Department of Medicine II, Rostock University Medical Center, Rostock, Germany
| | - M Mundi
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - S Schneider
- Gastroenterology and Nutrition, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, Nice, France
| | - K Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | - A Van Gossum
- Medico-Surgical Department of Gastroenterology, Hôpital Erasme, Free University of Brussels, Brussels, Belgium
| | - G Wanten
- Intestinal Failure Unit, Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - T Vanuytsel
- Translational Research Center for Gastrointestinal Disorders, KU Leuven, Leuven, Belgium
| | - L Pironi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Centre for Chronic Intestinal Failure, IRCCS AOUBO, Bologna, Italy
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García Almeida JM, Cornejo Pareja IM, Fernández Jiménez R, Lupiáñez Pérez Y, Molina Garrido MJ, Abreu Padín C, Alfaro-Martínez JJ, Andreu Gosalbez MD, Argente Pla M, Arosa Carril V, Artero A, Cayón-Blanco M, Cuéllar Olmedo LÁ, de la Maza Pereg L, Diego Perojo E, Díez-Muñiz-Alique M, Diezhandino García P, Fernández de Bobadilla-Pascual B, Fernández Soto ML, Fuentes Tudanca S, Gil Gascón JM, Irles-Rocamora JA, Juan Rodríguez L, Llamazares Iglesias O, Losfablos Callau F, Manzano García G, Marco-Alacid C, Pérez Cobos M, Mendoza Sierra MªE, Olay Gayoso L, Olivares Alcolea J, Pereira Cunill JL, Pérez Alonso O, Rebollo Pérez MI, Ruiz Palomar JM, Silva Rodríguez JJ, Sorribes Carreras P, Vázquez Vizcaíno B, Wu-Xiong NY. [Improving the nutritional care of oncology patients - Validation of a multidisciplinary protocol in the Spanish clinical setting]. NUTR HOSP 2024; 41:758-765. [PMID: 38967309 DOI: 10.20960/nh.05043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2024] Open
Abstract
Introduction Introduction: malnutrition is a very frequent problem in oncology patients and may have serious repercussions. Adequate nutritional management is cost-effective in terms of health and survival in this population, but it requires multidisciplinary coordination, specific training, and continuous follow-up. Objective: to validate the applicability and efficacy of a multidisciplinary nutritional support protocol in oncology patients. Methods: a multidisciplinary nutritional protocol was developed for oncology patients, with guidelines for screening and assessment of malnutrition, treatment, re-evaluation, and management of side effects, as well as guidance on supplementation and eating patterns. The protocol would be implemented in various clinical centers, collecting data through a structured questionnaire, registering variables before and after implementation. Results: the protocol and its impact were implemented and evaluated in 39 centers. An improvement in nutritional care was observed, evidenced by an earlier initiation of nutritional assessment and an increase in the number of patients receiving adequate care following the protocol implementation. Problems related to inadequate malnutrition coding in the centers, limited resources, and the need for greater interdepartmental collaboration were identified. Conclusions: the conduct of this study provides insights into how the implementation of a multidisciplinary nutritional support protocol can improve the nutritional care received by patients and informs about the main obstacles to adequate implementation.
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Affiliation(s)
- José Manuel García Almeida
- UGC de Endocrinología y Nutrición. Hospital Universitario Virgen de la Victoria. Servicio de Endocrinología y Nutrición. Hospital Quirónsalud Málaga
| | - Isabel María Cornejo Pareja
- UGC de Endocrinología y Nutrición. Hospital Universitario Virgen de la Victoria. Instituto de Investigación Biomédica de Málaga
| | | | - Yolanda Lupiáñez Pérez
- Unidad de Oncología Radioterápica y Radiofísica Hospitalaria. Hospital Universitario Virgen de la Victoria
| | | | | | | | | | - María Argente Pla
- Servicio de Endocrinología y Nutrición. Hospital Universitari i Politècnic La Fe
| | | | - Ana Artero
- Servicio de Endocrinología y Nutrición. Hospital General Universitario de Valencia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Juan José Silva Rodríguez
- Unidad de Nutrición. Unidad de Gestión Clínica de Endocrinología y Nutrición. Hospital Universitario Puerto Real
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Bozzetti F. The role of the nutrition in malnourished cancer patients: Revisiting an old dilemma. Clin Nutr 2024; 43:1320-1328. [PMID: 38669764 DOI: 10.1016/j.clnu.2024.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 03/10/2024] [Accepted: 03/20/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND & AIMS GLIM definition of malnutrition is recognised all over the world and, when is referring to cancer, it specifies that weight or muscle loss are associated with an inflammatory status. However, the real-world practice shows that GLIM definition cannot encompass all the wide and heterogenous clinical presentations of cancer patients with malnutrition, which involves many other drivers beyond inflammation. Moreover, placing an excessive emphasis on the inflammation can overshadow, in the clinical practice, the role of the nutritional support in malnourished cancer patients. The aim of this paper is not to criticize the rationale of the GLIM definition of cancer cachexia, but to show the complexity and heterogeneity of malnutrition of cancer patients and reasons why nutritional support should deserve such a better consideration among the oncologists. METHODS Literature pertinent to pathophysiology of malnutrition of cancer patients is scrutinised and reasons for the frequent underuse of nutritional support are critically analysed. RESULTS The appraisal of the literature shows that there are various pathophysiological patterns of malnutrition among cancer patients and inflammatory markers are not universally present in weight-losing cancer patients. Inflammation alone does not account for weight loss in all cancer patients and factors other than inflammation can drive hypophagia and weight loss, and hypophagia appears to be a primary catalyst for weight loss. Furthermore, malnutrition may be the consequence of the presence of several Nutrition Impact Symptoms or of the oncologic therapy. The nutritional support may fail to show benefits in malnourished cancer patients because the golden standard to validate a therapy relies on RCT, but it is ethically impossible to have an unfed control group of malnourished patients. Furthermore, nutritional interventions often fell short of the optimal standards, adherence to treatment plans was often poor, nutritional support was mainly reserved for very advanced patients and the primary endpoints of the studies on nutritional support were sometimes unrealistic. CONCLUSION There is a gap between the suggestion of the guidelines which advocate the use of nutritional support to improve the compliance of patients facing intensive oncologic treatments or to prevent an early demise when patients enter a chronic phase of slow nutritional deterioration, and the poor use of nutrition in the real-world practice. This requires a higher level of awareness of the oncologists concerning the reasons for the lacking evidence of efficacy of the nutritional support and an understanding of its potential contribute to improve the outcome of the patients. Finally, this paper calls for a change of the oncologist's approach to the cancer patient, from only focusing on the cure of the tumour to taking care of the patient as a whole.
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Moreno Villares JM, Virgili-Casas MN, Ashbaugh Enguídanos R, Wanden-Berghe C, Cantón Blanco A, Álvarez Hernández J, Bretón I, Del Olmo D, Ferrero López I, Lozano Fuster FM, Molina Soria JB. [Home parenteral nutrition in patients with malignant bowel obstruction. Ethical considerations]. NUTR HOSP 2024; 41:255-261. [PMID: 38095086 DOI: 10.20960/nh.05042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024] Open
Abstract
Introduction Background: patients with cancer are one of the main group of patients on home parenteral nutrition (HPN). Patients with malignant bowel obstruction (MBO) represent a challenging group when considering HPN. At the Ethics Working Group of SENPE ethical considerations on this subject were reviewed and a guidelines proposal was made. Methods: a literature search was done and a full set of questions arose: When, if ever, is HPN indicated for patients with MBO? How should the training program be? When withdrawal of HPN should be considered? Other questions should be also taken into consideration. May any Oncologist send home a patient with HPN? The educational program could be shortened? When considering to withdraw parenteral nutrition? Results: HPN in MBO has better outcomes when patients have a good functional status (Karnofsky ≥ 50 or ECOG ≤ 2), expected survival > 2-3 months, and low inflammatory markers. Very few data have been reported on quality of life, but HPN allows a valuable time at home albeit with a considerable burden for both patients and their families. Proposal: once a patient is considered for HPN, there is a need for a deep talk on the benefits, complications and risks. In this initial talk, when HNP should be stopped needs to be included. The palliative care team with the help of the nutrition support team should follow the patient, whose clinical status must be assessed regularly. HPN should be withdrawn when no additional benefits are achieved. Conclusion: HPN may be considered an option in patients with MBO when they have a fair or good functional status and a desire to spend their last days at home.
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Affiliation(s)
| | | | - Rosana Ashbaugh Enguídanos
- Unidad de Nutrición Clínica y Dietética. Servicio de Endocrinología y Nutrición. Hospital Universitario Príncipe de Asturias
| | | | - Ana Cantón Blanco
- Servicio de Endocrinología y Nutrición. Complejo Hospitalario Universitario de Santiago de Compostela (CHUS)
| | - Julia Álvarez Hernández
- Unidad de Nutrición Clínica y Dietética. Servicio de Endocrinología y Nutrición. Hospital Universitario Príncipe de Asturias
| | - Irene Bretón
- Nutrition Unit. Hospital General Universitario Gregorio Marañón. Instituto de Investigación Sanitaria Gregorio Marañón
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Pironi L, Cuerda C, Jeppesen PB, Joly F, Jonkers C, Krznarić Ž, Lal S, Lamprecht G, Lichota M, Mundi MS, Schneider SM, Szczepanek K, Van Gossum A, Wanten G, Wheatley C, Weimann A. ESPEN guideline on chronic intestinal failure in adults - Update 2023. Clin Nutr 2023; 42:1940-2021. [PMID: 37639741 DOI: 10.1016/j.clnu.2023.07.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 07/21/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND & AIMS In 2016, ESPEN published the guideline for Chronic Intestinal Failure (CIF) in adults. An updated version of ESPEN guidelines on CIF due to benign disease in adults was devised in order to incorporate new evidence since the publication of the previous ESPEN guidelines. METHODS The grading system of the Scottish Intercollegiate Guidelines Network (SIGN) was used to grade the literature. Recommendations were graded according to the levels of evidence available as A (strong), B (conditional), 0 (weak) and Good practice points (GPP). The recommendations of the 2016 guideline (graded using the GRADE system) which were still valid, because no studies supporting an update were retrieved, were reworded and re-graded accordingly. RESULTS The recommendations of the 2016 guideline were reviewed, particularly focusing on definitions, and new chapters were included to devise recommendations on IF centers, chronic enterocutaneous fistulas, costs of IF, caring for CIF patients during pregnancy, transition of patients from pediatric to adult centers. The new guideline consist of 149 recommendations and 16 statements which were voted for consensus by ESPEN members, online in July 2022 and at conference during the annual Congress in September 2022. The Grade of recommendation is GPP for 96 (64.4%) of the recommendations, 0 for 29 (19.5%), B for 19 (12.7%), and A for only five (3.4%). The grade of consensus is "strong consensus" for 148 (99.3%) and "consensus" for one (0.7%) recommendation. The grade of consensus for the statements is "strong consensus" for 14 (87.5%) and "consensus" for two (12.5%). CONCLUSIONS It is confirmed that CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for the underlying gastrointestinal disease and to provide HPN support. Most of the recommendations were graded as GPP, but almost all received a strong consensus.
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Affiliation(s)
- Loris Pironi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; Center for Chronic Intestinal Failure, IRCCS AOUBO, Bologna, Italy.
| | - Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Francisca Joly
- Center for Intestinal Failure, Department of Gastroenterology and Nutritional Support, Hôpital Beaujon, Clichy, France
| | - Cora Jonkers
- Nutrition Support Team, Amsterdam University Medical Centers, Location AMC, Amsterdam, the Netherlands
| | - Željko Krznarić
- Center of Clinical Nutrition, Department of Medicine, University Hospital Center, Zagreb, Croatia
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, United Kingdom
| | | | - Marek Lichota
- Intestinal Failure Patients Association "Appetite for Life", Cracow, Poland
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic College of Medicine, Rochester, MN, USA
| | | | - Kinga Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | | | - Geert Wanten
- Intestinal Failure Unit, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Carolyn Wheatley
- Support and Advocacy Group for People on Home Artificial Nutrition (PINNT), United Kingdom
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, St. George Hospital, Leipzig, Germany
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Sowerbutts AM, Lal S, Pironi L, Jones D, French C, Riis M, Clamp A, McCracken J, Williamson L, Wheatley C, Johnson B, Burden S. Patients, family members and healthcare professionals' top ten research priorities for adults receiving home parenteral nutrition for malignant or benign disease. Clin Nutr ESPEN 2023; 53:151-158. [PMID: 36657907 DOI: 10.1016/j.clnesp.2022.12.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 12/01/2022] [Accepted: 12/03/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Home parenteral nutrition (HPN) is the primary treatment for chronic intestinal failure (CIF) due to non-malignant disease and is increasingly used in patients with a diagnosis of cancer. This project engaged with patients, family members and healthcare professionals to ascertain what questions they want researched. METHODS This study followed the five-stage process of the James Lind Alliance that involved (1) setting up a steering group, (2) carrying out an initial survey to gather participants' questions, (3) data processing, (4) an interim priority setting survey and (5) final priority setting workshop. Surveys were translated and back translated into Italian, Danish and French. RESULTS The project was delivered by an international steering committee with representation from Denmark, Italy, the United Kingdom and United States consisting of three patients, six healthcare professionals and facilitated by University researchers. For the first survey, 633 questions were submitted by 292 respondents from 12 countries. There were 79 questions removed as out of scope or already in the published literature. Responses were collated into two interim surveys of 41 questions for benign CIF and 13 questions for HPN and cancer. In the second survey, 216 respondents prioritised their top ten questions. The ordering from the cancer and HPN survey was taken as definitive; top priorities were quality of life, survival, when to commence HPN, using HPN with anti-cancer treatments, access barriers, measuring benefit and ethical implications. For CIF with benign disease, 18 questions were discussed in two workshops attended by 13 patients and 7 healthcare professionals. The questions were ranked using a modified nominal group technique; the top research priorities were prevention and treatment of liver disease, improving central infusion lines, oral absorption, avoiding long-term negative consequences, vascular access, side effects, line infections, decreasing stoma output, quality of life and sleep. CONCLUSIONS Priorities identified will assist researchers to focus on research questions important to patients, family members and healthcare professionals.
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Affiliation(s)
| | - Simon Lal
- Salford Royal Foundation Trust, Salford, UK; School of Medical Sciences, University of Manchester, Manchester, UK
| | - Loris Pironi
- Alma Mater Studiorum -University of Bologna, Department of Medical and Surgical Sciences, Italy; IRCCS Azienda Ospedaliero-Universitaria di Bologna, Center for Chronic Intestinal Failure - Clinical Nutrition and Metabolism Unit, Italy
| | - Debra Jones
- School of Health Sciences, University of Manchester, Manchester, UK
| | - Chloe French
- School of Health Sciences, University of Manchester, Manchester, UK
| | | | - Andrew Clamp
- School of Medical Sciences, University of Manchester, Manchester, UK; Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
| | - Jennifer McCracken
- Richard Wells Rehabilitation Centre, The Royal Marsden NHS Foundation Trust, Sutton, UK
| | | | | | | | - Sorrel Burden
- School of Health Sciences, University of Manchester, Manchester, UK; Salford Royal Foundation Trust, Salford, UK
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Kopczynska M, Hvas CL, Jepsen P, Teubner A, Abraham A, Burden ST, Taylor M, Carlson G, Lal S. Standardised survival and excess Life Years Lost in patients with type 3 intestinal failure. Clin Nutr 2022; 41:2446-2454. [PMID: 36215864 DOI: 10.1016/j.clnu.2022.09.010] [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: 05/29/2022] [Revised: 08/27/2022] [Accepted: 09/16/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND & AIMS Long term outcomes have been reported in home parenteral nutrition (HPN)-dependent patients with type 3 intestinal failure (IF), but there are limited survival data standardised to the general population that would help provide a meaningful prognosis for patients and clinicians. The primary aim of this study was therefore to investigate the survival of HPN-dependent patients and to evaluate the specific impact of type 3 IF on their life expectancy standardised to that of the general population. METHODS This was a cohort study of adult patients initiated on HPN between 1978 and 2018 at a national UK IF reference centre and followed up until death or censoring date of 31st December 2020. The standardised mortality ratio (SMR) was calculated as observed deaths divided by expected deaths using UK Office for National Statistics database. Excess Life Years Lost (LYL) were calculated separately for each sex as the differences in average life expectancy between patients with type 3 IF and the general population. Survival data were evaluated using cox regression models adjusting for confounding. RESULTS In total, 1046 patients were identified, with a total observation time of 7344.1 patient-years. Patients with malignancy (n = 206) were excluded from the survival analysis. Of the remaining 840 patients, 398 were alive by the end of follow-up. The probability of survival was 91.8% at 1 year, 69.3% at 5 years, 54.3% at 10 years, 29.8% at 20 years and 16.7% at 30 years. Patients who did not achieve nutritional autonomy had an increased likelihood of death compared to patients who ceased HPN. In total, 40 (9.0%) deaths were HPN or IF-related, while underlying disease leading to IF accounted for 98 (22.2%) deaths. There were 270 (61.1%) deaths not related to IF, with the majority of these patients dying from infections unrelated to HPN. Overall mortality rates were higher among patients with a diagnosis of type 3 IF compared with the general UK population with a SMR of 7.48 (95% CI 6.80 to 8.21) and an excess mortality rate of 54.0 per 1000 person-years. All mechanisms of IF were associated with excess mortality, with SMR ranging from 6.82 (95% CI 5.98 to 7.72) for short bowel syndrome to 15.51 (95% CI 11.73 to 20.03) for dysmotility. On average, the excess LYL was 17.45 years for males and 17.39 years for females compared with the general population of the same age. CONCLUSION This the largest single-centre series reporting survival outcomes in patients with type 3 IF over more than a four-decade period and the first to report LYL in this patient cohort. Type 3 IF was associated with more than seven-fold higher mortality rates than for the general UK population and shorter life expectancies of more than 17 years. Survival, however, was better in those able to achieve nutritional autonomy. Since the majority of deaths were due to non-HPN or non-IF causes, there is clearly a need now to further explore these causes of death in order to improve our understanding of excessive mortality in type 3 IF and develop ways to prevent it.
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Affiliation(s)
- Maja Kopczynska
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, United Kingdom.
| | - Christian L Hvas
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Peter Jepsen
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Antje Teubner
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Arun Abraham
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Sorrel T Burden
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, United Kingdom; University of Manchester, Manchester, United Kingdom
| | - Michael Taylor
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Gordon Carlson
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, United Kingdom; University of Manchester, Manchester, United Kingdom
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Kopczynska M, Teubner A, Abraham A, Taylor M, Bond A, Clamp A, Wight R, Salih Z, Hasan J, Mitchell C, Jayson GC, Lal S. Home Parenteral Nutrition in Patients with Advanced Cancer: Quality Outcomes from a Centralized Model of Care Delivery. Nutrients 2022; 14:nu14163379. [PMID: 36014885 PMCID: PMC9414691 DOI: 10.3390/nu14163379] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/12/2022] [Accepted: 08/15/2022] [Indexed: 11/16/2022] Open
Abstract
Lack of expertise in home parenteral nutrition (HPN) management has been reported as a barrier to its initiation in patients with advanced cancer (AC), and there are limited data describing hospital readmissions and HPN-related complications. We aimed to assess a centralized approach for managing HPN in AC and evaluate associated outcomes, including hospital readmissions and HPN-related complications. This was a cohort study of adults with AC requiring palliative HPN between 2010–2018 at a tertiary intestinal failure (IF) center, primarily utilizing a centralized model of HPN oversight to discharge patients remotely from an oncology center to their homes over a wide geographic area. A total of 126 patients were included, with a median distance between the patient’s home and the IF center of 17.5 km (IQR 10.9–39.1; maximum 317.4 km). A total of 28 (22%) patients experienced at least one HPN-related complication, the most common being a central venous catheter (CVC) occlusion and electrolyte abnormalities. The catheter-related bloodstream infection (CRBSI) rate was 0.49/1000 catheter days. The CVC type, administration of concomitant chemotherapy via a distinct CVC lumen separate from PN, venting gastrostomy and distance between the patient’s home and the IF center were not associated with CRBSI or mechanical CVC complications. A total of 82 (65.1%) patients were readmitted while on HPN, but only 7 (8.5%) of these readmissions were HPN-related. A total of 44 (34.9%) patients died at home, 41 (32.5%) at a hospice and 41 (32.5%) in a hospital. In conclusion, this study demonstrates that a centralized approach to IF care can provide HPN to patients over a large geographical area while maintaining low HPN-related complications that are comparable to patients requiring HPN for benign conditions and low hospital readmission rates.
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Affiliation(s)
- Maja Kopczynska
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford M6 8HD, UK
- Correspondence: ; Tel.: +44-1612065116
| | - Antje Teubner
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford M6 8HD, UK
| | - Arun Abraham
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford M6 8HD, UK
| | - Michael Taylor
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford M6 8HD, UK
| | - Ashley Bond
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford M6 8HD, UK
- School of Health Sciences, University of Manchester, Manchester M13 9PL, UK
| | - Andrew Clamp
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK
| | - Rebecca Wight
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK
| | - Zena Salih
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK
| | - Jurjees Hasan
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK
| | - Claire Mitchell
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK
| | - Gordon C. Jayson
- School of Health Sciences, University of Manchester, Manchester M13 9PL, UK
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester M20 4BX, UK
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford M6 8HD, UK
- School of Health Sciences, University of Manchester, Manchester M13 9PL, UK
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