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Hirsch TI, Fligor SC, Tsikis ST, Mitchell PD, DeVietro A, Carbeau S, Wang SZ, McClelland J, Carey AN, Gura KM, Puder M. Administration of 4% tetrasodium EDTA lock solution and central venous catheter complications in high-risk pediatric patients with intestinal failure: A retrospective cohort study. JPEN J Parenter Enteral Nutr 2024; 48:624-632. [PMID: 38837803 PMCID: PMC11216891 DOI: 10.1002/jpen.2644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 05/06/2024] [Accepted: 05/07/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND Selection of central venous catheter (CVC) lock solution impacts catheter mechanical complications and central line-associated bloodstream infections (CLABSIs) in pediatric patients with intestinal failure. Disadvantages of the current clinical standards, heparin and ethanol lock therapy (ELT), led to the discovery of new lock solutions. High-risk pediatric patients with intestinal failure who lost access to ELT during a recent shortage were offered enrollment in a compassionate use trial with 4% tetrasodium EDTA (T-EDTA), a lock solution with antimicrobial, antibiofilm, and antithrombotic properties. METHODS We performed a descriptive cohort study including 14 high-risk pediatric patients with intestinal failure receiving 4% T-EDTA as a daily catheter lock solution. CVC complications were documented (repairs, occlusions, replacements, and CLABSIs). Complication rates on 4% T-EDTA were compared with baseline rates, during which patients were receiving either heparin or ELT (designated as heparin/ELT). RESULTS Patients initiated 4% T-EDTA at the time they were enrolled in the compassionate use protocol. Use of 4% T-EDTA resulted in a 50% reduction in CVC complications, compared with baseline rates on heparin/ELT (incidence rate ratio: 0.50; 95% CI, 0.25-1.004; P = 0.051). CONCLUSION In a compassionate use protocol for high-risk pediatric patients with intestinal failure, the use of 4% T-EDTA reduced composite catheter complications, including those leading to emergency department visits, hospital admissions, additional procedures, and mortality. This outcome suggests 4% T-EDTA has benefits over currently available lock solutions.
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Affiliation(s)
- Thomas I Hirsch
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Scott C Fligor
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Savas T Tsikis
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Paul D Mitchell
- Biostatistics and Research Design Center, Boston Children’s Hospital, Boston, MA, USA
| | - Angela DeVietro
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Boston, MA, USA
| | - Sarah Carbeau
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Boston, MA, USA
| | - Sarah Z Wang
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jennifer McClelland
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children’s Hospital, Boston, MA, USA
| | - Alexandra N Carey
- Harvard Medical School, Boston, MA, USA
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children’s Hospital, Boston, MA, USA
| | - Kathleen M Gura
- Harvard Medical School, Boston, MA, USA
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children’s Hospital, Boston, MA, USA
- Department of Pharmacy, Boston Children’s Hospital, Boston, MA, USA
| | - Mark Puder
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Jahns F, Hausen A, Keller P, Stolz V, Kalff JC, Kuetting D, von Websky MW. Life on the line - Incidence and management of central venous catheter complications in intestinal failure. Clin Nutr 2024; 43:1627-1634. [PMID: 38772069 DOI: 10.1016/j.clnu.2024.05.013] [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: 01/29/2024] [Revised: 04/16/2024] [Accepted: 05/04/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND & AIMS Loss of venous access is threatening for patients with intestinal failure (IF) under long-term parenteral nutrition (PN). We aimed to identify the incidence of central venous catheter (CVC) complications, compare different devices, and analyze interventional recanalizing procedures to restore the patency of occluded CVCs. METHODS For this retrospective cohort study, patient data from a prospective IF database spanning 16 years was analyzed at a tertiary referral center. Catheter dwell times (CDTs) were distinguished by Kaplan-Meier survival analysis and subgroup analyses were performed for different CVC types (tunneled/port catheters). Specific complications (occlusion, catheter-related infection (CRI), displacement, and material defect) were analyzed. Explantation rates and CDTs were compared. RESULTS Overall, 193 CVCs in 77 patients with IF under PN could be enrolled (62.524 "CVC-days"). Broviac type "B" was found to be significantly superior to type "A" regarding occlusion, CRI, and material defects (log-rank test: p = 0.05; p = 0.026; p = 0.005 respectively). Port catheters were displaying the highest incidence of CRI (2.13 events/1000 catheter days). Interventional catheter recanalization was performed 91 times and significantly increased the CDT from a median of 131 days (IQR: 62; 258) to 389 days (IQR: 262; 731) (Mann-Whitney-U-test: p= <0.001) without increasing complications. CONCLUSIONS Different complication rates and CDT were seen depending on CVC type. Tunneled catheters were significantly superior concerning CRI. Interventional catheter recanalization is a viable alternative to fibrinolytics to restore CVC patency, but long-term patency data is scarce.
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Affiliation(s)
- Franziska Jahns
- Department of General-, Visceral-, Thoracic- and Vascular Surgery, University Hospital of Bonn, Bonn, Germany
| | - Annekristin Hausen
- Department of Internal Medicine, University Hospital of Bonn, Bonn, Germany
| | - Peter Keller
- Department of General-, Visceral-, Thoracic- and Vascular Surgery, University Hospital of Bonn, Bonn, Germany
| | - Verena Stolz
- Department of General-, Visceral-, Thoracic- and Vascular Surgery, University Hospital of Bonn, Bonn, Germany
| | - Jörg C Kalff
- Department of General-, Visceral-, Thoracic- and Vascular Surgery, University Hospital of Bonn, Bonn, Germany
| | - Daniel Kuetting
- Department of Radiology, University Hospital of Bonn, Bonn, Germany
| | - Martin W von Websky
- Department of General-, Visceral-, Thoracic- and Vascular Surgery, University Hospital of Bonn, Bonn, Germany.
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Walter E, Dawoud C, Hütterer E, Stift A, Harpain F. Cost-effectiveness of teduglutide in adult patients with short bowel syndrome - a European socioeconomic perspective. Am J Clin Nutr 2024; 119:1187-1199. [PMID: 38431119 PMCID: PMC11130673 DOI: 10.1016/j.ajcnut.2024.02.031] [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: 09/03/2023] [Revised: 02/22/2024] [Accepted: 02/28/2024] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND Short bowel syndrome with intestinal failure (SBS-IF) is a rare but devastating medical condition. An absolute loss of bowel length forces the patients into parenteral support dependency and a variety of medical sequelae, resulting in increased morbidity and mortality. Interdisciplinary treatment may include therapy with the effective but expensive intestinotrophic peptide teduglutide. OBJECTIVES A time-discrete Markov model was developed to simulate the treatment effect [lifetime costs, quality-adjusted life years (QALYs), and life years (LYs)] of teduglutide plus best supportive care compared with best supportive care alone in patients with SBS-IF. METHODS The health status of the model was structured around the number of days on PS. Clinical data from 3 data sets were used: 1) an Austrian observational study (base case), 2) pooled observational cohort studies, and 3) a prospective study of teduglutide effectiveness in parenteral nutrition-dependent short bowel syndrome subjects. Direct and indirect costs were derived from published sources. QALYs, LYs, and costs were discounted (3% per annum). RESULTS Under the base case assumption, teduglutide is associated with costs of 2,296,311 € per patient and 10.78 QALYs (13.74 LYs) over a lifetime horizon. No teduglutide is associated with 1,236,816 € and 2.24 QALYs (8.57 LYs). The incremental cost-utility ratio (ICUR) amounts to 123,945 €. In case of the pooled clinical data set, the ICUR increases to 184,961 €. If clinical data based on the study of teduglutide effectiveness in parenteral nutrition-dependent short bowel syndrome subjects were used, the ICUR increased to 235,612 €. CONCLUSIONS Teduglutide in treating patients with SBS-IF meets the traditional cost-effectiveness criteria from a European societal perspective. Nevertheless, the varying concentrations of teduglutide efficacy leave a degree of uncertainty in the calculations.
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Affiliation(s)
- Evelyn Walter
- IPF Institute for Pharmaeconomic Research, Vienna, Austria
| | - Christopher Dawoud
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Elisabeth Hütterer
- Division of Oncology, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Anton Stift
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria
| | - Felix Harpain
- Division of Visceral Surgery, Department of General Surgery, Medical University of Vienna, Vienna, Austria.
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Cohen M, Hounkonnou C, Billiauws L, Lecoq E, Villain C, Alvarado C, Joly F. Central venous catheter (CVC) salvage in case of central line-associated bloodstream infection (CLABSI): A monocentric prospective study in patients on long-term home parenteral nutrition (HPN). Clin Nutr ESPEN 2023; 58:89-96. [PMID: 38057041 DOI: 10.1016/j.clnesp.2023.09.005] [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: 03/09/2023] [Revised: 08/07/2023] [Accepted: 09/07/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND & AIMS CLABSI is a major complication in HPN and frequently leads to central venous catheter (CVC) removal. We developed a salvaging attitude in long term HPN patients due to the necessity of venous preservation. The main objective of this study is to determine the prognosis of CLABSI. METHODS We followed-up for three months, in an approved HPN centre, a cohort of 250 adult patients receiving HPN with CLABSI from 2018 to 2020. CLABSI was defined by a blood culture growth differential [peripheral blood] - [CVC blood] ≥ 2h. A therapeutic approach to conserve CVC was established according to the department's protocol. The primary endpoint was conservation of CVC with negative CVC and peripheral blood cultures at 3 months without complications. RESULTS Data from 30 CLABSIs were collected for 22 HPN patients. The incidence rate of CLABSIs was 0.28 infections/1000 catheter days. Sixteen CVCs were removed immediately, with causes due to the type of germ (staphylococcus aureus: n = 6, candida parapsilosis: n = 4, klebsiella: n = 2), chronic colonization (n = 4) or initial complications (n = 4). Among the 14 non-removed CVC, 11 were maintained at 3 months with blood cultures on CVC and peripheral negative for 9 (80%) of them. 3 CVC were removed during the 3 months follow-up (non-CVC-related sepsis n = 2, and resistant pseudomonas aeruginosa n = 1). CONCLUSION The incidence rate of CLABSIs in an expert HPN centre remains low. In case of CLABSIs, according to specific protocol, approximately 50% of CVC were removed immediately (essentially due to bacteriological characteristics). In case of CLABSIs and without initial complication, 80% of CVCs can be maintained at 3 months. These results justify a conservative attitude according to standardized protocol.
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Affiliation(s)
- Mathilde Cohen
- Gastroenterology, MICI and Nutrition, MarDi Constitutive Centre, Beaujon Hospital, Clichy, France
| | - Cornelia Hounkonnou
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, IAME, CIC-EC 1425, F-75018 Paris, France; Department of Epidemiology Biostatistics and Clinical Research, APHP, Bichat Hospital, Paris, France
| | - Lore Billiauws
- Gastroenterology, MICI and Nutrition, MarDi Constitutive Centre, Beaujon Hospital, University of Paris, INSERM UMR1149, France
| | - Emilie Lecoq
- Gastroenterology, MICI and Nutrition, MarDi Constitutive Centre, APHP, Beaujon Hospital, Clichy, France
| | - Claude Villain
- Gastroenterology, MICI and Nutrition, MarDi Constitutive Centre, APHP, Beaujon Hospital, Clichy, France
| | - Cathy Alvarado
- Gastroenterology, MICI and Nutrition, MarDi Constitutive Centre, APHP, Beaujon Hospital, Clichy, France
| | - Francisca Joly
- Gastroenterology, MICI and Nutrition, MarDi Constitutive Centre, Beaujon Hospital, University of Paris, INSERM UMR1149, France.
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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: 7] [Impact Index Per Article: 7.0] [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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Luhn C, Agis H, Hütterer E, Simonitsch‐Klupp I, Dawoud C, Stift A, Harpain F. Teduglutide in amyloidosis-associated intestinal failure. Clin Case Rep 2023; 11:e7653. [PMID: 37601424 PMCID: PMC10433832 DOI: 10.1002/ccr3.7653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 06/19/2023] [Indexed: 08/22/2023] Open
Abstract
Amyloidosis is a heterogeneous disease characterized by tissue deposition of abnormally folded fibrillary proteins that can manifest itself by a wide variety of symptoms depending on the affected organs. GI involvement among amyloidosis patients is common. Its clinical manifestation often presents with nonspecific symptoms such as weight loss, diarrhea, and malabsorption. With no specific treatment existing for GI amyloidosis, therapy focuses on impeding amyloid deposition and managing the patients' symptoms with supportive measures. Here, we present an AL-amyloidosis patient with GI involvement and intestinal failure (IF) who was successfully treated with the glucagon-like peptide-2 (GLP-2) analogue teduglutide. Over the course of treatment with teduglutide, the patient was able to achieve independence from parenteral nutrition and experienced a significant improvement in quality of life (QoL) as stool frequency and consistency improved, urinary output was stabilized and body weight as well as body composition improved over the course of teduglutide therapy. With no longer being exposed to the burden and associated risks of parenteral nutrition, we were able to reduce the potential morbidity and mortality rate as well as to improve the patient's overall QoL. Intestinal tissue biopsy workup revealed a histopathological correlate for the clinical response; Congo-Red-positive intestinal depositions almost completely disappeared within 6 months of teduglutide therapy. Implementing intestinotrophic GLP-2 analogue teduglutide may enrich the spectrum of treatment options for amyloidosis patients with IF who are dependent on parenteral support.
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Affiliation(s)
- Clara Luhn
- Division of Visceral Surgery, Department of General SurgeryMedical University ViennaViennaAustria
| | - Hermine Agis
- Division of Hematology and Hemostaseology, Department of Internal Medicine IMedical University of ViennaViennaAustria
| | - Elisabeth Hütterer
- Division of Oncology, Department of Internal Medicine IMedical University of ViennaViennaAustria
| | | | - Christopher Dawoud
- Division of Visceral Surgery, Department of General SurgeryMedical University ViennaViennaAustria
| | - Anton Stift
- Division of Visceral Surgery, Department of General SurgeryMedical University ViennaViennaAustria
| | - Felix Harpain
- Division of Visceral Surgery, Department of General SurgeryMedical University ViennaViennaAustria
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Adorno A, Silinsky J, Ghio M, Rogers N, Simpson JT, Guidry C. High lipid, low dextrose parenteral nutrition allows patient to achieve nutritional autonomy: A case report. Int J Surg Case Rep 2023; 109:108510. [PMID: 37478700 PMCID: PMC10375845 DOI: 10.1016/j.ijscr.2023.108510] [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: 06/26/2023] [Revised: 07/10/2023] [Accepted: 07/15/2023] [Indexed: 07/23/2023] Open
Abstract
INTRODUCTION Prolonged use of parenteral nutrition can eventually lead to liver abnormalities. Causative factors include decreased enteral stimulation, high intakes of intravenous dextrose, proinflammatory 100 % soybean oil-based lipids, and increased burden on liver through 24-h infusions. We present a case report of a patient who received parenteral nutrition modifications to address liver dysfunction. PRESENTATION OF CASE Our patient was a 37-year-old African American male with a past medical history including refractory Crohn's disease complicated by multiple small bowel obstructions, several bowel surgeries, left lower quadrant colostomy placement, short bowel syndrome, severe protein calorie malnutrition, parenteral nutrition dependence, and elevated liver function tests. He was admitted for nutritional optimization before a planned takedown of multiple chronic enterocutaneous and perianal fistulas. His home parenteral nutrition order contained high amounts of dextrose (69 % kcal), and low amounts of 100 % soybean oil (11 % kcal). DISCUSSION Due to an elevated alkaline phosphatase level at baseline (1746 U/L), the Registered Dietitian maximized protein, decreased the dextrose by 62.5 %, and changed to SMOFlipid (a fish-oil containing lipid) at >1 g/kg/day to address liver abnormalities. Within 1.5 months of changing parenteral nutrition to high SMOFlipid (>30 % kcal) with low dextrose (<30 % kcal) content, alkaline phosphatase levels declined by 62 %, prealbumin levels increased by 56 %, and c-reactive protein levels decreased by 62 %. CONCLUSION Parenteral nutrition modifications led to reversal of chronic liver dysfunction. This patient ultimately underwent a successful high-risk fistula takedown procedure, allowing for complete weaning of parenteral nutrition and achievement of sustained nutritional autonomy.
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Affiliation(s)
- Andrew Adorno
- Department of Surgery, Tulane Medical Center, New Orleans, LA 70112, USA.
| | - Jennifer Silinsky
- Department of Surgery, Tulane Medical Center, New Orleans, LA 70112, USA.
| | - Michael Ghio
- Department of Surgery, Tulane Medical Center, New Orleans, LA 70112, USA.
| | - Nathaniel Rogers
- Department of Surgery, Tulane Medical Center, New Orleans, LA 70112, USA.
| | - John Tyler Simpson
- Department of Surgery, Tulane Medical Center, New Orleans, LA 70112, USA.
| | - Chrissy Guidry
- Department of Surgery, Tulane Medical Center, New Orleans, LA 70112, USA.
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Schönenberger KA, Reber E, Huwiler VV, Dürig C, Muri R, Leuenberger M, Mühlebach S, Stanga Z. Quality of Life in the Management of Home Parenteral Nutrition. ANNALS OF NUTRITION & METABOLISM 2023; 79:326-333. [PMID: 36934718 PMCID: PMC10614234 DOI: 10.1159/000530082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 03/03/2023] [Indexed: 03/19/2023]
Abstract
INTRODUCTION Home parenteral nutrition (HPN) is a rare but challenging therapy for patients with mostly severe underlying diseases. We aimed to investigate patient-reported health-related quality of life (QOL) of patients receiving HPN and its development over time in particular. METHODS We assessed QOL of HPN patients in a prospective multicenter observational study (SWISSHPN II study). We designed a questionnaire to record symptoms and negative impacts of HPN and completed the validated Optum® SF-36v2® Health Survey with the patients. RESULTS Seventy patients (50% women) on HPN were included. HPN commonly affected feelings of dependency (n = 49, 70%), traveling/leaving home (n = 37, 53%), attending cultural and social events (n = 25, 36%), and sleep (n = 22, 31%). Most frequently reported symptoms were diarrhea (n = 30, 43%), polyuria (n = 28, 40%), nausea/emesis (n = 27, 39%), dysgeusia (n = 23, 33%), and cramps (n = 20, 29%). At baseline, mean (standard deviation) SF-36v2® physical and mental health component summary scores (PCS and MCS) were 45 (20) and 57 (19), respectively, and there was a trend toward improvement in PCS over the study period, while MCS remained stable. Satisfaction with health care professionals involved in HPN care was high. CONCLUSION QOL is a crucial and decisive aspect of HPN patient care. Symptoms related to the underlying disease and PN are frequent. Impaired social life and an ambivalent attitude toward the life-saving therapy are major concerns for these patients and should be addressed in their care.
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Affiliation(s)
- Katja A. Schönenberger
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism (UDEM), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Emilie Reber
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism (UDEM), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Valentina V. Huwiler
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism (UDEM), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Christa Dürig
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism (UDEM), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Raphaela Muri
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism (UDEM), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michèle Leuenberger
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefan Mühlebach
- Division of Clinical Pharmacy and Epidemiology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Zeno Stanga
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism (UDEM), Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Wu G, Liu C, Zhou X, Zhao L, Zhang W, Wang M, Zhao Q, Liang T. Short- and long-term complications after living donor ileal resection. Am J Transplant 2022; 22:3053-3060. [PMID: 36066568 DOI: 10.1111/ajt.17193] [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: 07/04/2022] [Revised: 09/01/2022] [Accepted: 09/01/2022] [Indexed: 01/25/2023]
Abstract
Intestinal transplantation from deceased donors is the established procedure for patients with irreversible intestinal failure. However, a living-donor intestinal transplant has not been routinely performed yet because of undefined surgical risks to the donor. In this report, we reviewed our experience with living-donor ileal resection from May 1999 to December 2021. A total of 40 living-donor ileal resections were performed for 40 intestinal transplant recipients. Clinical data were prospectively collected and analyzed for postoperative complications after ileal procurement. None of the donors experienced life-threatening complications or mortality. Six (15%) of 40 donors experienced minor operative complications. Transit intestinal graft inadequacy including weight loss, diarrhea, and vitamin B12 deficiency was common early following surgery, but was manageable and disappeared in most cases within a year. All donors had significant reductions in total plasma cholesterol and low-density lipoprotein cholesterol concentrations after donation as compared with the baseline levels. With an average follow-up of 67.8 months, bilateral kidney stones occurred in one donor and gallstones in the other. All the donors have regained their normal capacity for work. Living-donor ileal resection is associated with minimal short- and long-term morbidity and remains an attractive alternative for potential recipients when suitable deceased donors are unavailable.
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Affiliation(s)
- Guosheng Wu
- Intestinal Transplant Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chaoxu Liu
- Intestinal Transplant Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xile Zhou
- Intestinal Transplant Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Long Zhao
- Intestinal Transplant Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wentong Zhang
- Intestinal Transplant Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Mian Wang
- Department of Gastrointestinal Surgery, the First Affiliated Hospital, the Fourth Military Medical University, Xi'an, China
| | - Qingchuan Zhao
- Department of Gastrointestinal Surgery, the First Affiliated Hospital, the Fourth Military Medical University, Xi'an, China
| | - Tingbo Liang
- Department of Hepatobiliary and Pancreatic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Provincial Key Laboratory of Pancreatic Disease, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang University Cancer Center, Zhejiang University, Hangzhou, China
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Cotogni P, Bozzetti F, Goldwasser F, Jimenez-Fonseca P, Roelsgaard Obling S, Valle JW. Supplemental parenteral nutrition in cancer care: why, who, when. Ther Adv Med Oncol 2022; 14:17588359221113691. [PMID: 36188487 PMCID: PMC9520136 DOI: 10.1177/17588359221113691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 06/28/2022] [Indexed: 11/15/2022] Open
Abstract
Malnutrition is an often-overlooked challenge for patients with cancer. It is associated with muscle mass reduction, poor compliance and response to cancer treatments, decreased quality of life, and reduced survival time. The nutritional assessment and intervention should be a vital part of any comprehensive cancer treatment plan. However, data on artificial nutrition supplied based on caloric needs during cancer care are scarce. In this review, we discuss the recommendations of the European and American societies for clinical nutrition on the use of nutritional interventions in malnourished patients with cancer in the context of current clinical practice. In particular, when enteral nutrition (oral or tube feeding) is not feasible or fails to meet the complete nutritional needs, supplemental parenteral nutrition (SPN) can bridge the gap. We report the available evidence on SPN in cancer patients and identify the perceived barriers to the wider application of this intervention. Finally, we suggest a ‘permissive’ role of SPN in cancer care but highlight the need for rigorous clinical studies to further evaluate the use of SPN in different populations of cancer patients.
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Affiliation(s)
- Paolo Cotogni
- Pain Management and Palliative Care, Department of Anesthesia, Intensive Care and Emergency, Molinette Hospital, University of Turin, Corso Bramante 88-90, Turin 10126, Italy
| | | | - François Goldwasser
- Medical Oncology Department, URP 4466, Cochin Hospital, AP-HP, Paris University, Paris, France
| | - Paula Jimenez-Fonseca
- Medical Oncology Department, Asturias Central University Hospital, ISPA, Oviedo, Spain
| | - Sine Roelsgaard Obling
- Department of Medical Gastroenterology, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Juan W Valle
- Division of Cancer Sciences, The University of Manchester, Manchester, UK.,Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, UK
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11
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Yeh DD, Vasileiou G, Mulder M, Byerly S, Ripat C, Byers PM. Severe Short Bowel Syndrome: Prognosis for Nutritional Independence Through Management by a Multidisciplinary Nutrition Service and Surgery. Am Surg 2022:31348221087901. [PMID: 35465680 DOI: 10.1177/00031348221087901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Short bowel syndrome (SBS) is a debilitating condition associated with significant morbidity and mortality. Historically, SBS patients require indefinite parenteral nutrition (PN) and endure lifelong nutritional challenges. The purpose of this study was to review the outcomes, specifically nutritional independence, of a multidisciplinary nutrition service. METHODS A retrospective analysis of SBS patients followed by our surgical nutrition service was performed. Patients without 1-year follow-up were excluded. Demographics and nutritional parameters were collected at 4 intervals: initial presentation, 1-year, 2-year, and 5-year follow-up. Short bowel syndrome anatomical subtypes identified through operative reports were characterized as end jejunostomy, jejunocolonic, or jejuno-ileocolonic with ileo-cecal valve intact. Intestinal failure was defined by the requirement of PN, while intestinal insufficiency was defined by enteral support requirement. Clinical outcomes examined included mortality, fistula closure, and nutritional independence. RESULTS The study cohort comprised 89 patients, 50 of whom had ≤ 100 cm intestinal length. Mean age was 57 ± 17y, 55 (62%) were female, and median initial intestinal length was 77 [60-120] cm. Short bowel syndrome was complicated by fistulas in 47 (53%) of patients. Overall mortality was 13%, and 67 (75%) were liberated from PN. A total of 58 (65%) underwent operative intervention and fistula closure was achieved in 37 of 47 (79%) patients. CONCLUSIONS Short bowel syndrome patients can experience significant benefit under treatment by a multidisciplinary nutrition service. By incorporating surgical intervention, the majority of patients previously relegated to lifelong PN have the opportunity to become nutritionally independent within 5 years.
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Affiliation(s)
| | | | | | - Saskya Byerly
- 12325University of Tennessee Health Science Center, Memphis, TN, USA
| | - Caroline Ripat
- University of Miami Miller School of Medicine, Miami, FL, USA
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12
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Cuerda C, Pironi L, Arends J, Bozzetti F, Gillanders L, Jeppesen PB, Joly F, Kelly D, Lal S, Staun M, Szczepanek K, Van Gossum A, Wanten G, Schneider SM, Bischoff SC. ESPEN practical guideline: Clinical nutrition in chronic intestinal failure. Clin Nutr 2021; 40:5196-5220. [PMID: 34479179 DOI: 10.1016/j.clnu.2021.07.002] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 07/02/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND This practical guideline is based on the ESPEN Guidelines on Chronic Intestinal Failure in Adults. METHODOLOGY ESPEN guidelines have been shortened and transformed into flow charts for easier use in clinical practice. The practical guideline is dedicated to all professionals including physicians, dieticians, nutritionists, and nurses working with patients with chronic intestinal failure. RESULTS This practical guideline consists of 112 recommendations with short commentaries for the management and treatment of benign chronic intestinal failure, including home parenteral nutrition and its complications, intestinal rehabilitation, and intestinal transplantation. CONCLUSION This practical guideline gives guidance to health care providers involved in the management of patients with chronic intestinal failure.
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Affiliation(s)
- Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
| | - Loris Pironi
- Alma Mater Studiorum - University of Bologna, Department of Medical and Surgical Sciences, Italy; IRCCS Azienda Ospedaliero-Universitaria di Bologna, Centre for Chronic Intestinal Failure - Clinical Nutrition and Metabolism Unit, Italy
| | - Jann Arends
- Department of Medicine I, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | | | - Lyn Gillanders
- Emeritus of Auckland City Hospital, Auckland, New Zealand
| | - Palle Bekker Jeppesen
- Rigshospitalet, Department of Intestinal Failure and Liver Diseases Gastroenterology, Copenhagen, Denmark
| | - Francisca Joly
- Centre for Intestinal Failure, Department of Gastroenterology and Nutritional Support, Hôpital Beaujon, Clichy, France
| | - Darlene Kelly
- Emeritus of Mayo Graduate School of Medicine, Rochester, Minnesota
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
| | - Michael Staun
- Rigshospitalet, Department of Intestinal Failure and Liver Diseases Gastroenterology, Copenhagen, Denmark
| | - Kinga Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | - André Van Gossum
- Medico-Surgical Department of Gastroenterology, Hôpital Erasme, Free University of Brussels, Belgium
| | - Geert Wanten
- Intestinal Failure Unit, Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Stéphane Michel Schneider
- Gastroenterology and Clinical Nutrition, CHU of Nice, University of Nice Sophia Antipolis, Nice, France
| | - Stephan C Bischoff
- Department of Nutritional Medicine and Prevention, University of Hohenheim, Stuttgart, Germany
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13
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[Our eight-year experience in home parenteral nutrition for adult patients]. NUTR HOSP 2021; 37:654-659. [PMID: 32686441 DOI: 10.20960/nh.03008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Introduction Background: home parenteral nutrition (HPN) is a technique that allows increasing the survival of patients with intestinal failure. Aim: to study the evolution of home parenteral nutrition over the last 8 years in our center. Methods: a retrospective study of adult patients receiving HPN between 2011 and 2019. Study variables are expressed as frequency and mean ± SD (range). Parametric, non-parametric tests, and a survival analysis (p < 0.05) were applied. Results: the use of HPN showed a substantial increase (up to 154 %). A total of 76 patients received HPN, 76.32 % had an oncological pathology, and consequently the main indication was intestinal obstruction (56.58 %). Average duration was 11.12 ± 23.38 months (0.17-139.17). In all, 44.74 % experienced one or several complications, primarily catheter-related bacteremia (CRB) (27.63 %), and metabolic disorders (40.79 %), mainly of hepatic type. CRB rate was 2.25/1,000 days of HPN. The main cause of death was the underlying disease. Overall survival in case of benign conditions at 1, 3, and 5 years was 65.5 %, 53.6 %, and 40.2 %, respectively. In case of malignancy overall survival at 3 months was 55.1 %, at 6 months 28.7 %, and at 1 years 19.1 %. Conclusions: oncological disease was the primary condition that led to an indication in our center. It is the underlying pathology what determines prognosis, which must be taken into account at the time of selecting patients. The BRC rate obtained is susceptible to improvement, so it is essential that health education and a correct technique be encouraged.
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14
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Pavurala RB, Stanich PP, Krishna SG, Guturu P, Hinton A, Conwell DL, Balasubramanian G. Predictors of Early Readmissions in Hospitalized Patients With Gastroparesis: A Nationwide Analysis. J Neurogastroenterol Motil 2021; 27:408-418. [PMID: 34210906 PMCID: PMC8266506 DOI: 10.5056/jnm20105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 11/06/2020] [Accepted: 11/17/2020] [Indexed: 12/01/2022] Open
Abstract
Background/Aims Gastroparesis is a chronic gastrointestinal disorder that frequently presents with symptoms that are difficult to manage, necessitating frequent hospitalizations. We sought to determine the predictors of early readmission due to gastroparesis based on etiology. Methods We identified all adults discharged with a principal diagnosis of gastroparesis after hospitalization from the 2014 Nationwide Readmission Database. We compared etiology wise (diabetes, post-surgical, and idiopathic) early readmission. Multivariate regression analyses were performed to identify significant predictors of 30-day readmission. Results A total of 12 689 patients were identified, 30.7% diabetic, 2.6% post-surgical, and 66.7% were idiopathic. Patients with diabetic gastroparesis were more likely to be readmitted within 30 days than idiopathic (adjusted odds ratio [aOR], 0.81; 95% confidence interval [CI], 0.69-0.94) and post-surgical gastroparesis (aOR, 0.58; 95% CI, 0.34-0.98). Pyloroplasty was associated with less likelihood of 30-day readmission (aOR, 0.45; 95% CI, 0.20-0.97). In addition, male gender (aOR, 1.18; 95% CI, 1.02-1.37), modified Elixhauser comorbidity score ≥ 3 (aOR, 1.38; 95% CI, 1.18-1.61), chronic pain syndrome (aOR, 1.41; 95% CI, 1.11-1.78), younger (18-64 years) age (aOR, 1.64; 95% CI, 1.34-2.00), need for percutaneous endoscopic gastrostomy/jejunostomy tube (aOR, 2.06; 95% CI, 1.21-3.52), and need for total parenteral nutrition (aOR, 1.70; 95% CI, 1.24-2.35) were associated with increased risk of 30-day readmission. Conclusions One in 5 patients was readmitted with gastroparesis within 30 days. In the diabetic group, diabetes-related complications contributed to readmissions than gastroparesis. Pyloroplasty is associated with reduced early hospital readmission. Prospective studies are needed for validation of these results.
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Affiliation(s)
- Ravi B Pavurala
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Peter P Stanich
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Somashekar G Krishna
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Praveen Guturu
- Division of Gastroenterology and Hepatology, University of Texas Medical Branch, Galveston, TX, USA
| | - Alice Hinton
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, OH, USA
| | - Darwin L Conwell
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Gokulakrishnan Balasubramanian
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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15
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Cost-effectiveness of Intestinal Transplantation Compared to Parenteral Nutrition in Adults. Transplantation 2021; 105:897-904. [PMID: 32453254 DOI: 10.1097/tp.0000000000003328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Intestinal transplantation (ITx) is the most expensive abdominal organ transplant. Detailed studies about exact costs and cost-effectiveness compared to home parenteral nutrition (HPN) therapy in chronic intestinal failure are lacking. The aim is to provide an in-depth analysis of ITx costs and evaluate cost-effectiveness compared to HPN. METHODS To calculate costs before and after ITx, costs were analyzed in 12 adult patients. To calculate the costs of patients with uncomplicated chronic intestinal failure, 28 adults, stable HPN patients were studied. Total costs including surgery, admissions, diagnostics, HPN therapy, medication, and ambulatory care were included. Median (range) costs are given. RESULTS Costs before ITx were €69 160 (€60 682-90 891) in year 2, and €104 146 (€83 854-186 412) in year 1. After ITx, costs were €172 133 (€122 483-351 407) in the 1st year, €40 619 (€3905-113 154) in the 2nd year, and dropped to €15 743 (€4408-138 906) in the 3rd year. In stable HPN patients, the costs were €83 402 (€35 364-169 146) in the 1st year, €70 945 (€31 955-117 913) in the 2nd year, and stabilized to €60 242 (€29 161-238 136) in the 3rd year. CONCLUSIONS ITx, although initially very expensive, is cost-effective compared to HPN in adults by year 4, and cost-saving by year 5.
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Clinical Characteristics and Outcomes of S. Aureus Bacteremia in Patients Receiving Total Parenteral Nutrition. Nutrients 2020; 12:nu12103131. [PMID: 33066383 PMCID: PMC7602162 DOI: 10.3390/nu12103131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/05/2020] [Accepted: 10/09/2020] [Indexed: 11/16/2022] Open
Abstract
Background: Patients on total parenteral nutrition (TPN) are at risk of developing central line-associated infections. Specifically, Staphylococcus aureus bacteremia (SAB) is feared for its high complication rates. This prospective cohort study compares characteristics, clinical course and outcome of SAB in patients with and without TPN support. Methods: Clinical and microbiological data from all patients with positive blood cultures for S. aureus from two facilities, including our referral center for TPN support, were retrieved (period 2013-2020). Primary outcome was overall mortality, and included survival analysis using a multivariate Cox regression model. Secondary outcomes comprised a comparison of clinical characteristics and outcomes between both patient groups and analysis of factors associated with complicated outcome (e.g., endocarditis, deep-seated foci, relapse and death) in patients on TPN specifically. Results: A total of 620 SAB cases were analyzed, of which 53 cases received TPN at the moment the blood culture was taken. Patients in the TPN group were more frequently female, younger and had less comorbidity (p < 0.001). In-hospital death and overall mortality were significantly lower in TPN patients (4% vs. 18%, p = 0.004 and 10% vs. 34%, p < 0.001, respectively). Positive follow-up blood cultures, delayed onset of therapy and previous catheter problems were associated with a higher incidence of complicated SAB outcome in patients on TPN. Conclusion: Our data show that patients on TPN have a milder course of SAB with lower mortality rates compared to non-TPN SAB patients.
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17
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Quirt J, Belza C, Pai N, Clause R, Markovic F, Wong‐Sterling S, Avitzur Y, Wales PW. Reduction of Central Line–Associated Bloodstream Infections and Line Occlusions in Pediatric Intestinal Failure Patients Receiving Long‐Term Parenteral Nutrition Using an Alternative Locking Solution, 4% Tetrasodium Ethylenediaminetetraacetic Acid. JPEN J Parenter Enteral Nutr 2020; 45:1286-1292. [DOI: 10.1002/jpen.1989] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 07/15/2020] [Accepted: 07/28/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Jill Quirt
- Group for Improvement of Intestinal Function and Treatment The Hospital for Sick Children University of Toronto Toronto Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children University of Toronto Toronto Canada
| | - Christina Belza
- Group for Improvement of Intestinal Function and Treatment The Hospital for Sick Children University of Toronto Toronto Canada
| | - Nikhil Pai
- Division of Gastroenterology and Nutrition, McMaster Children's Hospital McMaster University Hamilton Canada
| | - Rose‐Frances Clause
- Division of Gastroenterology and Nutrition, McMaster Children's Hospital McMaster University Hamilton Canada
| | - Filip Markovic
- Division of Gastroenterology and Nutrition, McMaster Children's Hospital McMaster University Hamilton Canada
| | - Sylvia Wong‐Sterling
- Group for Improvement of Intestinal Function and Treatment The Hospital for Sick Children University of Toronto Toronto Canada
| | - Yaron Avitzur
- Group for Improvement of Intestinal Function and Treatment The Hospital for Sick Children University of Toronto Toronto Canada
- Division of Gastroenterology, Hepatology, and Nutrition The Hospital for Sick Children University of Toronto Toronto Canada
| | - Paul W. Wales
- Group for Improvement of Intestinal Function and Treatment The Hospital for Sick Children University of Toronto Toronto Canada
- Division of General and Thoracic Surgery, The Hospital for Sick Children University of Toronto Toronto Canada
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18
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Saqui O, Fernandes G, Allard J. Central venous catheter infection in Canadian home parenteral nutrition patients: a 5-year multicenter retrospective study. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2020; 29:S34-S42. [PMID: 32324464 DOI: 10.12968/bjon.2020.29.8.s34] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
HIGHLIGHTS A lower central venous catheter (CVC) infection rate suggests an improvement in practice and education. CVC infection remains a complication that often requires significant health care resources. Use of tunneled CVC and patient education on catheter care reduces CVC infection rates. OBJECTIVES CVC infection is one of the most frequent, life-threatening complications in home parenteral nutrition (HPN) patients. Our objective was to conduct a 5-year retrospective chart review regarding CVC infections in 3 adult HPN programs. METHODS Data were collected from the Canadian HPN Registry and patient charts that include demography, infection diagnosis, blood cultures, and treatments. RESULTS Results are reported as median (range) ± standard error of mean or population frequency. Eighty-one charts were reviewed. Mean age was 51.98 ± 1.71 years. Short bowel syndrome (54.3%) was the primary diagnosis, with 36 months (range, 1324 months) median length of HPN therapy. Forty-seven subjects (58%) had infections over a 5-year period. Of these, there were 144 sepsis events. There was positive correlation (r=0.423; P<0.001) between number of infections and HPN duration. The median length of time the CVC was in place was 281 (range, 14-4380) days. There were 66.7% tunneled CVCs; 25.9% peripherally inserted central catheters (PICCs), and 7.4% implanted venous port. In this sample, there was no association between line infection and catheter type. Most patients presented with fever (58.3%) and chills (38.2%). Blood cultures were done (89.6%), and coagulase negative Staphylococcus was the resulting pathogen present in 25.7%. Patients with bloodstream infection were treated for 17.9 ± 1.2 days with combination antibiotics (22.2%). Overall, the CVC infection rate was 0.97 per 1000 catheter days. CONCLUSION We found the standard approach to infection prevention is comparable to reports in literature. However, a subset of patients with multiple CVC infections require education with an emphasis on preventive techniques in order to reduce the incidence of infection.
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Affiliation(s)
- Olivia Saqui
- Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - G Fernandes
- Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - J Allard
- Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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19
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Leiberman D, Stevenson RP, Banu FW, Gerasimidis K, McKee RF. The incidence and management of complications of venous access in home parenteral nutrition (HPN): A 19 year longitudinal cohort series. Clin Nutr ESPEN 2020; 37:34-43. [PMID: 32359753 DOI: 10.1016/j.clnesp.2020.03.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 02/02/2020] [Accepted: 03/28/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUNDS AND AIMS Long term central venous access for Home Parenteral Nutrition (HPN) is associated with catheter related complications. The most studied and well known of these is Catheter Related Blood Stream Infection (CRBSI). This paper looks at other venous access complications, including blocked and damaged catheters, catheter related thrombosis and CRBSI. This paper will also present treatment outcomes for each of these complications. This paper will also examine if there are any correlating patient or catheter related factors that can help predict future catheter related complications. By demonstrating the treatment outcomes for each line complication, it is hoped this will contribute to the literature that could be used for standard setting in complications related to long term central venous access. METHODS HPN data were analysed from the Greater Glasgow and Clyde (GGC) Home Parenteral Nutrition Database (HPN) which is a comprehensive, prospectively maintained electronic record of all HPN patients treated in GGC. The time period of data collection was 1998-2017. Descriptive statistics were used to report data frequency, age, and catheter days' distributions. Data were not normally distributed and so non-parametric tests were used. Spearman's Rho correlation was used to measure correlation between two numeric groups. Catheter complications were reported as a rate in count data, meaning that more than one event could be recorded per patient, with 1000 catheter days as the person-time denominator. Poisson means test and Fisher exact tests were used to compare different rates, as complications were treated as count data increasing over variable total time periods. P < 0.05 with 95% confidence interval (CI) was considered significant in all tests. Comparisons between binary data sets used two sample t-tests to compare the groups. RESULTS From 169 patients, 101 (59.8%) were female and 68 (40.2%) were male. The age when first starting HPN ranged from 16 to 79 years old with a median of 56 years. Total catheter days was 173,151 derived from 408 catheter insertions on 169 patients. 282 complications occurred in 85 patients over the study period. An overall catheter complication rate of 1.62/1000 days was found. 84 patients did not experience a single complication. There were 171 proven catheter infections in 66 patients over the study period. Infection rate from the entire period of report was 1.35 infections/1000 catheter days. This decreased over time. Infection was found to be correlated with length of time on HPN, catheter location, catheter diameter and use of Taurolock-Hep100. Thrombosis (n = 16) was associated with total time on HPN (r2 = 0.187, P < 0.05) and the number of infections (r2 = 0.207, P < 0.05). Damage was strongly associated with increasing time on HPN with (r2 of 0.494 and P < 0.005). Blockage was not associated with any patient or catheter factors. Overall catheter salvage rate for CRBSI by antibiotic treatment was 61.87%. Success varied according to organism cultured. Catheter salvage was less successful in other complications and overall catheter salvage rate was 41,115 catheters were salvaged from 282 complications. CONCLUSIONS This study has provided a baseline for rates of less common venous access complications in HPN and their management. Catheter salvage is possible after at least 41% of complications. It is likely that experience is helpful whether that of individual patient, the team or a clinical network. Our results support the use of smaller central venous catheters, in upper body veins, and the use of Taurolock-Hep100 in patients who have recurrent infections.
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Affiliation(s)
- D Leiberman
- Glasgow Royal Infirmary, Intestinal Failure Unit, Glasgow G4 0TF, UK
| | - R P Stevenson
- Glasgow Royal Infirmary, Intestinal Failure Unit, Glasgow G4 0TF, UK
| | - F W Banu
- University of Glasgow, School of Medicine, Dentistry & Nursing, New Lister Building, Glasgow Royal Infirmary G4 0SF, UK
| | - K Gerasimidis
- University of Glasgow, School of Medicine, Dentistry & Nursing, New Lister Building, Glasgow Royal Infirmary G4 0SF, UK
| | - R F McKee
- Glasgow Royal Infirmary, Intestinal Failure Unit, Glasgow G4 0TF, UK.
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20
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Vlug LE, Nagelkerke SCJ, Jonkers-Schuitema CF, Rings EHHM, Tabbers MM. The Role of a Nutrition Support Team in the Management of Intestinal Failure Patients. Nutrients 2020; 12:nu12010172. [PMID: 31936271 PMCID: PMC7019598 DOI: 10.3390/nu12010172] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 01/02/2020] [Accepted: 01/04/2020] [Indexed: 12/15/2022] Open
Abstract
Parenteral nutrition (PN) is a complex and specialized form of nutrition support that has revolutionized the care for both pediatric and adult patients with acute and chronic intestinal failure (IF). This has led to the development of multidisciplinary teams focused on the management of patients receiving PN: nutrition support teams (NSTs). In this review we aim to discuss the historical aspects of IF management and NST development, and the practice, composition, and effectiveness of multidisciplinary care by NSTs in patients with IF. We also discuss the experience of two IF centers as an example of contemporary NSTs at work. An NST usually consists of at least a physician, nurse, dietitian, and pharmacist. Multidisciplinary care by an NST leads to fewer complications including infection and electrolyte disturbances, and better survival for patients receiving short- and long-term PN. Furthermore, it leads to a decrease in inappropriate prescriptions of short-term PN leading to significant cost reduction. Complex care for patients receiving PN necessitates close collaboration between team members and NSTs from other centers to optimize safety and effectiveness of PN use.
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Affiliation(s)
- Lotte E. Vlug
- Erasmus Medical Center, Department of Pediatric Gastroenterology, Erasmus University Rotterdam, Sophia Children’s Hospital, 3015 GD Rotterdam, The Netherlands
- Correspondence: (L.E.V.); (S.C.J.N.)
| | - Sjoerd C. J. Nagelkerke
- Amsterdam UMC, Department of Pediatric Gastroenterology, University of Amsterdam, Emma Children’s Hospital, Hepatology and Nutrition, 1105 AZ Amsterdam, The Netherlands
- Correspondence: (L.E.V.); (S.C.J.N.)
| | - Cora F. Jonkers-Schuitema
- Amsterdam UMC, Department of Pediatric Gastroenterology, University of Amsterdam, Emma Children’s Hospital, Hepatology and Nutrition, 1105 AZ Amsterdam, The Netherlands
| | - Edmond H. H. M. Rings
- Erasmus Medical Center, Department of Pediatric Gastroenterology, Erasmus University Rotterdam, Sophia Children’s Hospital, 3015 GD Rotterdam, The Netherlands
- Department of Pediatric Gastroenterology, Leiden University Medical Center, University of Leiden, Willem Alexander Children’s Hospital, 2300 RC Leiden, The Netherlands
| | - Merit M. Tabbers
- Amsterdam UMC, Department of Pediatric Gastroenterology, University of Amsterdam, Emma Children’s Hospital, Hepatology and Nutrition, 1105 AZ Amsterdam, The Netherlands
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Suzuki R, Brown GA, Christopher JA, Scully CCG, Congreve M. Recent Developments in Therapeutic Peptides for the Glucagon-like Peptide 1 and 2 Receptors. J Med Chem 2019; 63:905-927. [PMID: 31577440 DOI: 10.1021/acs.jmedchem.9b00835] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Glucagon-like peptide 1 (GLP-1) and glucagon-like peptide 2 (GLP-2) are proglucagon derived peptides that are released from gut endocrine cells in response to nutrient intake. These molecules are rapidly inactivated by the action of dipeptidyl peptidase IV (DPP-4) which limits their use as therapeutic agents. The recent emergence of three-dimensional structures of GPCRs such as GLP-1R and glucagon receptor has helped to drive the rational design of innovative peptide molecules that hold promise as novel peptide therapeutics. One emerging area is the discovery of multifunctional molecules that act at two or more pharmacological systems to enhance therapeutic efficacy. In addition, drug discovery efforts are also focusing on strategies to improve patient convenience through alternative routes of peptide delivery. These novel strategies highlight the broad utility of peptide-based therapeutics in human disease settings where unmet needs still exist.
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Affiliation(s)
- Rie Suzuki
- Sosei Heptares , Steinmetz Building, Granta Park , Cambridge CB21 6DG , U.K
| | - Giles A Brown
- Sosei Heptares , Steinmetz Building, Granta Park , Cambridge CB21 6DG , U.K
| | - John A Christopher
- Sosei Heptares , Steinmetz Building, Granta Park , Cambridge CB21 6DG , U.K
| | - Conor C G Scully
- Sosei Heptares , Steinmetz Building, Granta Park , Cambridge CB21 6DG , U.K
| | - Miles Congreve
- Sosei Heptares , Steinmetz Building, Granta Park , Cambridge CB21 6DG , U.K
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22
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Canovai E, Ceulemans LJ, Peers G, De Pourcq L, Pijpops M, De Hertogh G, Hiele M, Pirenne J, Vanuytsel T. Cost analysis of chronic intestinal failure. Clin Nutr 2019; 38:1729-1736. [DOI: 10.1016/j.clnu.2018.07.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 07/24/2018] [Accepted: 07/25/2018] [Indexed: 02/07/2023]
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23
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Koelfat KVK, Huijbers A, Schaap FG, van Kuijk SMJ, Lenicek M, Soeters MR, Wanten GJA, Olde Damink SWM. Low circulating concentrations of citrulline and FGF19 predict chronic cholestasis and poor survival in adult patients with chronic intestinal failure: development of a Model for End-Stage Intestinal Failure (MESIF risk score). Am J Clin Nutr 2019; 109:1620-1629. [PMID: 31075790 DOI: 10.1093/ajcn/nqz036] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 02/21/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Patients with chronic intestinal failure (CIF) often develop cholestatic liver injury, which may lead to liver failure and need for organ transplantation. OBJECTIVES The aim of this study was to investigate whether citrulline (CIT) and the enterokine fibroblast growth factor 19 (FGF19) are associated with chronic cholestasis and survival in adult CIF patients, and to develop a risk score to predict their survival. METHODS We studied 135 adult CIF patients on intravenous supplementation (>3 mo). Associations of plasma CIT and FGF19 with chronic cholestasis and survival were estimated by logistic and Cox regression models. A predictive risk score was developed and validated internally. RESULTS Patients with chronic cholestasis (17%) had a reduced 5-y survival rate compared with patients without chronic cholestasis (38% and 62%, respectively). In multivariable analysis, low FGF19, low CIT, and female sex were associated with chronic cholestasis. Patients with low rather than high CIT or FGF19 also had reduced 5-y survival rates (29% compared with 69%; 54% compared with 66%, respectively). Risk factors identified in multivariable analysis of survival were low FGF19 (HR: 3.4), low CIT (HR: 3.3), and number of intravenous infusions per week (HR: 1.4). These 3 predictors were incorporated in a risk model of survival termed Model for End-Stage Intestinal Failure (MESIF) (C-statistic 0.78). The 5-y survival rates for patients with MESIF scores of 0 to <20 (n = 47), 20-40 (n = 75), and >40 (n = 13) were 80%, 58%, and 14%, respectively. CONCLUSIONS CIT and FGF19 predict chronic cholestasis and survival in this cohort of adult CIF patients, and the derived MESIF score is associated with their survival. Pending external validation, the MESIF score may help to identify patients for closer clinical monitoring or earlier referral to intestinal transplantation centers.
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Affiliation(s)
- Kiran V K Koelfat
- Department of Surgery, Maastricht, Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, Netherlands
| | - Angelique Huijbers
- Department of Gastroenterology & Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Frank G Schaap
- Department of Surgery, Maastricht, Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, Netherlands.,Department of General, Visceral and Transplantation Surgery, RWTH University Hospital Aachen, Aachen, Germany
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, Maastricht, Netherlands
| | - Martin Lenicek
- Department of Medical Biochemistry and Laboratory Diagnostics, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Maarten R Soeters
- Department of Endocrinology and Metabolism, Amsterdam University Medical Centers, location AMC, Amsterdam, Netherlands
| | - Geert J A Wanten
- Department of Gastroenterology & Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Steven W M Olde Damink
- Department of Surgery, Maastricht, Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, Netherlands.,Department of General, Visceral and Transplantation Surgery, RWTH University Hospital Aachen, Aachen, Germany
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24
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Wing VK, Song Y, Xiang C, Liu X, Macaulay D, Ponsillo M, Blumentals WA. Incidence of catheter-related complications among Japanese patients with central venous catheters as well as patients with short bowel syndrome. Clin Exp Gastroenterol 2018; 11:439-445. [PMID: 30568477 PMCID: PMC6276634 DOI: 10.2147/ceg.s172430] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose Short bowel syndrome (SBS) is a serious rare disorder that is usually managed with parenteral nutrition. Central venous catheter (CVC)-related complications are known to occur, but their incidence rates (IRs) in Japan are unknown. The aim of this study was to estimate the incidence of complications in Japanese patients with CVCs, including patients with SBS using CVCs. Patients and methods A retrospective cohort study in 64,817 patients with CVCs, including 81 patients with SBS, between April 2008 and October 2016 using a claims database in Japan was conducted. IRs of complications were calculated as total events divided by total catheter-days among all patients with CVCs and among patients with SBS. Results The majority (>90%) of patients in the CVC and SBS cohorts were ≥18 years old. Overall, IRs of any type of complication were numerically higher in patients with SBS compared with all patients with CVCs (2.68 vs 1.95 cases per 1,000 catheter-days, respectively). Among patients with SBS, septicemia, infection, and inflammatory reaction were the only complications observed. The complications with the highest incidence were catheter-related bloodstream infections (CRBSIs) in both the overall CVC cohort and the SBS cohort with IRs of 1.35 and 2.68 cases per 1,000 catheter-days, respectively. The IR of any CVC-related complication was numerically higher in patients with SBS with cancer vs without cancer (3.44 vs 1.86 cases per 1,000 catheter-days, respectively). Conclusion Our study quantifies the incidence of complications in patients with CVCs, including those with SBS, in Japan.
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Affiliation(s)
- Vicki K Wing
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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25
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Five-year survival and causes of death in patients on home parenteral nutrition for severe chronic and benign intestinal failure. Clin Nutr 2018; 37:1415-1422. [DOI: 10.1016/j.clnu.2017.06.016] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 05/14/2017] [Accepted: 06/13/2017] [Indexed: 11/18/2022]
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26
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Anderson KT, Bartz-Kurycki MA, Martin R, Imseis E, Austin MT, Speer AL, Lally KP, Tsao K. Tunneled central venous catheters in pediatric intestinal failure: a single-center experience. J Surg Res 2018; 231:346-351. [PMID: 30278951 DOI: 10.1016/j.jss.2018.05.081] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 05/25/2018] [Accepted: 05/31/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Parenteral nutrition for intestinal failure (IF) often requires a tunneled central venous catheter (CVC). The purpose of this study was to characterize complications after CVC placement and contributors to line loss in pediatric IF patients. METHODS An institutional review board-approved retrospective review of pediatric (<18 y) IF patients who had a silicone tunneled CVC newly inserted or exchanged from 2012 to 2016 in an IF center was conducted. Patient demographics, procedure service (surgery versus interventional radiology), procedure type (new versus exchange), vessel, and complications related to CVCs were evaluated. Complications included dislodgement, infection, break, occlusion/malfunction, and others. An ethanol-lock protocol for silicone CVCs in IF patients was instituted in January 2012. RESULTS Twenty-nine IF patients with tunneled CVCs were identified with 182 lines and 18,534 line d. Median age at line insertion was 17.1 mo (interquartile range [IQR] 7.6-31.5) with a median of five catheters (IQR 2-8) per patient. There were 19.2 complications per 1000 line d. Occlusions/malfunctions were the most common complication (6.0/1000 line d) followed by breaks (5.6/1000 line d). Median life of catheters was 51.5 d (IQR 21-129). On regression, adjusting for age, insertion service, and procedure type, shorter line life was associated with younger age (P = 0.04) and placement by interventional radiology (P < 0.01). Dislodgement was associated with newly placed lines relative risk 6.5 (95% CI 2.2-28.8). CONCLUSIONS CVCs in pediatric IF patients have frequent complications and short line lifetimes. Dislodgement of CVC was an unexpectedly common complication with loss of access in newly placed lines. There may be modifiable processes to mitigate CVC complications.
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Affiliation(s)
- Kathryn Tinsley Anderson
- Department of Pediatric Surgery, Center for Surgical Trials and Evidence-based Practice, McGovern Medical School, The University of Texas Health Science Center, Houston and Children's Memorial Hermann Hospital, Houston, Texas
| | - Marisa A Bartz-Kurycki
- Department of Pediatric Surgery, Center for Surgical Trials and Evidence-based Practice, McGovern Medical School, The University of Texas Health Science Center, Houston and Children's Memorial Hermann Hospital, Houston, Texas
| | - Robert Martin
- Department of Pediatric Surgery, Center for Surgical Trials and Evidence-based Practice, McGovern Medical School, The University of Texas Health Science Center, Houston and Children's Memorial Hermann Hospital, Houston, Texas
| | - Essam Imseis
- Department of Pediatric Surgery, Center for Surgical Trials and Evidence-based Practice, McGovern Medical School, The University of Texas Health Science Center, Houston and Children's Memorial Hermann Hospital, Houston, Texas
| | - Mary T Austin
- Department of Pediatric Surgery, Center for Surgical Trials and Evidence-based Practice, McGovern Medical School, The University of Texas Health Science Center, Houston and Children's Memorial Hermann Hospital, Houston, Texas
| | - Allison L Speer
- Department of Pediatric Surgery, Center for Surgical Trials and Evidence-based Practice, McGovern Medical School, The University of Texas Health Science Center, Houston and Children's Memorial Hermann Hospital, Houston, Texas
| | - Kevin P Lally
- Department of Pediatric Surgery, Center for Surgical Trials and Evidence-based Practice, McGovern Medical School, The University of Texas Health Science Center, Houston and Children's Memorial Hermann Hospital, Houston, Texas
| | - Kuojen Tsao
- Department of Pediatric Surgery, Center for Surgical Trials and Evidence-based Practice, McGovern Medical School, The University of Texas Health Science Center, Houston and Children's Memorial Hermann Hospital, Houston, Texas.
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Paediatric Intestinal Pseudo-obstruction: Evidence and Consensus-based Recommendations From an ESPGHAN-Led Expert Group. J Pediatr Gastroenterol Nutr 2018; 66:991-1019. [PMID: 29570554 DOI: 10.1097/mpg.0000000000001982] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Chronic intestinal pseudo-obstructive (CIPO) conditions are considered the most severe disorders of gut motility. They continue to present significant challenges in clinical care despite considerable recent progress in our understanding of pathophysiology, resulting in unacceptable levels of morbidity and mortality. Major contributors to the disappointing lack of progress in paediatric CIPO include a dearth of clarity and uniformity across all aspects of clinical care from definition and diagnosis to management. In order to assist medical care providers in identifying, evaluating, and managing children with CIPO, experts in this condition within the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition as well as selected external experts, were charged with the task of developing a uniform document of evidence- and consensus-based recommendations. METHODS Ten clinically relevant questions addressing terminology, diagnostic, therapeutic, and prognostic topics were formulated. A systematic literature search was performed from inception to June 2017 using a number of established electronic databases as well as repositories. The approach of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) was applied to evaluate outcome measures for the research questions. Levels of evidence and quality of evidence were assessed using the classification system of the Oxford Centre for Evidence-Based Medicine (diagnosis) and the GRADE system (treatment). Each of the recommendations were discussed, finalized, and voted upon using the nominal voting technique to obtain consensus. RESULTS This evidence- and consensus-based position paper provides recommendations specifically for chronic intestinal pseudo-obstruction in infants and children. It proposes these be termed paediatric intestinal pseudo-obstructive (PIPO) disorders to distinguish them from adult onset CIPO. The manuscript provides guidance on the diagnosis, evaluation, and treatment of children with PIPO in an effort to standardise the quality of clinical care and improve short- and long-term outcomes. Key recommendations include the development of specific diagnostic criteria for PIPO, red flags to alert clinicians to the diagnosis and guidance on the use of available investigative modalities. The group advocates early collaboration with expert centres where structured diagnosis and management is guided by a multi-disciplinary team, and include targeted nutritional, medical, and surgical interventions as well as transition to adult services. CONCLUSIONS This document is intended to be used in daily practice from the time of first presentation and definitive diagnosis PIPO through to the complex management and treatment interventions such as intestinal transplantation. Significant challenges remain to be addressed through collaborative clinical and research interactions.
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Ocón Bretón MJ, Luengo Pérez LM, Virizuela JA, Álvarez Hernández J, Jiménez Fonseca P, Cervera Peris M, Sendrós Madroño MJ, Grande E, Camblor Álvarez M. Nutritional support and parenteral nutrition in cancer patients: An expert consensus report. ENDOCRINOL DIAB NUTR 2018. [DOI: 10.1016/j.endien.2017.10.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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29
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Norsa L, Artru S, Lambe C, Talbotec C, Pigneur B, Ruemmele F, Colomb V, Capito C, Chardot C, Lacaille F, Goulet O. Long term outcomes of intestinal rehabilitation in children with neonatal very short bowel syndrome: Parenteral nutrition or intestinal transplantation. Clin Nutr 2018; 38:926-933. [PMID: 29478887 DOI: 10.1016/j.clnu.2018.02.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 12/17/2017] [Accepted: 02/06/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Intestinal rehabilitation is the preferred treatment for children with short bowel syndrome (SBS) whatever the residual bowel length, and depends on the accurate management of long-term parenteral nutrition (PN). If nutritional failure develops, intestinal transplantation (ITx) should be discussed and may be life-saving. This study aimed to evaluate survival, PN dependency and nutritional status in children with neonatal very SBS on PN or after ITx, in order to define indications and timing of both treatments. PATIENTS AND METHODS This retrospective cross-sectional study enrolled 36 children with very SBS (<40 cm) who entered our intestinal rehabilitation program from 1987 to 2007. RESULTS All the children on long-term PN (n = 16) survived with a follow-up of 17 years (9-20). Six of them were eventually weaned off PN. Twenty children underwent ITx: eight children died (40%) 29 months (0-127) after Tx. The others 12 patients were weaned off PN 73 days (13-330) after Tx. Follow-up after transplantation was 14 years (6-28). Seven out of 8 (88%) patients with a history of gastroschisis required ITx. Patients who required ITx had longer stoma duration. CONCLUSION Survival rate of children with very short bowel was excellent if no life-threatening complications requiring transplantation developed. Gastroschisis and delayed ostomy closure are confirmed as risk factor for nutritional failure. Intestinal rehabilitation may allow a total weaning of PN before adulthood. A follow-up by a multidisciplinary team is necessary to avoid PN complications in order to minimize indications for ITx.
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Affiliation(s)
- Lorenzo Norsa
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Intestinal Failure Rehabilitation Center, Hôpital Universitaire Necker Enfants Malades, 149 rue de Sèvres, 75015 Paris, France.
| | - Solene Artru
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Intestinal Failure Rehabilitation Center, Hôpital Universitaire Necker Enfants Malades, 149 rue de Sèvres, 75015 Paris, France
| | - Cecile Lambe
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Intestinal Failure Rehabilitation Center, Hôpital Universitaire Necker Enfants Malades, 149 rue de Sèvres, 75015 Paris, France
| | - Cecile Talbotec
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Intestinal Failure Rehabilitation Center, Hôpital Universitaire Necker Enfants Malades, 149 rue de Sèvres, 75015 Paris, France
| | - Benedicte Pigneur
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Intestinal Failure Rehabilitation Center, Hôpital Universitaire Necker Enfants Malades, 149 rue de Sèvres, 75015 Paris, France
| | - Frank Ruemmele
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Intestinal Failure Rehabilitation Center, Hôpital Universitaire Necker Enfants Malades, 149 rue de Sèvres, 75015 Paris, France; Faculté de Médecine, Universitè of Sorbonne-Paris-Cité, Paris Descartes, 15 Rue de l'École de Médecine, 75006 Paris, France
| | - Virginie Colomb
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Intestinal Failure Rehabilitation Center, Hôpital Universitaire Necker Enfants Malades, 149 rue de Sèvres, 75015 Paris, France
| | - Carmen Capito
- Department of Pediatric Surgery and Transplantation, Hôpital Universitaire Necker Enfants Malades, 149 rue de Sèvres, 75015 Paris, France
| | - Christophe Chardot
- Department of Pediatric Surgery and Transplantation, Hôpital Universitaire Necker Enfants Malades, 149 rue de Sèvres, 75015 Paris, France; Faculté de Médecine, Universitè of Sorbonne-Paris-Cité, Paris Descartes, 15 Rue de l'École de Médecine, 75006 Paris, France
| | - Florence Lacaille
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Intestinal Failure Rehabilitation Center, Hôpital Universitaire Necker Enfants Malades, 149 rue de Sèvres, 75015 Paris, France
| | - Olivier Goulet
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Intestinal Failure Rehabilitation Center, Hôpital Universitaire Necker Enfants Malades, 149 rue de Sèvres, 75015 Paris, France; Faculté de Médecine, Universitè of Sorbonne-Paris-Cité, Paris Descartes, 15 Rue de l'École de Médecine, 75006 Paris, France
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30
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Ocón Bretón MJ, Luengo Pérez LM, Virizuela JA, Álvarez Hernández J, Jiménez Fonseca P, Cervera Peris M, Sendrós Madroño MJ, Grande E, Camblor Álvarez M. Nutritional support and parenteral nutrition in cancer patients: An expert consensus report. ACTA ACUST UNITED AC 2017. [PMID: 29292219 DOI: 10.1016/j.endinu.2017.10.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Malnutrition is a common medical problem in cancer patients with a negative impact on quality of life. The aim of this study was to address different issues related to nutritional management of cancer patients in clinical practice. A multidisciplinary group of experts in Medical Oncology, Pharmacy, and Endocrinology and Nutrition prepared a list of topics related to the nutritional status of cancer patients and grouped them into three blocks: nutritional support, parenteral nutrition (PN), and home PN (HPN). A literature review was made of articles published in Spanish, English and French until April 2017. This consensus emphasizes several key elements that help physicians standardize management of the nutritional status of cancer patients in clinical practice, and establishes common guidelines for indication, monitoring, nutritional requirements, and access routes to PN.
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Affiliation(s)
- María Julia Ocón Bretón
- Servicio de Endocrinología y Nutrición, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España.
| | - Luis Miguel Luengo Pérez
- Unidad de Nutrición Clínica y Dietética, Hospital Universitario Infanta Cristina, Badajoz, España
| | | | - Julia Álvarez Hernández
- Servicio de Endocrinología y Nutrición. Hospital Universitario Príncipe de Asturias, Alcalá de Henares Madrid
| | - Paula Jiménez Fonseca
- Servicio de Oncología Médica, Hospital Universitario Central de Asturias, Oviedo, España
| | | | | | - Enrique Grande
- Servicio de Oncología Médica, Hospital Ramón y Cajal, Madrid, España
| | - Miguel Camblor Álvarez
- Servicio de Endocrinología y Nutrición, Hospital General Universitario Gregorio Marañón, Madrid, España
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31
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Virizuela JA, Camblor-Álvarez M, Luengo-Pérez LM, Grande E, Álvarez-Hernández J, Sendrós-Madroño MJ, Jiménez-Fonseca P, Cervera-Peris M, Ocón-Bretón MJ. Nutritional support and parenteral nutrition in cancer patients: an expert consensus report. Clin Transl Oncol 2017; 20:619-629. [PMID: 29043569 DOI: 10.1007/s12094-017-1757-4] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 09/30/2017] [Indexed: 12/28/2022]
Abstract
BACKGROUND Malnutrition is a frequent medical problem of cancer patients that negatively impacts their quality of life. METHODS A multidisciplinary group of experts in Medical Oncology, Pharmacy, and Nutrition convened to discuss the management of the nutritional support in cancer patients. RESULTS Of the 18 questions addressed, 9 focused on nutritional support, 5 were related to parenteral nutrition (PN) and 4 about home PN (HPN). The panel of experts recommends using nutritional screening routinely, at diagnosis and throughout the disease course, for detecting the risk of malnutrition and, if it is positive, to perform a complete nutritional assessment, to diagnose malnutrition. Currently, there are different screening tools and methods that allow us to detect nutritional risk. Based on the evidence and experience, the panel stated that PN is indicated mainly when it is not possible to use the digestive tract and/or oral feeding and/or enteral nutrition is not sufficient or possible. The nutritional needs of the cancer patients, except in those cases where individualized measures are required, should be considered similar to healthy individuals (25-30 kcal/kg/day). The panel considers that the nutritional monitoring of the cancer patient should be multidisciplinary and adapted to the characteristics of each center. Additionally, the objective of the HPN is to improve or maintain the nutritional status of a patient at home. CONCLUSIONS This document seeks to lay down a set of recommendations and to identify key issues that may be useful for the nutritional management of cancer patients.
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Affiliation(s)
- J A Virizuela
- Department of Medical Oncology, Virgen Macarena University Hospital, Calle Dr. Fedriani, 3, 41009, Sevilla, Spain.
| | - M Camblor-Álvarez
- Endocrinology and Nutritional Department, Gregorio Marañón University General Hospital, Madrid, Spain
| | - L M Luengo-Pérez
- Dietetic and Clinical Nutrition Unit, Endocrinology and Nutritional Department, Infanta Cristina University Hospital, Badajoz, Spain
| | - E Grande
- Department of Medical Oncology, Ramón y Cajal Hospital, Madrid, Spain
| | - J Álvarez-Hernández
- Endocrinology and Nutritional Department, Prince of Asturias University Hospital, Alcalá de Henares, Madrid, Spain
| | | | - P Jiménez-Fonseca
- Department of Medical Oncology, Asturias Central University Hospital, Oviedo, Spain
| | - M Cervera-Peris
- Pharmacy Department, Son Espases University Hospital, Palma de Mallorca, Spain
| | - M J Ocón-Bretón
- Endocrinology and Nutritional Department, Lozano Blesa Clinic University Hospital, Zaragoza, Spain
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Bonnes SL, Salonen BR, Hurt RT, McMahon MT, Mundi MS. Parenteral and Enteral Nutrition—From Hospital to Home: Will It Be Covered? Nutr Clin Pract 2017; 32:730-738. [DOI: 10.1177/0884533617734491] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Sara L. Bonnes
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Bradley R. Salonen
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ryan T. Hurt
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Megan T. McMahon
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Manpreet S. Mundi
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
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33
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Arenas Villafranca JJ, Nieto Guindo M, Álvaro Sanz E, Moreno Santamaria M, Garrido Siles M, Abilés J. Effects of cyclic parenteral nutrition on parenteral-associated liver dysfunction parameters. Nutr J 2017; 16:66. [PMID: 28978317 PMCID: PMC5628441 DOI: 10.1186/s12937-017-0289-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Accepted: 09/26/2017] [Indexed: 11/10/2022] Open
Abstract
Introduction One of the most common complications of parenteral nutrition (PN) is liver dysfunction (LD). Therapeutic approaches for LD include, among others, administering cyclic parenteral nutrition (cPN), allowing some hours for metabolic rest. The purpose of this study was to evaluate the effectiveness of cPN in treating PN-associated LD. Materials and methods A retrospective observational study was carried out at the Costa del Sol Hospital in Spain between 2013 and 2014. The study involved inpatients ≥18 years old prescribed with cPN due to the development of PN-associated LD. The hepatic biochemical parameters measured at baseline and after completion of cPN included aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma-glutamyltransferase (GGT), alkaline phosphatase (ALP) and total bilirubin (TB). Quantitative values (age, biochemical parameters) were compared using matched Student’s t-test; the mean change in qualitative variables (sex, indication of PN, hepatic comorbidities, presence of insulin in cPN, infection during cPN, management of LD prior to cPN administrarion) was estimated using Mann-Whitney U test, and bivariate correlation between quantitative variables was determined by Spearman’s coefficient of correlation. Results Thirty-seven patients met inclusion criteria. All hepatic function parameters except ALP improved after the administration of cPN, with statistically significant differences (p < 0.05) in AST GGT and TB. Conclusion cPN improves PN-associated LD by restoring abnormal AST, GGT, and BT levels to normal, and reducing ALT levels close to normal. The results obtained suggest that the administration of cPN is effective in reverting PN-associated LD.
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Affiliation(s)
- Jose J Arenas Villafranca
- Pharmacy and Nutrition Service, Costa del Sol Hospital, A7, km. 187, 29603, Marbella (Málaga), Spain
| | - Miriam Nieto Guindo
- Pharmacy and Nutrition Service, Costa del Sol Hospital, A7, km. 187, 29603, Marbella (Málaga), Spain
| | - Elena Álvaro Sanz
- Pharmacy and Nutrition Service, Costa del Sol Hospital, A7, km. 187, 29603, Marbella (Málaga), Spain. .,, C/ Fernando Villalón Edf. Lorcrisur, Bloque n°8, Bajo A, 29670, Marbella (Málaga), Spain.
| | - Manuela Moreno Santamaria
- Pharmacy and Nutrition Service, Costa del Sol Hospital, A7, km. 187, 29603, Marbella (Málaga), Spain
| | - Marga Garrido Siles
- Pharmacy and Nutrition Service, Costa del Sol Hospital, A7, km. 187, 29603, Marbella (Málaga), Spain
| | - Jimena Abilés
- Pharmacy and Nutrition Service, Costa del Sol Hospital, A7, km. 187, 29603, Marbella (Málaga), Spain
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Tribler S, Brandt CF, Petersen AH, Petersen JH, Fuglsang KA, Staun M, Broebech P, Moser CE, Jeppesen PB. Taurolidine-citrate-heparin lock reduces catheter-related bloodstream infections in intestinal failure patients dependent on home parenteral support: a randomized, placebo-controlled trial. Am J Clin Nutr 2017; 106:839-848. [PMID: 28793993 DOI: 10.3945/ajcn.117.158964] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 07/10/2017] [Indexed: 11/14/2022] Open
Abstract
Background: In patients with intestinal failure who are receiving home parenteral support (HPS), catheter-related bloodstream infections (CRBSIs) inflict health impairment and high costs.Objective: This study investigates the efficacy and safety of the antimicrobial catheter lock solution, taurolidine-citrate-heparin, compared with heparin 100 IE/mL on CRBSI occurrence.Design: Forty-one high-risk patients receiving HPS followed in a tertiary HPS unit were randomly assigned in a double-blinded, placebo-controlled trial. External, stratified randomization was performed according to age, sex, and prior CRBSI incidence. The prior CRBSI incidence in the study population was 2.4 episodes/1000 central venous catheter (CVC) days [95% Poisson confidence limits (CLs): 2.12, 2.71 episodes/1000 CVC days]. The maximum treatment period was 2 y or until occurrence of a CRBSI or right-censoring because of CVC removal. The exact permutation tests were used to calculate P values for the log-rank tests.Results: Twenty patients received the taurolidine-citrate-heparin lock and 21 received the heparin lock, with 9622 and 6956 treatment days, respectively. In the taurolidine-citrate-heparin arm, no CRBSIs occurred, whereas 7 CRBSIs occurred in the heparin arm, with an incidence of 1.0/1000 CVC days (95% Poisson CLs: 0.4, 2.07/1000 CVC days; P = 0.005). The CVC removal rates were 0.52/1000 CVC days (95% Poisson CLs: 0.17, 1.21/1000 CVC days) and 1.72/1000 CVC days (95% Poisson CLs: 0.89, 3.0/1000 CVC days) in the taurolidine-citrate-heparin and heparin arm, respectively, tending to prolong CVC survival in the taurolidine arm (P = 0.06). Costs per treatment year were lower in the taurolidine arm (€2348) than in the heparin arm (€6744) owing to fewer admission days related to treating CVC-related complications (P = 0.02).Conclusions: In patients with intestinal failure who are life dependent on HPS, the taurolidine-citrate-heparin catheter lock demonstrates a clinically substantial and cost-beneficial reduction of CRBSI occurrence in a high-risk population compared with heparin. This trial was registered at clinicaltrials.gov as NCT01948245.
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Affiliation(s)
| | | | - Anne H Petersen
- Department of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Jørgen H Petersen
- Department of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | | | | | | | - Claus E Moser
- Clinical Microbiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; and
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Strategies for early metabolic disturbances in patients with an end jejunostomy or end ileostomy. Experience from a specialized Home Parenteral Nutrition (HPN) center. GASTROENTEROLOGY REVIEW 2017; 12:111-117. [PMID: 28702099 PMCID: PMC5497124 DOI: 10.5114/pg.2016.58599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Accepted: 12/24/2015] [Indexed: 11/17/2022]
Abstract
INTRODUCTION An end stoma syndrome is usually the result of an intentional surgical intervention in the course of staged treatment or a complication of surgery. These patients most frequently suffer from water and electrolyte disturbances, malnutrition syndromes caused by malabsorption of trace elements and/or vitamins, and undernutrition. AIM To present early metabolic disturbances observed in patients with an end jejunostomy or end ileostomy syndrome on the first day of their hospitalization in a specialist Home Parenteral Nutrition (HPN) center. MATERIAL AND METHODS The study included 142 patients with an end stoma syndrome (76 women and 66 men), hospitalized between 2004 and 2014. Patients were divided into two main groups. Group A consisted of 90 patients with an end jejunostomy and group B consisted of 52 patients with an end ileostomy. RESULTS After comparing the patients with an end jejunostomy vs. those with an end ileostomy, significant differences were found as regards pH (7.34 vs. 7.39, p = 0.043) and BE (3.24 vs. -0.86, p = 0.005). Depending on the lack or possibility of oral food intake, patients in the end jejunostomy group had different levels of the markers phosphate, Mg, Ca, urea, and creatinine, with all of these parameters within normal laboratory limits. When the end ileostomy group was divided into subgroups depending on the lack or possibility of oral food intake, differences in C-reactive protein activity were found (55.6 vs. 25.7, p = 0.041). CONCLUSIONS Patients with an end jejunostomy syndrome are more prone to metabolic acidosis with significant alkali deficiencies.
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Identification of Depressive Signs in Patients and Their Family Members During iPad-based Audiovisual Sessions. Comput Inform Nurs 2017; 35:352-357. [PMID: 28445171 DOI: 10.1097/cin.0000000000000353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Home parenteral nutrition requires a daily life-sustaining intravenous infusion over 12 hours. The daily intravenous infusion home care procedures are stringent, time-consuming tasks for patients and family caregivers who often experience depression. The purposes of this study were (1) to assess home parenteral nutrition patients and caregivers for depression and (2) to assess whether depressive signs can be seen during audiovisual discussion sessions using an Apple iPad Mini. In a clinical trial (N = 126), a subsample of 21 participants (16.7%) had depressive symptoms. Of those with depression, 13 participants were home parenteral nutrition patients and eight were family caregivers; ages ranged from 20 to 79 years (with 48.9 [standard deviation, 17.37] years); 76.2% were female. Individual assessments by the mental health nurse found factors related to depressive symptoms across all 21 participants. A different nurse observed participants for signs of depression when viewing the videotapes of the discussion sessions on audiovisual technology. Conclusions are that depression questionnaires, individual assessment, and observation using audiovisual technology can identify depressive symptoms. Considering the growing provision of healthcare at a distance, via technology, recommendations are to observe and assess for known signs and symptoms of depression during all audiovisual interactions.
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Billiauws L, Bataille J, Boehm V, Corcos O, Joly F. Teduglutide for treatment of adult patients with short bowel syndrome. Expert Opin Biol Ther 2017; 17:623-632. [DOI: 10.1080/14712598.2017.1304912] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Lore Billiauws
- Hopital Beaujon - Department of Gastroenterology and Nutrition Support, APHP - University Paris VII, Clichy, France
| | - Julie Bataille
- Hopital Beaujon - Department of Pharmacy, APHP - University Paris VII, Clichy, France
| | - Vanessa Boehm
- Hopital Beaujon - Department of Gastroenterology and Nutrition Support, APHP - University Paris VII, Clichy, France
| | - Olivier Corcos
- Hopital Beaujon - Department of Gastroenterology and Nutrition Support, APHP - University Paris VII, Clichy, France
- Laboratory for Vascular Translational Science, UFR de Médecine Paris Diderot, Paris, France
| | - Francisca Joly
- Hopital Beaujon - Department of Gastroenterology and Nutrition Support, APHP - University Paris VII, Clichy, France
- Centre de Recherche sur l’Inflammation, Gastrointestinal and Metabolic Dysfunctions in Nutritional Pathologies, Paris, France
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Wang MY, Wu MH, Hsieh DY, Lin LJ, Lee PH, Chen WJ, Lin MT. Home Parenteral Nutrition Support in Adults: Experience of a Medical Center in Asia. JPEN J Parenter Enteral Nutr 2017; 31:306-10. [PMID: 17595440 DOI: 10.1177/0148607107031004306] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Parenteral nutrition (PN) support is mandatory in patients with gut failure. Short bowel syndrome is a term used for symptoms and pathophysiological disorders brought about by the removal or malfunction of a large portion of the small bowel. Inflammatory bowel disease, vascular disease, and malignancy are the most common causes of short bowel syndrome in adults. There are many complications associated with chronic use of PN. Cholestasis, nutrient deficiency, small bowel bacterial overgrowth, and catheter-related infections were noted in these patients. Due to the various etiologies, we tried to find the optimal method to manage these patients. METHODS We reviewed all patients over 16 years old, from 1989 to 2002, who required home PN support for at least 30 days. Charts were reviewed to obtain information regarding demographics, nutrition management, outcome, and complications related to PN. Survival was estimated by using the Kaplan-Meier method. The association of survival with primary disease, length of small bowel, age, and gender was assessed by proportional hazard regression analysis. RESULTS There were 31 patients who needed home PN support during this period, 14 male and 17 female. The average age was 55 (median age, 53; range, 28-88); the average period of PN administration was 19 months (median, 7; range, 1-115 months). The most common indications for home PN were alimentary tract obstruction and short bowel syndrome. Most deaths were related to their original diseases and catheter-related sepsis. Malignant diseases were a major indication for home PN (HPN). However, 20% of these patients with incurable diseases lived longer than 1 year. The disease patterns were different from those in western societies. Most patients had malignancies and vascular insults in our series. There was much less inflammatory bowel disease in our patients than in western countries; catheter-related infections were frequent and caused 25% of mortality. CONCLUSIONS HPN is very important to patients with intestinal failure or who are waiting for recovery from temporal intestine insufficiency. Even in malignant diseases, a significant number of patients survived for >1 year with treatment of HPN. Most complications related to their underlying diseases and associated infections. Improving patient education and treatment might improve the prognosis of these patients and expand the application of this technique to help more patients with small intestine failure.
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Affiliation(s)
- Ming-Yang Wang
- Department of Surgery, National Taiwan University Hospital Taipei, Taiwan, ROC
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DeLegge MH, Basel MD, Bannister C, Budak AR. Parenteral Nutrition (PN) Use for Adult Hospitalized Patients: A Study of Usage in a Tertiary Medical Center. Nutr Clin Pract 2017; 22:246-9. [PMID: 17374799 DOI: 10.1177/0115426507022002246] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The use of parenteral nutrition (PN) is essential for patients who are unable to meet their nutrition requirements through oral or enteral nutrition. Many earlier studies have noted that PN is often inappropriately used in the hospital setting, thereby increasing the risk of associated complications and costs. A prospective study was performed at the Medical University of South Carolina (MUSC), using a nutrition support database to determine the appropriateness of PN use and the associated hospital costs for patients on 3 surgical services over a 6-month period. Appropriateness of PN therapy was determined according to the American Society of Parenteral and Enteral Nutrition (A.S.P.E.N.) guidelines. A total of 139 new PN therapies were initiated in the 6-month period. Forty percent of the cases were deemed inappropriate. A total of 573 PN days ($80,000 hospital PN costs) could have been saved if inappropriate PN therapy had not been ordered. The avoidable costs only reflect the PN solution and not the additional costs associated with laboratory monitoring, central line placement and maintenance care, nursing administration, and ongoing pharmacy and dietitian clinical management. This study illustrated that PN was not always being provided according to A.S.P.E.N. guidelines. In addition, cost savings could be achieved if PN was provided only to MUSC patients who meet these guidelines.
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Affiliation(s)
- Mark H DeLegge
- Nutrition Services, Digestive Disease Center, Medical University of South Carolina, Charleston, SC 29425, USA
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Matarese LE, O'Keefe SJ, Kandil HM, Bond G, Costa G, Abu-Elmagd K. Short Bowel Syndrome: Clinical Guidelines for Nutrition Management. Nutr Clin Pract 2017; 20:493-502. [PMID: 16207689 DOI: 10.1177/0115426505020005493] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Intestinal failure is a condition in which inadequate digestion or absorption of fluid, electrolytes, and nutrients leads to dehydration or malnutrition. The most common cause of intestinal failure is short bowel syndrome (SBS) defined as <200 cm of functional small intestine. SBS may result from congenital abnormalities or from surgical resection. For the past 3 decades, patients with severe SBS were managed with home parenteral nutrition (HPN). With the emergence of new therapies, the clinician now has multiple options to treat these patients. These include intestinal rehabilitation regimens whereby patients are treated with specialized oral diets, soluble fiber, oral rehydration solutions (ORS), and trophic factors to enhance absorption. There are also a variety of surgical techniques available to preserve intestinal length. Small bowel and multivisceral transplantation has evolved during the last decade to be a valid therapeutic option for those patients who cannot be rehabilitated or who fail HPN. These are interrelated services designed to offer the patient the best therapeutic options to meet their individual needs. This article reviews the principles associated with the nutrition management of this very complex and diverse group of patients.
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Affiliation(s)
- Laura E Matarese
- Intestinal Rehabilitation and Transplant Center, Thomas E. Starzl Transplantation Institute, UPMC Montefiore, 7 South, 3459 Fifth Avenue, Pittsburgh, PA 15213, USA.
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Marshall JK, Gadowsky SL, Childs A, Armstrong D. Economic Analysis of HomevsHospital-Based Parenteral Nutrition in Ontario, Canada. JPEN J Parenter Enteral Nutr 2017; 29:266-9. [PMID: 15961683 DOI: 10.1177/0148607105029004266] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Advances in technology and infrastructure have facilitated transfer of complex services from acute care hospitals to the home. This increases the burden on community resources but may provide net savings to the health care system. We undertook a retrospective cohort study of patients transferred from hospital to home while receiving home parenteral nutrition (PN) to assess their costs of care. METHODS A detailed review of medical records was undertaken for all patients managed by the Hamilton Health Sciences Home PN Program between 1996 and 2001 whose PN was initiated in hospital. Mean per diem direct medical costs were estimated from the perspective of the provincial Ministry of Health for 3 periods: the last 2 weeks before discharge and the first month after discharge. Costs were compared among time intervals and among patients subgroups defined by age and underlying disease. RESULTS Twenty-nine eligible subjects were identified. Common indications for PN included malignancy (n = 12), inflammatory bowel disease (n = 6), and intestinal ischemia (n = 4). Mean per diem costs in the last week of hospitalization were higher than those in the first month after discharge (dollars 567 vs dollars 405, p < .0001). Acute care resources accounted for <10% of the overall costs on home PN. The estimated monthly savings per patient maintained on home PN were dollars 4860 (95% confidence interval dollars 2700-dollars 7000). Savings were even greater among patients with underlying malignancy and advanced age. CONCLUSIONS Home PN is cost saving when compared with hospital-based PN. Neither age nor underlying malignancy should pose a barrier to receipt of home PN.
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Affiliation(s)
- John K Marshall
- Department of Medicine, Division of Gastroenterology, McMaster University Medical Center, Hamilton, Ontario, Canada.
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Brown CR, DiBaise JK. Intestinal Rehabilitation: A Management Program for Short-Bowel Syndrome. Prog Transplant 2016; 14:290-6; quiz 297-8. [PMID: 15663014 DOI: 10.1177/152692480401400404] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Over the last 3 decades, there has been significant improvement in the survival and quality of life of patients who require home parenteral nutrition; however, parenteral nutrition remains costly, is associated with multiple complications, and does not promote the function of the remaining bowel. Intestinal rehabilitation refers to the process of restoring enteral autonomy and decreasing dependence on parenteral nutrition by utilizing dietary, pharmacological, and, occasionally, surgical interventions. A major focus of research has been to identify a trophic factor that will enhance adaptation of the remaining gastrointestinal tract following massive gut resection and allow enteral autonomy. Whether intestinal rehabilitation occurs as the result of increased intestinal adaptation or as the result of a comprehensive approach to care has yet to be determined. This article reviews intestinal failure as the result of short-bowel syndrome and the management strategy of an intestinal rehabilitation program in the care of these patients.
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Affiliation(s)
- Cindy R Brown
- Department of Surgery, University of Nebraska Medical Center, Omaha, Neb., USA
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Alberti G, Castet A, Villarroel del Pino LA, Cifuentes LI, Rivera-Cornejo M, Gana JC. Fish oil-based lipid emulsions versus standard lipid emulsions for treatment of parenteral nutrition-associated liver disease in children. Hippokratia 2016. [DOI: 10.1002/14651858.cd012359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Gigliola Alberti
- Division of Pediatrics, Escuela de Medicina, Pontificia Universidad Católica de Chile; Gastroenterology and Nutrition Department; 85 Lira Santiago Region Metropolitana Chile 8330074
| | - Alex Castet
- Pontificia Universidad Católica de Chile; Division of Paediatrics; Marcoleta 367 Santiago Chile
| | - Luis A Villarroel del Pino
- Faculty of Medicine, Pontificia Universidad Católica de Chile; Department of Public Health; Marcoleta 434 Santiago Chile 354-6894
| | - Lorena I Cifuentes
- Escuela de Medicina, Pontificia Universidad Católica de Chile; Division of Paediatrics, Evidence-based Health Care Programme; Lira 85, 5º piso Santiago Metroplitana Chile 833-0074
| | - Marcela Rivera-Cornejo
- Pontificia Universidad Católica de Chile; Sistema de Bibliotecas UC; Santiago Región Metropolitana Chile 8330074
| | - Juan Cristóbal Gana
- Division of Pediatrics, Escuela de Medicina, Pontificia Universidad Católica de Chile; Gastroenterology and Nutrition Department; 85 Lira Santiago Region Metropolitana Chile 8330074
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Chao CY, Battat R, Al Khoury A, Restellini S, Sebastiani G, Bessissow T. Co-existence of non-alcoholic fatty liver disease and inflammatory bowel disease: A review article. World J Gastroenterol 2016; 22:7727-7734. [PMID: 27678354 PMCID: PMC5016371 DOI: 10.3748/wjg.v22.i34.7727] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 06/19/2016] [Accepted: 08/01/2016] [Indexed: 02/06/2023] Open
Abstract
Emerging data have highlighted the co-existence of non-alcoholic fatty liver disease (NAFLD) and inflammatory bowel disease; both of which are increasingly prevalent disorders with significant complications and impact on future health burden. Cross-section observational studies have shown widely variable prevalence rates of co-existing disease, largely due to differences in disease definition and diagnostic tools utilised in the studies. Age, obesity, insulin resistance and other metabolic conditions are common risks factors in observational studies. However, other studies have also suggested a more dominant role of inflammatory bowel disease related factors such as disease activity, duration, steroid use and prior surgical intervention, in the development of NAFLD. This suggests a potentially more complex pathogenesis and relationship between the two diseases which may be contributed by factors including altered intestinal permeability, gut dysbiosis and chronic inflammatory response. Commonly used immunomodulation agents pose potential hepatic toxicity, however no definitive evidence exist linking them to the development of hepatic steatosis, nor are there any data on the impact of therapy and prognosis in patient with co-existent diseases. Further studies are required to assess the impact and establish appropriate screening and management strategies in order to allow early identification, intervention and improve patient outcomes.
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Naberhuis JK, Tappenden KA. Teduglutide for Safe Reduction of Parenteral Nutrient and/or Fluid Requirements in Adults. JPEN J Parenter Enteral Nutr 2016; 40:1096-1105. [DOI: 10.1177/0148607115582063] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 03/23/2015] [Indexed: 01/15/2023]
Affiliation(s)
| | - Kelly A. Tappenden
- Division of Nutritional Sciences
- Department of Food Science and Human Nutrition, University of Illinois, Urbana, Illinois
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Abstract
Despite recent therapeutic advances, patients with Crohn's disease (CD) continue to experience high recurrence with cumulative structural damage and ultimate loss of nutritional autonomy. With short bowel syndrome, strictures, and enteric fistulae being the underlying pathology, CD is the second common indication for home parenteral nutrition (HPN). With development of intestinal failure, nutritional management including HPN is required as a rescue therapy. Unfortunately, some patients do not escape the HPN-associated complications. Therefore, the concept of gut rehabilitation has evolved as part of the algorithmic management of these patients, with transplantation being the ultimate life-saving therapy. With type 2 intestinal failure, comprehensive rehabilitative measures including nutritional care, pharmacologic manipulation, autologous reconstruction, and bowel lengthening is often successful, particularly in patients with quiescent disease. With type 3 intestinal failure, transplantation is the only life-saving treatment for patients with HPN failure and intractable disease. With CD being the second common indication for transplantation in adults, survival outcome continues to improve because of surgical innovation, novel immunosuppression, and better postoperative care. Despite being a rescue therapy, the procedure has achieved survival rates similar to other solid organs, and comparable to those who continue to receive HPN therapy. With similar technical, immunologic, and infectious complications, survival is similar in the CD and non-CD recipients. Full nutritional autonomy is achievable in most survivors with better quality of life and long-term cost-effectiveness. CD recurrence is rare with no impact on graft function. Further progress is anticipated with new insights into the pathogenesis of CD and mechanisms of transplant tolerance.
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Abstract
Intestinal failure (IF) is a state in which the nutritional demands are not met by the gastrointestinal absorptive surface. A majority of IF cases are associated with short-bowel syndrome, which is a result of malabsorption after significant intestinal resection for numerous reasons, some of which include Crohn's disease, vascular thrombosis, and radiation enteritis. IF can also be caused by obstruction, dysmotility, and congenital defects. Recognition and management of IF can be challenging, given the complex nature of this condition. This review discusses the management of IF with a focus on intestinal rehabilitation, parenteral nutrition, and transplantation.
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Bharadwaj S, Meka K, Tandon P, Rathur A, Rivas JM, Vallabh H, Jevenn A, Guirguis J, Sunesara I, Nischnick A, Ukleja A. Management of gastroparesis-associated malnutrition. J Dig Dis 2016; 17:285-94. [PMID: 27111029 DOI: 10.1111/1751-2980.12344] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 02/07/2016] [Accepted: 03/24/2016] [Indexed: 12/11/2022]
Abstract
Gastroparesis (GP) is a chronic debilitating dysmotility characterized by unrelenting nausea, vomiting, bloating, early satiety, postprandial fullness and abdominal pain. Patients with GP experience other associated conditions, including gastroesophageal reflux disease, gastric bezoars and small bowel bacterial overgrowth. Furthermore, GP is associated with poor quality of life, increased emergency room visits, hospitalizations and subsequent increased healthcare costs. Currently, the managements of GP consist of glycemic control, antiemetics, prokinetics and the use of gastric electrical stimulation. However, most GP patients are at risk for significant nutritional abnormalities. As such, it is essential to screen and diagnose malnutrition in these patients. Poor oral intake in such patients could be supplemented by enteral tube feeding. Parenteral nutrition, although a last resort, is associated with a number of complications and should be used only for the short term. In summary, a systematic approach including initial nutritional screening, diet recommendations, medical therapy, nutritional re-evaluation and enteral and parental nutrition should be considered in complex GP patients.
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Affiliation(s)
- Shishira Bharadwaj
- Department of Gastroenterology/Hepatology, Center for Human Nutrition, Cleveland Clinic Foundation, College of Osteopathic Medicine Cleveland, Ohio, USA
| | - Krishna Meka
- Department of Gastroenterology/Hepatology, Michigan State University, East Lansing, MI, USA
| | - Parul Tandon
- Department of Gastroenterology/Hepatology, Michigan State University, East Lansing, MI, USA
| | - Abdullah Rathur
- Department of Gastroenterology/Hepatology, Michigan State University, East Lansing, MI, USA
| | - John M Rivas
- Department of Gastroenterology/Hepatology, Cleveland Clinic, West Palm Beach, Florida, USA
| | - Hiren Vallabh
- Department of Gastroenterology/Hepatology, Center for Human Nutrition, Cleveland Clinic Foundation, College of Osteopathic Medicine Cleveland, Ohio, USA
| | - Andrea Jevenn
- Department of Gastroenterology/Hepatology, Center for Human Nutrition, Cleveland Clinic Foundation, College of Osteopathic Medicine Cleveland, Ohio, USA
| | - John Guirguis
- Department of Gastroenterology/Hepatology, Center for Human Nutrition, Cleveland Clinic Foundation, College of Osteopathic Medicine Cleveland, Ohio, USA
| | - Imran Sunesara
- University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Amy Nischnick
- Department of Gastroenterology/Hepatology, Center for Human Nutrition, Cleveland Clinic Foundation, College of Osteopathic Medicine Cleveland, Ohio, USA
| | - Andrew Ukleja
- Department of Gastroenterology/Hepatology, Cleveland Clinic, West Palm Beach, Florida, USA
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Pichler J, Biassoni L, Easty M, Irastorza I, Hill S. Reduced risk of pulmonary emboli in children treated with long-term parenteral nutrition. Clin Nutr 2016; 35:1406-1413. [PMID: 27086197 DOI: 10.1016/j.clnu.2016.03.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 03/07/2016] [Accepted: 03/20/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND & AIMS Pulmonary embolism (PE) is a complication of parenteral nutrition (PN) with a prevalence of 35% in children. In 2003 new intravenous lipid emulsions (ILEs) with MCT, olive and/or fish oil in addition to soybean oil were introduced. The aim was to compare the incidence of PE before and after introduction. METHODS 327 surveillance ventilation-perfusion (V/Q) scintigraphies from 68 children aged 0.3-15 years, treated with PN from 1993 to 2010, were retrospectively reviewed. Rate of PE/1000 central venous catheter (CVC) days, number of children with PE pre- and post-introduction of ILEs were compared. Multivariate analyses were performed for risk factors. RESULTS Twenty-two (32%) children (19/42 before 2003 and 3/26 after 2003, p = 0.007) had at least one episode of PE. Thirty seven (11%) episodes of PE were detected accounting for a mean of 0.2/1000 CVC days prior to 2003 and 0.05/1000 CVC days after 2003, p = 0.04. Regression analysis indicated that higher content of ILE/infusion (p = 0.045) and frequency of ILE of >3 nights/week were associated with more PE (p = 0.001). New ILEs were associated with lower risk (p = 0.003). CONCLUSION With a four-fold fall in incidence with new ILE, PE remains a complication. We recommend 12-18 monthly surveillance with lung perfusion scan and anticoagulants if PE is diagnosed.
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Affiliation(s)
- Judith Pichler
- Department of Paediatric Gastroenterology, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond Street, London WC1N 3JH, United Kingdom; Department of Paediatric and Adolescent Medicine, Medical University Vienna, Währinger Gürtel 18-20, Vienna 1090, Austria.
| | - Lorenzo Biassoni
- Department of Radiology, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond Street, London WC1N 3JH, United Kingdom
| | - Marina Easty
- Department of Radiology, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond Street, London WC1N 3JH, United Kingdom
| | - Inaki Irastorza
- Department of Paediatric Gastroenterology, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond Street, London WC1N 3JH, United Kingdom; Department of Paediatric Gastroenterology, Cruces University Hospital, BioCruces, UPV/EHU, Barakaldo, Spain
| | - Susan Hill
- Department of Paediatric Gastroenterology, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond Street, London WC1N 3JH, United Kingdom
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Dibb M, Soop M, Teubner A, Shaffer J, Abraham A, Carlson G, Lal S. Survival and nutritional dependence on home parenteral nutrition: Three decades of experience from a single referral centre. Clin Nutr 2016; 36:570-576. [PMID: 26972088 DOI: 10.1016/j.clnu.2016.01.028] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 01/14/2016] [Accepted: 01/30/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Home parenteral nutrition (HPN) is the mainstay of treatment for patients with Type 3 intestinal failure (IF), however long term data on mortality and nutritional outcomes are limited. OBJECTIVES To assess the long-term survival and requirements for ongoing HPN in patients receiving treatment at a UK national referral centre for intestinal failure. METHODS Patients with IF who received HPN for more than 3 months at this Intestinal Failure Unit between 1978 and 2011 had their clinical records reviewed. SPSS 20 was utilised to perform Cox regression analysis and generate Kaplan Meier curves, with the aim of identifying factors associated with death and the continued need for HPN. RESULTS Case notes from 545 patients were reviewed. Overall survival (OS) in patients without malignancy at commencement of IF was 93%, 71%, 59% and 28% at 1, 5, 10 and 20 years after starting treatment. Crohn's disease, mesenteric ischaemia and chronic intestinal pseudo-obstruction were associated with a better OS than scleroderma and radiation enteritis on multivariate analysis. Older age at onset of IF was associated with poor OS, while shorter small bowel length or central line sepsis was not. 15% (25/170) of deaths were due to complications of HPN (central line sepsis = 10, IF-associated liver disease = 15). Continued HPN dependence in survivors was 83%, 63%, 59% and 53% at 1, 5, 10 and 15 years, respectively. Among the 153 patients without malignancy who achieved nutritional independence from HPN, 77 (50.3%) did so after surgical reconstruction of the alimentary tract (HPN duration mean 19 months, range 3-126 months). 76 patients (49.7%) weaned from HPN without undergoing surgical reconstruction. CONCLUSION This is the largest reported data set on long-term survival and dependence on HPN and will inform the indications, benefits and risks of treatment in disease specific groups. A significant proportion of patients achieved nutritional autonomy without surgical intervention.
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Affiliation(s)
- Martyn Dibb
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, United Kingdom.
| | - Mattias Soop
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, United Kingdom
| | - Antje Teubner
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, United Kingdom
| | - Jon Shaffer
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, United Kingdom
| | - Arun Abraham
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, United Kingdom
| | - Gordon Carlson
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, United Kingdom
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, United Kingdom
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