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Catron H, Hanson C, Beerman L, Carney J, Janiak K, Gerhardt B, Rochling F, Mercer D. Sustained elimination of parenteral support in adult patients with under 60 cm of small intestine: A case series. Nutr Clin Pract 2024; 39:227-234. [PMID: 37898826 DOI: 10.1002/ncp.11078] [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: 01/13/2023] [Revised: 08/10/2023] [Accepted: 08/27/2023] [Indexed: 10/30/2023] Open
Abstract
Patients with short bowel syndrome (SBS) are often managed by expert multidisciplinary teams. One of the main goals in the management of SBS is the weaning of parenteral support (PS). Weaning of PS removes the risks associated with long-term central line placement and eliminates the need for intestinal transplant. Whereas several papers detail the ongoing care and management of patients with SBS who are dependent on PS, there are few reports discussing the successful weaning of PS in this patient population. We present five case studies examining weaning of PS in adult patients with <60-cm small bowel and partial or full colon who were enrolled in a multidisciplinary adult intestinal rehabilitation program. The case studies demonstrate weaning can occur >2 years after initial assessment and enrollment in an expert program. The ability of the program to focus on individualized care and frequent patient communication is key to PS weaning in patients with SBS.
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Affiliation(s)
- Hilary Catron
- Department of Clinical Nutrition, The Nebraska Medical Center, Omaha, NE, USA
| | - Corrine Hanson
- CAHP Medical Nutrition, University of Nebraska Medical Center, Omaha, NE, USA
| | - Laura Beerman
- Department of Clinical Nutrition, The Nebraska Medical Center, Omaha, NE, USA
| | - Jaime Carney
- Department of Transplant: Liver-Intestine, The Nebraska Medical Center, Omaha, NE, USA
| | - Kathryn Janiak
- Department of Transplant: Liver-Intestine, The Nebraska Medical Center, Omaha, NE, USA
- Departement of Surgery, The Nebraska Medical Center, Omaha, NE, USA
| | - Brandi Gerhardt
- Department of Transplant: Liver-Intestine, The Nebraska Medical Center, Omaha, NE, USA
| | - Fedja Rochling
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - David Mercer
- Department of Surgery/Transplant, University of Nebraska Medical Center, Omaha, NE, USA
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Belcher E, Mercer D, Raphael BP, Salinas GD, Stacy S, Tappenden KA. Management of short-bowel syndrome: A survey of unmet educational needs among healthcare providers. JPEN J Parenter Enteral Nutr 2022; 46:1839-1846. [PMID: 35511707 PMCID: PMC9790246 DOI: 10.1002/jpen.2388] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 04/12/2022] [Accepted: 04/23/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Management of short-bowel syndrome with intestinal failure (SBS-IF) is complex and requires a multidisciplinary approach. Because of the rarity of SBS-IF, healthcare professionals (HCPs) often lack clinical experience with the disease and may benefit from education regarding SBS-IF and its management. This study identified unmet educational needs related to the management of patients with SBS-IF. METHODS This was a prospective, web-based survey (December 2019-January 2020) in which a series of clinical questions were posed to US HCPs after presenting three standardized SBS-IF cases to assess current practice patterns. HCPs were then asked a series of questions to identify potential knowledge gaps and unmet educational needs relating to SBS-IF management. RESULTS Overall, 558 HCPs completed the survey, with 12%-38% having a formal SBS-IF multidisciplinary team currently available to make treatment decisions within their institution. Clinicians involved in care included gastroenterologists (93%), registered dietitians (79%), gastroenterology nurse practitioners and physician assistants (37%), registered nurses (43%), social workers (45%), and psychologists/psychiatrists (27%). There was underuse of published guidelines and limited understanding of the course of intestinal adaptation. Responses to the clinical scenarios highlighted disparities in SBS-IF care delivery, including diagnosis, management goals, medications prescribed, and nutrition practices. CONCLUSIONS Future SBS-IF educational interventions for HCPs should aim to improve awareness and understanding of the disease, facilitate timely diagnosis, and standardize management practices to ensure patients receive optimal interdisciplinary care as widely as possible.
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Affiliation(s)
| | - David Mercer
- Department of Surgery, Division of TransplantationUniversity of Nebraska Medical CenterOmahaNebraskaUSA
| | | | | | | | - Kelly A. Tappenden
- Department of Kinesiology and NutritionUniversity of Illinois ChicagoChicagoIllinoisUSA
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Jeppesen PB, Chen K, Murphy R, Shahraz S, Goodwin B. Impact on caregivers of adult patients receiving parenteral support for short-bowel syndrome with intestinal failure: A multinational, cross-sectional survey. JPEN J Parenter Enteral Nutr 2021; 46:905-914. [PMID: 34368993 PMCID: PMC9293039 DOI: 10.1002/jpen.2248] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Patients with short‐bowel syndrome and intestinal failure (SBS‐IF) require parenteral support (PS) and may need long‐term home‐care support. This survey assessed the impact of care provision on adult caregivers of adult patients receiving PS for SBS‐IF. Methods An online, cross‐sectional survey of caregivers of adults with a self‐reported physician diagnosis of SBS‐IF was conducted in France, Germany, Italy, the UK, and USA. Impact on caregivers was evaluated using the 18‐item Caregiver Strain Index (CSI), the Work Productivity and Activity Impairment Questionnaire: Specific Health Problem (WPAI:SHP), and self‐reporting impact questionnaires. Results Caregivers (N = 121; aged 51 ± 13.7 years; 59% women) provided assistance for a mean of 9.9 ± 12.53 years; 77% were providing care 7 days per week. Patients (51 ± 16.4 years; 56% women) of caregivers were typically family members: spouse/partner (61%), adult son/daughter (19%), or parent (10%). Caregivers reported experiencing some strain (CSI score 4 ± 3.4). Among 71 of 73 employed caregivers, the WPAI:SHP assessment showed that caregivers missed 7% ± 12.7% of work hours in the preceding week and were present but not productive at work 37% ± 23.1% of the time; 28% of caregivers reported a reduced number of working hours because of caregiving. Many caregivers reported limitations in recreational activities (53%), and ≥30% had difficulty spending time with family and friends. Caregivers (87%) also reported worrying about the patient's health. Conclusions Caregivers of adult patients with SBS‐IF experience negative daily personal impacts and loss of productivity arising from their caregiving responsibilities.
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Affiliation(s)
- Palle B Jeppesen
- Department of Intestinal Failure and Liver Diseases, Rigshospitalet, Copenhagen, Denmark
| | - Kristina Chen
- Shire Human Genetic Therapies, Inc, a Takeda company, Cambridge, Massachusetts, USA
| | | | - Saeid Shahraz
- ICON plc, San Francisco, California, USA.,Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts, USA
| | - Bridgett Goodwin
- Takeda Development Center Americas, Inc, Cambridge, Massachusetts, USA
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Matarese LE, Harvin G. Nutritional Care for Patients with Intestinal Failure. Gastroenterol Clin North Am 2021; 50:201-216. [PMID: 33518165 DOI: 10.1016/j.gtc.2020.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Intestinal failure is a debilitating, complex disorder associated with loss of portions of intestine or loss of intestinal function. Short bowel syndrome is the most common form of intestinal failure and results in inability to maintain nutritional, fluid, and electrolyte status while consuming a regular diet. Nutrition interventions to treat short bowel syndrome include enteral and parenteral nutrition, intestinal rehabilitation techniques to enhance absorptive capacity of remnant bowel, and surgical reconstruction designed to provide more surface area for absorption. These therapies are interrelated services to restore nutritional status through the safest most effective therapy consistent with patient lifestyle and wishes.
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Affiliation(s)
- Laura E Matarese
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Brody School of Medicine, East Carolina University, 600 Moye Boulevard, Vidant MA 342, Mail Stop 734, Greenville, NC 27834, USA.
| | - Glenn Harvin
- Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, Brody School of Medicine, East Carolina University, 600 Moye Boulevard, Vidant MA 342, Mail Stop 734, Greenville, NC 27834, USA
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Manithody C, Denton C, Price A, Blomenkamp K, Patel Y, Welu A, Glbert E, Madnawat H, Jain S, Villalona GA, Jain AK. Development and validation of an ambulatory piglet model for short bowel syndrome with ileo-colonic anastomosis. Exp Biol Med (Maywood) 2020; 245:1049-1057. [PMID: 32264693 PMCID: PMC7357144 DOI: 10.1177/1535370220915881] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 03/10/2020] [Indexed: 12/19/2022] Open
Abstract
IMPACT STATEMENT Short bowel syndrome is associated with significant comorbidities and mortality. This study is important as unlike current systems, it provides a validated piglet model which mirrors anatomical, histological, and serological characteristics observed in human SBS. This model can be used to advance knowledge into mechanistic pathways and therapeutic modalities to improve outcomes for SBS patients. This study is novel in that in addition to significant reduction in the remnant bowel and noted liver disease, we also developed a method to emulate ileocecal valve resection and described gut adaptive responses which has important clinical implications in humans.
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Affiliation(s)
| | - Christine Denton
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO 63103, USA
| | - Amber Price
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO 63103, USA
| | - Keith Blomenkamp
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO 63103, USA
| | - Yogi Patel
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO 63103, USA
| | - Adam Welu
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO 63103, USA
| | - Ester Glbert
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO 63103, USA
| | - Himani Madnawat
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO 63103, USA
| | - Sonali Jain
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO 63103, USA
| | - Gustavo A Villalona
- Department of Surgery, Saint Louis University School of Medicine, Saint Louis, MO 63103, USA
| | - Ajay K Jain
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, MO 63103, USA
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Shie MY, Shen YF, Astuti SD, Lee AKX, Lin SH, Dwijaksara NLB, Chen YW. Review of Polymeric Materials in 4D Printing Biomedical Applications. Polymers (Basel) 2019; 11:E1864. [PMID: 31726652 PMCID: PMC6918275 DOI: 10.3390/polym11111864] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 11/06/2019] [Accepted: 11/08/2019] [Indexed: 12/30/2022] Open
Abstract
The purpose of 4D printing is to embed a product design into a deformable smart material using a traditional 3D printer. The 3D printed object can be assembled or transformed into intended designs by applying certain conditions or forms of stimulation such as temperature, pressure, humidity, pH, wind, or light. Simply put, 4D printing is a continuum of 3D printing technology that is now able to print objects which change over time. In previous studies, many smart materials were shown to have 4D printing characteristics. In this paper, we specifically review the current application, respective activation methods, characteristics, and future prospects of various polymeric materials in 4D printing, which are expected to contribute to the development of 4D printing polymeric materials and technology.
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Affiliation(s)
- Ming-You Shie
- School of Dentistry, China Medical University, Taichung City 404, Taiwan;
- 3D Printing Medical Research Center, China Medical University Hospital, Taichung City 404, Taiwan; (A.K.-X.L.); (S.-H.L.)
- Department of Bioinformatics and Medical Engineering, Asia University, Taichung City 413, Taiwan; (Y.-F.S.); (N.L.B.D.)
| | - Yu-Fang Shen
- Department of Bioinformatics and Medical Engineering, Asia University, Taichung City 413, Taiwan; (Y.-F.S.); (N.L.B.D.)
- 3D Printing Medical Research Institute, Asia University, Taichung City 413, Taiwan
| | - Suryani Dyah Astuti
- Biomedical Engineering Study Program, Department of Physic, Faculty of Science and Technology, Univerisitas Airlangga, Surabaya 61115, Indonesia;
| | - Alvin Kai-Xing Lee
- 3D Printing Medical Research Center, China Medical University Hospital, Taichung City 404, Taiwan; (A.K.-X.L.); (S.-H.L.)
- School of Medicine, China Medical University, Taichung City 404, Taiwan
| | - Shu-Hsien Lin
- 3D Printing Medical Research Center, China Medical University Hospital, Taichung City 404, Taiwan; (A.K.-X.L.); (S.-H.L.)
| | - Ni Luh Bella Dwijaksara
- Department of Bioinformatics and Medical Engineering, Asia University, Taichung City 413, Taiwan; (Y.-F.S.); (N.L.B.D.)
- Biomedical Engineering Study Program, Department of Physic, Faculty of Science and Technology, Univerisitas Airlangga, Surabaya 61115, Indonesia;
| | - Yi-Wen Chen
- 3D Printing Medical Research Institute, Asia University, Taichung City 413, Taiwan
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung City 404, Taiwan
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Mangus RS. Liver-Intestine/Multivisceral Perspective: Indications, Patient Selection, and Allocation Policy. Clin Liver Dis (Hoboken) 2019; 14:142-145. [PMID: 31709042 PMCID: PMC6832100 DOI: 10.1002/cld.848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 05/28/2019] [Indexed: 02/04/2023] Open
Affiliation(s)
- Richard S. Mangus
- Department of Surgery, Transplant DivisionIndiana University School of MedicineIndianapolisIN
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Ballinger R, Macey J, Lloyd A, Brazier J, Ablett J, Burden S, Lal S. Measurement of Utilities Associated with Parenteral Support Requirement in Patients with Short Bowel Syndrome and Intestinal Failure. Clin Ther 2018; 40:1878-1893.e1. [DOI: 10.1016/j.clinthera.2018.09.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 09/18/2018] [Indexed: 02/05/2023]
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Price A, Blomenkamp K, Manithody C, Saxena S, Abraham SM, Greenspon J, Villalona GA, Jain AK. Developing a Novel Ambulatory Total Parenteral Nutrition-Dependent Short Bowel Syndrome Animal Model. J Surg Res 2018; 234:13-19. [PMID: 30527464 DOI: 10.1016/j.jss.2018.08.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 07/22/2018] [Accepted: 08/24/2018] [Indexed: 01/27/2023]
Abstract
BACKGROUND Short bowel syndrome (SBS) results from extensive bowel resection. Patients with SBS require total parenteral nutrition (TPN) for survival. Understanding mechanisms contributing to TPN-associated liver injury and gut atrophy are critical in developing SBS therapies. Existing SBS models using tethered animals have significant limitations and are unlike ambulatory human SBS patients. We hypothesized that we could induce SBS in piglets and develop an ambulatory TPN-SBS model. MATERIAL AND METHODS Eighteen neonatal pigs received duodenal and jugular catheters. They were fitted with a jacket holding TPN and a miniaturized pump. Six piglets had 90% small bowel resection and catheter placement (SBS group). Non-SBS piglets were randomized into enteral nutrition (EN) or TPN. RESULTS Bowel resection was successfully accomplished in SBS animals. Weight gain was similar in all groups. SBS animals had increased serum bilirubin compared to EN. Mean conjugated bilirubin ± SD was 0.045 ± 0.01 for EN, (P = 0.03 EN versus TPN and P = 0.03 SBS versus EN) and 1.09 ± 1.25 for TPN, (P = 0.62 TPN versus SBS). Gut density was reduced in the TPN group compared to EN and SBS groups. Mean gut density ± SD was 0.11 ± 0.04 for TPN (P = 0.0004 TPN versus SBS and P = 0.00007 TPN versus EN) and not statistically different for EN versus SBS (P = 0.32). CONCLUSIONS We created a novel, ambulatory TPN-SBS model using piglets, mimicking long-term TPN delivery in human SBS patients. Our model demonstrated TPN-related conjugated hyperbilirubinemia and compensatory gut hypertrophy, as noted in humans with SBS. This model holds great potential for future research.
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Affiliation(s)
- Amber Price
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, Missouri
| | - Keith Blomenkamp
- Department of Surgery, Saint Louis University School of Medicine, Saint Louis, Missouri
| | | | - Saurabh Saxena
- Department of Surgery, Saint Louis University School of Medicine, Saint Louis, Missouri
| | - Salim Munoz Abraham
- Department of Surgery, Saint Louis University School of Medicine, Saint Louis, Missouri
| | - Jose Greenspon
- Department of Surgery, Saint Louis University School of Medicine, Saint Louis, Missouri
| | - Gustavo A Villalona
- Department of Surgery, Saint Louis University School of Medicine, Saint Louis, Missouri
| | - Ajay Kumar Jain
- Department of Pediatrics, Saint Louis University School of Medicine, Saint Louis, Missouri.
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Schoeler M, Klag T, Wendler J, Bernhard S, Adolph M, Kirschniak A, Goetz M, Malek N, Wehkamp J. GLP-2 analog teduglutide significantly reduces need for parenteral nutrition and stool frequency in a real-life setting. Therap Adv Gastroenterol 2018; 11:1756284818793343. [PMID: 30364471 PMCID: PMC6196620 DOI: 10.1177/1756284818793343] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 06/15/2018] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND To evaluate the benefits of teduglutide in a real-life setting, we analyzed the data of 14 patients with short bowel syndrome treated with teduglutide. Additionally, we studied glucagon-like peptide 2 (GLP-2) receptor expression in samples of small intestinal and colonic tissue to provide explanations for clinical observations. METHODS Stool frequency and consistency, sensation of thirst, parental calorie or fluid uptake and the number of days on parenteral support per week were collected for up to 2 years. Quantitative real-time polymerase chain reaction of the GLP-2 receptor in healthy controls was performed to better understand clinical response in different patient subgroups. RESULTS There was a significant reduction in parenteral support after 24 and 48 weeks (by 11.0 and 36.6%, respectively; p < 0.05). Further major improvements were made in several patients after over 1 year (reduction by 79.3%, p < 0.05). The proportion of patients who reduced parenteral support by at least 20% was 33.3%, 54.5% and 71.3% after 24 weeks, 48 weeks and beyond 1 year, respectively. Patients on daily parenteral support showed late but strong amelioration. The reduction of thirst was the earliest marker for response. While stool consistency increased (p < 0.01), stool frequency decreased (p < 0.05) significantly after 12 weeks. This reduction was even more pronounced in patients with colon in continuity. Supporting these clinical observations, we found a stronger physiological expression of the GLP-2 receptor in the colon than in the small intestine. CONCLUSIONS Patients benefit from teduglutide in a real-life setting, but in contrast to randomized, controlled studies reduction of parenteral support took longer. We identified early clinical markers of response, such as stool consistency and frequency as well as sensation of thirst. Clinical and molecular observations support the role of the colon as an important target organ of teduglutide.
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Affiliation(s)
- Marc Schoeler
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Tübingen, Tübingen, Germany
| | - Thomas Klag
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Tübingen, Tübingen, Germany
| | - Judith Wendler
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Tübingen, Tübingen, Germany
| | - Simon Bernhard
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Tübingen, Tübingen, Germany
| | - Michael Adolph
- Department of Anesthesiology, University Hospital Tübingen, Tübingen, Germany
| | | | - Martin Goetz
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Tübingen, Tübingen, Germany
| | - Nisar Malek
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Tübingen, Tübingen, Germany
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Johnson E, Vu L, Matarese LE. Bacteria, Bones, and Stones: Managing Complications of Short Bowel Syndrome. Nutr Clin Pract 2018; 33:454-466. [PMID: 29926935 DOI: 10.1002/ncp.10113] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Short bowel syndrome (SBS) occurs in patients who have had extensive resection. The primary physiologic consequence is malabsorption, resulting in fluid and electrolyte abnormalities and malnutrition. Nutrient digestion, absorption, and assimilation may also be diminished by disturbances in the production of bile acids and digestive enzymes. Small bowel dilation, dysmotility, loss of ileocecal valve, and anatomical changes combined with acid suppression and antimotility drugs increase the risk of small intestinal bacterial overgrowth, further contributing to malabsorption. Metabolic changes that occur in SBS due to loss of colonic regulation of gastric and small bowel function can also lead to depletion of calcium, magnesium, and vitamin D, resulting in demineralization of bone and the eventual development of bone disease. Persistent inflammation, steroid use, parenteral nutrition, chronic metabolic acidosis, and renal insufficiency may exacerbate the problem and contribute to the development of osteoporosis. Multiple factors increase the risk of nephrolithiasis in SBS. In the setting of fat malabsorption, increased free fatty acids are available to bind to calcium, resulting in an increased concentration of unbound oxalate, which is readily absorbed across the colonic mucosa where it travels to the kidney. In addition, there is an increase in colonic permeability to oxalate stemming from the effects of unabsorbed bile salts. The risk of nephrolithiasis is compounded by volume depletion, metabolic acidosis, and hypomagnesemia, resulting in a decrease in renal perfusion, urine output, pH, and citrate excretion. This review examines the causes and treatments of small intestinal bacterial overgrowth, bone demineralization, and nephrolithiasis in SBS.
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Affiliation(s)
- Erika Johnson
- Center for Human Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Long Vu
- Center for Human Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Laura E Matarese
- Department of Internal Medicine and Surgery, Brody School of Medicine, East Carolina University, Greenville, North Carolina, USA
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12
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Abstract
Short bowel syndrome with intestinal failure is a rare disease with a massive impairment in quality of life, requiring a multidisciplinary team approach to medical, surgical, and nutritional therapy. Current pharmacological and surgical therapeutic options are limited; an important cornerstone is enteral and parenteral nutrition. The changed physiology of carbohydrate digestion plays a major role in the adaptation process and can be a target for specific enteral nutrition interventions. An important prognostic factor is the preservation of at least portions of the colon in continuity with small bowel. This strategy has to include an evaluation of the anatomical situation and small bowel absorptive capacity, adaptation processes, and luminal microbiota including its fermentative properties. Starch is probably the most important complex carbohydrate in short bowel syndrome nutrition, because it is absorbed or fermented almost completely. Benefits of supplementation with complex carbohydrates include improved adaptive processes, positive trophic effects on the mucosa and its hormonal response, longer transit time, and possibly a faster time to wean from parenteral nutrition, but supplementation advice needs to weigh carefully the risks and benefits, especially considering bacterial overgrowth, osmotic load, and D-lactate acidosis.
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13
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Ukleja A, To C, Alvarez A, Lara LF. Long-Term Therapy With Teduglutide in Parenteral Support-Dependent Patients With Short Bowel Syndrome: A Case Series. JPEN J Parenter Enteral Nutr 2018; 42:821-825. [DOI: 10.1002/jpen.1149] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 12/21/2017] [Indexed: 11/09/2022]
Affiliation(s)
- Andrew Ukleja
- Department of Gastroenterology; Cleveland Clinic Florida; Weston Florida USA
| | - Chau To
- St. John's Episcopal Hospital; Far Rockaway; New York USA
| | | | - Luis F. Lara
- Department of Gastroenterology; Cleveland Clinic Florida; Weston Florida USA
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14
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Nelson EL, Yadrich DM, Thompson N, Wright S, Stone K, Adams N, Werkowitch M, Smith CE. Telemedicine Support Groups for Home Parenteral Nutrition Users. Nutr Clin Pract 2017; 32:789-798. [PMID: 29016235 DOI: 10.1177/0884533617735527] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Patients receiving home parenteral nutrition (HPN), a life-sustaining intravenous (IV) infusion that provides nourishment and hydration to patients with short gut or inflammatory bowel diseases, are often isolated and not in visual contact with peers or health providers. One completed clinical trial (Clinical Trials.gov NCT0190028) and 1 ongoing clinical trial (Clinical Trials.gov NCT02987569) are evaluating a mobile videoconferencing-delivered support group intervention for patients on HPN and their caregivers. This home-based telemedicine intervention uses encrypted tablet-based videoconferencing to connect multiple families in real time. The twice-daily IV regimen is challenging for patients who may experience infusion catheter-related bloodstream infections, difficulties with fatigue, loss of sleep, depressive disorders, and worry over the potential life-threatening side effects and the expenses of this therapy. Using secure telemedicine, the facilitated support group intervention aims to enhance HPN home care, daily functioning, and quality of life. The authors provide the rationale for the telemedicine approach with HPN users and caregivers. They provide "how-to" information about the content and process of the facilitated support group sessions via secure videoconferencing. They share lessons learned from the ongoing evaluation of the telemedicine approach.
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Affiliation(s)
- Eve-Lynn Nelson
- 1 KU Center for Telemedicine & Telehealth & Department of Pediatrics, University of Kansas Medical Center, Fairway, Kansas, USA
| | - Donna Macan Yadrich
- 2 School of Nursing, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Noreen Thompson
- 3 University of Kansas Health System, Kansas City, Kansas, USA
| | - Shawna Wright
- 4 KU Center for Telemedicine & Telehealth, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Kathaleen Stone
- 4 KU Center for Telemedicine & Telehealth, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Natasia Adams
- 4 KU Center for Telemedicine & Telehealth, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Marilyn Werkowitch
- 5 School of Nursing, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Carol E Smith
- 6 School of Nursing and Department of Preventive Medicine & Public Health, University of Kansas Medical Center, Frisco, Kansas, USA
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15
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Abstract
The diagnosis of irreversible intestinal failure confers significant morbidity, mortality, and decreased quality of life. Patients with irreversible intestinal failure may be treated with intestinal transplantation. Intestinal transplantation may include intestine only, liver-intestine, or other visceral elements. Intestinal transplantation candidates present with systemic manifestations of intestinal failure requiring multidisciplinary evaluation at an intestinal transplantation center. Central access may be difficult in intestinal transplantation candidates. Intestinal transplantation is a complex operation with potential for hemodynamic and metabolic instability. Patient and graft survival are improving, but graft failure remains the most common postoperative complication.
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Affiliation(s)
- Christine Nguyen-Buckley
- Department of Anesthesiology, David Geffen School of Medicine, University of California at Los Angeles, 757 Westwood Plaza, Suite 3304, Los Angeles, CA 90095, USA.
| | - Melissa Wong
- Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine, University of California at Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
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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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Worthington P, Balint J, Bechtold M, Bingham A, Chan LN, Durfee S, Jevenn AK, Malone A, Mascarenhas M, Robinson DT, Holcombe B. When Is Parenteral Nutrition Appropriate? JPEN J Parenter Enteral Nutr 2017; 41:324-377. [PMID: 28333597 DOI: 10.1177/0148607117695251] [Citation(s) in RCA: 126] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Parenteral nutrition (PN) represents one of the most notable achievements of modern medicine, serving as a therapeutic modality for all age groups across the healthcare continuum. PN offers a life-sustaining option when intestinal failure prevents adequate oral or enteral nutrition. However, providing nutrients by vein is an expensive form of nutrition support, and serious adverse events can occur. In an effort to provide clinical guidance regarding PN therapy, the Board of Directors of the American Society for Parenteral and Enteral Nutrition (ASPEN) convened a task force to develop consensus recommendations regarding appropriate PN use. The recommendations contained in this document aim to delineate appropriate PN use and promote clinical benefits while minimizing the risks associated with the therapy. These consensus recommendations build on previous ASPEN clinical guidelines and consensus recommendations for PN safety. They are intended to guide evidence-based decisions regarding appropriate PN use for organizations and individual professionals, including physicians, nurses, dietitians, pharmacists, and other clinicians involved in providing PN. They not only support decisions related to initiating and managing PN but also serve as a guide for developing quality monitoring tools for PN and for identifying areas for further research. Finally, the recommendations contained within the document are also designed to inform decisions made by additional stakeholders, such as policy makers and third-party payers, by providing current perspectives regarding the use of PN in a variety of healthcare settings.
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Affiliation(s)
| | - Jane Balint
- 2 Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | | | - Angela Bingham
- 4 University of the Sciences, Philadelphia, Pennsylvania, USA
| | | | - Sharon Durfee
- 6 Central Admixture Pharmacy Services, Inc, Denver, Colorado, USA
| | | | | | - Maria Mascarenhas
- 9 The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniel T Robinson
- 10 Ann & Robert H. Lurie Children's Hospital, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Beverly Holcombe
- 11 American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland, USA
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Cost of ambulatory care for the pediatric intestinal failure patient: One-year follow-up after primary discharge. J Pediatr Surg 2016; 51:798-803. [PMID: 26932248 DOI: 10.1016/j.jpedsurg.2016.02.026] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 02/07/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Survival of children with intestinal failure has improved over the last decade, resulting in increased health care expenditures. Our objective was to determine outpatient costs for the first year after primary discharge. METHODS A retrospective analysis was performed in pediatric intestinal failure (PIF) patients between 2010 and 2012. Patients were stratified into 3 groups (1=enteral support with no devices [7 patients], 2=enteral support with devices (gastrostomy and/or ostomy) [19 patients], 3=home parenteral nutrition (HPN) [22 patients]). Data abstraction included clinical characteristics and costs related to medication, enteral/parenteral nutrition, and supplies were calculated. Data were analyzed using one way ANOVA. RESULTS Forty-eight patients (mean age 7.6months; 31 males [65%]) were studied. See attached table for results. HPN patients had significantly more ambulatory visits (p<0.0001), number of admitted days (p=0.01), and productive days lost (p<0.0001). Total cost of care was significantly higher for HPN patients (mean=$320,368.50, p<0.0001) when compared to other groups. Costs covered by the health care system were significantly higher for patients on HPN (mean=$316,101.56, p<0.0001). CONCLUSION The outpatient expenditures to care for PIF patients in the first year post primary discharge are significant. Our single payer health care system supports the majority of costs, but families are also incurring expenses related to travel and lost productivity. Children on HPN have more visits to hospital, but have access to more funding options. Children solely on gastrostomy or stoma therapy, however, have a significantly greater personal financial burden.
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Rege A, Sudan D. Intestinal transplantation. Best Pract Res Clin Gastroenterol 2016; 30:319-35. [PMID: 27086894 DOI: 10.1016/j.bpg.2016.02.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 02/08/2016] [Accepted: 02/11/2016] [Indexed: 01/31/2023]
Abstract
Intestinal transplantation has now emerged as a lifesaving therapeutic option and standard of care for patients with irreversible intestinal failure. Improvement in survival over the years has justified expansion of the indications for intestinal transplantation beyond the original indications approved by Center for Medicare and Medicaid services. Management of patients with intestinal failure is complex and requires a multidisciplinary approach to accurately select candidates who would benefit from rehabilitation versus transplantation. Significant strides have been made in patient and graft survival with several advancements in the perioperative management through timely referral, improved patient selection, refinement in the surgical techniques and better understanding of the immunopathology of intestinal transplantation. The therapeutic efficacy of the procedure is well evident from continuous improvements in functional status, quality of life and cost-effectiveness of the procedure. This current review summarizes various aspects including current practices and evidence based recommendations of intestinal transplantation.
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Affiliation(s)
- Aparna Rege
- Department of Surgery, Division of Abdominal Transplantation, Duke University Medical Center, Durham, NC, USA.
| | - Debra Sudan
- Department of Surgery, Division of Abdominal Transplantation, Duke University Medical Center, Durham, NC, USA
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Smith CE, Spaulding R, Piamjariyakul U, Werkowitch M, Yadrich DM, Hooper D, Moore T, Gilroy R. mHealth Clinic Appointment PC Tablet: Implementation, Challenges and Solutions. ACTA ACUST UNITED AC 2015; 4:21-32. [PMID: 26604991 DOI: 10.7309/jmtm.4.2.4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Patients requiring daily intravenous (IV) home parenteral nutrition (HPN) would benefit from in-home professional observation to improve self-care, to assess, detect and prevent serious complications. AIMS The study aims are to assess the viability and utility of conducting mobile healthcare (mHealth) videoconference assessments with patients managing lifelong daily 12-hour IV nutrition infusions in their homes. The challenges and solutions to implementing mobile personal computer (PC) tablet based clinic appointments are described. METHODS A wireless Apple iPad Mini™ mobile touch-screen tablet computer with 5 mega-pixel camera was loaned to patients. Each tablet had Polycom RealPresence software and a fourth generation (4G) mobile telecommunications data plan. These supported audio-visual mobile videoconferencing encrypted connections between health professionals in their offices and HPN patients and their family members in their homes. Patients' and professionals' evaluations of their mHealth clinic experiences are collected. RESULTS Patients (mean age = 41.9, SD = 2.8 years) had been prescribed 12-hour home parenteral nutrition (HPN) infusions daily due short bowel disorders. Patients had been on HPN from 1 to 10 years (M=4, SD=3.6). Evaluation of clinic appointments revealed that 100% of the patients (n=45) and the professionals (n=6) indicated that they can clearly hear and easily see one another. The mHealth audio-visual interactions were highly rated by patients and family members. Professionals highly rated their ability to obtain a medical history and visual inspection of patients. Several challenges were identified and recommendations for resolutions are described. DISCUSSION All patients and professionals highly rated the iPad mHealth clinic appointments for convenience and ease of communicating between homes and offices. An important challenge for all mHealth visits is the clinical professional's ability to make clinically accurate judgments about what they observed and heard from the patients. Following our solutions for obtaining clear visuals with the iPad can improve ability to make clinical assessments.
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Affiliation(s)
- Carol E Smith
- Professor, School of Nursing and Preventive Medicine & Public Health Department, University of Kansas Medical Center
| | - Ryan Spaulding
- Research Associate Professor, Director, Center for Telemedicine and Telehealth, Interim Associate Vice Chancellor, Institute for Community Engagement, University of Kansas Medical Center
| | - Ubolrat Piamjariyakul
- Research Associate Professor, School of Nursing, University of Kansas Medical Center
| | | | | | - Dedrick Hooper
- Systems Coordinator, Center for Telemedicine and Telehealth, University of Kansas Medical Center
| | - Tyson Moore
- Research Assistant, School of Nursing, University of Kansas Medical Center
| | - Richard Gilroy
- Professor and Medical Director of Liver Transplantation, Department of Gastroenterology and Hepatology, University of Kansas Medical Center
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Kunz SN, McAdams RM, Diekema DS, Opel DJ. A Quality of Life Quandary: A Framework for Navigating Parental Refusal of Treatment for Co-Morbidities in Infants with Underlying Medical Conditions. THE JOURNAL OF CLINICAL ETHICS 2015. [DOI: 10.1086/jce2015261016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Kubal CA, Mangus RS, Tector AJ. Intestine and multivisceral transplantation: current status and future directions. Curr Gastroenterol Rep 2015; 17:427. [PMID: 25613179 DOI: 10.1007/s11894-014-0427-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Intestinal failure and associated parenteral nutrition-induced liver failure cause significant morbidity, mortality, and health care burden. Intestine transplantation is now considered to be the standard of care in patients with intestinal failure who fail intestinal rehabilitation. Intestinal failure-associated liver disease is an important sequela of intestinal failure, caused by parenteral lipids, requiring simultaneous liver-intestine transplant. Lipid minimization and, in recent years, the emergence of fish oil-based lipid emulsions have been shown to reverse parenteral nutrition-associated hyperbilirubinemia, but not fibrosis. Significant progress in surgical techniques and immunosuppression has led to improved outcomes after intestine transplantation. Intestine in varying combination with liver, stomach, and pancreas, also referred to as multivisceral transplantation, is performed for patients with intestinal failure along with liver disease, surgical abdominal catastrophes, neuroendocrine and slow-growing tumors, and complete portomesenteric thrombosis with cirrhosis of the liver. Although acute and chronic rejection are major problems, long-term survivors have excellent quality of life and remain free of parenteral nutrition.
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Affiliation(s)
- Chandrashekhar A Kubal
- Transplant Division, Department of Surgery, Indiana University School of Medicine, 550 N University Blvd, Room 4601, Indianapolis, IN, 46202-5250, USA,
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Abstract
PURPOSE OF REVIEW Teduglutide, a recombinant analog of human glucagon-like peptide 2, has recently been approved in the US and Europe (Gattex and Revestive, respectively) as the first targeted treatment of short bowel syndrome-associated intestinal failure (SBS-IF). Glucagon-like peptide 2 improves structural and functional intestinal adaptation following intestinal resection by decelerating a rapid gastric emptying, by decreasing gastric hypersecretion, by increasing intestinal blood flow and by promoting intestinal growth. This review summarizes the findings from phase 2 and 3 studies preceding the US Food and Drug Administration and the European Medicines Agency approval of subcutaneous teduglutide for this orphan condition. RECENT FINDINGS In a 3-week, phase 2, metabolic balance study, teduglutide increased intestinal wet weight absorption by approximately 700 g/day and reduced fecal energy losses by approximately 0.8 MJ/day (∼200 kcal/day). In two subsequent 24-week, phase 3 studies, teduglutide reduced the need for parenteral support in the same magnitude. Teduglutide had an acceptable tolerability profile, where adverse events generally were of gastrointestinal origin consistent with the known mechanism of action. SUMMARY Teduglutide will add incremental benefit to the limited medical treatment armamentarium in SBS patients by maximizing intestinal absorption, decreasing fecal losses, thereby decreasing or even eliminating the need for parenteral support. Future research should target and implement other key hormones with similar and possible additive or synergistic effects, thereby further promoting structural and functional adaptation and intestinal rehabilitation in these severely disabled SBS patients.
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