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Pauline ML, Labonne E, Wizzard PR, Turner JM, Wales PW. Association between 4%-tetrasodium EDTA and sepsis in neonatal piglets: A retrospective cohort study. JPEN J Parenter Enteral Nutr 2024; 48:495-501. [PMID: 38400572 DOI: 10.1002/jpen.2609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 01/10/2024] [Accepted: 01/28/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Central line-associated bloodstream infections are a major concern for children with intestinal failure and in animal research using parenteral nutrition (PN). In neonatal piglets receiving PN, we compared sepsis, line occlusions, line replacements, mortality, and costs with and without the use of a 4%-tetrasodium ethylenediaminetetraacetic acid (T-EDTA) locking solution. METHODS We performed a retrospective review of piglets with a central venous jugular catheter enrolled in 14-day exclusive PN (TPN) trials or in 7-day short bowel syndrome (SBS) trials, before and after initiation of T-EDTA. Lines were locked with a 1-ml solution for 2 h daily (T-EDTATPN, n = 17; T-EDTASBS, n = 48) and compared with our prior standard of care using 1.5-ml heparin flushes twice daily (CONTPN, n = 34; CONSBS, n = 48). Line patency and signs of sepsis were checked twice daily. Jugular catheters were replaced for occlusions whenever possible. Humane end points were used for sepsis not responding to antibiotic treatment or unresolved catheter occlusions. RESULTS Compared with CON, sepsis was reduced using T-EDTA, significantly for TPN (P = 0.006) and with a trend for SBS piglets (P = 0.059). Line occlusions necessitating line changes were reduced 15% in TPN studies (P = 0.16), and no line occlusions occurred for T-EDTA SBS piglets. CONCLUSION In our neonatal piglet research, use of T-EDTA locking solution decreased sepsis and, although not statistically significant, reduced occlusions requiring line replacements. Given the expense of animal research, adding a locking solution must be cost-effective, and we were able to show that T-EDTA significantly reduced total research costs and improved animal welfare.
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Affiliation(s)
- Mirielle L Pauline
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Evan Labonne
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Pamela R Wizzard
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Justine M Turner
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Paul W Wales
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
- Cincinnati Center of Excellence in Intestinal Rehabilitation (CinCEIR), Cincinnati, Ohio, USA
- Department of Surgery, Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
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da Silva ITF, Medeiros CO, Leobet J, Beux MR, Rabito EI, Etgeton SAP, Fiori LS. Assessment of the risk of contamination of enteral nutrition bottles based on the simulation of home use conditions and hygiene procedures. Nutr Clin Pract 2024. [PMID: 38491970 DOI: 10.1002/ncp.11144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 02/07/2024] [Accepted: 02/25/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Home-prepared enteral formulations are supplied to patients through enteral nutrition bottles, via a gravity bag or other container, which may be inadequately sanitized and reused more times than recommended by the manufacturer. Such procedures increase the risk of contamination and can compromise the patient's clinical outcome. In light of this, the present study aimed to assess the risk of contamination of enteral nutrition bottles by simulating home use conditions and hygiene procedures. METHODS A simulation of bottle usage was conducted across the three categories of enteral nutrition (homemade enteral preparations, blended enteral preparations, and commercial enteral formulas) for 3 days, using three hygiene procedures reported by caregivers: use of detergent (DET); use of detergent and boiling water (DET+BW); and use of detergent and bleach (DET+BL). The microbiological contamination was determined by the analysis of aerobic mesophilic microorganisms. RESULTS The bottles that were used for 3 days, regardless of the enteral nutrition category, were within the acceptable limit for aerobic mesophilic microorganisms (between <4 and 8.0 colony-forming units [CFU]/cm2 ) when sanitized using the DET+BW and DET+BL procedures. The enteral nutrition bottles, when cleaned using the DET procedure during the 3 days of usage, showed low microbial contamination (between <4 and 3.0 CFU/cm2 ) in blended preparation and commercial formula only. CONCLUSION Thus, regardless of the enteral nutrition category, we found that the bottles can be used for 3 days, as long as the DET+BW or DET+BL hygiene procedure is applied and safe food handling measures are adopted.
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Affiliation(s)
| | - Caroline O Medeiros
- Department of Nutrition, Federal University of Parana, Paraná, Brazil
- Postgraduate Program in Food and Nutrition, Department of Nutrition, Federal University of Parana, Paraná, Brazil
| | - Jaqueline Leobet
- Department of Nutrition, Federal University of Parana, Paraná, Brazil
| | - Márcia R Beux
- Postgraduate Program in Food and Nutrition, Department of Nutrition, Federal University of Parana, Paraná, Brazil
| | - Estela I Rabito
- Department of Nutrition, Federal University of Parana, Paraná, Brazil
- Postgraduate Program in Food and Nutrition, Department of Nutrition, Federal University of Parana, Paraná, Brazil
| | - Schaina A P Etgeton
- Postgraduate Program in Food and Nutrition, Department of Nutrition, Federal University of Parana, Paraná, Brazil
| | - Lize S Fiori
- Department of Nutrition, Federal University of Parana, Paraná, Brazil
- Postgraduate Program in Food and Nutrition, Department of Nutrition, Federal University of Parana, Paraná, Brazil
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3
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Bond A, Hall K, Taylor M, Duxbury A, Cawley C, Abraham A, Teubner A, Lal S. Outcomes for central venous catheter repair in patients receiving long-term home parenteral support: A descriptive cohort study. JPEN J Parenter Enteral Nutr 2024; 48:224-230. [PMID: 38142305 DOI: 10.1002/jpen.2594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/30/2023] [Accepted: 11/28/2023] [Indexed: 12/25/2023]
Abstract
BACKGROUND Central venous catheter (CVC) complications are frequently reported in patients receiving home parenteral support (HPS). Compromised CVC integrity or breakage is one such issue. Repairing such breakages can potentially avoid costly and risky catheter replacements. METHODS We completed a retrospective descriptive cohort study using a prospectively maintained data set, in a national UK intestinal failure reference center. Repair success, CVC longevity, and catheter-related bloodstream infection (CRBSI) rates after repair were the primary outcome measures. RESULTS A total of 763 patients received HPS. There were 137 CVC repairs: 115 (84%) tunneled CVCs and 22 peripherally inserted central catheters (PICCs) attempted in 72 patients. Of the 137 attempts at CVC repair, 120 (88%) were deemed to be successful, allowing a median duration of subsequent CVC use of 336 days following repair (range 3-1696 days), which equates to 99,602 catheter days of HPS infusion. Three patients had a CRBSI within 90 days of repair, and patients required admission to the hospital for refeeding on 14 occasions following repair, such that hospitalization was avoided in 103/120 (86%) occasions following successful CVC repair. There was no increase in the recorded rate of CRBSIs in patients undergoing CVC repair compared with the CRBSI rates of all HPS-dependent patients under our care during the study period (0.03 vs 0.344/1000 catheter days, respectively). CONCLUSION This is the largest single-center experience to demonstrate that CVCs, including PICCs, used for the administration of HPS can be safely repaired, prolonging CVC longevity without leading to an increased risk of CRBSI.
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Affiliation(s)
- Ashley Bond
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
- School of Medicine, University of Manchester, Manchester, UK
| | - Kirsty Hall
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
| | - Michael Taylor
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
| | - Andrea Duxbury
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
| | - Cathy Cawley
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
| | - Arun Abraham
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
| | - Antje Teubner
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
- School of Medicine, University of Manchester, Manchester, UK
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
- School of Medicine, University of Manchester, Manchester, UK
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da Costa RL, Medeiros CO, da Cunha DT, Stangarlin-Fiori L. Checklist to assess food safety when handling home enteral nutrition. Nutr Clin Pract 2023; 38:1309-1323. [PMID: 36822676 DOI: 10.1002/ncp.10962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 01/04/2023] [Accepted: 01/20/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Identifying food safety risks when handling enteral formulations at home is important to restore and maintain the health of patients. Therefore, this study developed and validated a food safety assessment checklist for handling home enteral nutrition (HEN). METHODS This methodological study developed a checklist based on a literature review and interviews with food safety professionals. The content validation, which was conducted by food safety and enteral feeding experts, assessed the relevance, clarity, and simplicity of the checklist using the content validity index of items (CVI-I), categories (CVI-C), and the entire instrument (CVI-EI). Each item was rated as either essential, necessary, or recommended according to the risk in relation to foodborne diseases. RESULTS The Food Safety for Handling Home Enteral Nutrition checklist (FSHEN checklist) that was developed includes 40 items and the following eight categories: physical structure; cleaning of facilities, equipment, furniture, and utensils; pests and waste; water supply; food handlers; ingredients and packaging; handling of enteral formulations; and the bottling and storage of enteral formulations. The CVI-EI was above the recommendation (≥0.93) for the three assessed criteria, as was the CVI-C in terms of clarity (≥0.95), relevance (≥0.98), and simplicity (≥0.84). A total of 52.5% of the items were rated as essential, 32.5% as necessary, and 15% as recommended. CONCLUSION The FSHEN checklist is relevant, clear, and easy to use. It can help health professionals and individuals working in the field to assess and prioritize items to improve food safety in the management of HEN.
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Affiliation(s)
- Rayane Luizi da Costa
- Postgraduate Program in Food and Nutrition, Federal University of Parana (UFPR), Curitiba, Brazil
| | - Caroline Opolski Medeiros
- Postgraduate Program in Food and Nutrition, Department of Nutrition, Federal University of Parana (UFPR), Curitiba, Brazil
| | - Diogo Thimoteo da Cunha
- Multidisciplinary Laboratory of Food and Health, School of Applied Sciences, State University of Campinas, Limeira, Brazil
| | - Lize Stangarlin-Fiori
- Postgraduate Program in Food and Nutrition, Department of Nutrition, Federal University of Parana (UFPR), Curitiba, Brazil
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5
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Lowthian TJ. Why are we settling? Improving home parenteral nutrition quality of life outcomes. JPEN J Parenter Enteral Nutr 2023; 47:827-829. [PMID: 37488680 DOI: 10.1002/jpen.2552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 07/24/2023] [Indexed: 07/26/2023]
Affiliation(s)
- Trinity J Lowthian
- Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
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6
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Ngai D, Kotamraju S, Do P, Luffy R, Winser-Bean C, Rockwell J, Hollaway L, Wright V, Barlow S, Sathe M. Standardizing and optimizing nutrition evaluation frequency of enterally fed patients in an ambulatory pediatric gastroenterology practice: A single-center study. Nutr Clin Pract 2023; 38:863-870. [PMID: 36453522 DOI: 10.1002/ncp.10939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 11/01/2022] [Accepted: 11/05/2022] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Nutrition monitoring is essential in feeding tube-dependent patients receiving home enteral nutrition (HEN). We identified lack of consistency in dietitian evaluations for our pediatric patients receiving HEN. Consequently, after establishing an institutional standard for nutrition reassessment intervals, we underwent a quality improvement (QI) initiative to improve rates of adherence to standard frequency of dietitian consults and referrals among patients receiving HEN. METHODS A prospective QI initiative from April 2021 to December 2021 was performed using multiple plan-do-study-act (PDSA) cycles. Interventions included (1) a reminder placard, (2) the display of feeding tube status and date of the last dietitian note in the electronic health record (EHR) clinic schedule dashboard, and (3) an autotext smart element to the EHR default clinic note template. The goal was to enable clinicians to quickly identify the need for nutrition evaluation with either a same-day dietitian consult or a referral to nutrition clinic. RESULTS Among 111 HEN patients with >6 months since last nutrition encounter, the dietitian referral/consult rate prior to any interventions was 58%. The placard (PDSA 1) was abandoned before obtaining reportable data because of sampling bias and clinic workflow inefficiencies. The clinic schedule dashboard modification (PDSA 2) improved the dietitian referral/consult rate to 66%. Subsequently, the clinic note smart element (PDSA 3) increased the rate to 77%. An 8-week postintervention check revealed a compliance rate of 78%. CONCLUSION Implementation of minimally interruptive EHR enhancements showed a sustained increase in dietitian referrals and consults for patients receiving HEN, which may improve nutrition outcomes.
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Affiliation(s)
- Derek Ngai
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Texas Southwestern, Dallas, Texas, USA
- Children's Medical Center, Dallas, Texas, USA
| | - Swetha Kotamraju
- Children's Medical Center, Dallas, Texas, USA
- Department of Pediatrics, University of Texas Southwestern, Dallas, Texas, USA
| | - Phinga Do
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Texas Southwestern, Dallas, Texas, USA
- Children's Medical Center, Dallas, Texas, USA
| | - Robin Luffy
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Texas Southwestern, Dallas, Texas, USA
- Children's Medical Center, Dallas, Texas, USA
| | - Christine Winser-Bean
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Texas Southwestern, Dallas, Texas, USA
- Children's Medical Center, Dallas, Texas, USA
| | - Jill Rockwell
- Department of Pediatric Clinical Nutrition, Children's Medical Center, Dallas, Texas, USA
| | - Lauren Hollaway
- Department of Pediatric Clinical Nutrition, Children's Medical Center, Dallas, Texas, USA
| | - Victoria Wright
- Quality and Patient Safety, Clinical Quality Improvement Consultant, Children's Medical Center, Dallas, Texas, USA
| | - Sarah Barlow
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Texas Southwestern, Dallas, Texas, USA
- Children's Medical Center, Dallas, Texas, USA
| | - Meghana Sathe
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Texas Southwestern, Dallas, Texas, USA
- Children's Medical Center, Dallas, Texas, USA
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7
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Roberts K, Shah ND, Parrish CR, Wall E. Navigating nutrition and hydration care in the adult patient with short bowel syndrome. Nutr Clin Pract 2023; 38 Suppl 1:S59-S75. [PMID: 37115029 DOI: 10.1002/ncp.10951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/12/2022] [Accepted: 12/17/2022] [Indexed: 04/29/2023] Open
Abstract
Attending diligently to the nutrition and hydration needs of patients with short bowel syndrome (SBS) is a key tenet of their care, both postoperatively and in the years that follow. For, without each, patients are left to themselves to navigate the nutrition consequences of SBS, including malnutrition, nutrient deficiencies, renal compromise, osteoporosis, fatigue, depression, and impaired quality of life. The intent of this review is to discuss the initial nutrition assessment, oral diet, hydration, and home nutrition support for the patient with SBS.
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Affiliation(s)
- Kristen Roberts
- College of Medicine, Department of Medical Dietetics, The Ohio State University, Columbus, Ohio, USA
| | - Neha D Shah
- Colitis and Crohn's Disease Center, University of California, San Francisco, California, USA
| | | | - Elizabeth Wall
- GI/Nutrition Support Team, The University of Chicago Medicine, Chicago, Illinois, USA
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8
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Lord LM, McGinnis C, Densmore C. Addressing the unique needs and quality of life issues for adults receiving long-term home enteral nutrition. Nutr Clin Pract 2023; 38:257-276. [PMID: 36917006 DOI: 10.1002/ncp.10965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/20/2023] [Accepted: 01/22/2023] [Indexed: 03/16/2023] Open
Abstract
Individuals who require home enteral nutrition (EN)-and, subsequently, their families-undergo major changes in family dynamics. They would benefit from an approach that provides ongoing nutrition, hydration, enteral access, and quality of life assessments from knowledgeable clinicians. Most individuals and families will be new to the enteral access device, handling and administration of the nutrition formula, medication delivery through feeding tubes, and troubleshooting associated complications. Educational sessions are typically given but may not be comprehensive enough to meet all needs, especially in the first weeks to months of home EN therapy. Quality of life assessments obtained in the early stages of EN support would help clinicians identify and focus on areas that need special attention for that individual and family. Ongoing clinical care is essential because over time, the nutrition prescription, delivery methods and schedules typically require alterations and feeding tubes need to be assessed and replaced. In addition to these important physical dimensions of care, attention should be placed on the psychological, cognitive, social, and ethical aspects of life for these individuals and their families.
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Affiliation(s)
- Linda M Lord
- Adult Nutrition Support Clinic, University of Rochester Medical Center, Rochester, NY, USA
| | - Carol McGinnis
- Sanford USD Medical Center, Center for Care Management, Sioux Falls, SD, USA
| | - Carly Densmore
- Adult Nutrition Support Clinic, University of Rochester Medical Center, Rochester, NY, USA
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9
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Steel C, Wile H, Li O, Yedulla S, Hare I, Hopkins B. Understanding the use and tolerance of a pediatric and an adult commercial blenderized enteral formula through real-world data. Nutr Clin Pract 2023; 38:449-457. [PMID: 36036217 DOI: 10.1002/ncp.10905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 07/13/2022] [Accepted: 07/30/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Home enteral nutrition (HEN) is frequently prescribed to individuals who cannot consume adequate food orally. Commercial blenderized enteral formulas (CBEF) containing real-food ingredients are becoming more popular and more widely available; however, the demographics of patients receiving these formulas have rarely been evaluated, and little data are available on patient tolerance in the community. METHODS US claims data were obtained for children and adolescents/adults who used the CBEF of interest as the sole source of nutrition via enteral feeding tube in the community setting following discharge from acute care. Demographics, concomitant medications, clinical diagnoses, and Charlson Comorbidity Index scores were tabulated using descriptive statistics. Gastrointestinal (GI) symptoms before and after hospital discharge were compared using significance tests. RESULTS The study included 231 participants (180 children, 51 adolescents/adults). CBEFs were prescribed to patients with a variety of diagnoses, of which the most common were digestive and respiratory disorders. Children experienced significantly lower rates of diarrhea, nausea, vomiting, constipation, and abdominal distension in the weeks following hospital discharge compared with the baseline (all P < 0.001). Adolescents/adults experienced significantly lower rates of constipation, nausea, and vomiting (all P < 0.05). Neither group increased their usage of GI medications following hospital discharge. CONCLUSION These CBEFs, based on real-food ingredients, were prescribed to diverse patients in the community and were well tolerated. These formulas offer an alternative to standard polymeric formulas and an alternative or adjunct to homemade blenderized formulas.
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Affiliation(s)
- Cindy Steel
- Nestlé Health Science Canada, North York, Ontario, Canada
| | - Heather Wile
- Nestlé Health Science Canada, North York, Ontario, Canada
| | - Olivia Li
- Clarivate Data Analytics & Insights, Toronto, Ontario, Canada
| | | | - Ian Hare
- Clarivate Data Analytics & Insights, Bicester, UK
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10
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Amaratunga H, Bostock K, Cunich M, Steffens D, Carey S. Systematic review of service improvements for home enteral tube feeding in adults. Nutr Clin Pract 2023; 38:329-339. [PMID: 35975316 DOI: 10.1002/ncp.10900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 06/28/2022] [Accepted: 07/16/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Patients receiving home enteral tube feeding (HETF) have a high risk of complications and readmission to hospital. This study aims to evaluate effectiveness of staff- and/or patient-focused service-improvement strategies on clinical, patient-reported, and economic outcomes for patients receiving HETF across adult settings. METHODS The search was conducted using MEDLINE, EMBASE, and CINAHL databases. Quality of studies were appraised using the Cochrane Collaboration Risk of Bias tool and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) assessment. RESULTS Eleven studies met the inclusion criteria. Pooled data found targeted HETF education with patients, carers, and staff significantly improved knowledge immediately after education and was sustained at 3-6 months. Multimodal interventions, including the formation of specialist HETF teams, significantly reduced complications such as infection, gastrostomy blockage, tube displacement, and feed intolerance but do not significantly reduce unplanned hospital encounters (outpatient clinic visits, hospitalizations, and emergency presentations). Owing to the high risk of bias in the included studies, there is low-quality evidence to support staff training, patient education, and dedicated HETF teams. CONCLUSION This review highlights the need for further quality research to allow higher-level evidence for determining the usefulness of interventions aimed at improving outcomes for patients receiving HETF. Future research needs to include greater assessment of quality of life, quantification of the value of interventions in economic terms, and use of translational research frameworks. However, effective staff and patient education programs, along with comprehensive multidisciplinary care, should be considered standard care until a larger research base is developed.
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Affiliation(s)
- Hasini Amaratunga
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Kimberley Bostock
- Department of Nutrition and Dietetics, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Michelle Cunich
- Sydney Health Economics Collaborative, Sydney Local Health District, Sydney, New South Wales, Australia.,Charles Perkins Centre, Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Daniel Steffens
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Sydney, New South Wales, Australia
| | - Sharon Carey
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia.,Department of Nutrition and Dietetics, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Institute of Academic Surgery, Royal Prince Alfred Hospital (RPAH), Sydney, New South Wales, Australia
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11
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Reddick CA, Greaves JR, Flaherty JE, Callihan LE, Larimer CH, Allen SA. Choosing wisely: Enteral feeding tube selection, placement, and considerations before and beyond the procedure room. Nutr Clin Pract 2023; 38:216-239. [PMID: 36917007 DOI: 10.1002/ncp.10959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/14/2023] [Accepted: 01/15/2023] [Indexed: 03/16/2023] Open
Abstract
When an enteral feeding tube (EFT) is placed, it is not always known how long this nutrition support intervention will be needed. As a result, the type of device the patient originally has placed may not match the function it is required to serve or the lifestyle needs of the patient throughout their enteral nutrition journey. Medicare considers an EFT a prosthetic device, as it is replacing a permanently inoperable or nonfunctioning organ. If we think about an EFT the same way we think about a prosthetic limb, one that needs to be customized to meet all of the patient's functional and lifestyle needs, we can also begin to think beyond the procedure room and carefully consider a variety of factors that impact the patient at home receiving enteral nutrition. Proper fit, function, and style is essential in order for the patient to have a positive relationship with their EFT, contributing to their successful home enteral nutrition experience. Clinicians who care for these patients in any setting and in any capacity would benefit from enhancing their understanding of available EFT options, their design components, and available methods of placement. Many home care and outpatient clinicians adopt the role of patient advocate as it relates to a patient's enteral nutrition journey, and this expanded knowledge could be used to benefit the patient by improving their overall enteral nutrition experience and ultimately their relationship with their "prosthetic."
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Affiliation(s)
| | - June R Greaves
- Enteral Division, Coram/CVS Specialty Infusion Services, Illinois, Northbrook, USA
| | - Janelle E Flaherty
- Enteral Division, Coram/CVS Specialty Infusion Services, Illinois, Northbrook, USA
| | - Lindsey E Callihan
- Enteral Division, Coram/CVS Specialty Infusion Services, Illinois, Northbrook, USA
| | - Cara H Larimer
- Enteral Division, Moog Medical, Utah, Salt Lake City, USA
| | - Sarah A Allen
- Enteral Division, Coram/CVS Specialty Infusion Services, Illinois, Northbrook, USA
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12
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Deutsch L, Cloutier A, Leahy G, Teubner A, Abraham A, Taylor M, Paine P, Lal S. Factors associated with strong opioid use for noncancer pain in patients with chronic intestinal failure. Nutr Clin Pract 2023; 38:129-137. [PMID: 36184884 PMCID: PMC10092843 DOI: 10.1002/ncp.10916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 08/08/2022] [Accepted: 09/02/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Chronic analgesic use is described in home parenteral nutrition (HPN)-dependent patients, but there are limited data on factors associated with opioid use for noncancerous pain. METHODS Patients attending a national UK intestinal failure reference center were divided in two groups according to strong opioid (SO) usage; risk factors for SO usage were analyzed using logistic regression. RESULTS A total of 168 HPN-dependent patients were included. During the study period, 73 patients (43.5%) had documented SO usage (SO group), whereas the remainder did not (No-SO group). The prevalence of Crohn's disease among the No-SO group was twofold higher than among the SO group (43.2% vs 24.7%; P = 0.013), whereas those with surgical complications were twice as prevalent among the SO group (19.2% vs 8.4%, respectively; P = 0.04). The rate of working-age unemployment was significantly higher in the SO group (90.6%) than the No-SO group (55.6%; P = 0.001). Multivariate regression showed unemployment as an independent risk factor for SO usage (OR, 6.005; 95% CI, 1.435-25.134), whereas Crohn's disease (OR, 0.284; 95% CI, 0.09-0.898) and <4 intravenous support (IVS) nights per week (OR, 0.113; 95% CI, 0.012-1.009) were protective factors. The life-long incidence of catheter-related bloodstream infection (CRBSI) was comparable between groups (34.2% SO vs 27.4% No-SO; P = 0.336). CONCLUSION SO use is frequent among HPN-dependent patients and associated with high rates of unemployment and ≥4 IVS nights per week, but not with increased rate of CRBSI. The reduced usage among patients with Crohn's disease warrants further evaluation but might be due to the chronicity as compared with other IF etiologies.
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Affiliation(s)
- Liat Deutsch
- Intestinal Failure Unit, Salford Royal NHS Foundation TrustSalfordUK
- Department of Gastroenterology and Liver Diseases, Tel‐Aviv Sourasky Medical Centre, affiliated to Sackler Faculty of MedicineTel‐Aviv UniversityTel‐AvivIsrael
| | - Anabelle Cloutier
- Intestinal Failure Unit, Salford Royal NHS Foundation TrustSalfordUK
- CHU de QuébecUniversité LavalQuébecCanada
| | - Gavin Leahy
- Intestinal Failure Unit, Salford Royal NHS Foundation TrustSalfordUK
| | - Antje Teubner
- Intestinal Failure Unit, Salford Royal NHS Foundation TrustSalfordUK
| | - Arun Abraham
- Intestinal Failure Unit, Salford Royal NHS Foundation TrustSalfordUK
| | - Michael Taylor
- Intestinal Failure Unit, Salford Royal NHS Foundation TrustSalfordUK
| | - Peter Paine
- Department of Gastroenterology, Salford Royal NHS Foundation TrustSalfordUK
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal NHS Foundation TrustSalfordUK
- Academic Health Sciences CentreUniversity of ManchesterManchesterUK
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Zaher S, Ajabnoor SM. A Cross Sectional Survey-Based Study to Investigate the Availability and Utilisation of Home Nutrition Support in Saudi Arabia. J Multidiscip Healthc 2023; 16:41-50. [PMID: 36660035 PMCID: PMC9842512 DOI: 10.2147/jmdh.s398569] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 01/05/2023] [Indexed: 01/13/2023] Open
Abstract
Background and Aims Many patients require long-term nutrition support, typically in the form of home nutrition support (HNS). The availability and utilisation of HNS in Saudi Arabia is currently unknown; therefore, this study was conducted to assess the availability of HNS in Saudi hospitals and to explore factors associated with the availability of HNS in different healthcare facilities in Saudi Arabia. Methods A cross-sectional study was conducted among physicians, dietitians, and pharmacists working in Saudi Arabia with regular practice in nutrition support. Data was collected through self-administered web-based survey, which was distributed via social-media platforms. Results A total of 114 responses were received from healthcare providers involved in nutrition support across Saudi Arabia. Of the respondents, 55 (48.2%) indicated that nutrition support services were available at their facility. Regression analysis showed that other regions in Saudi Arabia had lower odds of having HNS compared with the Western region (OR=0.01; 95% CI=0.01-0.69). The university and specialised hospitals had lower odds of having HNS compared with Ministry of Health hospitals (OR=0.11; 95% CI=0.02-0.71, OR=0.11; 95% CI=0.02-0.56, respectively). Hospitals with capacities of 100-250 beds and 251-500 had higher odds of having HNS than smaller hospitals (OR=13.17; 95% CI=1.09-159.5, OR=3.11; 95% CI=2.04-248.77, respectively). Conclusion There is lack of published reports from hospitals with implemented HNS. Therefore, it is difficult to assess the current situation of HNS programmes. Future national studies focusing on HNS are warranted as there is a rising international trend in the number of patients requiring HNS.
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Affiliation(s)
- Sara Zaher
- Clinical Nutrition Department, Faculty of Applied Medical Sciences, Taibah University, Madinah, Saudi Arabia,National Nutrition Committee (NNC), Saudi Food and Drug Authority (Saudi FDA), Riyadh, Saudi Arabia,Correspondence: Sara Zaher, Clinical Nutrition Department, Faculty of Applied Medical Sciences, Taibah University, P.O. Box 344, Madinah, 42353, Saudi Arabia, Email ;
| | - Sarah M Ajabnoor
- National Nutrition Committee (NNC), Saudi Food and Drug Authority (Saudi FDA), Riyadh, Saudi Arabia,Clinical Nutrition Department, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
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14
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Chen C, Zhu D, Zhao Z, Ye X. Quality of life assessment instruments in adult patients receiving home parenteral and enteral nutrition: A scoping review. Nutr Clin Pract 2022; 37:811-824. [PMID: 35235230 DOI: 10.1002/ncp.10848] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 01/16/2022] [Accepted: 01/22/2022] [Indexed: 12/18/2022] Open
Abstract
Quality of life (QoL) assessment is important to evaluate the effect of the intervention for patients treated with home parenteral and enteral nutrition (HPEN). The purpose of this scoping review is to describe, evaluate, and recommend QoL instruments used in adult patients receiving HPEN. We used the Arksey and O'Malley framework and performed literature searches in five databases (PubMed, CINAHL, EMBASE, Web of Science, and Cochrane Library) to identify possibly relevant articles that focused on QoL of adult patients receiving HPEN. Of the studies that qualify for full-text screening, two independent researchers extracted data. Twenty-seven QoL instruments were identified, consisting of seven generic instruments, 12 disease-specific instruments, and eight therapy-specific instruments. The Short Form-36 was the most widely used generic instrument and the European Organization for Research and Treatment of Cancer QLQ-C30 was the most commonly employed disease-specific instrument. The recently developed therapy-specific tools, NutriQoL and HPN-QoL, were increasingly employed in studies either alone or in combination with other types of instruments. Important aspects of each instrument were summarized to aid clinicians and researchers in selecting an appropriate instrument when measuring the QoL of adult HPEN patients. Findings could also help to identify the necessity to develop new tools or to modify pre-existing ones to measure QoL of HPEN patients.
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Affiliation(s)
- Chulin Chen
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, People's Republic of China
| | - Dongmei Zhu
- Department of Nursing, Jinling Hospital, Medical School of Nanjing University, Nanjing, People's Republic of China
| | - Zehua Zhao
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, People's Republic of China
| | - Xianghong Ye
- Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, People's Republic of China
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15
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Iyer KR, Winkler M, Zubizarreta N, Nisenholtz M, Lucero K, Lubarda J. Knowledge of chronic intestinal failure among US gastroenterologists: Cause for concern and learning opportunity. JPEN J Parenter Enteral Nutr 2021; 46:730-733. [PMID: 34713914 DOI: 10.1002/jpen.2283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Chronic intestinal failure (CIF) is an ultrarare disease, with an estimated national prevalence of ∼25,000 cases. There is a suspicion of widespread lack of expertise in CIF care, but no formal assessment tool or data exist. We developed and validated a knowledge test in CIF and now report our preliminary results from testing CIF knowledge in a cohort of US gastroenterologists. METHOD We developed a 20-question knowledge test in CIF, covering four key components of IF. After internal testing, refinement, and revision, we administered the test to a convenience sample of experts and nonexperts in IF. We then deployed the validated test to a cohort of 100 US gastroenterologists. RESULTS The test had a Cronbach alpha of 0.74, suggesting a reliable test, with a threshold score to discriminate experts and nonexperts of 13.4 (maximum 20) and with a sensitivity of 81.3% and specificity of 86.4%. The overall mean score of 8.2 for the 100 US gastroenterologists was at the level of nonexperts in our convenience sample. CONCLUSION The preliminary results of our validated knowledge test in IF among a broad group of US gastroenterologists demonstrate lack of knowledge in IF.
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Affiliation(s)
- Kishore R Iyer
- Intestinal Rehabilitation & Transplant Program, Icahn School of Medicine at Mount Sinai/Mount Sinai Hospital, New York, New York, USA
| | - Marion Winkler
- Department of Surgery/Nutrition Support, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Nicole Zubizarreta
- Intestinal Rehabilitation & Transplant Program, Icahn School of Medicine at Mount Sinai/Mount Sinai Hospital, New York, New York, USA
| | - Marjorie Nisenholtz
- Intestinal Rehabilitation & Transplant Program, Icahn School of Medicine at Mount Sinai/Mount Sinai Hospital, New York, New York, USA
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16
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Crooks B, Harrison S, Millward G, Hall K, Taylor M, Farrer K, Abraham A, Teubner A, Lal S. Catheter-related infection rates in patients receiving customized home parenteral nutrition compared with multichamber bags. JPEN J Parenter Enteral Nutr 2021; 46:254-257. [PMID: 34287965 DOI: 10.1002/jpen.2225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 06/08/2021] [Accepted: 07/16/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND The risk of bloodstream infections may be increased in hospitalized patients receiving ready-made parenteral nutrition (PN) multichamber bags (MCBs) compared with customized PN; however, as highlighted in recent international guidelines, there are no comparable data relating to home PN (HPN). METHODS Data from a prospectively maintained database were analyzed to compare incidence rates of catheter-related bloodstream infections (CRBSIs) between patients receiving customized HPN compared with MCB HPN at a national UK referral center between May 2018 and August 2020. RESULTS Sixty patients with chronic intestinal failure were commenced on MCBs and 45 received customized HPN for a total of 5914 and 7641 catheter days, respectively. No difference in CRBSI incidence was found (0.51/1000 catheter days for MCBs, 0.39/1000 catheter days for customized HPN; incidence rate ratio, 1.29; 95% CI, 0.26-6.37). Eighteen patients were switched from customized HPN to MCB HPN. The study period covered 7401 catheter days receiving customized HPN and 4834 days on MCBs. No significant change was noted in the CRBSI rates following this switch (0.27/1000 catheter days receiving customized HPN vs 0.21/1000 catheter days on MCBs; incidence rate ratio, 1.31; 95% CI, 0.12-14.3). CONCLUSION The use of MCBs for HPN patients is not associated with an increased risk of CRBSI. This study will inform international guidelines and provide reassurance for the continued, safe use of MCB HPN.
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Affiliation(s)
- Benjamin Crooks
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK.,Division of Diabetes, Endocrinology, and Gastroenterology, School of Medical Sciences, The University of Manchester and Manchester Academic Health Sciences Centre, Manchester, UK
| | - Simon Harrison
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK
| | - Graham Millward
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK
| | - Kirsty Hall
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK
| | - Michael Taylor
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK
| | - Kirstine Farrer
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK
| | - Arun Abraham
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK
| | - Antje Teubner
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK.,Division of Diabetes, Endocrinology, and Gastroenterology, School of Medical Sciences, The University of Manchester and Manchester Academic Health Sciences Centre, Manchester, UK
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17
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Abstract
Coronavirus disease 2019 (COVID-19), after initially being detected in Wuhan, China in late 2019, quickly spread to most regions of the world, meeting World Health Organization criteria for a pandemic. Social distancing along with other measures implemented to control spread had a drastic impact on the provision of healthcare including deferred elective procedures and surgeries as well as delayed care and evaluation for emergent diagnoses such as heart attacks and strokes. In the home nutrition practice, patients began to delay routine laboratory tests and were canceling or deferring annual visits. Our group soon began to rapidly deploy telehealth to meet the needs of the home nutrition patients. Telehealth is not a new concept with descriptions of healthcare being provided at a distance with the use of telephone in the 1870s. However, widespread adoption has been limited because of regulation (licensure, prescriptions, credentialing, and privileges), lack of reimbursement, as well as adoption and availability of technology needed to carry out telehealth visits. As regulations and limits on reimbursements were waived during COVID-19 pandemic, our home nutrition practice began to evaluate core components of the care we provide for our patients and assess which could be successfully transitioned to telehealth. In addition to the history and regulation of telehealth, the current manuscript provides details regarding successful implementation of telehealth visits such as change management, selection of telehealth platform, scheduling and logistics, as well as carrying out the virtual visit including history and physical exam.
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Affiliation(s)
- Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Osman Mohamed Elfadil
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - 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 Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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18
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Siu AHY, Carey S, Jones L, Morton RL, Koh CE. Detailed analysis of in-hospital costs for adult patients with type III intestinal failure: A single-center study with global implications. JPEN J Parenter Enteral Nutr 2021; 46:685-692. [PMID: 33929048 DOI: 10.1002/jpen.2136] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Home parenteral nutrition (HPN) is the recommended treatment for patients with type III intestinal failure (IF). However, owing to IF's rarity, the economic cost of managing these patients is not well understood. These patients often develop complications resulting in readmissions, which in turn contribute to ongoing costs. This study aims to document the costs of type III IF within the hospital, from initial admission, including readmissions, and to compare incurred costs with current government reimbursement. METHODS A retrospective study design reviewed costs and reimbursement for 25 consecutive patients commencing HPN at a quaternary hospital (October 2011 to September 2017). Hospital admissions were separated into the initial admission and readmission(s) period. Healthcare use and cost data were collected using electronic medical records. Hospital reimbursement costs were retrieved from Sydney Local Health District's Targeted Activity and Reporting Systems. Patient demographics were tabulated, and healthcare use and cost data were compared using Wilcoxon signed rank tests. RESULTS The median cost of the initial hospital admission was substantially higher than the median reimbursement ($36,675; interquartile range [IQR], $23,196-$67,439 vs $19,247; IQR, $7485-$41,090; P < .001). Similar results were observed in the readmissions period, with median incurred costs of $13,898; (IQR, $11,151-$32,130) vs reimbursement of $8469 (IQR, $5625-$13,078) (P = .001). CONCLUSION Results indicate that type III IF patients have high inpatient costs, which substantially outweigh current reimbursement. Improved funding models are needed to ensure hospitals that accept the management challenge of type III IF patients are not unduly penalized.
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Affiliation(s)
- Adrian H Y Siu
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Camperdown, Australia.,Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia.,Graduate School of Medicine, University of Wollongong, NSW, Australia
| | - Sharon Carey
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia.,Department of Dietetics and Nutrition, Royal Prince Alfred Hospital, Sydney, Australia.,School of Life and Environmental Sciences, University of Sydney, Sydney, Australia.,Intestinal Failure and Home Parenteral Nutrition Service, Royal Prince Alfred Hospital, Sydney, Australia
| | - Lynn Jones
- Intestinal Failure and Home Parenteral Nutrition Service, Royal Prince Alfred Hospital, Sydney, Australia
| | - Rachael L Morton
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Camperdown, Australia
| | - Cherry E Koh
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, Australia.,Intestinal Failure and Home Parenteral Nutrition Service, Royal Prince Alfred Hospital, Sydney, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Discipline of Surgery, Central Clinical School, Sydney Medical School, University of Sydney, Sydney, Australia.,RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, Australia
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19
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Sandhu R, Saran D, Ho G, Vandop K, Hussain W. High costs and limited dietitian services for home enteral nutrition users: A Canadian study. Nutr Clin Pract 2021; 37:167-175. [PMID: 33754366 DOI: 10.1002/ncp.10649] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Home enteral nutrition (HEN) is the provision of nutrition through a tube outside the hospital. The Canadian prevalence of HEN is not previously well understood. This study aimed to (1) describe the demographics and healthcare usage of HEN in adults in a Canadian health authority, (2) compare the proportion of HEN-related hospital visits between patients who did and did not receive a community registered dietitian (RD) follow-up, and (3) determine associations between demographic and healthcare usage of HEN adults . METHODS A retrospective chart review was conducted on the records of HEN patients with a tube placed between April 1, 2012, and March 31, 2015. Descriptive and comparative statistics were applied. RESULTS A total of 390 adults were discharged receiving HEN. The majority (74.9%, n = 271) of the sample did not have any record of visiting a community RD up to 6 years after tube placement. Fifty-three percent of the sample visited the hospital for HEN-related complications, costing CAD $14,324,465.00 (USD $10,677,946.00) to the healthcare system. Multiple regression analysis revealed that females ( P < .05), jejunostomy tubes ( P < .05), and older age ( P < .05) were associated with more hospital or emergency room visits. CONCLUSION This study found a higher prevalence of HEN patients and more varied demographic and clinical characteristics than previously reported. The healthcare costs per patient per year exceed previous reports. Further research is needed to explore the population's experiences and develop interventions that improve gaps in the healthcare system.
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Affiliation(s)
- Rebekah Sandhu
- Fraser Health Authority, Surrey, British Columbia, Canada
| | - Delara Saran
- Fraser Health Authority, Surrey, British Columbia, Canada
| | - Gloria Ho
- British Columbia Women's and Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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20
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Wong A, Goh QL, Goh SN, Sowa PM, Banks MD, Bauer JD. Medical Nutrition Reimbursement in Singapore: Who Are the Patients Receiving MediFund Assistance? An Audit of Clinical Outcomes and Issues Pertaining to Reimbursement in a Public Hospital in Singapore. JPEN J Parenter Enteral Nutr 2020; 45:1532-1541. [PMID: 33128464 DOI: 10.1002/jpen.2043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 10/27/2020] [Accepted: 10/28/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND Financial reimbursement (MediFund) of medical nutrition products (MNPs) was recently implemented in some of the public hospitals in Singapore for patients with financial difficulties. This study aimed to investigate the sustainability of this policy and the benefits conferred. METHODS We performed a 1-year retrospective audit of patients in a tertiary hospital who received MediFund. Demographics, presupport and postsupport clinical outcomes, and cost of support were determined and analyzed. RESULTS A total of 129 patients received MediFund for MNPs. The median length of financial support was 115 days (interquartile range, 37-269). Overall, body mass index increased after nutrition support (20.9 ± 5.1 vs 20.4 ± 5.3; P = .012). There was a significant decrease in the number of malnourished patients (final, 55.1% vs initial, 86.8%; P < .001) and a significant increase in 7-point subjective global assessment scores (final, 4.9 ± 1.3 vs initial, 4.1 ± 1.3; P < .001) after MNP support. MNP adherence was high for 88.5% of patients who returned for follow-up appointments. Patients who defaulted follow-up appointments were more likely to have 30-day readmission (50% vs 19.5%; P < .001) and had higher mortality rates (35.7% vs 10.3%; P < .001). Total reimbursement of S $108,960 was provided to subsidize MNPs over 1 year. CONCLUSION Supporting patients with financial difficulties led to an improvement in their nutrition status. Regular dietitian reviews of patients and monitoring compliance to consumption of MNPs are essential to ensure patients benefit from the support.
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Affiliation(s)
- Alvin Wong
- Department of Dietetic and Food Services, Changi General Hospital, Singapore, Singapore.,School of Human Movement and Nutrition Sciences, The University of Queensland, St Lucia, Queensland, Australia
| | - Qiu Le Goh
- Department of Dietetic and Food Services, Changi General Hospital, Singapore, Singapore
| | - Soon Noi Goh
- Department of Medical Social Services, Changi General Hospital, Singapore, Singapore
| | - Przemyslaw M Sowa
- Centre for the Business and Economics of Health, The University of Queensland, St Lucia, Australia
| | - Merrilyn D Banks
- Royal Brisbane and Women's Hospital, Department of Nutrition and Dietetics, Herston, Queensland, Australia
| | - Judith D Bauer
- School of Human Movement and Nutrition Sciences, The University of Queensland, St Lucia, Queensland, Australia
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21
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Park CJ, Shaughnessy MP, Zhang L, Armenia SJ, Caty MG, Cowles RA. National Survey of Pediatric Intestinal Rehabilitation Programs in the United States. JPEN J Parenter Enteral Nutr 2020; 45:1249-1258. [PMID: 32797633 DOI: 10.1002/jpen.1997] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 07/08/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Pediatric intestinal rehabilitation (PIR) programs are associated with improved outcomes in children with intestinal failure but remain heterogeneous nationally. This study characterizes PIR program components to aid those seeking to establish or expand a program. METHODS Members of the Children's Hospital Association reporting a PIR program to the US News and World Report completed a 14-item questionnaire using the Qualtrics Online Survey Software. Programs were categorized as small or large (≤50 vs >50 patients) and new or established (≤10 vs >10 years). RESULTS Seventy-one programs were identified and 61 surveys were returned for a response rate of 86%. Majority of programs had gastroenterology, surgery, nutrition, nursing, and social work services involved. Large programs (n = 34; 59%) were more likely to serve as referral centers; have greater participation by nursing, social work, and primary care; have more dedicated time by gastroenterology, surgery, nursing, nutrition, and social work; have more frequent meetings; and have various funding sources (P < .05). CONCLUSION Critical components of a PIR program include gastroenterology, surgery, and nutrition services with strong nursing and social work support. These data document the components of modern PIR programs, though further studies on the relationship between program structure and patient outcomes are warranted.
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Affiliation(s)
- Christine J Park
- Department of Surgery, Division of Pediatric Surgery at Yale University, New Haven, Connecticut, 06510, USA
| | - Matthew P Shaughnessy
- Department of Surgery, Division of Pediatric Surgery at Yale University, New Haven, Connecticut, 06510, USA
| | - Lucy Zhang
- Department of Surgery, Division of Pediatric Surgery at Yale University, New Haven, Connecticut, 06510, USA
| | - Sarah J Armenia
- Department of Surgery, Division of Pediatric Surgery at Yale University, New Haven, Connecticut, 06510, USA
| | - Michael G Caty
- Department of Surgery, Division of Pediatric Surgery at Yale University, New Haven, Connecticut, 06510, USA
| | - Robert A Cowles
- Department of Surgery, Division of Pediatric Surgery at Yale University, New Haven, Connecticut, 06510, USA
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22
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Cotogni P, Mussa B, Degiorgis C, De Francesco A, Pittiruti M. Comparative Complication Rates of 854 Central Venous Access Devices for Home Parenteral Nutrition in Cancer Patients: A Prospective Study of Over 169,000 Catheter-Days. JPEN J Parenter Enteral Nutr 2020; 45:768-776. [PMID: 32511768 DOI: 10.1002/jpen.1939] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/17/2020] [Accepted: 05/27/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Whether peripherally inserted central catheters (PICCs) are appropriate as safe and durable venous access devices (VADs) is still controversial. The aim of this 7-year, prospective cohort study was to compare the incidence rate differences of catheter-related complications (CRCs) among 4 types of central VADs in cancer patients receiving home parenteral nutrition (HPN). METHODS We enrolled all adult cancer outpatients who were candidates for HPN and who had a central VAD inserted during the study period, focusing on the incidence rate of CRCs. RESULTS We evaluated 854 central VADs (401 PICCs, 137 nontunneled centrally inserted central catheters [CICCs], 118 tunneled-cuffed CICCs, and 198 ports) in 761 patients, for a total of 169,116 catheter-days. Overall, the rate of total CRCs was 1.08/1000 catheter-days. The incidence of catheter-related bloodstream infections was low (0.29/1000), particularly for PICCs (0.08/1000; P < .001 vs tunneled-cuffed CICCs) and for ports (0.21/1000; P < .019 vs tunneled-cuffed CICCs). The rates of mechanical complications (0.58/1000) and of catheter-related symptomatic thrombosis (0.09/1000) were low and similar for PICCs, tunneled-cuffed CICCs, and ports. In terms of duration and removal rate due to complications, PICCs were like tunneled-cuffed CICCs and ports. Altogether, PICCs had fewer total complications than tunneled-cuffed CICCs (P < .001), there was no difference in total complications between PICCs and ports. CONCLUSION PICCs had significantly better outcomes than tunneled-cuffed CICCs and were safe and durable as ports. Our extensive, long-term study suggests that PICCs can be successfully used as safe and long-lasting VADs for HPN in cancer patients.
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Affiliation(s)
- Paolo Cotogni
- Unit of Parenteral Nutrition in Oncology, Department of Internal Medicine, Molinette Hospital, Turin, Italy
| | - Baudolino Mussa
- Central Venous, Access Team, Department of Surgical Sciences, Molinette Hospital, University of Turin, Turin, Italy
| | - Claudia Degiorgis
- Central Venous, Access Team, Department of Surgical Sciences, Molinette Hospital, University of Turin, Turin, Italy
| | | | - Mauro Pittiruti
- Department of Surgery, Catholic University Hospital, Rome, Italy
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Smith CE, Yadrich D, Wright S, Ridder L, Werkowitch M, Bruce A, Bonar JRM. Themes of Stressors, Emotional Fatigue, and Communication Challenges Found in Mobile Care Discussion Sessions With Patients Requiring Lifelong Home Parenteral Nutrition Infusions. JPEN J Parenter Enteral Nutr 2020; 45:499-506. [PMID: 32495954 DOI: 10.1002/jpen.1854] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 03/28/2020] [Accepted: 04/14/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The purpose of this article is to examine themes and topics that emerged from 35 discussion sessions with teens and young adults requiring long-term home parenteral nutrition (HPN) intravenous infusions. The goal was to gain a more detailed understanding of participants' challenges and successes of living with HPN. METHODS These patients were invited to attend 3 discussion group sessions facilitated by health professionals. A secure iPad Mini was selected as the mobile tablet device for hosting these encrypted audio-visual group discussions. Content analysis, a standard research data-sorting technique, was used to summarize the anonymous data. Words, phrases, and topics in patients' discussions were coded and grouped together with similar concepts and subsequently categorized into themes. RESULTS Themes in these discussions were related to patients' daily, complex management of HPN. These "themes" included having multiple repetitive illness-related stressors and how those stressors were managed; managing emotions; communication challenges with professionals, family, friends, and using social media; and lastly, the least frequent but no less important theme discussed was how HPN effects their daily lives. CONCLUSION Teens and young adults living with lifelong HPN face a variety of unique psychological, physical, and emotional stressors and may benefit from numerous methods for managing these challenges.
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Affiliation(s)
- Carol E Smith
- School of Nursing, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Donna Yadrich
- School of Nursing, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Shawna Wright
- University of Kansas Center for Telemedicine & Telehealth, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Lavonne Ridder
- School of Nursing, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Marilyn Werkowitch
- School of Nursing, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Amanda Bruce
- Department of Pediatrics, University of Kansas Medical Center, Center for Children's Healthy Lifestyles and Nutrition, Kansas City, Kansas, USA
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24
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Abstract
The popularity of homemade blenderized tube feeding (HBTF) continues to increase among enteral nutrition (EN) consumers and healthcare providers alike, citing improved feeding tolerance over standard commercial enteral formulas, among other health outcomes. Within the past 5-10 years, there has been a surge in the development of commercial blenderized tube feeding (CBTF) products. CBTF products promote similar benefits from whole foods like those used in HBTF while being a nutritionally-consistent, easy to use, and shelf-stable option for EN consumers. Research is improving but is still limited for HBTF and virtually nonexistent for CBTF products. This review aims to summarize current health outcomes of HBTF, compare HBTF with CBTF, evaluate CBTF products, and provide considerations for future research and practices.
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25
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Zamanillo Campos R, Colomar Ferrer MT, Ruiz López RM, Sanchís Cortés MP, Urgelés Planella JR. Specific Quality of Life Assessment by the NutriQoL® Questionnaire Among Patients Receiving Home Enteral Nutrition. JPEN J Parenter Enteral Nutr 2020; 45:490-498. [PMID: 32459026 PMCID: PMC8048598 DOI: 10.1002/jpen.1852] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 04/14/2020] [Indexed: 12/13/2022]
Abstract
Background Home enteral nutrition (HEN), including tube feeding and oral supplementation, can improve or worsen quality of life (QoL). The specific assessment of factors affecting QoL may identify the inherent problems associated with HEN. The aim of this study was to evaluate whether the validated NutriQoL® questionnaire is useful for assessing the QoL and the factors influencing it in patients receiving HEN. Methods A total of 78 patients receiving HEN completed both the NutriQoL and the SF‐12 questionnaires during their routine visits to nutrition service at the hospital. Results Ninety percent of patients receiving HEN had cancer, 58% received oral supplements, and 42% received tube feeding. At recruitment, the mean score ± SD of the NutriQoL was 66 ± 14, whereas that of the SF‐12 was 40 ± 9. A positive correlation between NutriQoL and SF‐12 scores (ρ = 0.5; P < .001) was found. Multivariate analysis showed that HEN type (oral vs tube) (odds ratio [OR], 5.6; 95% CI 2.0–15.3; P = .001) and the absence of secondary effects (OR, 3.0; 95% CI, 1.2–7.9; P = .024) were both variables explaining NutriQoL results adjusted by sex and age. The SF‐12 results did not show associations with nutrition factors. On visit 2, we observed significant improvements in NutriQoL results. Conclusion The NutriQoL questionnaire identifies specific problems that affect the QoL of patients receiving HEN, whereas SF‐12 does not. The route of entry and the occurrence of complications influence specific QoL. NutriQoL is a useful tool to identify the factors that worsen the QoL in patients receiving HEN.
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Affiliation(s)
- Rocío Zamanillo Campos
- Department of Endocrinology and Nutrition, Son Espases University Hospital, Balearic Islands, Spain.,Department of Health, Valencian International University (VIU), Valencia, Spain.,Health Research Institute of the Balearic Islands (IdISBa), Balearic Islands, Spain
| | | | - Rosa María Ruiz López
- Department of Endocrinology and Nutrition, Son Espases University Hospital, Balearic Islands, Spain
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26
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Sawbridge D, Taylor M, Teubner A, Abraham A, Woolfson P, Abidin N, Chadwick PR, Lal S. Infective Endocarditis in Patients With Intestinal Failure: Experience From a National Referral Center. JPEN J Parenter Enteral Nutr 2020; 45:309-317. [PMID: 32282945 DOI: 10.1002/jpen.1828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 02/22/2020] [Accepted: 03/04/2020] [Indexed: 11/12/2022]
Abstract
BACKGROUND Infective endocarditis (IE) is a recognized complication of central line-associated bloodstream infection (CLABSI). Central venous access devices (CVADs) are essential for the delivery of long-term parenteral nutrition (PN), yet there are no published data as to the prevalence, characteristics and outcomes of IE in this population. METHODS A prospectively maintained database of patients with intestinal failure (IF) types 2 and 3, managed by a national intestinal failure center between January 2010 and December 2018, was analyzed retrospectively and relevant factors extracted from case records. RESULTS A total of 745 patients with IF and CVADs in situ on admission, or placed during their stay, were admitted over the duration of this study, 640 with type 2 IF and 105 with type 3 IF. Two hundred eighty-two echocardiograms were performed to investigate potential IE associated with a CLABSI event. Four cases of IE were identified in the entire cohort of 782,666 catheter days (IE incidence rate: 0.005 per 1000 catheter days and 187 per 100,000 person-years for the entire cohort; 0.048 per 1000 inpatient catheter days for acute type 2 IF, 0.0026 per 1000 outpatient catheter days [ie, 99 per 100,000 person-years for outpatients with type 3 IF]). CONCLUSION IE is rare in the type 3 IF population and a rare consequence of CLABSI in inpatient acute type 2 IF. However, mortality and morbidity are high. Routine echocardiography may not be warranted for investigation of CLABSI unless there is a high risk of IE or a virulent organism is involved.
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Affiliation(s)
- David Sawbridge
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
| | - Michael Taylor
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
| | - Antje Teubner
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
| | - Arun Abraham
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
| | - Peter Woolfson
- Department of Cardiology, Salford Royal Foundation Trust, Salford, UK
| | - Nik Abidin
- Department of Cardiology, Salford Royal Foundation Trust, Salford, UK
| | - Paul R Chadwick
- Department of Microbiology, Salford Royal Foundation Trust, Salford, UK
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
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27
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Stevens T, Keller H, Williams N, Downar J, Guthrie DM. Cross-Sectional Nutrition Profile of Palliative Home Care Clients in Ontario and Performance of the interRAI Palliative Care Nutrition Clinical Assessment Protocol. JPEN J Parenter Enteral Nutr 2020; 45:183-192. [PMID: 32267007 DOI: 10.1002/jpen.1827] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 03/03/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND The nutrition profile of palliative home care clients is unknown. This study describes this group and their nutrition issues and evaluates the performance of the interRAI nutrition Clinical Assessment Protocol (CAP). METHODS This was a cross-sectional secondary analysis using Ontario interRAI Palliative Care (interRAI PC) Assessment data. The sample represents 74,963 unique Ontario home care clients assessed between 2011 and 2018. Frequencies and standardized differences (stdiffs) of nutrition characteristics were presented for cancer (n = 62,394) and noncancer (n = 12,569) diagnostic subgroups. Rates of triggering the nutrition CAP were presented by nutrition issue to evaluate its performance. RESULTS Of this sample, 16.7% were ≥85 years of age, 52.6% had a prognosis between 6 weeks and 6 months, and 41.4% required assistance with eating. The prevalence was higher among those with nervous/mental/behavioral disorders (72.6%) compared with those with cancer (37.6%; stdiff = 0.75). However, most nutrition issues experienced were similar (stdiff < 0.20) across diagnostic groups. Of the entire sample, 21% triggered the nutrition CAP, indicating a need for further evaluation or intervention. Yet, 73.4% of those who experienced dry mouth, 71.8% of those who required assistance with eating, and 68.4% of those who received a nutrition consult within the last 3 days did not trigger the nutrition CAP. CONCLUSIONS Nutrition issues are prevalent in palliative home care clients, regardless of diagnosis; yet the nutrition CAP identified a small fraction of this group. There is a need to focus research and care guidelines toward life-limiting illnesses beyond cancer and address nutrition-related issues in this population.
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Affiliation(s)
- Tara Stevens
- Department of Kinesiology and Physical Education and Department of Health Sciences, Wilfrid Laurier University, Waterloo, Ontario, Canada
| | - Heather Keller
- Department of Kinesiology, University of Waterloo, Waterloo, Ontario, Canada.,Schlegel-University of Waterloo Research Institute for Aging, Waterloo, Ontario, Canada
| | - Nicole Williams
- Department of Kinesiology and Physical Education and Department of Health Sciences, Wilfrid Laurier University, Waterloo, Ontario, Canada
| | - James Downar
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
| | - Dawn M Guthrie
- Department of Kinesiology and Physical Education and Department of Health Sciences, Wilfrid Laurier University, Waterloo, Ontario, Canada
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28
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Wozniak LJ, Bechtold HM, Reyen LE, Chan AP, Marcus EA, Vargas JH. Epidemiology and Risk Factors for Outpatient-Acquired Catheter-Related Bloodstream Infections in Children Receiving Home Parenteral Nutrition. JPEN J Parenter Enteral Nutr 2018; 42:942-948. [PMID: 29446842 DOI: 10.1002/jpen.1037] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 10/11/2017] [Indexed: 11/05/2022]
Abstract
BACKGROUND Few studies have examined the epidemiology and risk factors for the development of outpatient-acquired catheter-related bloodstream infections (CRBSIs) in children receiving home parenteral nutrition. This study aimed to (1) characterize the incidence, clinical presentation, and epidemiology of CRBSIs and (2) identify risk factors for CRBSIs in children receiving home parenteral nutrition. METHODS A longitudinal database approved by our Institutional Review Board was created to prospectively track CRBSIs in the UCLA pediatric population from January to December 2012. Eligible patients included those < 18 years old receiving home parenteral nutrition. RESULTS Thirty of 60 patients (50%) were diagnosed with 66 CRBSIs, for an overall CRBSI rate of 3.6 per 1000 catheter days. Of the CRBSIs, 73% were due to single microorganisms and 27% were polymicrobial. There was a significant difference in median (range) time for blood cultures to turn positive depending on type of CRBSIs (p = 0.03), with polymicrobial infections detected at 13.4 (8.7-24.3) hours, gram-negative infections at 16.5 (9-30.8) hours, and gram-positive infections at 18.9 (8.4-37.1) hours. The most common presenting symptom was fever (82%), followed by gastrointestinal symptoms (42%) and chills (29%). The only significant multivariate risk factor for CRBSIs was presence of a feeding tube (2.3-fold increase in CRBSI risk, p = 0.04). DISCUSSION Outpatient-acquired CRBSIs are common in children receiving home parenteral nutrition. CRBSIs typically present with fever, but are also associated with gastrointestinal and/or respiratory symptoms. The presence of feeding tubes may predispose children on home parenteral nutrition to developing CRBSIs.
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Affiliation(s)
- Laura J Wozniak
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | | | - Laurie E Reyen
- Department of Nursing, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA
| | - Alvin P Chan
- Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Elizabeth A Marcus
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.,VA Greater Los Angeles Health Care System, Los Angeles, California, USA
| | - Jorge H Vargas
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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29
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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30
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Murphy MK, Gura KM, Tascione C, Carey AN, Duggan CP, Raphael BP. Home Parenteral Nutrition and Intravenous Fluid Errors Discovered Through Novel Clinical Practice of Reconciling Compounding Records: A Case Series. Nutr Clin Pract 2017; 32:820-825. [PMID: 28850287 DOI: 10.1177/0884533617722759] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Home parenteral nutrition (HPN) and home intravenous (IV) hydration are complex, high-risk life-sustaining therapies for children and adults with severe digestive disorders. HPN compounding errors have the potential to cause serious patient harm. Here we present a retrospective case series at an interdisciplinary pediatric HPN program that includes specialized pharmacists reconciling prescriptions against commercial compounding records. Seven HPN or IV hydration patients were affected by significant errors in anion balance, copper, potassium, sodium, and infusion volume. Outpatient pharmacists' or other clinicians' review of compounding records as part of routine quality assurance process is critical for identifying and preventing errors.
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Affiliation(s)
- Margaret K Murphy
- 1 Department of Pharmacy, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Kathleen M Gura
- 1 Department of Pharmacy, Boston Children's Hospital, Boston, Massachusetts, USA.,2 Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Christina Tascione
- 2 Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Alexandra N Carey
- 2 Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Christopher P Duggan
- 2 Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Bram P Raphael
- 2 Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
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31
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Corrigan ML, Huang S, Weaver A, Keeler D, Rahe K, Balint J, Marti M, Goodman B, Nagy T, DeLano V, Bond B. Resources for the Provision of Nutrition Support to Children in Educational Environments. Nutr Clin Pract 2017; 32:834-843. [PMID: 28700266 DOI: 10.1177/0884533617718471] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The use of nutrition support outside of institutional settings has contributed to maintaining the health, well-being, and nutrition status of many medically complex children. As these children grow and enter educational settings, there is a need for awareness of the care that these children require for nutrition support therapy. This document is designed to raise awareness to these needs, provide best practice educational resources for those involved in the supervision or provision of nutrition support to children in an educational environment, and promote safe and effective care. Care of children requiring nutrition support is an ongoing and shared partnership among the educational team, medical team, homecare team, and parents/caregivers. Care is individualized to the specific child and may include provision of nutrition support therapy while in the school setting, maintenance of a nutrition access device, and monitoring to safely prevent or act on signs of potential complications. Suggested roles and responsibilities of those involved with nutrition support care are discussed; however, all interventions and routine care must be in accordance with physician's orders, school nurse privileges and competencies, and state and local regulations.
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Affiliation(s)
- Mandy L Corrigan
- 1 Home Nutrition Support and Center for Gut Rehabilitation and Transplantation, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Shirley Huang
- 2 Oley Foundation Board of Trustees, Newtonville, Massachusetts, USA
| | | | - David Keeler
- 4 Intestinal Rehabilitation Program, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Katina Rahe
- 5 Enteral Access Team, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Jane Balint
- 6 Center for Intestinal Rehabilitation, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Michelle Marti
- 7 Parent Advocate of Home Parenteral Nutrition Schoolchildren, Vancouver, Canada
| | | | - Traci Nagy
- 9 Feeding Tube Awareness Foundation, Merrick, New York, USA
| | | | - Betty Bond
- 10 Oley Foundation Board of Trustees, Levittown, Pennsylvania, USA
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32
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Drake R, Ozols A, Nadeau WJ, Braid-Forbes MJ. Hospital Inpatient Admissions With Dehydration and/or Malnutrition in Medicare Beneficiaries Receiving Enteral Nutrition: A Cohort Study. JPEN J Parenter Enteral Nutr 2017. [PMID: 28636843 DOI: 10.1177/0148607117713479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Enteral nutrition (EN) supports many older and disabled Americans. This study describes the frequency and cost of acute care hospitalization with dehydration and/or malnutrition of Medicare beneficiaries receiving EN, focusing on those receiving home EN. METHODS Medicare 5% Standard Analytic Files were used to determine Medicare spending for EN supplies and the proportion and cost of beneficiaries receiving EN, specifically home EN, admitted to the hospital with dehydration and/or malnutrition. RESULTS In 2013, Medicare paid $370,549,760 to provide EN supplies for 125,440 beneficiaries, 55% of whom were also eligible for Medicaid. Acute care hospitalization with dehydration and/or malnutrition occurred in 43,180 beneficiaries receiving EN. The most common principal diagnoses were septicemia (21%), aspiration pneumonitis (9%), and pneumonia (5%). In beneficiaries receiving EN at home, >one-third (37%) were admitted with dehydration and/or malnutrition during a mean observation interval of 231 ± 187 days. Admitted patients were usually hospitalized more than once with dehydration and/or malnutrition (1.73 ± 1.30 admissions) costing $23,579 ± 24,966 per admitted patient, totaling >$129,685,622 during a mean observation interval of 276 ± 187 days. Mortality in the year following enterostomy tube placement was significantly higher for admitted compared with nonadmitted patients (40% vs 33%; P = .05). CONCLUSION Acute care hospitalizations with dehydration and/or malnutrition in Medicare beneficiaries receiving EN were common and expensive. Additional strategies to reduce these, with particular focus on vulnerable populations such as Medicaid-eligible patients, are needed.
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Affiliation(s)
- Rachel Drake
- Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Audrey Ozols
- Covidien LP, a Medtronic company, Boulder, Colorado, and Mansfield, Massachusetts, USA
| | - William J Nadeau
- Covidien LP, a Medtronic company, Boulder, Colorado, and Mansfield, Massachusetts, USA
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33
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Abstract
Blenderized tube feeding has been steadily gaining in popularity among parents and caregivers of tube-fed children. Numerous websites and social media accounts are devoted to the topic, and the parent may be the one to initially broach the subject of implementing this type of feeding plan. This article discusses several different approaches to planning a blenderized tube feeding. As practitioners build their knowledge of and familiarity with blenderized tube feeding, they may feel more comfortable recommending this method to a wider variety of patients.
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Affiliation(s)
- Stacey Zettle
- 1 Department of Clinical Nutrition, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania, USA
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34
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Vallabh H, Konrad D, DeChicco R, Cresci G, Lopez R, Steiger E, Kirby DF. Thirty-Day Readmission Rate Is High for Hospitalized Patients Discharged With Home Parenteral Nutrition or Intravenous Fluids. JPEN J Parenter Enteral Nutr 2016; 41:1278-1285. [PMID: 27540042 DOI: 10.1177/0148607116664785] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Reducing hospital readmissions decreases healthcare costs and improves quality of care. There are no published studies examining the rate of, and risk factors for, 30-day readmissions for patients discharged with home parenteral support (HPS). OBJECTIVE Determine the rate of 30-day readmissions for patients discharged with HPS and whether malnutrition and other demographic or clinical factors increase the risk. MATERIALS AND METHODS Retrospective review of patients discharged with HPS from the Cleveland Clinic between July 1, 2013, and June 30, 2014, and followed by the Cleveland Clinic Home Nutrition Support Service. RESULTS Of the 224 patients studied, 31.6% (n = 71) had unplanned readmissions within 30 days of hospital discharge. Of these, 21.1% (n = 15) were HPS related, with catheter-related bloodstream infection (n = 5) and dehydration (n = 5) the most common. The majority of patients (84.4%) were diagnosed with malnutrition, but the presence or degree did not influence the readmission rate ( P = .41). According to univariable analysis, patients with an ostomy ( P = .037), a small bowel resection ( P = .002), a higher HPS volume at discharge ( P < .001), and a shorter period between HPS consult and hospital discharge ( P < .026) had a lower risk of 30-day readmission than their counterparts. On multivariable analysis, patients had a higher risk of 30-day readmission if they had a history of heart disease ( P = .048) and for every 1-unit increase in white blood cells ( P = .026). CONCLUSIONS Patients discharged with HPS have a high 30-day readmission rate, although most readmissions were not related to the HPS itself. The presence and degree of malnutrition were not associated with 30-day readmissions.
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Affiliation(s)
- Hiren Vallabh
- 1 Department of Gastroenterology, West Virginia University-Ruby Memorial Hospital, Morgantown, West Virginia, USA.,2 Center for Human Nutrition, Cleveland Clinic, Cleveland, Ohio, USA
| | - Denise Konrad
- 2 Center for Human Nutrition, Cleveland Clinic, Cleveland, Ohio, USA
| | - Robert DeChicco
- 2 Center for Human Nutrition, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gail Cresci
- 3 Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rocio Lopez
- 3 Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ezra Steiger
- 4 Department of General Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Donald F Kirby
- 3 Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio, USA
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35
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Mundi MS, Vallumsetla N, Davidson JB, McMahon MT, Bonnes SL, Hurt RT. Use of Home Parenteral Nutrition in Post-Bariatric Surgery-Related Malnutrition. JPEN J Parenter Enteral Nutr 2016; 41:1119-1124. [PMID: 27208038 DOI: 10.1177/0148607116649222] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Bariatric surgery is one of the most effective techniques for achieving sustained weight loss but can be associated with surgical complications or malabsorption so significant that it leads to malnutrition. Parenteral nutrition (PN) may be necessary to help treat surgical complications or malnutrition from these procedures. There are limited data describing this patient population and role for home PN (HPN). METHODS A retrospective review of our HPN database was conducted to identify patients who were initiated on HPN between January 1, 2003, and August 31, 2015, and had a history of bariatric surgery. RESULTS A total of 54 HPN patients (6.3%) had a history of bariatric surgery. Average age was 52.1 ± 12.8 years, and 80% were female. The most common surgical procedure was Roux-en-Y gastric bypass (72%), with malnutrition or failure to thrive being the most common HPN indication (57%). Weight at the time of HPN initiation was 71.9 ± 20.4 kg and significantly increased to 78.9 ± 24.4 kg by the end of treatment ( P = .0001). Serum albumin levels rose from 2.8 ± 0.77 g/dL to 3.7 ± 0.58 g/dL by the end of HPN ( P < .0001). Forty-five of 54 patients (83.3%) went on to revision surgery. CONCLUSION The results of this retrospective review support initiation of HPN in the malnourished post-bariatric surgery patient both nutritionally and as a bridge to revision surgery.
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Affiliation(s)
- Manpreet S Mundi
- 1 Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Nishanth Vallumsetla
- 1 Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Jacob B Davidson
- 2 Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Megan T McMahon
- 2 Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sara L Bonnes
- 2 Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ryan T Hurt
- 1 Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA.,2 Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.,3 Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA.,4 Division of Gastroenterology, Hepatology and Nutrition, University of Louisville, Kentucky, USA
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36
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Halliday V, Baker M, Thomas AL, Bowrey D. Patient and Family Caregivers' Experiences of Living With a Jejunostomy Feeding Tube After Surgery for Esophagogastric Cancer. JPEN J Parenter Enteral Nutr 2015; 41:837-843. [PMID: 26318373 PMCID: PMC5534339 DOI: 10.1177/0148607115604114] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Jejunostomy feeding tubes (JFTs) can be used to provide nutrition support to patients who have had surgery for esophagogastric cancer. Although previous research reports how patients cope with a gastrostomy tube, little is known about the impact of having a JFT. The aim of this qualitative study was to explore how patients and their informal caregivers experience living with a JFT in the first months following surgery. METHODS Participants were purposively sampled from a cohort of patients recruited to a trial investigating home enteral nutrition vs standard care after esophagogastric surgery for cancer. The sampling framework considered age, sex, and marital status. Informal caregivers were also invited to participate. Interviews were audio recorded, transcribed verbatim, and anonymized. Inductive thematic analysis was used to identify key themes related to living with a JFT. RESULTS Fifteen patient interviews were conducted; 8 also included a family caregiver. Analysis of the data resulted in 2 main themes: "challenges" and "facilitators" when living with a JFT. While "physical effects," "worries" and "impact on routine" were the main challenges, "support," "adaptation" and "perceived benefit" were what motivated continuation of the intervention. CONCLUSION Findings suggest that participants coped well with a JFT, describing high levels of compliance with stoma care and the feeding regimen. Nonetheless, disturbed sleep patterns and stoma-related problems proved troublesome. A better understanding of these practical challenges, from the patient and family caregiver perspective, should guide healthcare teams in providing proactive support to avoid preventable problems.
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Affiliation(s)
- Vanessa Halliday
- 1 The School of Health and Related Research (ScHARR), University of Sheffield, UK
| | - Melanie Baker
- 2 Department of Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Anne L Thomas
- 3 Department of Cancer Studies, University of Leicester, Leicester, UK
| | - David Bowrey
- 2 Department of Surgery, University Hospitals of Leicester NHS Trust, Leicester, UK
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Austhof SI, DeChicco R, Cresci G, Corrigan ML, Lopez R, Steiger E, Kirby DF. Expediting Transition to Home Parenteral Nutrition With Fast-Track Cycling. JPEN J Parenter Enteral Nutr 2015; 41:446-454. [PMID: 26187939 DOI: 10.1177/0148607115595620] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Delivery of home parenteral nutrition (PN) is typically cycled over 12 hours. Discharge to home on PN is often delayed due to potential adverse events (AEs) associated with cycling PN. The purpose was to determine whether patients requiring long-term PN can be cycled from 24 hours to 12 hours in 1 day instead of 2 days without increasing the risk of PN-related AEs. METHODS Hospitalized patients receiving PN at goal calories infused over 24 hours without severe electrolyte or blood glucose abnormalities were eligible. Patients were randomly assigned to a 1-step "fast-track" protocol or 2-step "standard" protocol. AEs were defined as hypoglycemia or hyperglycemia, new-onset or worsening dyspnea, tachycardia, tachypnea, lower extremity or sacral edema, pulmonary edema, or abdominal ascites and were graded as minor or major. RESULTS In the 63 patients studied, the most prevalent PN-related AE was hyperglycemia, occurring in 24.2% and 30.0% of patients in the fast-track and standard groups, respectively. Overall, there was no significant difference in the prevalence of PN-related minor AEs between fast-track and standard groups (33.3% and 53.3%, P = .5). No major PN-related AEs occurred in the fast-track group, while 1 major PN-related AE (pulmonary edema) occurred in the standard group. CONCLUSIONS Fast-track cycling is as safe as standard cycling in patients without diabetes mellitus or major organ dysfunction requiring long-term PN. Fast-track cycling could potentially expedite hospital discharge, resulting in decreased healthcare costs and improved patient satisfaction.
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Affiliation(s)
- Sandra I Austhof
- 1 Center for Human Nutrition TT-22, Cleveland Clinic, Cleveland, Ohio, USA
| | - Robert DeChicco
- 1 Center for Human Nutrition TT-22, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gail Cresci
- 2 Gastroenterology and Hepatology M-17, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Rocio Lopez
- 4 Quantitative Health Sciences JJN3-01, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ezra Steiger
- 5 Center for Human Nutrition/General Surgery A100, Cleveland Clinic, Cleveland, Ohio, USA
| | - Donald F Kirby
- 6 Center for Human Nutrition/Gastroenterology A51, Cleveland Clinic, Cleveland, Ohio, USA
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Aryana K, Greenway F, Dhurandhar N, Tulley R, Finley J, Keenan M, Martin R, Pelkman C, Olson D, Zheng J. A resistant-starch enriched yogurt: fermentability, sensory characteristics, and a pilot study in children. F1000Res 2015; 4:139. [PMID: 26925221 PMCID: PMC4712773 DOI: 10.12688/f1000research.6451.1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/19/2015] [Indexed: 12/11/2022] Open
Abstract
The rising prevalence of obesity and the vulnerability of the pediatric age group have highlighted the critical need for a careful consideration of effective, safe, remedial and preventive dietary interventions. Amylose starch (RS2) from high-amylose maize (HAM) ferments in the gut and affects body weight. One hundred and ten children, of 7-8 (n=91) or 13-14 (n=19) years of age scored the sensory qualities of a yogurt supplemented with either HAM-RS2 or an amylopectin starch. The amylopectin starch yogurt was preferred to the HAM-RS2-enriched yogurt by 7-8 year old panelists (
P<0.0001). Appearance, taste, and sandiness scores given by 13- to 14-year-old panelists were more favorable for the amylopectin starch yogurt than for HAM-RS2-enriched yogurt (
P<0.05). HAM-RS2 supplementation resulted in acceptable (≥6 on a 1-9 scale) sensory and hedonic ratings of the yogurt in 74% of subjects. Four children consumed a HAM-RS2-enriched yogurt for four weeks to test its fermentability in a clinical trial. Three adolescents, but not the single pre-pubertal child, had reduced stool pH (
P=0.1) and increased stool short-chain fatty acids (SCFAs) (
P<0.05) including increased fecal acetate (
P=0.02), and butyrate (
P=0.089) from resistant starch (RS) fermentation and isobutyrate (
P=0.01) from protein fermentation post-treatment suggesting a favorable change to the gut microbiota. HAM-RS2 was not modified by pasteurization of the yogurt, and may be a palatable way to increase fiber intake and stimulate colonic fermentation in adolescents. Future studies are planned to determine the concentration of HAM-RS2 that offers the optimal safe and effective strategy to prevent excessive fat gain in children.
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Affiliation(s)
- Kayanush Aryana
- School of Animal Sciences, College of Agriculture, Louisiana State University, Baton Rouge, LA, 70808, USA; Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, LA, 70808, USA
| | - Frank Greenway
- Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, LA, 70808, USA
| | - Nikhil Dhurandhar
- Department of Nutritional Sciences, Texas Tech University, Lubbock, TX, 79409, USA
| | - Richard Tulley
- School of Nutrition and Food Science, College of Agriculture, Louisiana State University, Baton Rouge, LA, 70803, USA
| | - John Finley
- School of Nutrition and Food Science, College of Agriculture, Louisiana State University, Baton Rouge, LA, 70803, USA
| | - Michael Keenan
- School of Nutrition and Food Science, College of Agriculture, Louisiana State University, Baton Rouge, LA, 70803, USA
| | - Roy Martin
- University of California, University of California, Davis, CA, 95616, USA
| | | | - Douglas Olson
- School of Animal Sciences, College of Agriculture, Louisiana State University, Baton Rouge, LA, 70808, USA
| | - Jolene Zheng
- Pennington Biomedical Research Center, Louisiana State University, Baton Rouge, LA, 70808, USA
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Sant VR, Arnell TD, Seres DS. Zinc Deficiency With Dermatitis in a Parenteral Nutrition-Dependent Patient Due to National Shortage of Trace Minerals. JPEN J Parenter Enteral Nutr 2015; 40:592-5. [PMID: 25564425 DOI: 10.1177/0148607114566465] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 10/17/2014] [Indexed: 11/17/2022]
Abstract
The shortages of intravenous drugs remains critical, with sterile injectables accounting for 80% of the approximately 300 shortages. The impact is being felt in patients dependent on parenteral nutrition (PN), and severe deficiencies are becoming more commonplace. We report here a man who developed severe zinc deficiency, manifesting as a painful desquamative rash, due to an inability to obtain multi-trace element additives for his PN.
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Affiliation(s)
- Vivek R Sant
- College of Physicians and Surgeons, Columbia University, New York, New York
| | - Tracey D Arnell
- Department of Surgery, Columbia University Medical Center, New York, New York
| | - David S Seres
- Department of Medicine, Columbia University Medical Center, New York, New York
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Barone M, Viggiani MT, Amoruso A, Licinio R, Iannone A, Montenegro L, Scavo MP, Addante I, Di Leo A. Influence of age and type of underlying disease on complications related to home enteral nutrition: a single Italian center experience. JPEN J Parenter Enteral Nutr 2014; 38:991-5. [PMID: 23934935 DOI: 10.1177/0148607113498422] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND No data about the influence of age and underlying diseases on home enteral nutrition (HEN)-related complications are reported in the literature. Herein, we retrospectively investigated this issue by analyzing HEN-related complications in a cohort of consecutive patients grouped according to the underlying disease and age. MATERIAL AND METHODS We reviewed the medical records of 101 patients referring to our team in 2007-2010 to obtain patients' demographic data, age, nutrition status, duration of HEN treatment, and type of HEN-related complications. They were divided in cancer and neurologic patients and subgrouped on the basis of their age. HEN-related complications were expressed as complication rates. RESULTS Patients with neurological diseases suffered a significantly higher number of complications as compared with cancer patients (P = .04). Age did not significantly influence complication rates. The mechanical complications were the most frequent. The majority of HEN-related complications were resolved at home. CONCLUSION Our data strongly suggest that HEN-related complications are influenced by underlying diseases and not by age. In neurologic patients, dementia, loss of autonomy, and the different therapies administered by PEG probably play an important role in increasing the number of HEN-related complications as compared with cancer patients. The most frequent complications can be managed at home, reducing the costs of hospitalizations and discomfort for the patient.
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Affiliation(s)
- Michele Barone
- Gastroenterology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Maria Teresa Viggiani
- Gastroenterology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Annabianca Amoruso
- Gastroenterology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Raffaele Licinio
- Gastroenterology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Andrea Iannone
- Gastroenterology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Lucia Montenegro
- Gastroenterology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Maria Principia Scavo
- Gastroenterology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Irene Addante
- Gastroenterology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Alfredo Di Leo
- Gastroenterology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
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Rosen D, Schneider R, Bao R, Burke P, Ceballos C, Hoffstadter-Thal K, Benkov K. Home Nasogastric Feeds: Feeding Status and Growth Outcomes in a Pediatric Population. JPEN J Parenter Enteral Nutr 2014; 40:350-4. [PMID: 25261413 DOI: 10.1177/0148607114551967] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 08/23/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND Home enteral nutrition (HEN) is a safe method for providing nutrition to children with chronic diseases. Advantages of HEN include shorter hospitalizations, lower cost, and decreased risk of malnutrition-associated complications. Follow-up after hospital discharge on HEN is limited. The purpose of this study was to look at children discharged on nasogastric (NG) feeds to assess follow-up feeding status and impact on growth. METHODS A retrospective chart review was conducted of pediatric patients discharged from Mount Sinai Medical Center on NG feeds between January 2010 and March 2013. RESULTS A total of 87 patients were included. Average age was 1.2 years. The most common diagnoses were congenital heart disease (47%), metabolic disease (17%), neurologic impairment (10%), liver disease (9%), prematurity (8%), and inflammatory bowel disease (6%). At most recent follow-up, 44 (50.6%) were on full oral feeds, 8 (9.2%) were still on NG feeds, 9 (10.3%) had a gastrostomy tube placed, 9 (10.3%) were deceased, and 17 (19.5%) had transferred care or were lost to follow-up. Average time to discontinuation of NG feeds was 4.8 months. Change in body mass index from hospital discharge to follow-up visit 6 to 12 weeks after discharge was statistically significant, from a mean (SD) of 13.78 (2.82) to 14.58 (2.1) (P = .02). Change in weight z score was significant for neurologic impairment (-1.35 to -0.04; P = .03). Height z score change was significant for prematurity (-3.84 to -3.34; P = .02). There was no significant change in height or weight z scores for the other diagnoses. CONCLUSIONS NG feeds can help to improve short-term growth after hospital discharge in children with chronic illnesses.
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Affiliation(s)
- Danya Rosen
- Department of Pediatric Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Rachael Schneider
- Department of Pediatric Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ruijun Bao
- Department of Pediatric Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Patrice Burke
- Department of Pediatric Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Clare Ceballos
- Department of Pediatric Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Kathy Hoffstadter-Thal
- Department of Pediatric Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Keith Benkov
- Department of Pediatric Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY
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Kim H, Spaulding R, Werkowitch M, Yadrich D, Piamjariyakul U, Gilroy R, Smith CE. Costs of multidisciplinary parenteral nutrition care provided at a distance via mobile tablets. JPEN J Parenter Enteral Nutr 2014; 38:50S-7S. [PMID: 25245253 DOI: 10.1177/0148607114550692] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Determining the costs of healthcare delivery is a key step for providing efficient nutrition-based care. This analysis tabulates the costs of delivering home parenteral nutrition (HPN) interventions and clinical assessments through encrypted mobile technologies to increase patients' access to healthcare providers, reduce their travel expenses, and allow early detection of infection and other complications. METHODS A traditional cost-accounting method was used to tabulate all expenses related to mobile distance HPN clinic appointments, including (1) personnel time of multidisciplinary healthcare professionals, (2) supply of HPN intervention materials, and (3) equipment, connection, and delivery expenses. RESULTS A total of 20 mobile distance clinic appointments were conducted for an average of 56 minutes each with 45 patients who required HPN infusion care. The initial setup costs included mobile tablet devices, 4G data plans, and personnel's time as well as intervention materials. The initial costs were on average $916.64 per patient, while the follow-up clinic appointments required $361.63 a month, with these costs continuing to decline as the equipment was used by multiple patients more frequently over time. Patients reported high levels of satisfaction with cost savings in travel expenses and rated the quality of care comparable to traditional in-person examinations. CONCLUSION This study provides important aspects of the initial cost tabulation for visual assessment for HPN appointments. These findings will be used to generate a decision algorithm for scheduling mobile distance clinic appointments intermittent with in-person visits to determine how to lower costs of nutrition assessments. To maximize the cost benefits, clinical trials must continue to collect clinical outcomes.
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Affiliation(s)
- Heejung Kim
- University of Kansas School of Nursing, Kansas City, Kansas
| | - Ryan Spaulding
- University of Kansas School of Medicine, Kansas City, Kansas
| | | | - Donna Yadrich
- University of Kansas School of Nursing, Kansas City, Kansas
| | | | - Richard Gilroy
- University of Kansas School of Medicine, Kansas City, Kansas
| | - Carol E Smith
- University of Kansas School of Nursing and Preventive Medicine & Public Health, Kansas City, Kansas
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Wales PW, Allen N, Worthington P, George D, Compher C, Teitelbaum D. A.S.P.E.N. clinical guidelines: support of pediatric patients with intestinal failure at risk of parenteral nutrition-associated liver disease. JPEN J Parenter Enteral Nutr 2014; 38:538-57. [PMID: 24696095 DOI: 10.1177/0148607114527772] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Accepted: 02/21/2014] [Indexed: 11/07/2023]
Abstract
BACKGROUND Children with severe intestinal failure and prolonged dependence on parenteral nutrition are susceptible to the development of parenteral nutrition-associated liver disease (PNALD). The purpose of this clinical guideline is to develop recommendations for the care of children with PN-dependent intestinal failure that have the potential to prevent PNALD or improve its treatment. METHOD A systematic review of the best available evidence to answer a series of questions regarding clinical management of children with intestinal failure receiving parenteral or enteral nutrition was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group. A consensus process was used to develop the clinical guideline recommendations prior to external and internal review and approval by the American Society for Parenteral and Enteral Nutrition Board of Directors. QUESTIONS (1) Is ethanol lock effective in preventing bloodstream infection and catheter removal in children at risk of PNALD? (2) What fat emulsion strategies can be used in pediatric patients with intestinal failure to reduce the risk of or treat PNALD? (3) Can enteral ursodeoxycholic acid improve the treatment of PNALD in pediatric patients with intestinal failure? (4) Are PNALD outcomes improved when patients are managed by a multidisciplinary intestinal rehabilitation team?
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Affiliation(s)
- Paul W Wales
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nancy Allen
- Children's Mercy Hospital, Kansas City, Missouri
| | | | | | - Charlene Compher
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
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Abstract
Short bowel syndrome (SBS) refers to the malabsorptive state caused by physical or functional loss of portions of the small intestine, most commonly following extensive intestinal resection. Such resections hinder absorption of adequate amounts of macronutrients, micronutrients, electrolytes, and water, resulting in malnutrition, diarrhea, and dehydration. Clinical features of SBS vary along a continuum, depending on the extent and anatomy of intestine lost and the ability of the patient and the remaining intestine to compensate for the loss. The impact of SBS can be extensive, leading to diminished health-related quality of life because of its many physical and psychological effects on patients. SBS is associated with decreased survival; risk factors for SBS-related mortality include very short remnant small bowel, end-jejunal remnant anatomy, and arterial mesenteric infarction as primary cause. Although parenteral nutrition and/or intravenous fluid (PN/IV) is a life-saving measure for many patients with SBS, patients with the most severe malabsorption (ie, dependent on PN/IV) are at risk for severe, chronic complications and death. Patients' treatment needs vary depending on disease severity and resection type; thus, each patient should be individually managed. This review discusses the spectrum of disease in patients with SBS and presents common complications encountered by these patients to highlight the importance of individualized management and treatment.
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Affiliation(s)
- Palle B Jeppesen
- Department of Medical Gastroenterology, Rigshospitalet, Copenhagen, Denmark
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45
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Abstract
Diarrhea associated with short bowel syndrome (SBS) can have multiple etiologies, including accelerated intestinal transit, gastric acid hypersecretion, intestinal bacterial overgrowth, and malabsorption of fats and bile salts. As a result, patients may need multiple medications to effectively control fecal output. The armamentarium of antidiarrheal drugs includes antimotility agents, antisecretory drugs, antibiotics and probiotics, bile acid-binding resins, and pancreatic enzymes. An antidiarrheal regimen must be individualized for each patient and should be developed using a methodical, stepwise approach. Treatment should be initiated with a single first-line medication at the low end of its dosing range. Dosage and/or dosing frequency can then be slowly escalated to achieve maximal effect while minimizing adverse events. If diarrhea remains poorly controlled, additional agents can be incorporated sequentially. If modification of the regimen is required, a single medication should be altered or exchanged at a time. After each adjustment of the regimen, sufficient time should be permitted to fully assess response (≥3-5 days) before initiating additional changes. SBS-associated malabsorption is a major obstacle to optimization of an antidiarrheal regimen because drug absorption is impaired. Patients may benefit from high dosages and/or frequent dosing intervals, liquid preparations, or nonoral routes of drug delivery. Although the diarrhea associated with SBS can be debilitating, effective pharmaceutical management has the potential to substantially improve health outcomes and quality of life for these patients.
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Elfassy S, Kassam Z, Amin F, Khan KJ, Haider S, Armstrong D. Epidemiology and risk factors for bloodstream infections in a home parenteral nutrition program. JPEN J Parenter Enteral Nutr 2013; 39:147-53. [PMID: 24072741 DOI: 10.1177/0148607113502361] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND An increasing number of patients with intestinal failure are receiving home parenteral nutrition (HPN). Associated complications include bloodstream infections (BSIs), but data on rates and risk factors for HPN-related BSIs are scarce. METHODS A retrospective review was conducted of patients enrolled in the regional HPN program between 2001 and 2008. Demographic information and data on indication for HPN, duration of PN therapy, type and date of insertion of central venous access device, and blood culture results were recorded. RESULTS In total, 155 patients (165 courses of HPN) were included for a total of 45,876 catheter days. The mean patient age was 49 years, and 105 (64%) patients were female. A total of 105 organisms were cultured from 93 distinct episodes of BSIs. The rate of BSI was found to be 2.0 per 1000 catheter days, but excluding BSIs with a single positive culture of coagulase-negative staphylococcus and diphtheroid bacilli, the rate of infection was 1.4 per 1000 catheter days. Male sex and underlying malignancy were significant predictors of BSI, with hazard ratios of 1.69 (95% confidence interval [CI], 1.14-2.60; P = .009) and 2.38 (95% CI, 1.53-3.50; P < .001). CONCLUSION In a large heterogeneous group of HPN patients, the BSI rate ranged between 1.4 and 2.0 infections per 1000 catheter days. Isolated organisms were similar to those found in hospitalized patients. Male sex and underlying malignancy were significant risk factors for BSI. These high-risk patients are likely to benefit from interventions aimed at reducing BSIs.
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Affiliation(s)
- Sam Elfassy
- Gastroenterology and Clinician Investigator Programs, McMaster University Medical Centre, Hamilton, Ontario, Canada
| | - Zain Kassam
- Gastroenterology Program, McMaster University Medical Centre, Hamilton, Ontario, Canada
| | - Faizan Amin
- Internal Medicine Program, McMaster University Medical Centre, Hamilton, Ontario, Canada
| | - Khurram J Khan
- Division of Gastroenterology, McMaster University Medical Centre, Hamilton, Ontario, Canada
| | - Shariq Haider
- Division of Infectious Diseases, Department of Medicine, McMaster University Medical Centre, Hamilton, Ontario, Canada
| | - David Armstrong
- Division of Gastroenterology, McMaster University Medical Centre, Hamilton, Ontario, Canada
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Buchman AL, Opilla M, Kwasny M, Diamantidis TG, Okamoto R. Risk factors for the development of catheter-related bloodstream infections in patients receiving home parenteral nutrition. JPEN J Parenter Enteral Nutr 2013; 38:744-9. [PMID: 23744839 DOI: 10.1177/0148607113491783] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Accepted: 05/06/2013] [Indexed: 12/28/2022]
Abstract
BACKGROUND Risk factors for development of catheter-related bloodstream infections (CRBSI) were studied in 125 adults and 18 children who received home parenteral nutrition (HPN). METHODS Medical records from a national home care pharmacy were reviewed for all patients that had HPN infused at least twice weekly for a minimum of two years from January 1, 2006-December 31, 2011. Infection and risk factor data were collected during this time period on all patients although those patients who received HPN for a longer period had data collected since initiation of HPN. RESULTS In adults, 331 central venous catheters (CVCs) were placed. Total catheter years were 1157. Median CVC dwell time was 730 days. In children, there were 53 CVCs placed. Total catheter years were 113.1. Median CVC dwell time was 515 days. There were 147 CRBSIs (0.13/catheter year;0.35/1000 catheter days). In children there were 33 CRBSIs (0.29/catheter year;0.80/1000 days; P < .001 versus adults). In adults, univariate analysis showed use of subcutaneous infusion ports instead of tunneled catheters (P = .001), multiple lumen catheters (P = .001), increased frequency of lipid emulsion infusion (P = .001), obtaining blood from the CVC (P < 0.001), and infusion of non-PN medications via the CVC (P < .001) were significant risk factors for CRBSI. Increased PN frequency was associated with increased risk of CRBSI (P = .001) in children, but not in adults. Catheter disinfection with povidone-iodine was more effective than isopropyl alcohol alone. There were insufficient patients to evaluate chlorhexidine-containing regimens. CONCLUSION Numerous risk factors for CRBSI were identified for which simple and current countermeasures already exist.
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Affiliation(s)
| | | | - Mary Kwasny
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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