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Raghu VK, Rumbo C, Horslen SP. From intestinal failure to transplantation: Review on the current need for transplant indications under multidisciplinary transplant programs worldwide. Pediatr Transplant 2024; 28:e14756. [PMID: 38623905 DOI: 10.1111/petr.14756] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 11/24/2023] [Accepted: 04/01/2024] [Indexed: 04/17/2024]
Abstract
INTRODUCTION Intestinal failure, defined as the loss of gastrointestinal function to the point where nutrition cannot be maintained by enteral intake alone, presents numerous challenges in children, not least the timing of consideration of intestine transplantation. OBJECTIVES To describe the evolution of care of infants and children with intestinal failure including parenteral nutrition, intestine transplantation, and contemporary intestinal failure care. METHODS The review is based on the authors' experience supported by an in-depth review of the published literature. RESULTS The history of parenteral nutrition, including out-patient (home) administration, and intestine transplantation are reviewed along with the complications of intestinal failure that may become indications for consideration of intestine transplantation. Current management strategies for children with intestinal failure are discussed along with changes in need for intestine transplantation, recognizing the difficulty in generalizing recommendations due to the high level of heterogeneity of intestinal pathology and residual bowel anatomy and function. DISCUSSION Advances in the medical and surgical care of children with intestinal failure have resulted in improved transplant-free survival and a significant fall in demand for transplantation. Despite these improvements a number of children continue to fail rehabilitative care and require intestine transplantation as life-saving therapy or when the burden on ongoing parenteral nutrition becomes too great to bear.
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Affiliation(s)
- Vikram K Raghu
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Carolina Rumbo
- Unidad de Soporte Nutricional, Rehabilitación y Trasplante Intestinal Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
| | - Simon P Horslen
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Catron H, Hanson C, Beerman L, Carney J, Janiak K, Gerhardt B, Rochling F, Mercer D. Sustained elimination of parenteral support in adult patients with under 60 cm of small intestine: A case series. Nutr Clin Pract 2024; 39:227-234. [PMID: 37898826 DOI: 10.1002/ncp.11078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 08/10/2023] [Accepted: 08/27/2023] [Indexed: 10/30/2023] Open
Abstract
Patients with short bowel syndrome (SBS) are often managed by expert multidisciplinary teams. One of the main goals in the management of SBS is the weaning of parenteral support (PS). Weaning of PS removes the risks associated with long-term central line placement and eliminates the need for intestinal transplant. Whereas several papers detail the ongoing care and management of patients with SBS who are dependent on PS, there are few reports discussing the successful weaning of PS in this patient population. We present five case studies examining weaning of PS in adult patients with <60-cm small bowel and partial or full colon who were enrolled in a multidisciplinary adult intestinal rehabilitation program. The case studies demonstrate weaning can occur >2 years after initial assessment and enrollment in an expert program. The ability of the program to focus on individualized care and frequent patient communication is key to PS weaning in patients with SBS.
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Affiliation(s)
- Hilary Catron
- Department of Clinical Nutrition, The Nebraska Medical Center, Omaha, NE, USA
| | - Corrine Hanson
- CAHP Medical Nutrition, University of Nebraska Medical Center, Omaha, NE, USA
| | - Laura Beerman
- Department of Clinical Nutrition, The Nebraska Medical Center, Omaha, NE, USA
| | - Jaime Carney
- Department of Transplant: Liver-Intestine, The Nebraska Medical Center, Omaha, NE, USA
| | - Kathryn Janiak
- Department of Transplant: Liver-Intestine, The Nebraska Medical Center, Omaha, NE, USA
- Departement of Surgery, The Nebraska Medical Center, Omaha, NE, USA
| | - Brandi Gerhardt
- Department of Transplant: Liver-Intestine, The Nebraska Medical Center, Omaha, NE, USA
| | - Fedja Rochling
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - David Mercer
- Department of Surgery/Transplant, University of Nebraska Medical Center, Omaha, NE, USA
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Tappenden KA. Anatomical and physiological considerations in short bowel syndrome: Emphasis on intestinal adaptation and the role of enterohormones. Nutr Clin Pract 2023; 38 Suppl 1:S27-S34. [PMID: 37115026 DOI: 10.1002/ncp.10991] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 02/06/2023] [Revised: 03/10/2023] [Accepted: 03/13/2023] [Indexed: 04/29/2023] Open
Abstract
Short bowel syndrome (SBS)-associated intestinal failure (IF) is a complex, life-threatening condition that requires complex care of multiple factors impacting the patient's long-term prognosis. Various etiologies result in SBS-IF, with three primary anatomical subtypes occurring following intestinal resection. Depending on the extent and segment(s) of the intestine resected, malabsorption can be nutrient specific or sweeping; however, such issues and the associated prognosis for the patient can be predicted with analysis of the residual intestine, along with baseline nutrient and fluid deficits and extent of malabsorption. The provision of parenteral nutrition/intravenous (PN-IV) fluids and antisymptomatic agents is fundamental; however, optimal management should focus on intestinal rehabilitation, wherein intestinal adaptation is prioritized and PN-IV fluids are weaned over time. Key strategies to maximize intestinal adaptation include hyperphagic consumption of an individualized SBS diet and the appropriate use of trophic agents, such as a glucagon-like peptide 2 analog.
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Affiliation(s)
- Kelly A Tappenden
- Department of Kinesiology and Nutrition, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, Illinois, USA
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Pironi L. Definition, classification, and causes of short bowel syndrome. Nutr Clin Pract 2023; 38 Suppl 1:S9-S16. [PMID: 37115031 DOI: 10.1002/ncp.10955] [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: 11/24/2022] [Revised: 12/30/2022] [Accepted: 01/01/2023] [Indexed: 04/29/2023] Open
Abstract
The term "short bowel syndrome (SBS)" defines "the clinical feature associated with a remaining small bowel in continuity of less than 200 cm from the ligament of Treitz" and is characterized by malabsorption, diarrhea, fatty stools, malnutrition, and dehydration. SBS is the primary pathophysiological mechanism of chronic intestinal failure (CIF), defined as the "reduction of gut function below the minimum necessary for the absorption of macronutrients and/or water and electrolytes, such that intravenous supplementation (IVS) is required to maintain health and/or growth" in a metabolically stable patient. By contrast, the reduction of gut absorptive function that does not require IVS has been termed "intestinal insufficiency or deficiency" (II/ID). The classification of SBS can be categorized as follows: anatomical (anatomy and length of the residual bowel), evolutional (early, rehabilitative, and maintenance phases), pathophysiological (SBS with or without a colon in continuity), clinical (with II/ID or CIF), and severity of CIF (type and volume of the required IVS). Appropriate and homogeneous patient categorization is the mainstay of facilitating communication in clinical practice and in research.
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Affiliation(s)
- Loris Pironi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Centre for Chronic Intestinal Failure, IRCCS AOUBO, Bologna, Italy
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Goldani HA, Ceza MR, Godoy LL, Giesta JM, Beier S, Oliveira JG, Nunes DL, Feldens L, Lucena IR, Taniguchi AN, Hallberg SC, Durant D, Boettcher S, Schneider MA, Mello PP, Riberg MG, Signorini AV, Miller C, Santos BL, Silveira CO, Morais MC, Laggazio TV, Costa CC, Kieling CO. Outcomes of the First 54 Pediatric Patients on Long-Term Home Parenteral Nutrition from a Single Brazilian Center. J Pediatr Gastroenterol Nutr 2022; 75:104-109. [PMID: 35578384 PMCID: PMC9236303 DOI: 10.1097/mpg.0000000000003473] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 03/28/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Data on multidisciplinary programs dedicated to home parenteral nutrition (HPN) in Latin America are limited. This study describes the results of the first multidisciplinary pediatric intestinal rehabilitation program for HPN at a public tertiary hospital in Brazil. METHODS We retrospectively reviewed patients aged 0-18 years with intestinal failure (IF) who required parenteral nutrition (PN) for >60 days between January/2014 and December/2020. RESULTS Fifty-four patients were discharged on HPN (15 achieved enteral autonomy, 34 continued on HPN at the end of the study, 1 underwent intestinal transplantation, and 4 died). The median (IQR) age at the study endpoint of patients who achieved enteral autonomy was 14.1 (9.7-19) versus 34.7 (20.4-53.9) months in those who did not achieve enteral autonomy. Overall prevalence of catheter-related thrombosis was 66.7% and catheter-related bloodstream infection rate was 0.39/1000 catheter-days. Intestinal failure-associated liver disease (IFALD) was present in 24% of all patients; none of the patients who achieved enteral autonomy had IFALD. All patients showed significant improvement in anthropometric parameters during the HPN period. The sociodemographic characteristics of the patients' family members were mothers less than 20 years old (7.5%), schooling time more than 10 years (55.5%), and household income between 1 and 3 times the minimum wage (64.8%). The 5-year survival rate for HPN is 90%, and 27.7% of patients achieve enteral autonomy. CONCLUSION The treatment of pediatric patients with IF followed by a multidisciplinary pediatric intestinal rehabilitation program with HPN is feasible and safe in the Brazilian public health system.
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Affiliation(s)
- Helena A.S. Goldani
- From the Pediatric Gastroenterology Unit, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
- Graduate Program in Child and Adolescent Health, Universidade Federal do Rio Grande do Sul
| | - Marilia R. Ceza
- From the Pediatric Gastroenterology Unit, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Liege L. Godoy
- Pediatric Nursing Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Juliana M. Giesta
- Nutrition Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Simone Beier
- Social Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Juliana G. Oliveira
- From the Pediatric Gastroenterology Unit, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Daltro L. Nunes
- From the Pediatric Gastroenterology Unit, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Leticia Feldens
- Pediatric Surgery Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Iara R.S. Lucena
- Radiology Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | | | - Silvia C. Hallberg
- Psychology Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Daiane Durant
- Pediatric Nursing Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Simone Boettcher
- Pediatric Nursing Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Marcia A. Schneider
- Nutrology Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Patricia P. Mello
- Nutrology Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Mariana G.L. Riberg
- Pharmacy Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Alana V. Signorini
- Speech and Language Therapy Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Cristina Miller
- Physiotherapy Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Berenice L. Santos
- Graduate Program in Child and Adolescent Health, Universidade Federal do Rio Grande do Sul
| | - Claudete O. Silveira
- Administrative Department, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Maira C.M. Morais
- Administrative Department, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Terezinha V. Laggazio
- Administrative Department, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Carla C. Costa
- Social Service, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | - Carlos O. Kieling
- From the Pediatric Gastroenterology Unit, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
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Williams KJ, Donnelly S, Gabe S, Gupta A, Holman R, Preston S, Vaizey CJ, Corr A, Mehta AM. Standardized documentation and synoptic reporting of complex intestinal anatomy in enteric fistulation and intestinal failure. Colorectal Dis 2022; 24:530-534. [PMID: 34860451 DOI: 10.1111/codi.16007] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 11/23/2021] [Accepted: 11/25/2021] [Indexed: 12/06/2022]
Abstract
AIM In intestinal failure, delineation of both structure and function are key to controlling symptoms and planning further intervention. We have developed a template for developing an 'anatomy at a glance' patient-specific map to aid decision making and counselling. METHOD A core dataset was developed and used to create an editable template to demonstrate the gastrointestinal tract, its relationship to the genitourinary tract, and specific anterior abdominal wall features. This was then used to create an anatomical template, specific to each patient, and stored in the electronic patient record and imaging archive. RESULTS We have developed a technique for integration of multi-modal information into one diagram, easily referenced by the multidisciplinary team. Radiology, endoscopy and previous operation notes can be used to fill out a core dataset, which is then transposed into a standardized template. A worked example is shown. CONCLUSION The mapping template has been successfully integrated into practice and aided decision making at all stages of the patient's therapeutic journey. It has been found helpful in planning routes of nutrition, preoperative optimization, surgical planning, interpreting postoperative imaging and managing patient expectations.
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Affiliation(s)
- Katherine J Williams
- Lennard-Jones Intestinal Rehabilitation Unit, Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - Suzanne Donnelly
- Lennard-Jones Intestinal Rehabilitation Unit, Department of Gastroenterology, St Mark's Hospital, London, UK
| | - Simon Gabe
- Lennard-Jones Intestinal Rehabilitation Unit, Department of Gastroenterology, St Mark's Hospital, London, UK
| | - Arun Gupta
- Department of Gastrointestinal Imaging, St Mark's Hospital, London, UK
| | - Richard Holman
- Lennard-Jones Intestinal Rehabilitation Unit, Department of Gastroenterology, St Mark's Hospital, London, UK
| | - Stephen Preston
- Multimedia and Audiovisual Services, St Mark's Academic Institute, London, UK
| | - Carolynne J Vaizey
- Lennard-Jones Intestinal Rehabilitation Unit, Department of Colorectal Surgery, St Mark's Hospital, London, UK
| | - Alison Corr
- Department of Gastrointestinal Imaging, St Mark's Hospital, London, UK
| | - Akash M Mehta
- Lennard-Jones Intestinal Rehabilitation Unit, Department of Colorectal Surgery, St Mark's Hospital, London, UK
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Spolidoro JVN, Souza MC, Goldani HAS, Tanzi MN, Busoni VB, Padilla MDC, Ramirez NE, Cofre C, Valdivieso LP, Saure C, Jimenez-Arguedas G, Mateus MSM, Serra R, Cuadros-Mendonza C, Rivera-Medina J, Gattini D, Dos Santos BJ, Plata C, Sandy NS. International Latin American Survey on Pediatric Intestinal Failure Team. Nutrients 2021; 13:2754. [PMID: 34444914 DOI: 10.3390/nu13082754] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/09/2021] [Accepted: 07/12/2021] [Indexed: 11/17/2022] Open
Abstract
There is little data on the experience of managing pediatric Intestinal Failure (IF) in Latin America. This study aimed to identify and describe the current organization and practices of the IF teams in Latin America and the Caribbean. An online survey was sent to inquire about the existence of IF teams that managed children on home parenteral nutrition (HPN). Our questionnaire was based on a previously published European study with a similar goal. Twenty-four centers with pediatric IF teams in eight countries completed the survey, representing a total number of 316 children on HPN. The median number of children on parenteral nutrition (PN) at home per team was 5.5 (range 1-50). Teams consisted of the following members: pediatric gastroenterologist and a pediatric surgeon in all teams, dietician (95.8%), nurse (91.7%), social worker (79.2%), pharmacist (70.8%), oral therapist (62.5%), psychologist (58.3%), and physiotherapist (45.8%). The majority of the centers followed international standards of care on vascular access, parenteral and enteral nutrition, and IF medical and surgical management, but a significant percentage reported inability to monitor micronutrients, like vitamins A (37.5%), E (41.7%), B1 (66.7%), B2 (62.5%), B6 (62.5%), active B12 (58.3%); and trace elements-including zinc (29.2%), aluminum (75%), copper (37.5%), chromium (58.3%), selenium (58.3%), and manganese (58.3%). Conclusion: There is wide variation in how IF teams are structured in Latin America-while many countries have well-established Intestinal rehabilitation programs, a few do not follow international standards. Many countries did not report having an IF team managing pediatric patients on HPN.
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Nikoupour H, Arasteh P, Shamsaeefar A, Ghanbari F, Boorboor A, Almayali AMJ, Shafiekhani M, Samidoust P, Shahriarirad R, Shojazadeh A, Ranjbar K, Darabi MH, Tangestanipour S, Hosseini SM, Zahiri L, Nikeghbalian S. Experiences with intestinal failure from an intestinal rehabilitation unit in a country without home parenteral nutrition. JPEN J Parenter Enteral Nutr 2021; 46:946-957. [PMID: 34291839 DOI: 10.1002/jpen.2231] [Citation(s) in RCA: 2] [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] [Indexed: 01/04/2023]
Abstract
OBJECTIVE For the first time, we reported experiences with an intestinal rehabilitation unit (IRU) from a country without home parenteral nutrition (HPN). METHODS We included patients with a diagnosis of intestinal failure (IF) since the establishment of our IRU from February 2018 to February 2020. We further report on our protocols for management of enterocutaneous fistulas (ECFs), short-bowel syndrome (SBS), chronic intestinal pseudo-obstruction and motility disorders. RESULTS Among a total of 349 patients who have been admitted, 100 patients had IF and were included . Mean (SD) age of patients was 46.3 ± 16.1 years. Most common cause of IF was ECFs (32%), SBS (24%), and SBS + fistula (22%). Most common causes of SBS were mesenteric ischemia (63.3%) and repeated surgery (22.4%). Median (interquartile range [IQR]) duration of parenteral nutrition (PN) for patients was 32 (18-60) days. The most common reconstructive surgery performed was resection and anastomosis (75.4%), followed by serial transverse enteroplasty procedure (10.5%) and closure of ostoma (7%). Patients were hospitalized for a median (IQR) of 33 (17.5-61) days. Most common complications were sepsis (45%), catheter infections (43%), and catheter thrombosis (20%), respectively. At the final follow-up, 61% stopped receiving PN, 23% became candidates for transplantation, and 16% died. CONCLUSION Considering that most countries lack facilities for HPN, by establishing IRUs using specific treatment protocols and autologous gastrointestinal reconstruction techniques will provide a means to manage patients with IF, thus decreasing death rates and number of patients who require intestinal transplantations due to IF.
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Affiliation(s)
- Hamed Nikoupour
- Shiraz Transplant Center, Abu Ali Sina Hospital, Shiraz University of Medical Sciences, 7193711351, Shiraz, Iran
| | - Peyman Arasteh
- Shiraz Transplant Center, Abu Ali Sina Hospital, Shiraz University of Medical Sciences, 7193711351, Shiraz, Iran
| | - Alireza Shamsaeefar
- Shiraz Transplant Center, Abu Ali Sina Hospital, Shiraz University of Medical Sciences, 7193711351, Shiraz, Iran
| | - Fardin Ghanbari
- Shiraz Transplant Center, Abu Ali Sina Hospital, Shiraz University of Medical Sciences, 7193711351, Shiraz, Iran
| | - Arash Boorboor
- Shiraz Transplant Center, Abu Ali Sina Hospital, Shiraz University of Medical Sciences, 7193711351, Shiraz, Iran
| | | | - Mojtaba Shafiekhani
- Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Department of Clinical Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Pirouz Samidoust
- Razi Clinical Research Development Unit, Razi Hospital, Guilan University of Medical Sciences, Rasht, Iran
| | - Reza Shahriarirad
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Science, Shiraz, Iran.,Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Alireza Shojazadeh
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Keivan Ranjbar
- Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Science, Shiraz, Iran.,Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Sina Tangestanipour
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyed Morteza Hosseini
- Shiraz Transplant Center, Abu Ali Sina Hospital, Shiraz University of Medical Sciences, 7193711351, Shiraz, Iran
| | - Leila Zahiri
- Department of Internal Medicine, Shiraz University of Medical Science, Shiraz, Iran
| | - Saman Nikeghbalian
- Shiraz Transplant Center, Abu Ali Sina Hospital, Shiraz University of Medical Sciences, 7193711351, Shiraz, Iran
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Casey LM, Strauss J, Dhaliwal KK, Butterworth S, Piper HG, Albersheim SG. NeoCHIRP: A model for intestinal rehabilitation in the neonatal intensive care unit. Nutr Clin Pract 2021; 36:1320-1327. [PMID: 34270133 DOI: 10.1002/ncp.10734] [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: 11/09/2022] Open
Abstract
Multidisciplinary intestinal rehabilitation (IR) teams have transformed care in pediatric intestinal failure (IF).1 Although most children with IF are identified in the neonatal intensive care unit (NICU), IR teams may not be involved at this stage. We describe our collaborative model, blending NICU and IR expertise to optimize care. Over 6 years, the NeoCHIRP (Neonatal Children's IR Program) team followed 164 babies for weekly visits (median, 8; range, 1-27). Bedside rounds included CHIRP team physician and surgeons, neonatologist champion, attending neonatologist and fellow, NICU dietitian, bedside nurse, and family. Medical and nutrition status, nutrition history, and laboratory data were discussed, and a nutrition plan to support IR, considering the child's other medical needs, was created to guide the next week's management. Typical issues addressed included parenteral nutrition (PN) composition, enteral nutrition plan, oral feeding, management of small-intestinal bacterial overgrowth and sodium status, and cholestasis. A total of 164 babies were followed by the NeoCHIRP team. Of 153 survivors, IF resolved by discharge in 89% (136 of 153). Seventeen of 153 babies (11%) went on to require home PN and were transferred from NICU directly to the CHIRP team. By discharge, 99% of babies were orally fed (69/136, 50% fully, 67/136, 49% partially), and cholestasis improved or resolved in 80/105 (76%). Eleven babies (7%) died; four deaths were unrelated to IF, but in seven babies, IF was at least a contributing factor. In this high-risk cohort, most babies achieved good outcomes, and those who required longer-term IR transitioned smoothly to the CHIRP team.
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Affiliation(s)
- Linda M Casey
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, BC Children's Hospital/University of British Columbia, Vancouver, British Columbia, Canada
| | - Jaclyn Strauss
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, BC Children's Hospital/University of British Columbia, Vancouver, British Columbia, Canada.,Division of Pediatric Gastroenterology, Hepatology & Nutrition, University of Calgary, Calgary, Alberta, Canada
| | - Keerat K Dhaliwal
- Division of Neonatology, BC Women's Hospital and Health Centre/University of British Columbia, Vancouver, British Columbia, Canada
| | - Sonia Butterworth
- Division of Pediatric Surgery, BC Children's Hospital/University of British Columbia, Vancouver, British Columbia, Canada
| | - Hannah G Piper
- Division of Pediatric Surgery, BC Children's Hospital/University of British Columbia, Vancouver, British Columbia, Canada
| | - Susan G Albersheim
- Division of Neonatology, BC Women's Hospital and Health Centre/University of British Columbia, Vancouver, British Columbia, Canada
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10
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Neam VC, Faino A, O'Hara M, Wendel D, Horslen SP, Javid PJ. Prospective evaluation of the family's health-related quality of life in pediatric intestinal failure. JPEN J Parenter Enteral Nutr 2021; 46:652-659. [PMID: 34170551 DOI: 10.1002/jpen.2212] [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: 11/11/2022]
Abstract
BACKGROUND Due to altered nutrition regimens and complex medical needs, pediatric intestinal failure (IF) may have a powerful impact on health-related quality of life (HRQOL). Studies have shown that children with IF experience lower HRQOL. Data on the HRQOL of families of children with IF are lacking. METHODS We performed a prospective analysis of the HRQOL of families of children with IF in a regional intestinal rehabilitation program from 2011 to 2018. The Pediatric Quality of Life Family Impact Module (FIM) was administered annually to parents. FIM scores were regressed on risk factors using linear mixed-effect models that accounted for repeated surveys within families. RESULTS A total of 117 families completed 272 surveys. FIM scores increased with patient age across nearly all survey dimensions. Total FIM scores were lower when compared to families of healthy children (median differences = -5, P = .01) and similar to families of chronically ill children. While IF families reported major deficits in the Communication (-11, P < .001) and Worry (-17, P < .001) dimensions, they also reported higher Family Relationship scores (+7, P < .01). On multivariable regression, presence of a major comorbidity and four or more hospital admissions in the prior year were associated with lower family HRQOL (P < .05). Parenteral nutrition dependence was independently associated with lower scores in the Communication (-7, P = .03) and Daily Activities (-10, P = .02) dimensions. CONCLUSION Families of children with IF experience a decreased HRQOL that may improve with patient age. Intestinal rehabilitation programs should address the HRQOL of families in addition to patients.
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Affiliation(s)
| | - Anna Faino
- Seattle Children's Research Institute, Seattle, Washington, USA
| | | | - Danielle Wendel
- Seattle Children's Hospital, Seattle, Washington, USA.,University of Washington School of Medicine, Seattle, Washington, USA
| | - Simon P Horslen
- Seattle Children's Hospital, Seattle, Washington, USA.,University of Washington School of Medicine, Seattle, Washington, USA
| | - Patrick J Javid
- Seattle Children's Hospital, Seattle, Washington, USA.,University of Washington School of Medicine, Seattle, Washington, USA
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Prathapan KM, King DE, Raghu VK, Ackerman K, Presel T, Yaworski JA, Ganoza A, Bond G, Sevilla WMA, Rudolph JA, Alissa F. Megacystis Microcolon Intestinal Hypoperistalsis Syndrome: A Case Series With Long-term Follow-up and Prolonged Survival. J Pediatr Gastroenterol Nutr 2021; 72:e81-e85. [PMID: 33264186 PMCID: PMC9124153 DOI: 10.1097/mpg.0000000000003008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Describe clinical characteristics, management, and outcome in a cohort of megacystis microcolon intestinal hypoperistalsis syndrome (MMIHS) patients. METHODS We conducted a retrospective chart review of MMIHS patients followed at a large transplant and intestinal rehabilitation center over a period of 17 years. RESULTS We identified 25 patients with MMIHS (68% girls, 13 transplanted). One transplanted and 1 nontransplanted patient were lost to follow-up. We estimated 100, 100, and 86% for 5-, 10-, and 20-year survival, respectively, with only 1 death. Of the 22 patients alive at the time of study (11 transplanted, 11 nontransplanted), median age was 9.2 years (range 2.7-22.9 years). Longest posttransplant follow-up was 16 years. Seventeen patients had available prenatal imaging reports; all showed distended bladder. Eight had genetic testing (5, ACTG2; 2, MYH11; 1, MYL9). Almost all patients had normal growth with median weight z-score -0.77 (interquartile range -1.39 to 0.26), height z score -1.2 (-2.04 to -0.48) and body mass index z-score 0.23 (-0.37 to 0.93) with no statistical difference between transplanted and nontransplanted patients. All nontransplanted patients were on parenteral nutrition with minimal/no feeds, and all except 1 of the transplanted patients were on full enteral feeds. Recent average bilirubin, INR, albumin, and creatinine fell within the reference ranges. CONCLUSIONS This is the largest single-center case series with the longest duration of follow-up for MMIHS patients. In the current era of improved intestinal rehabilitation and transplantation, MMIHS patients have excellent outcomes in survival, growth, and liver function. This observation contradicts previous reports and should alter counselling and management decisions in these patients at diagnosis.
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Affiliation(s)
- Krishnapriya Marangattu Prathapan
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Dale E. King
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Vikram Kalathur Raghu
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Kimberly Ackerman
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Tracey Presel
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Jane Anne Yaworski
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Armando Ganoza
- Hillman Center for Pediatric Liver Transplantation, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Geoffrey Bond
- Hillman Center for Pediatric Liver Transplantation, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Wednesday Marie A. Sevilla
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Jeffrey A. Rudolph
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Feras Alissa
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, PA
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Yap JYK, Roberts AJ, Bines JE. Paediatric intestinal failure and transplantation. J Paediatr Child Health 2020; 56:1747-1753. [PMID: 33197983 DOI: 10.1111/jpc.15052] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 06/11/2020] [Accepted: 06/11/2020] [Indexed: 12/31/2022]
Abstract
Intestinal failure is a complex and debilitating condition characterised by inadequate small intestinal function requiring parenteral or intravenous nutrition to maintain health and, for children, to enable growth and development. Although parenteral nutrition can be prescribed in many hospitals, children with chronic intestinal failure have improved outcomes when managed at a paediatric centre by a multidisciplinary team with specialised expertise in the comprehensive management of intestinal failure. Recent advances in the medical, surgical and nutritional approach have been effective at optimising intestinal rehabilitation and achieving enteral autonomy while limiting complications of intestinal failure. The role of intestinal transplantation in the management of the child with intestinal failure continues to evolve as an option for children with life-threatening complications of intestinal failure. The aim of this review is to highlight key advances in the care of children with intestinal failure.
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Affiliation(s)
- Jason Y K Yap
- Department of Gastroenterology, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Amin J Roberts
- Department of Paediatric Gastroenterology, Starship Child Health University of Auckland and National Intestinal Failure and Rehabilitation Service, Auckland, New Zealand
| | - Julie E Bines
- Department of Gastroenterology, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Enteric Diseases Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
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13
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Raghu VK, Rudolph JA, Smith KJ. Cost-effectiveness of teduglutide in pediatric patients with short bowel syndrome: Markov modeling using traditional cost-effectiveness criteria. Am J Clin Nutr 2020; 113:172-178. [PMID: 33021637 PMCID: PMC9630124 DOI: 10.1093/ajcn/nqaa278] [Citation(s) in RCA: 7] [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] [Received: 04/23/2020] [Accepted: 09/07/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Teduglutide use in pediatric patients with short bowel syndrome can aid in the achievement of enteral autonomy, but with a price of >$400,000 per y. OBJECTIVE The current study evaluated the cost-effectiveness of using teduglutide in conjunction with offering intestinal transplantation in US pediatric patients with short bowel syndrome. DESIGN A Markov model was used to evaluate the costs (in US dollars) and effectiveness [in quality-adjusted life years (QALYs)] of using teduglutide compared with offering intestinal transplantation. Parameters were estimated from published data where available. The primary effect modeled was the probability of weaning from parenteral nutrition while on teduglutide. Sensitivity analyses were performed on all model parameters. RESULTS Compared with offering only intestinal transplantation, adding teduglutide cost ${\$}$124,353/QALY gained. Reducing the cost of the medication by 16% allowed the cost to reach the typical benchmark of ${\$}$100,000/QALY gained. Probabilistic sensitivity analysis favored transplantation without offering teduglutide in 68% of iterations at a ${\$}$100,000/QALY threshold. Never using teduglutide created an opportunity cost of over ${\$}$100,000 per patient. CONCLUSIONS At its current price, teduglutide does not provide a cost-effective addition to transplantation in the treatment of pediatric short bowel syndrome. Further work should look to identify cost-reducing strategies, including alternative dosing regimens.
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Affiliation(s)
| | - Jeffrey A Rudolph
- Departments of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Kenneth J Smith
- Departments of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
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14
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Galloway DP, Mathis MS, Wilkinson LT, Venick RS, Wendel D, Cole CR, Martin CA. Effect of the COVID-19 Pandemic on Pediatric Intestinal Failure Healthcare Delivery. JPEN J Parenter Enteral Nutr 2020; 45:50-56. [PMID: 32941671 DOI: 10.1002/jpen.2000] [Citation(s) in RCA: 6] [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] [Received: 07/17/2020] [Accepted: 08/18/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic has influenced how healthcare is being provided, particularly in patients whose diagnoses require multidisciplinary care, such as pediatric intestinal failure (IF). We sought to ascertain the effects of the COVID-19 pandemic on healthcare delivery for pediatric patients with IF. METHODS A 20-question survey was administered to members of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Intestinal Rehabilitation (IR) Special Interest Group. Input values were "yes" and "no," along with a free-text response. Following a 10-day open survey period, data were divided into cohorts based on patient population size and disease burden by state. Analysis was then performed using the χ2 test application. RESULTS Responses from 29 centers were included in analysis. Centers that followed >50 patients on parenteral nutrition (PN) were more likely to have social workers present in telemedicine visits and observed more central line difficulties among families. Centers located in states with <40,000 reported cases of COVID-19 saw patients less frequently and were more likely to withhold changes to PN prescriptions. Additionally, the survey revealed a significant degree of financial hardship and food insecurity among families. CONCLUSION Many aspects of pediatric IF healthcare delivery have been impacted by the COVID-19 pandemic, both for care providers and caregivers. Despite the availability of telemedicine, IR centers should remain attentive to the global needs of the pediatric IF patient, as well as their families.
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Affiliation(s)
- David P Galloway
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of Alabama at Birmingham, Alabama, Birmingham, USA
| | - Michelle S Mathis
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of Alabama at Birmingham, Alabama, Birmingham, USA
| | - Linda T Wilkinson
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of Alabama at Birmingham, Alabama, Birmingham, USA
| | - Robert S Venick
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, University of California at Los Angeles, California, Los Angeles, USA
| | - Danielle Wendel
- Division of Gastroenterology and Hepatology, Seattle Children's Hospital, University of Washington School of Medicine, Washington, Seattle, USA
| | - Conrad R Cole
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, College of Medicine, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, USA
| | - Colin A Martin
- Department of Surgery, Division of Pediatric Surgery, University of Alabama at Birmingham, Alabama, Birmingham, USA
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15
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Neam VC, Oron AP, Nair D, Edwards T, Horslen SP, Javid PJ. Factors Associated with Health-Related Quality of Life in Children with Intestinal Failure. J Pediatr 2020; 216:13-18.e1. [PMID: 31590945 DOI: 10.1016/j.jpeds.2019.08.049] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 08/20/2019] [Accepted: 08/26/2019] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To evaluate disease-specific and age-related factors contributing to health-related quality of life (HRQOL). in children with intestinal failure. STUDY DESIGN A prospective study of HRQOL was performed in a regional intestinal rehabilitation program. Parent-proxy Pediatric Quality of Life Inventory surveys were administered annually to families of 91 children with intestinal failure over a 6-year period. Survey data was stratified by age and compared with pediatric HRQOL data in healthy and chronically ill populations. Linear mixed-effect models using multivariable regression were constructed to identify associations with HRQOL. RESULTS A total of 180 surveys were completed by 91 children and their families. HRQOL scores were lowest for children ages 5-7 years (P < .001) and 8-12 years (P < .01), and these changes were primarily related to school dimension scores. In multivariable regression, age of 5 years and older and developmental delay were independently associated with lower HRQOL scores. The trend toward lower HRQOL scores parallels reference data from healthy and chronically ill children, although patients with intestinal failure scored lower than both populations at school age. CONCLUSIONS Children with intestinal failure experience lower parent-proxy HRQOL scores in the 5-7 and 8-12 year age groups primarily related to school dimension scores. Multicenter data to validate these findings and identify interventions to improve QOL for children with intestinal failure are needed.
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Affiliation(s)
| | | | | | - Todd Edwards
- University of Washington School of Public Health, Seattle, WA
| | - Simon P Horslen
- Seattle Children's Hospital, Seattle, WA; University of Washington School of Medicine, Seattle, WA
| | - Patrick J Javid
- Seattle Children's Hospital, Seattle, WA; University of Washington School of Medicine, Seattle, WA
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16
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Raghu VK, Binion DG, Smith KJ. Cost-effectiveness of teduglutide in adult patients with short bowel syndrome: Markov modeling using traditional cost-effectiveness criteria. Am J Clin Nutr 2020; 111:141-148. [PMID: 31665212 PMCID: PMC7307185 DOI: 10.1093/ajcn/nqz269] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [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: 07/26/2019] [Accepted: 10/03/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Adults with short bowel syndrome have a high mortality and significant morbidity due to unsuccessful attempts at rehabilitation that necessitate chronic use of parenteral nutrition (PN). Teduglutide is a novel therapy that promotes intestinal adaptation to improve rehabilitation but with a price >$400,000/y. OBJECTIVE The current study evaluated the cost-effectiveness of using teduglutide in US adult patients with short bowel syndrome. METHODS A Markov model evaluated the costs (in US dollars) and effectiveness (in quality-adjusted life years, or QALYs) of treatment compared with no teduglutide use, with a presumed starting age of 40 y. Parameters were obtained from published data or estimation. The primary effect modeled was the increased likelihood of reduced PN days per week when using teduglutide, leading to greater quality of life and lower PN costs. Sensitivity analyses were performed on all model parameters. RESULTS In the base scenario, teduglutide cost $949,910/QALY gained. In 1-way sensitivity analyses, only reducing teduglutide cost decreased the cost/QALY gained to below the typical threshold of $100,000/QALY gained. Specifically, teduglutide cost would need to be reduced by >65% for it to reach the threshold value. Probabilistic sensitivity analysis favored no teduglutide use in 80% of iterations at a $100,000/QALY threshold. However, teduglutide therapy was cost-saving in 13% of model iterations. CONCLUSIONS Teduglutide does not meet a traditional cost-effectiveness threshold as treatment for PN reduction in adult patients with short bowel syndrome compared with standard intestinal rehabilitation. Subpopulations that demonstrate maximum benefit could be cost-saving, and complete nonuse could lead to financial loss. Teduglutide becomes economically reasonable only if its cost is substantially reduced.
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Affiliation(s)
- Vikram K Raghu
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA,Address correspondence to VKR (e-mail: )
| | - David G Binion
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Kenneth J Smith
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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17
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Harvie ML, Norris MAT, Sevilla WMA. Soluble Fiber Use in Pediatric Short Bowel Syndrome: A Survey on Prevailing Practices. Nutr Clin Pract 2018; 33:539-544. [PMID: 29767462 DOI: 10.1002/ncp.10089] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND In pediatric short bowel syndrome (SBS), adding fiber to enteral feedings is 1 treatment method to manage increased stool output. However, there are no standardized recommendations on the use of fiber in this setting, including type, dosage, titration strategies, etc. OBJECTIVE: The aim of this study is to determine current prevailing practices on the use of fiber in the treatment of chronic high stool output in the pediatric SBS population. METHODS An anonymous electronic survey with 13 questions was sent through health professional electronic mailing lists. The survey was completed by healthcare professionals including physicians (primary care, subspecialists, and surgeons), nurse practitioners, and registered dietitians. RESULTS A total of 94 responses were received. The most common supplemental fiber used was pectin (62.8%). The 2 major factors considered when initiating fiber therapy were consistency of stool (74.5%) and volume of stool output (85.1%). The major factor that determined discontinuation of fiber was abdominal distention (67%). A majority of providers waited 2 weeks or less to see improvement following fiber initiation before discontinuing it. CONCLUSIONS The goal of the survey was to gather more information with regard to fiber use in the management of SBS patients. The data collected can be used to provide future direction on determining best practices for fiber use in SBS patients.
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Affiliation(s)
- Meredith Linley Harvie
- University of Tennessee Health Sciences Center, Department of Pediatrics, Memphis, Tennessee, USA
| | | | - Wednesday Marie A Sevilla
- Children's Hospital of Pittsburgh, Division of Pediatric Gastroenterology, Hepatology and Nutrition, Pittsburgh, Pennsylvania, USA
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18
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Groen H, Neelis EG, Poley MJ, Olieman JF, Scheenstra R, Krabbe PF, Dijkstra G, Rings EH. Intestinal rehabilitation for children with intestinal failure is cost-effective: a simulation study. Am J Clin Nutr 2017; 105:417-425. [PMID: 28052886 DOI: 10.3945/ajcn.116.135160] [Citation(s) in RCA: 12] [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: 04/09/2016] [Accepted: 11/29/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Children with intestinal failure (IF) depend on parenteral nutrition (PN). The goal in the treatment of IF is to wean children off PN through intestinal rehabilitation (IR). Although the healthcare burden of IF is enormous, to our knowledge there has been no previous cost-effectiveness analysis in pediatric IF including IR. OBJECTIVE We sought to determine the cost-effectiveness of IR in terms of costs and life-years. DESIGN We simulated the treatment of IF in children in a discrete-event model. Data for this model were derived from patient records, the Dutch Registry of Intestinal Failure and Transplantation, the Intestinal Transplant Registry, and the literature. The time horizon of the model was 40 y. Simulated patients were enrolled at a rate of 40 patients/mo for 10 y. Actual costs were calculated for hospital admissions, surgical interventions, endoscopies, PN, and immunosuppressive medication. We evaluated the cost-effectiveness of IR by comparing 1 scenario with IR with 1 scenario without IR. In the scenario with IR, a proportion of patients who represented those with the ability to wean off PN were assigned to IR. In the scenario without IR, all patients progressed to home PN (HPN). In both scenarios, a proportion of patients receiving HPN were eventually eligible for an intestinal transplantation. RESULTS IR prolonged survival; the mean number of life-years per patient was 19.4 in the scenario with IR compared with 18.2 in the scenario without IR. Average total costs per patient were €819,292 in the scenario with IR compared with €1,176,830 in the scenario without IR (equivalent to 1,129,230 US$ and 1,622,025 US$, respectively, in January 2014); costs mainly included hospital admissions and PN. CONCLUSIONS On the basis of our simulations, we concluded that IR improved the survival of children with IF and was associated with cost savings. Therefore, we consider IR to be a cost-effective treatment for children with IF.
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Affiliation(s)
| | | | - Marten J Poley
- Pediatric Surgery, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, Netherlands.,Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Joanne F Olieman
- Pediatric Surgery, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, Netherlands.,Department of Dietetics, Erasmus Medical Center, Rotterdam, Netherlands
| | - René Scheenstra
- Department of Pediatric Gastroenterology, University of Groningen, University Medical Center Groningen-Beatrix Children's Hospital, Groningen, Netherlands; and
| | | | - Gerard Dijkstra
- Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Edmond Hhm Rings
- Departments of Pediatric Gastroenterology and.,Department of Pediatrics, Leiden University Medical Center-Willem Alexander Children's Hospital, Leiden, Netherlands
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19
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Goodhue CJ, Demeter NE, Burke RV, Toor KT, Upperman JS, Merritt RJ. Mixed-Methods Pilot Study: Disaster Preparedness of Families With Children Followed in an Intestinal Rehabilitation Clinic. Nutr Clin Pract 2015; 31:257-65. [PMID: 26449891 DOI: 10.1177/0884533615605828] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [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: 01/09/2023] Open
Abstract
BACKGROUND Children with special healthcare needs are a vulnerable population in disasters. Special-needs families tend to be less prepared for a disaster than the general public. The purpose of this pilot project was to examine the disaster preparedness levels of families in an intestinal rehabilitation (IR) clinic. MATERIALS AND METHODS We administered an anonymous survey to a convenience sample of IR clinic families and conducted 2 focus groups. Descriptive analyses were used for survey data; Atlas.ti was used to analyze focus group data. RESULTS Survey findings revealed that 69% of families lacked an emergency supply kit, and 93% did not have a clinician-completed emergency information form. On a scale of 1-10, the mean confidence in their family's disaster preparations was 4.9. The overarching theme from focus group discussions was challenges and/or barriers to disaster preparedness. CONCLUSION IR clinic families are generally unprepared for a disaster. These findings are highly relevant to our goal of developing a disaster survival toolkit for the IR families. Toolkits are being distributed in the IR clinic.
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Affiliation(s)
- Catherine J Goodhue
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Natalie E Demeter
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Rita V Burke
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California Keck School of Medicine, University of Southern California, California
| | - Khadija T Toor
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital Los Angeles, Los Angeles, California
| | - Jeffrey S Upperman
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California Keck School of Medicine, University of Southern California, California
| | - Russell J Merritt
- Keck School of Medicine, University of Southern California, California Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital Los Angeles, Los Angeles, California
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20
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Abstract
A primary goal of intestinal rehabilitation programs is to facilitate intestinal adaptation. Adult patients with short bowel syndrome (SBS) who are dependent on parenteral nutrition and/or intravenous fluid (PN/IV) support have 2 hormonal pharmacologic treatment options available that may promote intestinal growth: a glucagon-like peptide 2 analog (teduglutide) and recombinant human growth hormone (somatropin). In two phase III clinical trials (N=169), 24 weeks of teduglutide administered to outpatients with SBS resulted in significant decreases in PN/IV volume requirements of 2.5-4.4 L/wk. In an extension study of one of these trials, patients with SBS who completed 30 months of teduglutide experienced a mean PN/IV reduction of 7.6 L/wk from baseline. Furthermore, some patients achieved independence from PN/IV support. The most common adverse events associated with teduglutide treatment in clinical trials were gastrointestinal symptoms, including abdominal distension, abdominal pain, and nausea. This safety profile is consistent with the associated underlying diseases leading to SBS or the known mechanism of action of teduglutide. A single phase III study (N=41) evaluated the safety and efficacy of a 4-week inpatient course of somatropin in combination with a glutamine-supplemented diet for adults with SBS. Somatropin treatment significantly reduced parenteral support requirements by 1.1 L/d in these patients. The most common adverse events were peripheral edema and musculoskeletal events. Large-scale, long-term follow-up studies of somatropin for SBS have not been conducted. Although treatment for patients with SBS must be individualized, teduglutide and somatropin are positive extensions to existing fluid and nutrient management strategies.
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Affiliation(s)
- Palle B Jeppesen
- Department of Medical Gastroenterology, Rigshospitalet, Copenhagen, Denmark
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21
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Abstract
Short bowel syndrome (SBS) is the most common cause of intestinal failure in infants. In neonates and young infants, necrotizing enterocolitis, gastroschisis, intestinal atresia, and intestinal malrotation/volvulus are the leading causes of SBS. Following an acute postsurgical phase, the residual gastrointestinal tract adapts with reorganization of the crypt-villus histoarchitecture and functional changes in nutrient absorption and motility. A cohesive, multidisciplinary approach can allow most neonates with SBS to transition to full enteral feeds and achieve normal growth and development. In this article, the clinical features, management, complications, and prognostic factors in SBS are reviewed.
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