Direct costs of a home parenteral nutrition programme

BACKGROUND & AIMS

Home parenteral nutrition (HPN) is a lifesaving treatment for people with chronic intestinal failure and its cost has been reported to be very high. The purpose of the present paper was to study the direct healthcare and non-healthcare costs associated with the HPN programme managed by a tertiary hospital.

METHODS

Observational, retrospective study of all adult patients on HPN from 11.1.2014 to 10.31.2015 treated at Gregorio Marañón University Hospital (Madrid, Spain). An economic evaluation was undertaken to calculate the direct healthcare (HPN provision, outpatient monitoring and management of complications) and non-healthcare costs (transportation process) of the HPN programme. The variables were collected from medical records, the dispensary and the hospital's financial services. The unit costs were taken from official price lists.

RESULTS

Thirty-two patients met the inclusion criteria. Total direct healthcare and non-healthcare costs amounted to €13,363.53 per patient (€124.02 per patient per day). The direct healthcare costs accounted for 98.32% of overall costs, while the non-healthcare costs accounted for the remaining 1.68%. HPN provision accounted for the majority of the costs (74.25%), followed by management of complications (21.85%) and outpatient monitoring (2.23%).

CONCLUSIONS

The direct healthcare costs accounted for the majority of HPN expenditure, specifically HPN provision was the category with the highest percentage.

[Nutritional support in chronic neurological diseases]

Malnutrition is common in neurodegenerative disorders and is associated with a worse prognosis and an increased risk of complications. Factors leading to malnutrition in these patients are: diseased nutrient intake, due to anorexia, dysphagia and other factors, gastrointestinal symptoms, and energy expenditure alterations. Nutritional evaluation and monitoring is mandatory and should be part of regular clinical evaluation. It will help to identify those patients that need specialized nutritional support. In this paper, relevant aspects regarding nutritional evaluation and support in patients suffering from a neurodegenerative disorder are reviewed, including amyotrophic lateral sclerosis, multiple sclerosis, Parkinson's disease and dementia.

Effect of a mixture of inulin and fructo-oligosaccharide on Lactobacillus and Bifidobacterium intestinal microbiota of patients receiving radiotherapy: a randomised, double-blind, placebo-controlled trial

BACKGROUND & AIMS

The pathogenesis of enteritis after abdominal radiotherapy is unknown, although changes in faecal microbiota may be involved. In several studies, Lactobacillus and Bifidobacterium have proven beneficial for the host. Prebiotics stimulate the proliferation of Lactobacillus and Bifidobacterium, and this may have positive effects on the intestinal mucosa during abdominal radiotherapy.

METHODS

We performed a randomised double-blind, placebo-controlled trial including 31 patients with gynaecological cancer who received radiotherapy (29 sessions, 52.2 Gy) after surgery. Patients were randomised to two groups: prebiotic and placebo. The first group received a mixture of fibre (50% inulin and 50% fructo-oligosaccharide) and the second received 6 g of maltodextrin twice daily from one week before to three weeks after radiotherapy. Lactobacillus and Bifidobacterium counts were determined in faeces samples (day -7 before radiotherapy, day 15 of radiotherapy, at the end of treatment, and three weeks after radiotherapy) by culture in selective media and fluorescent in situ hybridization (FISH) using genus-specific probes. Bacterial counts by FISH were significantly higher than by culture method.

RESULTS

There were no differences in baseline microbiota between groups. At the end of radiotherapy, we observed a statistically significant decrease in Lactobacillus and Bifidobacterium counts in both groups. By cultural analysis, we observed higher numbers of Lactobacillus and Bifidobacterium three weeks after radiotherapy in the prebiotic group (5.6 vs. 6.3, p = 0.04 and 5.5 vs. 6 log cfu/g, p = 0.03).

CONCLUSIONS

Abdominal radiotherapy negatively affects Lactobacillus and Bifidobacterium counts. The prebiotic mixture of inulin and fructoligosaccharide can improve the recovery of both genera after radiotherapy. Registered under ClinicalTrials.gov Identifier no. NCT01549782.

Comparison of four nutritional screening tools to detect nutritional risk in hospitalized patients: a multicentre study

BACKGROUND/OBJECTIVES

The prevalence of malnutrition in hospitals is high. No nutritional screening tool is considered the gold standard for identifying nutritional risk. The aims of this study were to evaluate nutritional risk in hospitalized patients using four nutritional screening tools.

SUBJECTS/METHODS

Four nutritional screening tools were evaluated: nutritional risk screening (NRS-2002), the malnutrition universal screening tool (MUST), the subjective global assessment (SGA) and the mini nutritional assessment (MNA). Patients were assessed within the first 36 h after hospital admission. Date of admission, diagnosis, complications and date of discharge were collected. To compare the tools, the results were reorganized into: patients at risk and patients with a good nutritional status. The statistical analysis included the χ(2)-test to assess differences between the tests and the κ statistic to assess agreement between the tests.

RESULTS

The study sample comprised 400 patients (159 women, 241 men), mean age 67.3 (16.1) years. The prevalence of patients at nutritional risk with the NRS-2002, MUST, SGA and MNA was 34.5, 31.5, 35.3 and 58.5%, respectively. Statistically significant differences were observed between the four nutritional screening tools (P<0.001). The agreement between the tools was quite good except for the MNA (MNA-SGA κ=0.491, NRS-2002-SGA κ=0.620 and MUST-SGA κ=0.635). Patients at nutritional risk developed more complications during admission and had an increased length of stay.

CONCLUSIONS

The prevalence of nutritional risk in hospitalized patients was high with all the tools used. The best agreement between the tools was for NRS-2002 with SGA and MUST with SGA. At admission, NRS-2002 and MUST should be used to screen for nutritional status.

Atrophy of the intestinal villi in a post-gastrectomy patient with severe iron deficiency anemia

BACKGROUND & AIMS

Iron deficiency anemia is a common complication of gastric surgery that in certain patients can be refractory to treatment with oral iron and needs to be treated parenterally.

METHODS

A 48-year woman underwent gastric surgery for a gastric ulcer. She was referred to the nutrition unit for the study and treatment of a 3-year iron deficiency anemia refractory to oral iron supplementation. Blood tests, endoscopy and jejunal biopsy were made to study the case.

RESULTS

Intestinal villi atrophy in the absence of celiac disease was the result. She was treated with intravenous iron, resolving the villous atrophy and thus oral iron supplementation could be effective.

CONCLUSION

This case illustrates that iron deficiency may cause villous atrophy. In this setting, parenteral iron administration is necessary to correct the haematological and non-hematological alterations associated with this deficiency.

[Sea-blue histiocyte syndrome associated with home parenteral nutrition]

A case of a 55 years-old male with long-term Crohn's disease without response to medical treatment and many intestinal fistula is presented. After the last bowel resection, home parenteral nutrition was started. He presented chronic hepatopathy and pancytopaenia. After 9 months of home parenteral nutrition hepatic function and pancytopaenia began to deteriorate. Bone marrow examination revealed an infiltrate of sea-blue histiocytes. He made unsatisfactory progress and died due to a multiorganic failure.

[Gastric surgery as a nutritional risk factor]

BACKGROUND

The stomach has a role in the digestion and absorption of nutrients, so patients are in nutritional risk after gastric resection. The aim of this work was to study the nutritional status of postgastrectomy outpatients followed in our hospital.

METHODS

We retrospectively studied 54 patients (27 M, 27 F) followed more than 12 months postgastrectomy. Mean age was 61 +/- 14 yr and median follow-up was 35 months. The nutritional assessment included anthropometry, biochemical data and measurement of bone mineral density by dual-energy X-ray absorptiometry. The statistical analysis was performed by non-parametric tests.

RESULTS

Malignancy was the most frequent indication (85%), 63% of patients had total gastrectomy. Patients were supplemented with iron (43%), B12 (87%), calcium (18%) and vitamin D (17%). 13% of patients had a BMI < 18.5. The incidence of 25 OH vitamin D deficiency and secondary hyperparathyroidism was 45% and 76%, respectively. The incidence of osteoporosis at lumbar spine was 46%. Matched with same age-sex people patients had 85.6% of bone mineral density.

CONCLUSIONS

The loss of weight and the metabolic bone disease were the most prevalent impairments after gastric resection. These impairments point to the importance of a nutritional surveillance of patients after gastric resection.

How accurate are predictive formulas calculating energy expenditure in adolescent patients with anorexia nervosa?

BACKGROUND & AIMS

To compare resting energy expenditure, measured by indirect calorimetry, to values estimated by different predictive formulas in adolescent patients with anorexia nervosa.

METHODS

We studied 22 female in-patients with a mean age of 14.7 years (SD 1.2). Resting energy expenditure was measured by indirect calorimetry (Deltatrac II MBM-200). We compared measured resting energy expenditure to values estimated by several predictive formulas [Fleisch, Harris-Benedict, FAO, Schofield-HW, Schebendach] using the intraclass correlation coefficient and the Bland-Altman method.

RESULTS

Body mass index increased significantly (P<0.001). Measured resting energy expenditure increased during hospitalization (P<0.05). All formulas overestimated resting energy expenditure with respect to indirect calorimetry except the Schebendach formula. The intraclass correlation between indirect calorimetry and the formulas were poor (0.09-0.20). We observed a poor clinical agreement (Bland-Altman).

CONCLUSIONS

Body mass index and resting energy expenditure increased during hospitalization. The majority of the predictive formulas overestimate resting energy expenditure in adolescent patients with anorexia nervosa. Therefore, indirect calorimetry may be a very useful tool for calculating caloric requirements in these patients.

[Osteoporosis and inflammatory bowel disease]

Inflammatory bowel disease is a chronic disease with an unknown ethiology although multiple factors intervene such as individual, genetic and immunologic susceptibility, as well as different environmental factors. Like other multisystemic diseases, its clinical manifestations are diverse and it may affect other organs besides the gastrointestinal tract. In the last few years there is a growing interest for one of these extraintestinal manifestations, osteoporosis and osteopenia that may affect up to 42% of patients and can condition an important increase in morbility. Inactivity, prolonged corticosteroid treatment, nutritional deficiencies and the disease per se have an important role in the development of this complication. This article reviews clinical and ethiological aspects of inflammatory bowel disease associated osteoporosis and offers a strategy for diagnosis and treatment.

[Long-term follow-up of home parenteral nutrition at a general hospital: complications and quality of life]

OBJECTIVE

The present study assesses the septic, thrombotic and hepatic complications and also the quality of life of patients with home parenteral nutrition (NPD in its Spanish acronym).

METHODS

The case histories of patients treated with NPD at our hospital were collected for the period January, 1986, to January, 2001. We had 20 patients, mean age 48 +/- 14 years (mean +/- SD), with a total catheterization time of 16,292 days. The main causes of intestinal failure were mesenteric ischaemia and radical enteritis. Quality of life was assessed by means of the Sickness Impact Profile (SIP) and the Karnofsky Index (KI).

RESULTS

We found a catheter infection rate of 0.42 per 100 days of catheter, mostly produced by coagulase-negative staphylococci (63%). In 30% of the cases, it was necessary to remove the catheter, including in all cases produced by Candida. Cather occlusion rate was 0.05 per 100 days. Five patients presented an increase in transaminases and alkaline phosphatase, and one female patient developed cholestasis. Two patients died of NPD-related causes. The results of the quality of life analysis showed it was moderately affected, with SIP scores of 14.6 +/- 3.5 and KI results of 70 +/- 20 (mean +/- SD).

CONCLUSIONS

Home parenteral nutrition allows a greater survival in cases of intestinal failure. The most frequent complication is an infection of the catheter. The results of the quality of life analysis in our series reveal it was moderately affected in most cases.

Nutritional support in chronic renal failure: systematic review

BACKGROUND AND AIMS

The purpose of this systematic review was to locate and assess in patients with chronic renal disease the quality of scientific evidence to establish graded recommendations based on the efficacy and effectiveness of nutritional support.

METHODS

Computerized and online versions of MEDLINE (from 1989 through March 1999) and EMBASE (from 1988 through January 1999) were consulted. The Cochrane Library and the online Healthstar (from 1975) databases were also searched for clinical trials. A total of 593 studies were assessed. Following methodological review (primary reviewer), only 45 studies reviewed met criteria for selection and were analyzed by a group of experts (secondary reviewer). A final consensus was reached between the co-ordinators, experts and methodologists.

RESULTS AND CONCLUSIONS

Low and very low-protein diets associated with specific enteral supplements are indicated in most patients with chronic renal disease and in patients with incipient diabetic nephropathy to slow progression of disease and to improve their overall status, contributing to improved survival (grade A recommendation). The use of protein-restricted diets in diabetic nephropathy is only indicated in type I diabetes mellitus (grade A recommendation). An improvement in nutritional parameters was found when specific diets were given in chronic renal disease (grade C recommendation).

[Response of prolactin to thyrotrophin-RH(TRH) and chlorpromazine stimulation in the syndrome of hypogonadism and anosmia (author's transl)]

Basal and stimulatory tests of FSH, LH and PRL are reported in three cases of hypogonadism-anosmia syndrome (Maestre-Kallmann-De Morsier syndrome), two of whom were brothers. Basal FSH levels were low (mean = 1.7 mU/ml) and did not respond to the first acute stimulation with intravenous LRH (x = 2.3 mU/ml), but after intramuscular LRH, 500 microgram/day for 10 days, a clear-cut response was noted in two patients (from a mean of 7.8 mU/ml to 16.8 mU/ml), while the other patient continued without response. Low basal LH levels (mean 1.8 mU/ml) responded poorly to the first LRH stimulation (mean 4.6 mU/ml), while after intramuscular LRH for 10 days there was a marked increase in all three cases (mean 29.7 mU/ml). In no case was there a response to clomiphene. With regard to PRL, all cases had a clear response to TRH, although it was subnormal in two of them. Opposite results were obtained in one case of Klinefelter's syndrome, namely, elevated basal PRL levels (44 ng/ml) with an exaggerated response to TRH. Chlorpromazine administration caused an elevation of PRL to 43 and 30 ng/ml, respectively, in the two patients with a subnormal response to TRH, while the third case responded less than to TRH. In conclusion, the response to TRH of FSH and LH with lack of response to clomiphene supports the hypothalamic nature of the hypogonadism, while the response of PRL to both TRH and chlorpromazine, along with the normal levels of the remaining pituitary hormones (ACTH, TSH and STH) demonstrate the selectivity of the hypothalamic lesion whereby only gonadotrophin control is impaired.

No inhibition of corticotrophin (ACTH)-hypersecretion in adrenal insufficiency by somatostatin

Somatostatin (250 micrograms as a bolus iv and 250 micrograms as a 1 h infusion) was administered to 6 patients with primary adrenal insufficiency (Addison's disease). The fall in plasma ACTH during the infusion period ranged between 0-30% with a mean reduction of 11.2 +/- 11.6%. These findings suggest that with the method employed, somatostatin is not an inhibitor of ACTH secretion in a condition in which glucocorticoids are lacking.