Parenteral nutrition-related complications in older patients with acute intestinal failure: A descriptive cohort study.

INTRODUCTION: Reported outcomes for parenteral nutrition (PN)-related complications in older adult patients with acute intestinal failure who are receiving PN in the acute hospital setting are limited. Our study aims to compare PN-related complications between older and younger adult patients. METHODS: A retrospective descriptive study of inpatients who were administered PN from January 1, 2019, to December 31, 2019, was performed. Patients were categorized into older (≥65 years old) and younger (<65 years old) adult groups. RESULTS: Two hundred thirty-five patients were included. There were 103 patients in the older adult group (mean age: 73.9 [SD: 6.9] years) and 132 patients in the younger adult group (mean age: 52.4 [SD: 12.5] years). There was a significantly higher Charlson Comorbidity Index score and lower Karnofsky score in the older adult group. The older adult group received significantly lower total energy (20.8 [SD: 7.8] vs 22.8 [SD: 6.3] kcal/kg/day), dextrose (3.1 [SD: 1.4] vs 3.6 [SD: 1.4] g/kg/day), and protein (1.1 [SD: 0.4] vs 1.2 [SD: 0.3] g/kg/day) than the younger group received. The mean length of stay was significantly shorter in the older adult group (35.9 [SD: 21.3] vs 59.8 [SD: 55.3]; P < 0.05). There was no significant difference in PN-related complications and clinical outcomes (catheter-related bloodstream infections, hypoglycemia or hyperglycemia, fluid overload, or inpatient mortality) between the two groups. CONCLUSION: Despite more comorbidities in the older adult, the usage of PN in older adult patients with acute intestinal failure was associated with neither an increased rate of PN-related complications nor worse clinical outcomes when compared with that of younger patients.

Approximately 1 in 10 ambulatory inflammatory bowel disease patients are at risk of malnutrition: A prospective Singapore cohort.

OBJECTIVES: Prevalence of malnutrition among ambulatory inflammatory bowel disease (IBD) patients in Singapore is unknown. We aimed to evaluate the prevalence of ambulatory IBD patients at risk of malnutrition (ARMN) using Malnutrition Universal Screening Tool (MUST) and its clinical outcomes. METHODS: IBD patients were recruited from March to June 2018 and followed up for 6 months. ARMN patients were defined as having a MUST score of 2 or more compared with those not at risk (non-ARMN). RESULTS: Altogether 217 patients were recruited, including 128 (59.0%) with ulcerative colitis (UC) and 89 (41.0%) with Crohn's disease (CD). The mean body mass index (BMI) was 23.5 ± 4.5 kg/m2 ; 35 (16.1%) patients were on biologics, and 52 (24.0%) were on steroids. Among them 25 (11.5%) patients were ARMN, with a predominance of UC (n = 15, 60.0%). The majority of ARMN patients were underweight (n = 23, 92.0%) while 114 (59.4%) non-ARMN patients were overweight. ARMN patients had a significantly lower albumin (38.3 g/L vs 41.9 g/L) and a significantly increased proportion of patients with C-reactive protein ≥5 mg/L (36.0% vs 19.3%). There was a trend towards longer hospital stay among ARMN patients, although this was not statistically significant. Use of biologics or immunomodulators and albumin levels were associated with being ARMN. CONCLUSION: Using MUST, 11.5% of our ambulatory IBD patients in Singapore were identified to be ARMN. Among ARMN patients, a trend was demonstrated towards a longer hospital stays for admitted patients. This underscores the need to actively screen ambulatory IBD patients for malnutrition.

The use of standardized commercially available parenteral nutrition as a bridge to customized compounded bag in the acute hospital setting is safe and feasible.

BACKGROUND & AIMS: The use of standardized commercially available parenteral nutrition (SCAPN) as a starter bag to bridge to customized compounded PN offers the advantage of starting PN on the same day of consult, avoiding delays in nutrition delivery. We aim to evaluate the safety and feasibility of using SCAPN as a bridge to compounded PN in the acute hospital setting. METHODS: Retrospective review of patients on PN from Aug 2018 to Sep 2019 was performed. SMOFKABIVEN® Peripheral 800 kcal in 1206 ml was used. Electrolyte replacements on the day and the day after PN commencement were compared between SCAPN and compounded PN. Results were reported as means (95% confidence intervals). P value < 0.05 was considered statistically significant. RESULTS: 135 (78.5%) patients received SCAPN while 37 (21.5%) received compounded PN on the first day of PN. Baseline characteristics of both groups were almost similar with higher BMI in the SCAPN. Baseline serum potassium 4.0 (3.9, 4.1) vs 4.0 (3.8, 4.1), p = 0.46; phosphate 1.1 (1.0, 1.1) vs 1.1 (1.0, 1.3), p = 0.40 and magnesium 0.8 (0.8, 0.9) vs 0.9 (0.9, 1.0), p < 0.05 for SCAPN and compounded PN respectively. Follow-up serum potassium was 3.9 (3.8, 3.9) vs 3.9 (3.8, 4.1), p = 0.36; phosphate 0.9 (0.9, 0.9) vs 1.1 (1.0, 1.2), p < 0.05 and magnesium 0.9 (0.9, 0.9) vs 0.9 (0.9, 1.0), p = 0.18. Baseline calories and protein were lower in SCAPN group. Electrolyte replacements were similar in both groups at baseline and follow up. CONCLUSION: Using our in-house protocol, the use of a SCAPN as a bridge to customized compounded PN is safe and feasible.

Immunoglobulin G in non-alcoholic steatohepatitis predicts clinical outcome: A prospective multi-centre cohort study.

BACKGROUND: Autoimmune markers including plasma cells (PC), anti-smooth-muscle antibody (ASMA), anti-nuclear antibody (ANA), and raised immunoglobulin G (IgG) are commonly observed in non-alcoholic steatohepatitis (NASH), however their clinical significance is unknown. AIM: To determine if autoimmune markers in NASH patients are independently associated with poorer clinical outcomes. METHODS: Consecutive patients with biopsy proven NASH from Christchurch Hospital, New Zealand and Singapore General Hospital (SGH) were included between 2005 to 2016 in a prospective multi-centre cohort study. Patients with other causes of chronic liver disease were excluded. IgG > 14 g/L or globulin fraction > 50%, ANA ≥ 1:40, SMA ≥ 1:40 were considered positive. Multivariate analysis was performed to assess which markers were independently associated with mortality and hepatic decompensation. RESULTS: Total 261 patients were included of which 201 were from SGH. The median age was 53 and 51.9% were male. Advanced fibrosis was present in 31.4% at diagnosis. PC, ASMA, ANA and raised IgG were observed in 13.1%, 4.9%, 27.8% and 30.1% of patients respectively. After multivariate analysis, elevated IgG [Hazard Ratio (HR) 6.79, 95%CI: 2.93-17.15] and fibrosis stage (HR 1.37, 95%CI: 1.03-1.87) were found to be independently associated with increased risk of liver decompensation. Age (HR 1.06, 95%CI: 1.02-1.10) and elevated IgG (HR 3.79, 95%CI: 1.90-7.68) were independent factors associated with higher mortality risk. CONCLUSION: Elevated IgG, rather than ANA, ASMA or plasma cells, is independently associated with increased risk of hepatic decompensation and mortality in NASH. It could hence be important for prognostication.

Modified minimal-contact COVID-19 workflow allows for safe, remote parenteral nutrition prescribing in non-critically ill patients.

BACKGROUND: In line with recent guidance from the American Society for Parenteral and Enteral Nutrition (ASPEN) and the European Society for Clinical Nutrition and Metabolism (ESPEN) to minimize healthcare team exposure by clustering care and relying on other providers or telehealth to collect relevant nutrition assessments, our nutrition support team has adopted a modified workflow using information technology to provide parenteral nutrition (PN) remotely in a safe and timely manner. We aim to compare our prescribing adequacy and PN-related complications before and during the coronavirus disease 2019 (COVID-19) outbreak using the modified workflow in non-critically ill patients. METHODS: This study reviewed a prospectively recruited cohort of adults receiving PN in the general wards or high-dependency units from December 5, 2019, to April 15, 2020. Demographic data, nutrition assessment, PN prescriptions, blood results, electronic notes, capillary blood glucose monitoring, and catheter-related bloodstream infection rates were reviewed for patients who received PN. RESULTS: We found that patients who started PN during COVID-19 were more malnourished with lower body mass index and higher proportion of Subjective Global Assessment B/C scores (52 [92.9%] vs 36 [73.5%], P < .005). The proportion of patients who achieved target energy amounts within 5 days was similar in both groups. Protein prescription was >1 g/kg/day in both groups, though there was a trend of higher protein prescription during COVID-19. Complications were similar in both groups. CONCLUSION: Our study demonstrates that minimal contact with effective multidisciplinary communication using the modified workflow can allow for safe and timely PN administration.

Clinical profile of non-alcoholic fatty liver disease in nonobese patients.

BACKGROUND AND AIM: Non-alcoholic fatty liver disease (NAFLD) is associated with metabolic syndrome. Worryingly, it has been increasingly reported among nonobese patients. This study aims to analyse patient characteristics of biopsy-proven NAFLD in an Asian cohort and explore differences stratified by body mass index (BMI). METHODS: Clinical, laboratory, and histological data were collected from 263 adults with biopsy-proven NAFLD. Patients with and without obesity (BMI cut-off 25) were compared. The ability to predict advanced liver fibrosis with three non-invasive scores, the NAFLD Fibrosis score (NFS), Fibrosis-4 (FIB4), and the aspartate aminotransferase to platelet ratio index (APRI), was compared. RESULTS: Obese subjects had a lower mean age (49.5 ± 12.5 vs 54.0 ± 12.9 years, P = 0.017), a higher prevalence of diabetes (52.4% vs 36.8%, P = 0.037), and a higher waist circumference (113.9 ± 16.0 cm vs 87.0 ± 18.4 cm, P = 0.022). The prevalence of dyslipidaemia (68.0% vs 61.4%, P = 0.353) and hypertension (61.7% vs 49.1%, P = 0.190) was comparable between the two groups. The distribution of non-alcoholic steatohepatitis (NASH) (63.1% versus 61.4%, P = 0.710) and advanced fibrosis (31.6% versus 26.3%, P = 0.447) were also similar in both groups. All three non-invasive scores (NFS, FIB4, and APRI) performed poorly in predicting advanced fibrosis in nonobese patients with NAFLD. The FIB4 was the most accurate non-invasive score in predicting advanced fibrosis in the obese group. CONCLUSIONS: Obese and nonobese patients are equally at risk of NASH and advanced fibrosis. While the FIB4 is the most accurate non-invasive score in predicting advanced fibrosis among obese individuals, further research is warranted to develop a nonobese specific score to correctly identify nonobese NAFLD patients with advanced fibrosis.