Comprehensive outcomes after Roux-en-Y gastric bypass with a near-complete 15-year follow-up.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass has a well-established safety and efficacy profile in the short and mid-term. Long-term outcomes remain limited in the literature, especially for follow-up periods of >10 years. The purpose of the study is to evaluate the long-term durability and safety of laparoscopic Roux-en-Y gastric bypass over a near-complete 15-year follow-up. METHODS: This is a single-center retrospective cohort study of patients who underwent primary laparoscopic Roux-en-Y gastric bypass between 2008 and 2009 with ≥14-year follow-up. Data collected and analyzed were weight loss, obesity-related medical condition resolution and recurrence, weight recurrence, complication rate, and mortality rate. RESULTS: A total of 264 patients were included. Patients were predominantly female (81.8%), and the mean age and preoperative body mass index were 48.5 ± 12.2 years and 44.9 ± 7.3 kg/m2, respectively. The maximum mean percentage total weight loss achieved at 1 year was 31.5% ± 5.7% and was consistently >20% throughout follow-up. Sustained resolution of obesity-related medical conditions was achieved with a remission rate of 60.8% for type 2 diabetes mellitus, 46.7% for denoted dyslipidemia, and 40% for hypertension. Obesity-related medical condition recurrence was observed with a recurrence rate of 24.1% for type 2 diabetes mellitus, 17.9% for hypertension, and 14.8% for denoted dyslipidemia. Significant factors associated with weight loss were maximum percentage total weight loss and preoperative type 2 diabetes mellitus. Over 15 years, the weight recurrence rate was 51.1%, with predictors of higher preoperative body mass index and preoperative type 2 diabetes mellitus. CONCLUSION: Laparoscopic Roux-en-Y gastric bypass provides sustainable weight loss over a 15-year period, with consistent long-term weight-loss outcomes and resolution of obesity-related medical conditions sustained for ≥10 years after surgery.

Optimizing Intravenous Access for Long-Term Parenteral Nutrition.

PURPOSE OF REVIEW: Securing safe and effective intravenous (IV) access is of utmost importance for administering parenteral nutrition (PN). Sustaining this access can indeed pose challenges, especially when dealing with the risk of complications associated with long-term PN. This review emphasizes best practices to optimize intravenous access and reviews the current evidence-based recommendations and consensus guidelines. RECENT FINDINGS: An individualized approach when selecting central venous catheters (CVC) is recommended, considering the estimated duration of need for IV access and the number of lumens needed. Established and novel approaches to minimize complications, including infection and thrombosis, are recognized. These include placement and positioning of the catheter tip under sonographic guidance and the use of antimicrobial lock therapies. Moreover, when possible, salvaging CVCs can reduce the risk of vascular access loss. CVC selection for patients requiring PN depends on several factors. Carefully reviewing an individual patient's clinical characteristics and discussing options is important. Given the increased infection risk, CVC lumens should be minimized. For long-term PN beyond 6 months, using CVCs with skin barriers and larger diameters should be considered.

Preoperative duration of type 2 diabetes mellitus and remission after Roux-en-Y gastric bypass: A single center long-term cohort study.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) has demonstrated excellent glycemic control and type 2 diabetes mellitus (T2DM) remission for patients with obesity and T2DM. Duration of T2DM is a consistent negative predictor of remission after RYGB. However, the exact timing to offer surgical intervention during the course of the disease is not well elucidated. MATERIAL AND METHODS: We performed a retrospective cohort study between 2008-2020 to establish the exact association between duration of T2DM and remission after RYGB. We divided our cohort into quartiles of preoperative disease duration to quantify the change in remission rates for each year of delay between T2DM diagnosis and RYGB. We also compared the average time to remission and changes in glycemic control parameters. RESULTS: A total of 519 patients (67.2% female; age 53.4±10.7 y; BMI 46.6±8.4 kg/m2) with a follow-up period of 6.6±3.8 years were included. Remission was demonstrated in 51% of patients. Longer duration of T2DM was a significant negative predictor of remission with an estimated decrease in remission rates of 7% for each year of delay ([OR=0.931 (95% CI 0.892-0.971)]; P<0.001). Compared to patients with <3 years of T2DM, remission decreased by 37% for patients with 3-6 years, 64% for those with 7-12 years and 81% for patients with more than 12 years (P<0.001). Half of the patients reached T2DM remission after 0.5 and 1.1 years respectively for the first and second quartiles, while patients in the other quartiles never reached 50% remission. Lastly, we noted an overall improvement in all glycemic control parameters for all quartiles at last follow-up. CONCLUSION: Patients with a recent history of T2DM who undergo early RYGB experience significantly higher and earlier T2DM remission compared to patients with a prolonged history of preoperative T2DM, suggesting potential benefit of early surgical intervention to manage patients with obesity and T2DM.

Long-Term Safety and Efficacy of Bariatric Surgery in Septuagenarians.

BACKGROUND: Metabolic and bariatric surgery (MBS) has been shown to be safe and effective in the elderly population. Unfortunately, utilization of MBS in patients aged 70 years or older remains low, as MBS was just recently endorsed by the American Society for Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity (IFSO) for septuagenarians. MATERIALS AND METHODS: We performed a single-center retrospective cohort study of 103 patients aged ≥ 70 years who underwent sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) from January 2008 until March 2023. The data analyzed included patient demographics, post-operative complications, resolution of obesity-related comorbidities, and weight loss. RESULTS: A total of 103 patients (71% female; age 72.1 ± 2.5 years; BMI 43.7 ± 6.8 kg/m2) were included. Sixty-two patients (60.2%) underwent RYGB while the remaining 41 underwent SG (39.8%), with a mean follow-up of 4.7 ± 3.7 years. There was no MBS-related mortality. All-cause mortality rates were 7.3% for the SG group after a mean period of 4.5 ± 3.9 years compared to 8.1% for the RYGB cohort after 7.7 ± 3.5 years (p = 0.601). RYGB was reported to have a higher rate of early and late complications when compared to LSG (p = 0.083 and p = 0.274). T2DM (p = 0.011) and OSA (p = 0.019) resolved significantly after RYGB. CONCLUSION: Our study demonstrates that bariatric surgery is safe and effective in patients aged 70 years and older. Bariatric surgery should not be denied to this group of patients based on chronological age alone. Further studies are required to support these findings.

ESPEN guideline on chronic intestinal failure in adults - Update 2023.

BACKGROUND & AIMS: In 2016, ESPEN published the guideline for Chronic Intestinal Failure (CIF) in adults. An updated version of ESPEN guidelines on CIF due to benign disease in adults was devised in order to incorporate new evidence since the publication of the previous ESPEN guidelines. METHODS: The grading system of the Scottish Intercollegiate Guidelines Network (SIGN) was used to grade the literature. Recommendations were graded according to the levels of evidence available as A (strong), B (conditional), 0 (weak) and Good practice points (GPP). The recommendations of the 2016 guideline (graded using the GRADE system) which were still valid, because no studies supporting an update were retrieved, were reworded and re-graded accordingly. RESULTS: The recommendations of the 2016 guideline were reviewed, particularly focusing on definitions, and new chapters were included to devise recommendations on IF centers, chronic enterocutaneous fistulas, costs of IF, caring for CIF patients during pregnancy, transition of patients from pediatric to adult centers. The new guideline consist of 149 recommendations and 16 statements which were voted for consensus by ESPEN members, online in July 2022 and at conference during the annual Congress in September 2022. The Grade of recommendation is GPP for 96 (64.4%) of the recommendations, 0 for 29 (19.5%), B for 19 (12.7%), and A for only five (3.4%). The grade of consensus is "strong consensus" for 148 (99.3%) and "consensus" for one (0.7%) recommendation. The grade of consensus for the statements is "strong consensus" for 14 (87.5%) and "consensus" for two (12.5%). CONCLUSIONS: It is confirmed that CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for the underlying gastrointestinal disease and to provide HPN support. Most of the recommendations were graded as GPP, but almost all received a strong consensus.

Nutrition dose in the early acute phase of critical illness: Finding the sweet spot and heeding the lessons from the NUTRIREA trials.

The landmark NUTRIREA-2 and NUTRIREA-3 trials compared the route and dose of nutrition, respectively, in critically ill patients with circulatory shock. The results of both trials support a "less-is-more" paradigm shift in the early acute phase of critical illness. In this review, the authors outline and appraise the results of the NUTRIREA-2 and NUTRIREA-3 trials, introduce the concept of identifying the "sweet spot" for nutrition dose based on severity of illness/nutrition risk and nutrition dose, and identify the unintended consequences of delivering full-dose nutrition in sicker critically ill patients during the early acute phase of critical illness.

COVID-19 infection in patients on long-term home parenteral nutrition for chronic intestinal failure.

BACKGROUND AND AIMS: To investigate the incidence and the severity of COVID-19 infection in patients enrolled in the database for home parenteral nutrition (HPN) for chronic intestinal failure (CIF) of the European Society for Clinical Nutrition and Metabolism (ESPEN). METHODS: Period of observation: March 1st, 2020 March 1st, 2021. INCLUSION CRITERIA: patients included in the database since 2015 and still receiving HPN on March 1st, 2020 as well as new patients included in the database during the period of observation. Data related to the previous 12 months and recorded on March 1st 2021: 1) occurrence of COVID-19 infection since the beginning of the pandemic (yes, no, unknown); 2) infection severity (asymptomatic; mild, no-hospitalization; moderate, hospitalization no-ICU; severe, hospitalization in ICU); 3) vaccinated against COVID-19 (yes, no, unknown); 4) patient outcome on March 1st 2021: still on HPN, weaned off HPN, deceased, lost to follow up. RESULTS: Sixty-eight centres from 23 countries included 4680 patients. Data on COVID-19 were available for 55.1% of patients. The cumulative incidence of infection was 9.6% in the total group and ranged from 0% to 21.9% in the cohorts of individual countries. Infection severity was reported as: asymptomatic 26.7%, mild 32.0%, moderate 36.0%, severe 5.3%. Vaccination status was unknown in 62.0% of patients, non-vaccinated 25.2%, vaccinated 12.8%. Patient outcome was reported as: still on HPN 78.6%, weaned off HPN 10.6%, deceased 9.7%, lost to follow up 1.1%. A higher incidence of infection (p = 0.04), greater severity of infection (p < 0.001) and a lower vaccination percentage (p = 0.01) were observed in deceased patients. In COVID-19 infected patients, deaths due to infection accounted for 42.8% of total deaths. CONCLUSIONS: In patients on HPN for CIF, the incidence of COVID-19 infection differed greatly among countries. Although the majority of cases were reported to be asymptomatic or have mild symptoms only, COVID-19 was reported to be fatal in a significant proportion of infected patients. Lack of vaccination was associated with a higher risk of death.

Impact of Early Gastrojejunal Stenosis on Weight Loss in Patients Undergoing Roux-en-Y Gastric Bypass.

BACKGROUND: Gastrojejunal (GJ) anastomotic stenosis is a well-described complication after Roux-en-Y gastric bypass (RYGB); however, its impact on weight loss outcomes is not well elucidated. METHODS: We performed a retrospective cohort study of adult patients who underwent RYGB at our institution between 2008 and 2020. Propensity score matching was used to match 30 patients who developed GJ stenosis within the first 30 days post-RYGB with 120 control patients who did not develop this outcome. Short and long-term complications and mean percentage of total body weight loss (TWL) were recorded at 3 months, 6 months, 1 year, 2 years, 3 to 5 years, and 5 to 10 years postoperatively. Hierarchical linear regression modeling was used to analyze the association between early GJ stenosis and the mean percentage of TWL. RESULTS: Patients who developed early GJ stenosis had a 13.6% increase in the mean percentage of TWL when compared with controls in the hierarchical linear model [ P < 0.001 (95% CI: 5.7; 21.5)]. These patients were also more likely to present to an intravenous infusion center (70% vs 4%; P < 0.01), require readmission within 30 days (16.7% vs 2.5%; P < 0.01), and/or develop an internal hernia (23.3% vs 5.0%) postoperatively. CONCLUSIONS: Patients who develop early GJ stenosis after RYGB have a greater degree of long-term weight loss compared with patients who do not develop this complication. Although our findings support the key contribution that restrictive mechanisms play in maintaining weight loss after RYGB, GJ stenosis remains a complication associated with significant morbidity.

Home enteral nutrition: A descriptive study.

BACKGROUND: With data demonstrating benefit, the prevalence of home enteral nutrition (HEN) has increased significantly over the last few decades. Despite this increase, there remains a paucity of data regarding real-world use of HEN including clinical outcomes and complications. METHODS: Descriptive analysis of prospectively maintained database of our specialized HEN program was undertaken. Patients who received care in our program with HEN initiation date between January 1, 2018, and December 31, 2020, were included in the analysis. Data regarding demographic information, anthropometrics, enteral nutrition (EN) regimen, electrolytes, and nutrition therapy history were included and tracked until July 31, 2021. RESULTS: During the study period, 1600 patients initiated HEN treatment under our care. Majority of the study population needed EN therapy due to malignancy and its complications, including malignant dysphagia or mechanical obstruction (60.6%) followed by neurodegenerative diseases (7.5%). By the end of the study period, a majority of the patients (82%) stopped HEN treatment. Of these, 44.2% achieved EN goals and/or oral autonomy. Patients continued HEN treatment for a median of 100 (interquartile range, 32-301) days. Overall, 53.2% of patients experienced/reported at least one HEN-related complication that was clinically managed by the HEN team. Complications included tube-related, enteral feeding intolerance (EFI), and electrolyte shifts. CONCLUSION: In our study population, HEN was most utilized to manage malignancy-related complications, including dysphagia. Unfortunately, complications, including EFI and tube-related complications, remained quite prevalent. Further evaluation regarding risk factors for complications and preventive mechanisms, such as increased education, is indicated.

Peptide-based formula: Clinical applications and benefits.

The use of enteral nutrition (EN) continues to increase given benefits. However, with this increase in use, it is also becoming evident that enteral feeding intolerance (EFI) is also quite prevalent, leading to the inability to meet nutrition needs in many patients. Given the wide variability in the EN population as well as the number of formulas available, there is not a clear consensus regarding the best approach to EFI management. One approach that is emerging to improve EN tolerance is the use of peptide-based formulas (PBFs). PBFs refer to enteral formulas containing proteins that have been enzymatically hydrolyzed to dipeptides and tripeptides. These hydrolyzed proteins are often combined with higher medium-chain triglyceride content to generate an enteral formula that is essentially easier to absorb and utilize. Emerging data demonstrate that the use of PBF in patients with EFI may improve clinical outcomes along with a corresponding reduction in healthcare utilization and potentially the cost of care. This review aims to navigate through key clinical applications and benefits of PBF and to discuss relevant data shared in the literature.

Discharged on Enteral Nutrition: What Now? The Poor State of Outpatient Support for Patients on Enteral Nutrition Support.

PURPOSE OF REVIEW: While the use of enteral nutrition (EN) has increased, and more medical centers have developed inpatient programs to address the unique needs of these patients, our collective experience at a few large institutions indicates that there is very little systemic support for patients after discharge. Here, we discuss what we have observed to be some of the barriers to providing outpatient follow up care, summarize the impact we have seen on patients, and propose some possible solutions. RECENT FINDINGS: We have observed and identified some of the root causes to include financial barriers; uncoordinated care transitions; high complexity of care, including medication management; and diffuse leadership to a multidisciplinary problem. Systematic support for outpatient care for patients discharged on enteral nutrition is rare and limited, due to many root causes. There are a few tools and tips that we have summarized here for individual providers, and a few promising methods in development, but a systematic approach is in great need.

Butyrate: More Than a Short Chain Fatty Acid.

PURPOSE OF REVIEW: The mechanistic understanding of the importance and the potential benefits of the gut microbiome has exploded in potential roles in human health and disease. Short chain fatty acids (SCFAs), including butyrate, are one of the key metabolic end products that has been a major focus of microbiome understanding. This brief review aims to describe butyrate's relation to certain biological concepts and their clinical application. RECENT FINDINGS: Butyrate has reportedly been described as a potent pro-resolution molecule that has a significant role in maintaining gut immunity, supporting gut barrier function, regulation of histone deacetylase (HDAC), and numerous systemic roles. Further research is needed to explore potential benefits of adding SCFAs for patients receiving total parenteral nutrition. Butyrate plays several biological roles in intestinal epithelium anti-inflammatory pathways with clear benefits in numerous acute and chronic disease states and overall human health helping to maintain homeostasis.

Management of long-term home parenteral nutrition: Historical perspective, common complications, and patient education and training.

Intestinal failure (IF) is a rare disease that requires ongoing intravenous supplementation to sustain growth and health. Advancements in parenteral nutrition (PN) and central venous access in the 1960s and 1970s transformed a life-limiting disease to a chronic one in which patients are able to administer hydration, electrolytes, micronutrients, and macronutrients in the comfort of their home. However, despite ongoing advancements in the field of home PN (HPN), complications-whether related to central venous catheters or PN itself-remain common and can be associated with significant morbidity and mortality. Central venous access can be associated with thrombosis, central line-associated bloodstream infection, or damage and can result in loss of access over time. PN can be associated with IF-associated liver disease or hyperglycemia. The key to preserving central venous access and quality of life and maintaining health for patients with chronic IF (CIF) is education focused on prevention and prompt management of CIF complications as they arise. This education typically takes place at the time of initiation of HPN, either in the hospital setting or in the patient's home. The present manuscript describes the historical progression of HPN, prevalence and characteristics of CIF, and an in-depth discussion of the most common catheter-related and PN-related complications and their management, along with a discussion of our education and training process.

Impact of Chronic Immunosuppression on Short-, Mid-, and Long-Term Bariatric Surgery Outcomes.

INTRODUCTION: Bariatric surgical outcomes depend heavily on proper healing of gastrointestinal anatomy, metabolic alterations, and patient lifestyle modifications which are all negatively impacted by immunosuppression and underlying inflammatory diseases. There is a lack of literature exploring how patients with diseases requiring immunosuppression respond to bariatric surgical intervention in the long term. METHODS: A retrospective analysis of chronically immunosuppressed patients who underwent primary bariatric surgeries at Mayo Clinic was conducted (2008-2020). Data collected included patient demographics, BMI, underlying disease, and immunosuppression regimen and complications at 3, 6, 12, 24, and 60 months. RESULTS: We identified a total of 89 (RYGB = 49, SG = 34, BPD/DS = 6) patients on chronic immunosuppression who underwent bariatric surgery at our center. RYGB (N = 49), 38.2% had a SG (N = 34) and 6.7% had a BPD/DS (N = 6). Rheumatoid arthritis and renal transplantation were the most underlying condition at 20.22% each (N = 18). There were a total of 2 (2.25%) intraoperative complications. In the immediate post-operative period, there were 15 (16.5%) minor complications. In follow-up, 6.1% of RYGB patients experienced marginal ulcerations, while no gastrointestinal leaks occurred. The mean pre-surgical BMI was 48.29 kg/m2 (SD = 18.41). Percent total weight loss (%TWL) and BMI reduction were 30.89% and 14.83 kg/m2 (SD = 9.07) at 12 months and 29.48% and 14.43 kg/m2 (SD = 13.46) at 60 months, respectively. The mean follow-up time was 30.49 months. CONCLUSIONS: Bariatric surgery remains safe and effective therapy for chronically immunosuppressed patients with excellent long-term outcomes for patients with moderate to severe obesity.

Case presentation and panel discussion: Transitions in care.

There is evidence that significant quality problems arise as patients transitions in care from one setting to another. Attention to nutrition during transitions of care is important to avoid complication. During the American Society for Parenteral and Enteral Nutrition 2022 preconference course, nutrition during transition of care from pediatric to adult care, from the intensive care unit to the hospital floors and from the hospital to home was addressed.

Safety and Efficacy of Revisional Surgery as a Treatment for Malnutrition after Bariatric Surgery.

BACKGROUND: Malnutrition after bariatric operation is a rare but potentially life-threatening complication. The safety and efficacy of revisional bariatric operation in malnourished patients are not well elucidated. STUDY DESIGN: We performed a retrospective chart review of patients who underwent revisional bariatric operation for severe malnutrition at our institution between 2008 and 2020. Associations of demographic and clinical characteristics with dichotomous outcomes of interest were examined using Fisher's exact tests, Cochran-Armitage tests for trend, and two-sample t -tests when appropriate. RESULTS: Fifty-three patients underwent revisional bariatric operation for malnutrition from 2008 and 2020. The median follow-up was 24 months. The anatomy before revision was Roux-en-Y gastric bypass (n = 40, 75%), biliopancreatic diversion with duodenal switch (n = 6, 11%), sleeve gastrectomy (n = 4, 8%), and mini gastric bypass (n = 3, 6%). The percentage of patients requiring supplemental or total nutritional support decreased from 89% preoperatively (47% on enteral feedings and 42% on total parenteral nutrition (TPN) with or without tube feeding) to 13.2% at the last encounter after revision (7.5% still requiring enteral feedings and 5.7% on TPN). There was an association between the number of prior abdominal operations and postoperative pneumonia (p 0.03) and need for blood transfusion (p 0.01). There were no associations between major complications or last encounter nutrition and any preoperative variables other than age at the time of operation. There were 2 mortalities during a median follow-up of 24 months, and both occurred more than 1 year postoperatively. CONCLUSION: Revisional operation for severely malnourished bariatric operation patients is effective in the discontinuation of supportive nutrition. Postoperative complications are increased but not prohibitive.

Usability of a Novel Enteral Feeding System: A Summative Study.

Background: Utilization of long-term home enteral nutrition (HEN) for nutrition therapy is increasing across the world. However, HEN can be a mobility-limiting experience affecting quality of life (QoL). Improvement of QoL for patients receiving HEN is a universal goal within the nutrition community. This study evaluated usability of Mobility+®, a novel enteral feeding system (EFS). Methods: A summative study evaluating usability of the novel EFS was conducted with novices (NV), non-novices (NN), and healthcare professionals (HCP). Subjects in NV and NN groups received familiarization training where they were introduced to the novel EFS and walked through steps to fill pouch, simulate feeding, flush (rinse), and wear the system, using the Instructions for Use (IFU) booklet, followed by a testing session where they simulated system use on their own. HCP self-trained using the IFU and instructional videos. A fill from ready-to-hang (RTH) formula bag method was also tested in HCP. Participants' ability to loosely coil the tubing and sit, stand, and move around wearing a filled feeding pouch inside a crossbody bag was also evaluated. Results: Forty-five participants completed the study. All participants successfully and safely simulated use of the novel EFS, with 97.8% (44/45) doing so on first attempt. All participants could wear the novel EFS in crossbody bag and move around without any use errors or safety issues. Conclusion: The examined novel EFS can be safely used in intended use population, with or without previous experience with enteral nutrition, on provision of basic familiarization training and written IFU. Additionally, HCP can successfully self-train on this system with instructional videos.

Dietitian Involvement Improves Consumption of Oral Nutrition Supplements in Hospitalized Patients.

Hospitalized patients are at an increased risk of malnutrition due to multiple factors including, but not limited to, acute and chronic diseases especially those affecting gastrointestinal tract, surgery, appetite, and frequent nil per os while undergoing diagnostic workup. Because of this, guidelines suggest the use of oral nutritional supplements (ONS) in hospitalized patients to reduce the risk of malnutrition and its complications. The current report aims to highlights key findings from a cross-sectional survey of 99 hospitalized patients who were at risk for or diagnosed with malnutrition and prescribed ONS. Data regarding ONS prescriber information as well as number ordered and consumed were collected. Of the 2.4 ± 1.5 supplements ordered per person each day, only 1.3 ± 1.1 were consumed, and there was 48% wastage of prescribed ONS. However, dietitian involvement was associated with significant reduction in wastage. Given the need and benefit, it is imperative for the nutrition community to further explore best practices to improve ONS consumption.

Characteristics of chronic intestinal failure in the USA based on analysis of claims data.

BACKGROUND: This study investigated the prevalence, characteristics, and management of patients with chronic intestinal failure (CIF) in the United States in 2012-2020, based on parenteral support (PS) prescription claims and healthcare utilization. METHODS: Patients with CIF were identified from the Integrated DataVerse® claims database if they had at least two PS prescriptions within 6 months and a relevant diagnosis. Analysis included prevalence and characteristics of patients with CIF, their travel distance to receive PS prescriptions, and the distribution of PS providers and their prescribing history. RESULTS: Up to 24,048 patients with CIF were identified, equivalent to 75 patients per million. CIF affected people of all ages, being more prevalent in women than in men. Many providers signed PS orders for small patient groups over short time periods, whereas few providers signed PS orders for large patient groups long term, indicating a lack of centralization. The distribution of PS providers suggested a disparity in healthcare coverage in rural vs urban areas, leading to patients traveling considerable distances to receive PS prescriptions. This may be exacerbated by a decline of providers with expertise in CIF and nutrition. CONCLUSIONS: Healthcare disparities for patients with CIF have likely been obscured by the lack of CIF-specific diagnostic and procedure codes, obliging providers to code for their patients under other codes. Effective policy changes, including centralized care, revision of reimbursement models, and expansion of nutrition-focused education in addition to the newly introduced International Classification of Diseases codes, are needed to provide the best care for patients.