An evaluation of plasma vitamin C concentrations in individuals requiring home parenteral nutrition.

BACKGROUND: Ascorbic acid (VitC) is an essential coenzyme to maintain health, but there are minimal data on the adequacy of VitC supply in patients requiring home parenteral nutrition (HPN). METHODS: A prospective pilot study was carried out measuring plasma VitC, serum vitamins A, D and E, and the minerals zinc, copper, selenium and magnesium in 28 adult HPN-dependent (≥6 months) patients. RESULTS: Fifty-seven percent of patients had insufficient VitC status. There was a strong, positive correlation between HPN provision of VitC and plasma VitC concentrations (rs = 0.663, p = 0.00) with an 83% insufficiency rate below a provision of 800 mg week-1 . There was no association seen between plasma VitC and number of HPN days week-1 (p = 0.539), number of months on HPN (p = 0.773) or dependency on HPN (86% ± 31% of energy requirements met via HPN (77% ± 23%, p = 0.39). CONCLUSIONS: VitC insufficiency is prevalent in HPN-dependent patients. Our data highlight the need for regular monitoring of VitC in those living with type III intestinal failure.

Evolution of the Greater Manchester Nutrition and Hydration Programme.

Older adults in the community are at risk of malnutrition and dehydration. The present article aims to outline an intervention and a population-health approach to raise awareness of the importance of good nutrition and hydration in later life. This was addressed by developing strong partnership working, governance frameworks and local steering committees. Through the Greater Manchester Nutrition and Hydration Programme, 39 500 older people have been asked about appetite and weight loss and/or used the PaperWeight Armband to date. A total of 5586 people from this population were found to be at risk of malnutrition. All were provided resources, advice and signposting to address this issue. The gross fiscal return on investment over a 5-year period was 3.2-fold and the net present budget impact was £800 000. The long-term cashable fiscal return on investment was estimated at 2.69. This very promising approach has potential to enable older adults to extend their healthy life span and deliver cost savings to the health and care system.

Multi-chamber parenteral nutrition (PN) bags are safe and cost-effective in replacing compounded PN regimens in hospitalised patients.

BACKGROUND & AIMS: There is varied international practice in the use of ready-made multi-chamber bags (MCBs) and compounded parenteral nutrition (PN). Recent national aseptic pharmacy capacity limitations have restricted compounded PN production so we aimed to explore outcomes associated with the increased use of MCB vs compounded regimens during a period of change in PN supplies. METHODS: This was a point prevalence study conducted over two time periods, Period 1: 01.01.2022-31.03.2022 and Period 2: 01.10.2022-31.12.2022. Data were collected on PN regimen, outcomes, cost and aseptic time required to prepare PN bags. RESULTS: 263 patients were included: 132 in Period 1 and 131 in Period 2. Overall, 2263 PN bags were utilised; 1179 in Period 1 and 1084 in Period 2. In Period 1, of all utilised bags, 138 (11.7%) were compounded PN, 356 (30.2%) supplemented MCBs and 685 (58.1%) manipulated MCBs whereas in Period 2, 0 were compounded PN, 546 (50.3%) supplemented MCBs and 538 (49.6%) manipulated MCBs. There were no significant differences in the proportion of patients with deranged blood tests between the study periods. In both periods there were only two episodes of catheter-related blood stream infection. The total cost saved in Period 2 compared to Period 1 was £20,684 and total aseptic staff time saved was 191 h. CONCLUSION: Wider use of in-hospital MCB PN regimens could lead to a reduction in the need for compounded PN produced by aseptic pharmacy facilities, saving costs while maintaining good patient outcomes.

Experience and opinions relating to pregnancy in patients with chronic intestinal failure: an international survey.

Introduction: Pregnancy in patients with chronic intestinal failure (CIF) is a relatively rare occurrence but is an important contemporary topic given both the increasing use of home parenteral nutrition (HPN) and the demographics of patients with CIF. Method: An opinion-based survey was produced in a multidisciplinary manner, which was then distributed internationally, via the European Society for Clinical Nutrition and Metabolism network, using a web-based survey tool for healthcare professionals with a specialist interest in the management of CIF. Results: Seventy specialists from 11 countries completed the survey. Fifty-four per cent of the respondents reported some experience of managing pregnancy in patients with CIF. However, 60% stated that they did not feel that it was their role to discuss the topic of pregnancy with their patients, with fewer than 10% stating that they routinely did so. Respondents felt that an individualised approach was required when considering alterations to parenteral support prior to conception, during pregnancy and in the postnatal period. Most respondents also felt there was no increased risk of catheter-related blood stream infections, while catheter-related thrombosis was deemed to be the most significant HPN-related complication for pregnant women. Conclusion: This study reports a variable experience, knowledge and confidence of healthcare professionals when considering pregnancy in patients with CIF. The risk of HPN-related complication was felt to be greater during pregnancy, with an individualised approach being the preferred route for most aspects of care. The findings support the need for an international registry and subsequent consensus guidelines for the management of pregnancy in CIF.

Brief intervention using the PaperWeight Armband to identify older people at risk of undernutrition in the community: a preliminary evaluation.

BACKGROUND: The risk of undernutrition in older adults in the community is high, with clear negative impacts on health and well-being. Nutritional screening is not routine and undernutrition often goes unrecognised. A community-level population public health intervention has the potential to target environments where the risk of undernutrition is highest. A programme has been established locally using the PaperWeight Armband as a simple nutritional screening tool in residents over 65 years, followed by supporting advice and community interventions. We undertook a nested pilot cohort evaluation within the wider programme to assess whether this could impact positively. METHODS: Participants found to be at risk of undernutrition in the programme were recruited consecutively. Baseline weight and other descriptors including accommodation and frailty were recorded, and then again at 12 weeks. RESULTS: 83 participants were recruited from a wide variety of community settings, age range 65-99 years; 75% were women. Sixty-seven recruits were followed up for 12-week review. Of these, 54 (81%) had a positive outcome, recording either weight gain (66%) or no weight loss (15%) at 12 weeks. Benefit was seen in all living circumstances but was least evident in the frailest participants. CONCLUSION: The intervention is associated with positive outcomes, with reduction or stabilisation of nutritional risk in the majority of participants studied. The intervention can be delivered in a wide range of settings and does not require healthcare professions for the screening. Longer and larger studies are now required to study the health, well-being and socioeconomic impacts of the intervention in depth.

Body composition in patients with type 2 intestinal failure.

BACKGROUND: Measurement of body composition is a valuable clinical tool for nutrition assessments, but there are no data on the merits of assessment modalities in type 2 intestinal failure (IF). The aim of this study was to evaluate the prevalence of low muscle mass and quality in type 2 IF, comparing bioelectric impedance analysis (BIA) and computed tomography (CT) at the third lumbar vertebra level. METHODS: Patients admitted with acute severe (type 2) IF to a national UK IF center who had BIA measurement and CT scan as part of routine care within 40 days of anthropometric measurement were included in this cross-sectional study. Data were also collected on patient demographics and clinical characteristics. RESULTS: Forty-four patients meeting inclusion criteria were included. Low muscle mass was detected in 37 out of 44 (84.1%) patients by CT scan and in 30 of out 44 (68.2%) by BIA. Low muscle quality was detected in 22 out of 44 (50%) patients by CT scan and in 40 out of 44 (90.1%) by BIA. Comparison of CT and BIA measurements showed a moderate correlation of muscle, Spearman ρ 0.65 (95% CI, 0.42-0.81; P < 0.001), and a strong correlation of body fat mass measurements, Spearman ρ 0.79 (95% CI, 0.62-0.89; P < 0.001). CONCLUSION: This is the first study to demonstrate that low muscle mass is common in patients with type 2 IF, regardless of body composition assessment modality. A larger cohort study is required to validate the impact of low muscle mass and quality on clinical outcomes and the role of targeted interventions to improve the care of patients with type 2 IF.

Hybrid model of compounded and multichamber bag parenteral nutrition for adults with chronic intestinal failure.

BACKGROUND: Although international guidelines support the use of commercially available multichamber bags (MCBs), the majority of home parenteral nutrition (HPN) in the United Kingdom has been compounded PN, tailored to the patient. However, national capacity limitations in aseptic facilities have necessitated the increased use of MCBs. There are no studies evaluating the appropriateness or benefits of using a "hybrid" regimen incorporating both MCBs and compounded PN in patients already established on compounded HPN. METHODS: This was a cross-sectional audit evaluation conducted on September 1, 2021, at a national United Kingdom reference center. All HPN-dependent adults prescribed HPN for chronic intestinal failure were assessed by a multidisciplinary team for their potential of being switched to a "hybrid" regimen of MCBs and compounded PN. RESULTS: Of 180 patients currently receiving compounded HPN that included intravenous nitrogen with glucose ± lipid, 65 (36.1%) were deemed clinically suitable for a hybrid PN regimen, with minimal variance in PN constituents per week (volume 0%, non-nitrogen kilocalories 0%, nitrogen 0%, fat -0.2%, glucose 0%, sodium 0%, potassium 0%, calcium 0%, magnesium 0%, and phosphate -0.1%) and requiring no additional central venous catheter manipulations. The potential reduction in compounded PN would reduce by 3627 bags per year, equating to a cost saving of £141,453 per year (equivalent to $178,885). CONCLUSION: Wider use of hybrid MCB/compounded HPN regimens could lead to a reduction in the need for compounded PN to be produced by aseptic facilities. Further evaluation of acceptability and tolerance of hybrid regimens by patients already receiving compounded HPN is required.

Catheter-related infection rates in patients receiving customized home parenteral nutrition compared with multichamber bags.

BACKGROUND: The risk of bloodstream infections may be increased in hospitalized patients receiving ready-made parenteral nutrition (PN) multichamber bags (MCBs) compared with customized PN; however, as highlighted in recent international guidelines, there are no comparable data relating to home PN (HPN). METHODS: Data from a prospectively maintained database were analyzed to compare incidence rates of catheter-related bloodstream infections (CRBSIs) between patients receiving customized HPN compared with MCB HPN at a national UK referral center between May 2018 and August 2020. RESULTS: Sixty patients with chronic intestinal failure were commenced on MCBs and 45 received customized HPN for a total of 5914 and 7641 catheter days, respectively. No difference in CRBSI incidence was found (0.51/1000 catheter days for MCBs, 0.39/1000 catheter days for customized HPN; incidence rate ratio, 1.29; 95% CI, 0.26-6.37). Eighteen patients were switched from customized HPN to MCB HPN. The study period covered 7401 catheter days receiving customized HPN and 4834 days on MCBs. No significant change was noted in the CRBSI rates following this switch (0.27/1000 catheter days receiving customized HPN vs 0.21/1000 catheter days on MCBs; incidence rate ratio, 1.31; 95% CI, 0.12-14.3). CONCLUSION: The use of MCBs for HPN patients is not associated with an increased risk of CRBSI. This study will inform international guidelines and provide reassurance for the continued, safe use of MCB HPN.

Glucagon-like peptide 2 analogues in the treatment of intestinal failure: A qualitative exploration of the views of patients and their families in decision making.

BACKGROUND AND AIMS: Patients with short bowel syndrome and type 3 intestinal failure (SBS-IF) are dependent on parenteral nutrition (PN), a lifesaving treatment but inconvenient and with risks. Glucagon-like peptide 2 analogue (teduglutide) can reduce patients' need for PN. However, it comes with the risk of a number of side effects. This qualitative study investigated patients' decision making process to start teduglutide and how family members contributed to the decision. METHODS: In-depth semi-structured interviews were conducted with nine participants, six patients with SBS-IF and three family members about the decision to take teduglutide. Interviews were transcribed verbatim and analysed using framework analysis. RESULTS: The prominent motivation for taking teduglutide (Revestive® Takeda Pharmaceuticals Limited) was reducing or stopping PN. Other motivations were to help others by assisting in developing the knowledge base around teduglutide, patients felt that they had nothing to lose by trying the drug and the support of relatives. The reasons patients considered not taking the drug were that they had accepted being on PN, the potential side effects of teduglutide and undergoing extra monitoring. However, the monitoring programme also acted as a motivator providing reassurance that patients would be observed and supported with side effects. Family members were happy to support patients' decision to try teduglutide, although they had more reservations, indicating a higher risk threshold. CONCLUSION: Patients considered potential benefits of teduglutide outweighed any disadvantages. Relatives, although supportive, had more reservations.

Jejunal feeding: when is it the right thing to do?

The decision to commence jejunal feeding in patients with structural abnormalities, which prevent oral or intragastric feeding, is usually straightforward. However, decisions surrounding the need for jejunal feeding can be more complex in individuals with no clear structural abnormality, but rather with foregut symptoms and pain-predominant presentations, suggesting a functional origin. This appears to be an increasing issue in polysymptomatic patients with multi-system involvement. We review the differential diagnosis together with the limitations of available functional clinical tests; symptomatic management options to avoid escalation where possible including for patients on opioids; tube feeding options where necessary; and an approach to weaning from established jejunal feeding in the context of a multidisciplinary approach to minimise iatrogenesis.

Successful implementation of remote video consultations for patients receiving home parenteral nutrition in a national UK Centre.

RATIONALE: Our intestinal failure unit provides care for patients from a wide geographical area. Patients dependent on home parenteral nutrition (HPN) are routinely reviewed in the clinic at 3-6 monthly intervals. Between March 2008 and 2015, we noted a significant rise in the number of patients under our care, with an associated 51% increase in clinic appointments offered. We evaluated whether telemedicine would provide a strategy to reduce patients' need to travel while maintaining safe clinical standards. METHODS: Implementation began in December 2015 via patient consultation and small tests of change. Clinical data were obtained from a prospectively maintained database. Remote video consultation discussions were carried out via internet video call service (Skype). An anonymous satisfaction questionnaire was offered to patients for completion following consultation. The number of miles saved by obviating the need to attend hospital was calculated for each patient. RESULTS: During the study period, patients receiving HPN rose by 18% to 288. Twenty-five patients used telemedicine for HPN follow-up, three of these for follow-up with the psychologist. By avoiding hospital attendance, this saved a mean travel distance of 56.7 miles with a total of 18 346.6 cumulative miles saved. Sixty-three per cent of patients rated their satisfaction with the system at ≥90%, with a mean satisfaction of 85%. Eight per cent of the telemedicine cohort was admitted with an HPN complication, compared with an admission rate of 24% for the whole HPN cohort. One emergency admission was avoided. CONCLUSION: Telemedicine can obviate the need for clinic attendance in HPN-dependent patients, so reducing the need of individuals with chronic illness to travel while maintaining standards for follow-up.

Reversal of intestinal failure-associated liver disease (IFALD): emphasis on its multifactorial nature.

Patients with intestinal failure (IF) and home parenteral nutrition commonly develop abnormal liver function tests. The presentations of IF-associated liver disease (IFALD) range from mild cholestasis or steatosis to cirrhosis and decompensated liver disease. We describe the reversal of IFALD in an adult patient with IF secondary to severe Crohn's disease and multiple small bowel resections. The patient developed liver dysfunction and pathology consistent with IFALD. Multiple causal factors were implicated, including nutrition-related factors, catheter sepsis and the use of hepatotoxic medications. Multidisciplinary treatment in a tertiary IF referral centre included aggressive sepsis management, discontinuation of hepatotoxic medications and a reduction of parenteral nutrition dependency through optimisation of enteral nutrition via distal enteral tube feeding. Upon this, liver function tests normalised.

Refeeding syndrome: a clinical review.

Refeeding syndrome can result in a wide variety of complications and may be life threatening. Although well described in hospital practice, refeeding syndrome is often under-recognized and inadequately treated.