Characteristics and feeding intolerance in critically ill adult patients receiving peptide-based enteral nutrition: A retrospective cross-sectional study.

BACKGROUND & AIMS: Patients who experience gastrointestinal (GI) intolerance and hyperglycemia (or glucose intolerance) may not achieve appropriate caloric requirements and experience poor outcomes. The aim was to examine patient characteristics, disease severity, and enteral nutrition (EN) formula use in relation to feeding intolerance and healthcare resource utilization. METHODS: A retrospective, cross-sectional design using real-world data from PINC AI™ Healthcare Database, 2015-2019 was used. Critically ill hospitalized adults who required ≥3 days of 100% whey peptide-based EN, other peptide-based diets, or intact-protein standard and diabetic EN formulas were included. Primary outcomes were enteral feeding intolerance, including GI intolerance and hyperglycemia. Pairwise comparisons of other peptide-based and standard intact-protein groups with 100% whey-peptide were completed. Associations between EN group with GI intolerance and hyperglycemia, respectively, were evaluated via multivariable logistic regressions. RESULTS: Across 67 US hospitals, 19,679 inpatients (3242,100% whey-peptide, 3121 other peptide-based, and 13,316 standard intact-protein) were included. The 100% whey-peptide group had higher severity of illness and frequencies of comorbidities compared with other peptide-based and standard intact-protein groups. Hospital length of stay, intensive care unit stay, and 30-day readmission were similar across peptide-based cohorts. After controlling for demographic, visit, and severity characteristics, odds of GI intolerance were 18% higher for the other peptide-based group and 15% higher for the standard intact-protein group compared with the 100% whey-peptide group (each P < 0.03). In secondary analysis, odds of hyperglycemia were 81% higher for the other peptide-based group compared with the subgroup of very high-protein/low carbohydrate 100% whey-peptide (P < 0.001). CONCLUSIONS: Lower GI intolerance and greater glycemic control were associated with the use of 100% whey-peptide formulas relative to other formulas. Appropriate and optimal delivery of EN using specialized peptide-based formulas is a strategy to minimize feeding intolerance and benefit critically ill patients.

Characteristics, Hospital Length of Stay, and Readmissions Among Individuals Undergoing Abdominal Ostomy Surgery: Review of a Large US Healthcare Database.

PURPOSE: The purpose of this study was to examine patient characteristics, length of stay (LOS), hospital revisits, and complications of patients undergoing abdominal ostomy surgery. DESIGN: Retrospective cohort study. SUBJECTS AND SETTING: Data were extracted from the PINC AI Healthcare Database (PHD), a large archive that stores data from 25% of all US inpatient hospital discharges. Patients were admitted to 658 hospitals in the United States between December 1, 2017, and November 30, 2018. The sample comprised 27,658 adult patients; 15,512 underwent creation of a colostomy, 10,207 underwent ileostomy construction, and 1930 had a urostomy procedure. Their median age was 64 years (interquartile range [IQR] = 19 years). Emergent admission type was 71.2% for patients who underwent a colostomy procedure, 49.4% for ileostomy, and 9.9% for urostomy. The majority of patients underwent open surgery (77.7%); 22.3% of procedures used an endoscopic approach. METHODS: Patients were identified as having undergone abdominal ostomy surgery via ICD-10-PCS (International Classification of Diseases, Tenth Revision, Procedure Coding System) procedure codes. Demographic, visit, hospital and clinical characteristics, LOS, and hospital revisits (ie, readmissions and emergency department [ED]) were captured for qualifying patients. Data were evaluated using unadjusted descriptive analyses. RESULTS: The median LOS of 9 days (IQR = 9 days) varied by ostomy surgery; the cumulative postsurgical LOS was 7 days (IQR = 5 days). The most frequent underlying diagnoses resulting in ostomy surgery were diverticulitis of the large bowel (19.6%) managed by colostomy, colorectal cancer managed by ileostomy (22.5%), or urothelial cancer managed by urostomy (78.1%). Slightly less than a quarter (23.7%) of patients were discharged home without home care, 43.0% went home with home healthcare, and 29.6% were discharged to a non-acute care facility. Hospital readmission within 120 days of discharge was 36.3% for patients with a colostomy, 52.3% for those with an ileostomy, and 34.6% for patients with a urostomy. Ostomy complications were identified as the reason for readmission in 62.4% of patients. Slightly more than 1 in 5 patients (20.7%) had a subsequent ED visit within 120 days, 39.7% of which involved ostomy complication. CONCLUSIONS: Characteristics of patients undergoing abdominal stoma surgery varied based on underlying diagnosis and ostomy type. The median hospital LOS was more than 1 week. Patients experienced high rates of healthcare utilization (hospital admission or ED visits) during the 120 days following surgery.

Healthcare Resource Utilization and Cost Comparisons of High-Protein Enteral Nutrition Formulas Used in Critically Ill Patients.

Background: High-protein enteral nutrition is advised for patients who are critically ill. Options include immunonutrition formulas of various compositions and standard high-protein formulas (StdHP). Additional research is needed on the health economic value of immunonutrition in a broad cohort of severely ill hospitalized patients. Objective: The study goal was to compare healthcare resource utilization (HCRU) and cost between immunonutrition and StdHP using real-world evidence from a large US administrative database. Methods: A retrospective cohort study was designed using the PINC AI™ Healthcare Database from 2015 to 2019. IMPACT® Peptide 1.5 (IP) was compared with Pivot® 1.5 (PC), and StdHP formulas. Inclusion criteria comprised patients age 18+ with at least 1 day's stay in the intensive care unit (ICU) and at least 3 out of 5 consecutive days of enteral nutrition. Pairwise comparisons of demographics, clinical characteristics, HCRU, and costs were conducted between groups. Multivariable regression was used to assess total hospital cost per day associated with enteral nutrition cohort. Results: A total of 5752 patients were identified across 27 hospitals. Overall, a median 7 days of enteral nutrition was received over a 16-day hospital and 10-day ICU stay. Median total and daily hospital costs were lower for IP vs PC ($71 196 vs $80 696, P<.001) and ($4208 vs $4373, P=.019), with each higher than StdHP. However, after controlling for covariates such as mortality risk, surgery, and discharge disposition, average total hospital cost per day associated with IP use was 24% lower than PC, and 12% lower than StdHP (P<.001). Readmissions within 30 days were less frequent for patients receiving IP compared with PC (P<.02) and StdHP (P<.001). Discussion: Choice of high-protein enteral nutrition for patients in the ICU has implications for HCRU and daily hospital costs. Considering these correlations is important when comparing formula ingredients and per unit costs. Among the enteral nutrition products studied, IP emerged as the most cost-saving option, with lower adjusted hospital cost per day than PC or StdHP. Conclusions: Using a select immunonutrition formula for critically ill patients may provide overall cost savings for the healthcare system.

Longitudinal change in reproductive hormones and depressive symptoms across the menopausal transition: results from the Study of Women's Health Across the Nation (SWAN).

CONTEXT: The contribution of reproductive hormones to mood has been the focus of considerable research. Results from clinical and epidemiological studies have been inconsistent. It remains unclear whether alterations in serum hormone levels across the menopausal transition are linked to depressive symptoms. OBJECTIVES: To evaluate the relationship between serum hormone levels and high depressive symptoms and whether hormone levels or their change might explain the association of menopausal status with depressive symptoms previously reported in a national sample of midlife women. DESIGN: A longitudinal, community-based, multisite study of menopause. Data were collected at baseline and annually from December 1995 to January 2008 on a range of factors. Early follicular phase serum samples were assayed for levels of estradiol, follicle-stimulating hormone, testosterone, and dehydroepiandrosterone sulfate. SETTING: Seven communities nationwide. PARTICIPANTS: A community-based sample of 3302 multiethnic women, aged 42 to 52 years, still menstruating and not using exogenous reproductive hormones. Main Outcome Measure Depressive symptoms assessed with the Center for Epidemiological Studies Depression Scale (CES-D). The primary outcome was a CES-D score of 16 or higher. RESULTS: In multivariable random-effects logistic regression models, log-transformed testosterone level was significantly positively associated with higher odds of a CES-D score of 16 or higher (odds ratio = 1.15; 95% confidence interval, 1.01-1.31) across 8 years, and a larger increase in log-transformed testosterone from baseline to each annual visit was significantly associated with increased odds of a CES-D score of 16 or higher (odds ratio = 1.23; 95% confidence interval, 1.04-1.45). Less education, being Hispanic, and vasomotor symptoms, stressful life events, and low social support at each visit were each independently associated with a CES-D score of 16 or higher. No other hormones were associated with a CES-D score of 16 or higher. Being perimenopausal or postmenopausal compared with being premenopausal remained significantly associated with a CES-D score of 16 or higher in all analyses. CONCLUSIONS: Higher testosterone levels may contribute to higher depressive symptoms during the menopausal transition. This association is independent of menopausal status, which remains an independent predictor of higher depressive symptoms.

Racial differences in women who have a hysterectomy for benign conditions.

OBJECTIVE: To evaluate if there are racial differences between African-American and Caucasian women who have hysterectomy for benign conditions in terms of (1) presenting symptoms (prolapse, vaginal bleeding, pain, and known history of leiomyomas), (2) serum estradiol and testosterone levels at the visit before hysterectomy, and (3) uterine weight. METHODS: A multi-ethnic, multisite, community-based longitudinal cohort study of 3,302 women ages 42-52 at enrollment was conducted. During 9 years of follow-up, 203 African-American and Caucasian women reported a hysterectomy, 90 with evidence of uterine leiomyomas. Women were surveyed regarding their overall perceived health before and after hysterectomy, presenting symptoms, and their motivations for surgery. Serum estradiol and testosterone levels were measured. Uterine weight at time of hysterectomy and clinical pathology were determined via medical record abstraction. RESULTS: Previously diagnosed leiomyomas were presenting symptoms more frequently in African-American women than Caucasian women (85% vs. 63%; p = .02). African-American women had less prolapse than Caucasian women (0% vs. 10%; p = 0.04). Chronic pain was a more frequent reason for hysterectomy in African-American women than in Caucasian women (49% vs. 29%; p = .05). There were no differences between the groups in levels of estradiol or testosterone. African-American women had almost twice the uterine weight as that of Caucasian women (448 vs. 240 g; p = .0005). CONCLUSION: Racial differences in frequency of hysterectomy for benign conditions are consistent with differences in presenting symptoms, where African-American women seemingly have larger, more symptomatic fibroids.

Adenomyosis a variant, not a disease? Evidence from hysterectomized menopausal women in the Study of Women's Health Across the Nation (SWAN).

OBJECTIVE: Our study evaluates the symptoms commonly attributed to adenomyosis in women undergoing the menopausal transition. We hypothesized that adenomyosis is more commonly seen in women with fibroids, pelvic pain, abnormal uterine bleeding, and in the presence of endometriosis. DESIGN: Retrospective cohort. SETTING: Multisite community-based study. PATIENT(S): Enrollees in the Study of Women's Health Across the Nation who had hysterectomies. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Relationship of adenomyosis to presenting symptoms and other patient characteristics. RESULT(S): Adenomyosis was found in 48% of 137 patients. Frequencies of presenting symptoms were similar in those with and without evidence of adenomyosis. The same prevalence of fibroids was seen in the presence or absence of adenomyosis: 37% versus 43%, endometriosis, 3% versus 5%, abnormal bleeding, 27% versus 33%, or chronic pelvic pain in the presence of fibroids 12% versus 17%. CONCLUSION(S): Adenomyosis is a common diagnosis seen in hysterectomized specimens from women undergoing the perimenopausal transition. Adenomyosis is equally common in women who also have fibroids, endometriosis, pelvic pain, or abnormal uterine bleeding, and women who do not. Therefore, adenomyosis is an incidental finding, not the source of the symptomatology. It appears not to be a "disease" per se but rather a normal variant.

Segment-specific effects of cardiovascular risk factors on carotid artery intima-medial thickness in women at midlife.

OBJECTIVE: We investigated associations between segment-specific carotid intima-medial thickness (IMT) and cardiovascular risk factors collected before menopause for insight into mechanisms of atherosclerosis development. METHODS AND RESULTS: Participants were 453 healthy women (aged 46 to 58 years) enrolled in a dietary and physical activity randomized clinical trial. Ultrasound scan measures were taken approximately 2.7 years after baseline in the common carotid artery (CCA), bifurcation (bulb), and internal carotid artery (ICA) segments. When scanned, 84% remained premenopausal. In linear regression models adjusted for age, menopausal status, and intervention group, measures independently (P<0.05) and positively associated were as follows: baseline weight (beta=0.007 per 5 kg), systolic blood pressure (SBP; beta=0.008 per 10 mm Hg), and age (beta=0.02 per 5 years) with CCA IMT; smoking (beta=0.08), weight (beta=0.009), and SBP (beta=0.02) with bulb IMT; and apoprotein B (beta=0.01 per 0.1 g/L) with ICA IMT. Differential effects in a repeated measures model with all 3 IMT locations showed these risk factors to have segment-specific positive associations. The effect of weight was strongest in the CCA, smoking and SBP were specific to the bulb, and apoprotein B was strongest in the ICA segment. CONCLUSIONS: Analyses indicate that cardiovascular risk factors may differentially affect IMT in the CCA, bulb, and ICA segments of healthy middle-aged women.