A multi-national survey of experience and attitudes towards commencing home parenteral nutrition for patients with advanced cancer.

INTRODUCTION: Advanced cancer (AC) is increasingly an indication for home parenteral nutrition (HPN) but an area with possible variation in practice between geographical locations. The aims of this study are to explore the views and experiences of international multi-disciplinary teams to determine opinions and practices. METHODS: An online questionnaire was developed with members of the Home Artificial Nutrition and Chronic Intestinal Failure interest group of the European Society for Clinical Nutrition and Metabolism (ESPEN) and distributed to colleagues involved in managing patients with AC on HPN. RESULTS: A total of 220 responses were included from 5 continents including 36 countries, with 90% of all responses from Europe. Predicted survival was a key factor influencing the decision to commence HPN for most respondents 152/220 (75%), with the majority of participants reporting that patients should have a predicted survival of ≥3 months if considered for HPN (≥3 months: n = 124, 56% vs. <3 months: n = 47, 21%, p < 0.001). However, most respondents were not confident about predicting overall survival in more than 50% of cases (confident n = 40, 23% vs not confident n = 135, 77%, p < 0.001). Barriers to utilising HPN in AC included colleagues' objections (n = 91, 46%), lack of local expertise (n = 55, 28%) and funding restrictions (n = 34, 17%). CONCLUSIONS: Significant consensus was observed regarding AC as indication for HPN, while areas of variation exist. Survival prognostication is often used as an indication for commencing HPN in people with AC, although the majority of respondents were not confident in prognosticating, suggesting better clinical prognostication tools will be of assistance. Further studies are also required to better understand the obstacles faced by clinical teams to commencing HPN that may explain variations in clinical practice between countries, as well as adressing variation in funding.

[Severe malnutrition after gastric: the importance of lifelong follow-up]. / Ernstige malnutritie na gastric bypass.

Two cases are described of patients who present with severe malnutrition more than five years after undergoing a Roux-en-Y gastric bypass and who have deficiencies of both micronutrients (vitamins and minerals) and macronutrients (proteins). This problem appears to be caused by both iatrogenic malabsorption after gastric bypass as well as dysphagia due to a local anastomotic complication (stenosis and marginal ulcer). Although both the severity of the deficiencies and the timing are exceptional, we want to emphasize the importance of lifelong supplement use and follow-up after bariatric surgery. Given the important role of general practitioners in this, we argue for implementation of this topic in national guidelines to improve the quality of follow-up.

Risk factors for thiopurine-induced myelosuppression and infections in inflammatory bowel disease patients with a normal TPMT genotype.

BACKGROUND: Leucopenia is a common side effect in patients treated with thiopurines. Variants in the thiopurine S-methyltransferase (TPMT) gene are the best-known risk factor, but only explain up to 25% of leucopenia cases. AIM: To identify the clinical risk factors for thiopurine-induced leucopenia in patients without a common TPMT variant, and explore if these patients are at increased risk for infections. METHODS: Post hoc analysis of the Thiopurine response Optimisation by Pharmacogenetic testing in Inflammatory bowel disease Clinics (TOPIC) trial. For this analysis, patients without a variant in TPMT (*2, *3A or*3C) were included. Uni- and multivariate Cox-proportional hazard models were used to identify risk factors for leucopenia and infections. Leucopenia was defined as a white blood cell (WBC) count <3.0 × 109 /L and infections were classified according to the Common Terminology Criteria for Adverse Events. RESULTS: Sixty hundred and ninety-five patients (90.6%) included in the TOPIC-trial had no variant in TPMT, of which 45 (6.5%) developed leucopenia. Median time to leucopenia was 56 (29-112) days. Multivariate analysis showed that use of mercaptopurine compared to azathioprine was associated with leucopenia (hazard ratio [HR] 2.61 [95% CIs, 1.39-4.88; P < .01]) and a higher baseline WBC count was protective (HR 0.80 [95% CIs, 0.71-0.89; P < .01]). Risk factors for infections were older age (per 10 year; HR 2.07 [95% CIs, 1.18-3.63; P = .01]) and concomitant use of biologic drugs (HR 2.15 [95% CIs, 1.14-4.07; P = .02]). CONCLUSIONS: Low baseline WBC count and mercaptopurine, due to a relatively higher dose, were risk factors for thiopurine-induced leucopenia in patients without a TPMT variant.

Long-term olive oil-based parenteral nutrition sustains innate immune function in home patients without active underlying disease.

BACKGROUND & AIMS: It remains unclear whether impaired host defenses contribute to the increased risk for infectious complications seen in patients on home parenteral nutrition (HPN). The aim of this study was to compare the innate immune function of patients on olive oil-based HPN with that of healthy controls. METHODS: Innate immune functions and (anti-)oxidant balance were studied in 20 patients on olive oil-based HPN without an active underlying immune-mediated disease (Clinoleic(®), ≥ 6 months; >3 times/week), and 21 age- and sex-matched healthy controls. RESULTS: Neutrophils of patients and controls had a similar capacity to eliminate Streptococcus pneumoniae. Also, levels of activation markers (CD66b, CD11b, CD62L) in granulocytes and monocytes, phorbol ester- and zymosan-induced neutrophil oxygen radical production were not different between patients and controls. No differences in (anti-)oxidant status were found, except for higher concentrations of oxidized glutathione and lower plasma selenium and vitamin C in patients compared to controls. CONCLUSION: Compromised innate immune function does not seem to explain the increased risk for infectious complications in HPN patients using olive oil-based lipid emulsions.

Screening for psychosocial distress in patients with long-term home parenteral nutrition.

BACKGROUND & AIMS: Long-term home parenteral nutrition (HPN) may cause distress and negatively affect quality of life (QoL). The HPN version of the Distress Thermometer and Problem List (DT/PL) was developed to evaluate distress during HPN. This study validates the DT/PL, examines referral wish for additional care, assesses opinions on the DT/PL, and studies risk factors for distress and referral wish. METHODS: Dutch and Scottish patients completed questions on socio-demographic and HPN-related general characteristics, the DT/PL, referral wish, the Hospital Anxiety and Depression Scale, and opinions on the DT. RESULTS: The HPN version of the DT/PL seemed valid and the PL sufficiently reliable. Cut-off score appeared to be 6. Consequently, 45% of patients were diagnosed as clinically distressed. Fifty-three percent had a referral wish. Emotional and physical problems were most strongly associated with distress. Not being able to work related to elevated distress. Female gender and co-morbidity related to referral wish. Opinions on the DT were generally positive. CONCLUSION: The DT/PL appears to be a good instrument to regularly gain insight into distress and referral wish in HPN patients. Use of the DT/PL facilitates support to patients who most need and want it, thus improving quality of care and QoL.

[Current options for percutaneous endoscopic access to the digestive tract]. / Huidige mogelijkheden voor percutane endoscopische toegang tot de tractus digestivus.

Four patients, aged 67, 52, 56 and 64 years, respectively, undergoing percutaneous colostomy or jejunostomy are presented to illustrate current options for percutaneous endoscopic access to the digestive tract. The first patient had Parkinson's disease and required percutaneous jejunostomy for continuous post-pyloric administration of medication. The second patient had impaired gastric emptying due to gastric graft-versus-host disease following bone marrow transplantation. He was successfully treated with percutaneous jejunostomy, which was removed 2 years later after full recovery. The third patient had severe constipation due to the use ofmorphinomimetic analgesics. She received percutaneous caecostomy for colonic lavage and desufflation. The fourth patient had combined constipation and sphincteric insufficiency. Although the percutaneous endoscopic colostomy was clinically successful, the catheter had to be removed due to local pain and abscess formation.

[Treatment of intestinal failure in adults. II. Pharmacological treatment options]. / De behandeling van darmfalen bij volwassenen. II. Medicamenteuze opties.

For patients with severe intestinal failure caused by short-bowel syndrome, pharmacological treatment options are available that can reduce the period in which parenteral nutrition is required. Appropriate agents include acid inhibitors, bile-salt binders, inhibitors of motility and secretion, antibiotics and pre- and probiotics. A number of intestinotrophic factors have also been identified that are reported to enhance the functional adaptation of the intestine following surgery or illness. These include glutamine, growth hormone, and glucagon-like peptide 2 and its analogues. Absorption of certain agents is reduced when specific portions of the intestine are lacking. For example, fat-soluble cyclosporine is poorly resorbed in patients without an ileum.

Recurrent pancreatitis after trimethoprim-sulfamethoxazole rechallenge.

We report a female patient who repeatedly developed pancreatitis after trimethoprim-sulfamethoxazole (TMP/SMX) use. During childhood she had undergone an ureterosigmoidostomy after which she had been on TMP/SMX 480 mg daily as prophylaxis for pyelonephritis for many years. The patient presented with abdominal pain caused by acute pancreatitis. No other cause, except for TMP/SMX use, could be identified. A causal relationship was confirmed by relapse of the pancreatitis after rechallenge. Our case is unique in demonstrating that acute pancreatitis related to the use of TMP/SMX may occur even after long-term treatment. We advise that the medication is discontinued immediately if a causal relationship with pancreatitis is suspected.

[Ocular infection by Pseudomonas aeruginosa in a mechanically ventilated patient]. / Ooginfectie door Pseudomonas aeruginosa bij een mechanisch beademde patiënt.

A 59-year-old man developed bilateral keratitis several weeks after the initiation of mechanical ventilation because of respiratory failure and sepsis following abdominal surgery. Colonisation of the upper airways by P. aeruginosa had been established before. Invasion through corneal epithelial defects based on dehydration keratitis was the presumed route of infection. Despite aggressive treatment, including antibiotics, the infection was rapidly progressive in both eyes. The patient died of deterioration of his general condition. In order to prevent such eye infections in a patient on mechanical ventilation, there is a need of good eye care, prevention of corneal lesions and alertness, especially when the patient is colonised by virulent micro-organisms like P. aeruginosa.

Optimizing screening procedures for Staphylococcus aureus nasal carriage in patients on haemodialysis.

BACKGROUND: So far it remains unclear what the optimal screening method for detection of S. aureus nasal carriage in patients on haemodialysis is with regard to number of cultures performed, culture interval, and necessity of a broth-enrichment procedure. METHODS: A prospective, uncontrolled study was performed at the renal unit of a tertiary care centre, including all haemodialysis patients (n=91) attending the unit during the study period. The purpose was to determine the optimal screening method for S. aureus nasal carriage in patients on haemodialysis. RESULTS: When compared to the conventional culture method, inclusion of a broth-enrichment procedure increased the number of cultures positive for S. aureus significantly (31 vs 24%, P<0.0001). Of 91 patients 37% were S. aureus carriers (defined as at least 1 of 5 cultures positive), 33% were stable carriers (defined as at least 2 of 5 cultures positive). Fourth and 5th cultures, taken at subsequent dialysis sessions, captured only two additional carriers (6% of all carriers). With respect to culture results and identification of carrier status a short (1-h) and a long (>24-h) sampling procedure showed no significantly different results. CONCLUSIONS: S. aureus nasal carriage in haemodialysis patients can be conveniently established with three nasal cultures taken with 1-h intervals, and the inclusion of a broth-enrichment procedure.

Antineutrophil cytoplasmic autoantibodies with myeloperoxidase specificity in a patient with anti-glomerular basement membrane disease.

An unusual case is described of a patient with both anti-glomerular basement membrane (GBM) disease and anti-neutrophil cytoplasmic autoantibodies with myeloperoxidase specificity (MPO-ANCA) presenting with acute renal failure. Four years before a seronegative arthritis of the left wrist was diagnosed. Tests for ANCA by indirect immunofluorescence were repeatedly negative. The diagnosis was made by renal biopsy and by testing the serum with specific enzyme-linked immunosorbent assays (ELISA) for MPO-ANCA and anti-GBM antibodies. To our knowledge, this is the first patient presenting with such findings in the Dutch literature.