Home parenteral nutrition and employment in patients with intestinal failure: Factors associated with return to employment.

BACKGROUND & AIMS: Home parenteral nutrition (HPN) is provided to patients with intestinal failure (IF). HPN can however affect the patients' quality of life and ability to remain in employment. The aim of this study was to determine the effect of HPN on employment and factors associated with the likelihood of maintaining or returning to employment while on HPN. METHODS: Patients with chronic IF were identified from a prospectively maintained IF Unit database. A structured questionnaire was designed to probe employment both before and after starting HPN, intention to work and social welfare status (benefits & pensions). RESULTS: A total of 196 (62.8% females, median age 53 years) patients participated in the study of which 184 (94%) patients were in full or part time employment before their illness. At the time of starting HPN, 102 (52%) patients had the desire to return to work with 19 (18%) and 48 (47%) patients returning to full time or part time employment respectively. Multivariate analysis demonstrated that the frequency of the HPN infusion per week (p = 0.045) and intention to work after starting HPN (p = 0.001) were significantly associated with returning to work. CONCLUSIONS: Patients on HPN can have their employment status affected. The number of days per week on HPN and the desire of the patient to return to employment are significantly associated with employment.

Mesenteric Infarction: Clinical Outcomes After Restoration of Bowel Continuity.

INTRODUCTION: Patients who have a bowel resection for mesenteric infarction may require parenteral nutrition (PN). This study primarily aimed to determine the aetiological factors for a mesenteric infarction and the effects of restoring bowel continuity on the long-term PN requirements. METHODS: A retrospective review of data on patients treated for mesenteric infarction from 2000 to 2010. RESULTS: A total of 113 patients (61 women, median age 54 years) were identified. Seventy-four (65%) had a superior mesenteric artery thromboembolism, 25 (22%) had a superior mesenteric vein thrombosis, and 4 (3%) had superior mesenteric artery stricture or spasm. Patients younger than 60 years most commonly had a clotting abnormality (n = 23/46, 50%), whereas older patients had a cardiological risk factor (n = 11/17, 65%). All patients with a jejunostomy required long-term PN. Fifty-seven (49%) patients had restoration of bowel continuity (colon brought into circuit). After this, PN was stopped within 1 year in 20 (35%), within 2 years in 29 (50%) patients and within 5 years in 44 (77%) patients (P = 0.001). CONCLUSIONS: A thrombotic tendency is the main etiological factor in most patients younger than 60 years. An anastomosis of the remaining jejunum to the colon can allow PN to be stopped.

Assessment of long chain n-3 polyunsaturated fatty acid status and clinical outcome in adults receiving home parenteral nutrition.

BACKGROUND & AIMS: Long term parenteral nutrition rarely supplies the long chain n-3 polyunsaturated fatty acids (PUFA), eicosapentaenoic acid (EPA), docosapentaenoic acid (DPA) and docosahexaenoic acid (DHA). The aim of this study was to assess long chain n-3 PUFA status in patients receiving home parenteral nutrition (HPN). METHODS: Plasma phospholipid fatty acids were measured in 64 adult HPN patients and compared with 54 age, sex and BMI matched controls. Logistic regression analysis was used to identify factors related to plasma fatty acid fractions in the HPN patients, and to identify factors associated with the risk of clinical complications. RESULTS: Plasma phospholipid fractions of EPA, DPA and DHA were significantly lower in patients receiving HPN. Factors independently associated with low fractions included high parenteral energy provision, low parenteral lipid intake, low BMI and prolonged duration of HPN. Long chain n-3 PUFA fractions were not associated with incidence of either central venous catheter associated infection or central venous thrombosis. However, the fraction of EPA were inversely associated with plasma alkaline phosphatase concentrations. CONCLUSIONS: This study demonstrates abnormal long chain n-3 PUFA profiles in patients receiving HPN. Reduced fatty acid intake may be partly responsible. Fatty acid metabolism may also be altered.

Restraint in order to feed: justifying a lawful policy for the UK.

In the UK, restraining medical patients in order to provide care is widely considered to be outmoded and difficult to justify. The prevailing clinical intuition that restraining patients is generally wrong (even when restraint is essential in order to provide artificial nutrition and hydration) has prompted us to develop a policy that is compatible with common law, the Mental Capacity Act 2005 and the Human Rights Act 1998. The nature and scope of the problem are illustrated with clinical cases. These, in turn, serve to demonstrate the tension that arises between article 2, article 3 and article 8 rights, when incompetent patients are restrained in order to feed.

Assessment of polyglycolic acid mesh and bioactive glass for soft-tissue engineering scaffolds.

Sufficient neovascularization of neotissue is currently a limiting factor for the engineering of large tissue constructs. 45S5 Bioglass has been investigated extensively in bone tissue engineering but there has been relatively little previous research on its application to soft-tissue engineering. The objectives of this study were to investigate the use of 45S5 Bioglass in soft-tissue engineering scaffolds using in vitro and in vivo models. A fibroblast cell line (208F) was used for in vitro evaluation of surfaces coated with 45S5 Bioglass. Increased proliferation of fibroblasts was observed after growth on polystyrene surfaces coated with low concentrations (0.01-0.2%wt/vol) of 45S5 Bioglass for 24 h in vitro, determined as a change in total cell number by measuring lactate dehydrogenase. At higher concentrations of 45S5 Bioglass and longer periods of incubation (48 and 72 h) on coated surfaces, cell proliferation was reduced. Light microscopy revealed that the morphology of fibroblasts grown on 45S5 Bioglass-coated surfaces was not altered at low concentrations, but at higher concentrations fibroblasts became vacuolated. Enzyme-linked immunosorbent assay of conditioned culture medium collected from fibroblasts grown for 24 h on surfaces coated with low concentrations of 45S5 Bioglass (0.01%wt/vol) was found to contain significantly higher concentrations of vascular endothelial growth factor. Histological examination of polyglycolic acid (PGA)/45S5 Bioglass composite scaffolds that had been implanted subcutaneously into rats revealed that 45S5 Bioglass-coated meshes were well tolerated. Light microscopy revealed that neovascularization into 45S5 Bioglass-coated meshes was significantly increased at 28 and 42 days. Electron microscopy revealed fibroblasts adhering closely to the PGA mesh but not to 45S5 Bioglass particles. The apparent ability of 45S5 Bioglass incorporated into scaffolds to increase neovascularization would be extremely beneficial during the engineering of larger soft-tissue constructs.