Safety and Efficacy of Midline vs Peripherally Inserted Central Catheters Among Adults Receiving IV Therapy: A Randomized Clinical Trial.

Importance: Midline catheters (MCs) are widely used, but safety and efficacy compared with peripherally inserted central catheters (PICCs) has not been adequately evaluated. Objective: To compare the safety and efficacy of MCs with PICCs among adult patients with an anticipated intravenous therapy lasting from 5 to 28 days. Design, Setting, and Participants: This parallel, 2-group, open-label, randomized clinical trial (RCT) was conducted in Denmark from October 2018 to February 2022 at a single academic tertiary care center. Adult inpatients and outpatients were consecutively randomized. Intervention: Patients were randomized in a 1:1 ratio to either the MC group or the PICC control group. Main Outcomes and Measures: The primary outcome was catheter-related bloodstream infection (CRBSI), analyzed using the Fisher exact test. Secondary outcomes were symptomatic catheter-related thrombosis and catheter failure, including mechanical cause, phlebitis, infiltration, pain in relation to drug or fluid administration, and leaking from the puncture site. Incidence rate ratios (IRRs) were calculated to assess between-group failure rates over device dwell time using Poisson regression. An intention-to-treat analysis was performed. Results: A total of 304 patients (mean [SD] age, 64.6 [13.5] years; 130 [42.8%] female) were included in the analysis, and 152 patients were allocated to each catheter group. The incidence of CRBSI was low, with 0 in the MC group and 1 in the PICC control group (P > .99). The MC group had a higher catheter-related complication rate (20 [13.2%] vs 11 [7.2%]), and an IRR of 2.37 (95% CI, 1.12-5.02; P = .02) for complications compared with the PICC control group. In a post hoc analysis stratified by catheter dwell time, no significant difference in complication rate (IRR, 1.16; 95% CI, 0.50-2.68; P = .73) was found between the 2 groups for catheters used less than 16 days. Conclusions and Relevance: In this RCT with patients who received medium- to long-term intravenous therapy, the incidence of CRBSI was low, with no difference between MCs and PICCs. The use of MCs resulted in a higher incidence of catheter-related complications compared with use of PICCs. This finding should be balanced in the decision of type of catheter used at the individual patient level. Trial Registration: ClinicalTrials.gov Identifier: NCT04140916.

Dissection of the coeliac trunk.

This is a case report of two men aged 39 and 43 years with dissection of the coeliac trunk involving the splenic arteries causing splenic infarction. One case was associated with an increase in abdominal pressure during defaecation and the other occurred during treatment with methylphenidate. Based on the published 43 cases, risk factors include male sex, increased intraabdominal pressure or increased vascular pressure. Methylphenidate most likely increased the blood pressure, and dissections of other arteries have been described during treatment with this and the similar drug amphetamine.

Prospective comparison of diagnostic tests for bile acid diarrhoea.

BACKGROUND: Bile acid diarrhoea is often missed because gold standard nuclear medicine tauroselcholic [75-Se] acid (SeHCAT) testing has limited availability. Empirical treatment effect has unknown diagnostic performance, whereas plasma 7α-hydroxy-4-cholesten-3-one (C4) is inexpensive but lacks sensitivity. AIMS: To determine diagnostic characteristics of empirical treatment and explore improvements in diagnostics with potential better availability than SeHCAT. METHODS: This diagnostic accuracy study was part of a randomised, placebo-controlled trial of colesevelam. Consecutive patients with chronic diarrhoea attending SeHCAT had blood and stool sampled. Key thresholds were C4 > 46 ng/mL and SeHCAT retention ≤10%. A questionnaire recorded patient-reported empirical treatment effect. We analysed receiver operating characteristics and explored machine learning applied logistic regression and decision tree modelling with internal validation. RESULTS: Ninety-six (38%) of 251 patients had SeHCAT retention ≤10%. The effect of empirical treatment assessed with test results for bile acid studies blinded had 63% (95% confidence interval 44%-79%) sensitivity and 65% (47%-80%) specificity; C4 > 46 ng/mL had 47% (37%-57%) and 92% (87%-96%), respectively. A decision tree combining C4 ≥ 31 ng/mL with ≥1.1 daily watery stools (Bristol type 6 and 7) had 70% (51%-85%) sensitivity and 95% (83%-99%) specificity. The logistic regression model, including C4, the sum of measured stool bile acids and daily watery stools, had 77% (58%-90%) sensitivity and 93% (80%-98%) specificity. CONCLUSIONS: Diagnosis of bile acid diarrhoea using empirical treatment was inadequate. Exploration suggested considerable improvements in the sensitivity of C4-based testing, offering potential widely available diagnostics. Further validation is warranted. CLINICALTRIALS: gov: NCT03876717.

Drug absorption from oral formulations in patients with short bowel syndrome: a comprehensive update of the literature.

INTRODUCTION: Drug absorption is often altered and typically diminished in patients with short bowel syndrome (SBS). It is important to understand the patient's gastrointestinal anatomy, the absorptive capacity of the remaining bowel, and the physicochemical and pharmacokinetic properties of the drug to optimize oral pharmacotherapy. AREAS COVERED: The primary focus was to provide an updated understanding of the absorption of various drugs in patients with short bowel syndrome. Forty-seven studies covering 13 different drug classes were included in the review and study details, patient characteristics, drug characteristics and pharmacokinetic findings were summarized for each drug class. EXPERT OPINION: Improving and simplifying drug treatment in patients with SBS have high priority, but the patients are multi diseased so knowledge regarding absorption of drugs as e.g. antithrombotic agents, immunosuppressants is urgently needed. Therefore, it is crucial to advance our understanding of the fundamental factors involved in drug absorption, spanning from drug design to pathophysiology. With the growing knowledge in drug design and gastrointestinal pathophysiology, we anticipate the development of computer models that can accurately predict optimal absorption in the future.

Efficacy and safety of colesevelam for the treatment of bile acid diarrhoea: a double-blind, randomised, placebo-controlled, phase 4 clinical trial.

BACKGROUND: Bile acid diarrhoea is a common but overlooked cause of chronic watery diarrhoea. Plasma 7α-hydroxy-4-cholesten-3-one (C4) is an alternative to the gold standard tauroselcholic [75Se] acid (SeHCAT) test. Low-certainty evidence supports sequestrant treatment, including colesevelam. We aimed to determine the efficacy and safety of colesevelam in bile acid diarrhoea. METHODS: In this randomised, double-blind, placebo-controlled, investigator-initiated phase 4 trial of the sequestrant colesevelam in bile acid diarrhoea (SINBAD), we enrolled consecutive patients aged 18-79 years without inflammatory bowel disease attending SeHCAT testing for suspected bile acid diarrhoea at four Danish secondary care centres. Participants were randomly allocated 1:1 to receive 12 days of treatment with colesevelam (overencapsulated tablets of 625 mg) or placebo, with the starting dose of two capsules twice daily and titrated to effect during the first 5 days of treatment. A pharmacist independent of the clinical investigators generated a randomisation list on the web page randomization.com using block randomisation (randomisation was not stratified). C4 and SeHCAT diagnostic results were blinded during treatment. We treated all patients with diarrhoea, with a daily mean of 3·0 or more bowel movements or 1·0 or more watery bowel movements (Bristol stool scale type 6 and 7). Remission was defined as the absence of both these criteria during treatment days 6-12. The primary outcome was the intention-to-treat remission rate in bile acid diarrhoea diagnosed by C4 concentration greater than 46 ng/mL. A secondary outcome was the intention-to-treat remission rate in bile acid diarrhoea diagnosed by SeHCAT retention of 10% or less. This trial is registered with ClinicalTrials.gov, NCT03876717. FINDINGS: Between Oct 25, 2018, and July 1, 2021, 168 patients were randomly assigned to receive colesevelam (n=84) or placebo (n=84). 41 patients had C4 concentration greater than 46 ng/mL (22 assigned to the colesevelam group and 19 to the placebo group). For the C4-defined primary outcome, 14 (64%) of 22 participants receiving colesevelam versus three (16%) of 19 participants receiving placebo achieved remission (adjusted odds ratio 9·1, 95% CI 1·9-62·8; p=0·011). For the SeHCAT-defined secondary outcome, 75 of the 168 participants had retention of less than 10% (37 assigned to the colesevelam group and 38 assigned to the placebo group); 22 (59%) of 37 participants receiving colesevelam achieved remission versus five (13%) of 38 participants receiving placebo (adjusted odds ratio 11·1, 95% CI 3·4-45·6; p=0·00020). There were no serious adverse events. Common adverse events were transient. For patients receiving colesevelam within the primary outcome population, five had abdominal pain, nine had bloating, and four had nausea. For patients receiving placebo, four had abdominal pain, four had bloating, and one had nausea. No participants with bile acid diarrhoea withdrew due to adverse events. INTERPRETATION: Colesevelam was superior to placebo at inducing remission of bile acid diarrhoea diagnosed with C4 concentration greater than 46 ng/mL. Secondary outcome data suggest similar efficacy treating SeHCAT-defined bile acid diarrhoea. Colesevelam was safe during the treatment. FUNDING: Fabrikant Vilhelm Pedersen og hustrus mindelegat; recommended by the Novo Nordisk Foundation.

Prevalence of sarcopenia in patients with chronic intestinal failure-how are SARC-F and the EWGSOP algorithm associated before and after a physical exercise intervention.

INTRODUCTION: Patients with chronic intestinal failure (IF) have a low degree of physical activity, decreased muscle mass, and decreased muscle strength, leading to a high risk of sarcopenia. We aimed to test the prevalence of sarcopenia by the use of SARC-F and EWGSOP and to investigate the association between the two at baseline and after 12 weeks of an exercise intervention. METHODS: Thirty-one patients with chronic IF completed 12 weeks of three weekly home-based individualized exercise sessions. Body composition was measured by bioimpedance analysis and physical function by handgrip strength (HGS) and timed up-and-go (TUG). Sarcopenia was assessed by SARC-F and EWGSOP. Multiple regression analysis was used to test for the association between the two tools. RESULTS: The prevalence of sarcopenia measured by EWGSOP was 59%. This prevalence did not change after the intervention. At baseline, 38.8% of patients were screened as at risk for sarcopenia by SARC-F. This decreased to 29.0% after the intervention (P < 0.001). A statistically significant increase was achieved in muscle mass (P = 0.017) and muscle mass index (P = 0.016). Furthermore, both TUG (P = 0.033) and HGS (P = 0.019) improved. CONCLUSIONS: Sarcopenia is prevalent in patients with chronic IF. EWGSOP finds more patients to be at risk of sarcopenia than SARC-F but was not sufficiently sensitive to measure changes induced by the physical intervention. The significant change in SARC-F may illustrate that patients, themselves, find an improvement in self-perceived health.

Personalized exercise intervention in HPN patients - A feasibility study.

BACKGROUND: Physical health status may be predictive of readmissions, psychological health and mortality in patients with short bowel syndrome. AIMS: This study aimed to investigate the feasibility and effect of an individualized exercise intervention and secondary, oral nutrition intake counseling on Timed-Up-and-Go (TUG) and 30 s Chair Stand Test (CST) as well as body-composition and EuroQol (EQ)-5D-5L, in patients with chronic intestinal failure (IF) type III receiving HPN and/or fluid therapy. METHODS: A 12-week individualized exercise intervention consisting on three weekly home based sessions, and nutrition counselling focusing on protein intake and reducing high stoma output, was performed. Weekly follow-up by phone was done on motivation to exercise. RESULTS: The study invited 71 patients, 44 accepted the invitation (62%), 37(52%) were included, and 31 (84%) completed the intervention. The exercise intervention was well tolerated. TUG improved from 8.9(SD 5.5) to 7.7(SD 3.8) (p = 0.033). CST improved by four repetitions (<0.001∗). A statistical, however not clinically relevant improvement was seen in muscle mass. No improvement was seen in (EQ)-5D-5L total, but insignificantly (p = 0.055) for physical function only. Protein intake improved by 10.6 g/day (p = 0.008). CONCLUSIONS: A 12 weeks individualized exercise intervention showed very feasible and beneficial in HPN patients. Physical function improved statistically and clinically, and oral protein intake improved. QoL overall did not improve, however COVID-19 was an uninvited partner throughout the study period, which may have influenced general QoL. As only 62% accepted the invitation to participate, home based exercise intervention may not apply to all patients.

Danish national guideline for the treatment of Clostridioides difficile infection and use of faecal microbiota transplantation (FMT).

Aim: This Danish national guideline describes the treatment of adult patients with Clostridioides (formerly Clostridium) difficile (CD) infection and the use of faecal microbiota transplantation (FMT). It suggests minimum standard for implementing an FMT service.Method: Four scientific societies appointed members for a working group which conducted a systematic literature review and agreed on the text and recommendations. All clinical recommendations were evalluated for evidence level and grade of recommendation.Results: In CD infection, the use of marketed and experimental antibiotics as well as microbiota-based therapies including FMT are described. An algorithm for evaluating treatment effect is suggested. The organisation of FMT, donor recruitment and screening, laboratory preparation, clinical application and follow-up are described.Conclusion: Updated evidence for the treatment of CD infection and the use of FMT is provided.

Oral absorption of oxycodone in patients with short bowel syndrome.

BACKGROUND: Short bowel syndrome is a disorder with several complications such as malnutrition and failure of drug therapy. Treatment with opioids is needed in many patients, and oral medication is preferred. However, optimal dosing is a difficult task as current guidelines are based on an intact gastrointestinal tract. Hence, the aim of this explorative case study was to assess the pharmacokinetics of orally administered oxycodone in patients with short bowel syndrome. METHODS: Six patients with short bowel syndrome were administered 10 mg oral solution oxycodone after an overnight fast. Oxycodone plasma concentrations were determined over a 6-hour period. Pharmacokinetic profiles were visually inspected. Pharmacokinetic parameters: maximum plasma concentration, time of maximum concentration and area under the curve were calculated. Data were also compared to mean values obtained in healthy participants. RESULTS: A clinically relevant concentration of oxycodone was found in all patients, although with large inter-individual variation. The absorption fraction tended to correlate positively with total intestinal length. Additionally, preservation of some or the entire colon seemed further to increase the absorption fraction. Time of maximum concentration varied from 30 min to approximately 90 min. CONCLUSIONS: Oxycodone is absorbed in a clinically relevant extent in patients with short bowel syndrome, but bioavailability varies greatly between patients, which shall be taken into consideration. Absorption is related to functional small intestinal length, but preservation of colon is also beneficial. Still, optimal therapeutic dosing must be individualized, and other factors such as those related to malnutrition and motility shall also be taken into consideration.

Biochemical Diagnosis of Bile Acid Diarrhea: Prospective Comparison With the 75Seleno-Taurohomocholic Acid Test.

INTRODUCTION: The diagnosis of bile acid diarrhea is often missed because the availability of the seleno-taurohomocholic acid (SeHCAT) test is limited. We aimed to compare the biomarkers 7α-hydroxy-4-cholesten-3-one (C4) and fibroblast growth factor 19 (FGF19) with the SeHCAT test. METHODS: Patients with chronic diarrhea without intestinal resection referred for SeHCAT were prospectively recruited for this diagnostic accuracy study. Blood was sampled at fasting and after a stimulation meal with chenodeoxycholic acid. SeHCAT retention ≤10% defined bile acid diarrhea and >10% defined miscellaneous diarrhea. Receiver operating characteristics (ROC) were analyzed with SeHCAT as the gold standard. www.clinicaltrials.gov (NCT03059537). RESULTS: Patients with bile acid diarrhea (n = 26) had mean C4 of 30 ng/mL (95% confidence interval: 19-46) vs 8 (7-11; P < 0.001) in the miscellaneous diarrhea group (n = 45). Area under the ROC curve (ROCAUC) for C4 was 0.83 (0.72-0.93). C4 < 15 ng/mL had 85% (74%-96%) negative predictive value; C4 > 48 ng/mL had 82% (59%-100%) positive predictive value. Twenty patients had C4 values 15-48 ng/mL, of whom 11/20 had SeHCAT ≤10%. Median fasting FGF19 was 72 pg/mL (interquartile range: 53-146) vs 119 (84-240) (P = 0.004); ROCAUC was 0.71 (0.58-0.83). Stimulated FGF19 responses did not differ (P = 0.54). DISCUSSION: We identified C4 thresholds with clinically useful predictive values for the diagnosis of and screening for bile acid diarrhea in patients with chronic watery diarrhea. Further validation of the cutoff values with the placebo-controlled effect of sequestrant therapy is warranted (see Visual Abstract, Supplementary Digital Content 2, http://links.lww.com/AJG/B603).

Restoration of enteroendocrine and pancreatic function after internal hernia and short bowel syndrome in a young woman with gastric bypass - a 2-year follow-up.

A serious complication to the laparoscopic Roux-en-Y gastric bypass (RYGB) is internal hernia, which can lead to massive bowel necrosis that may result in short bowel syndrome. We determined postprandial enteropancreatic hormonal responses and metabolites in a 22-year-old nondiabetic woman with a history of RYGB experiencing severe internal herniation with widespread bowel necrosis. Extensive resections were performed leaving her with a saliva fistula from the pouch-enteric anastomosis, an intact duodenum, 15 cm of jejunum, 35 cm of ileum, and intact colon. Parenteral nutrition was initiated and 10 months after the bowel resection, intestinal continuity was re-established. After 6 weeks the patient reached parenteral nutrition independence. She underwent standardized liquid mixed meal tests before, 3 months after and 2 years after intestinal continuity was re-established. Gut hormone responses were completely restored postoperatively leading to very high concentrations in plasma. After 2 years, plasma concentrations had, however, decreased markedly, suggesting desensitization of the gut ostensibly in response to chronic hyperstimulation. There was no evidence of cephalic phase insulin secretion.

The prevalence of sarcopenia is markedly increased in patients with intestinal failure and associates with several risk factors.

BACKGROUND & AIMS: Intestinal insufficiency and intestinal failure are conditions associated with malabsorption of micro- and macronutrients. Consequently, malnutrition and ensuing alterations in body composition are common in this context and patients may have an increased risk of progressive loss of skeletal muscle mass and function (i.e. sarcopenia). We investigated the prevalence of sarcopenia in patients with intestinal insufficiency and intestinal failure and identified associated risk factors. METHODS: This was a cross-sectional study including 113 clinically stable outpatients with intestinal insufficiency or intestinal failure. Body composition was assessed using bioelectrical impedance analysis and muscle function (strength or performance) using a handheld dynamometer and a timed up-and-go test. Sarcopenia was classified using the European Working Group on Sarcopenia in Older People criteria. Several parameters, including smoking, alcohol, and concurrent morbidities, were analyzed for association with sarcopenia. RESULTS: The prevalence of sarcopenia was 53.1% (95% CI; 43.8 to 62.2) in the combined patient group. In patients with intestinal failure the prevalence of sarcopenia was 72.7% (95% CI; 59.3 to 83.0) compared to 34.5% (95% CI; 23.3 to 47.8) in those with intestinal insufficiency (OR 5.07 [95% CI; 2.27 to 11.31]; p < 0.001). Excessive alcohol consumption (OR 7.69 [95% CI; 1.50 to 39.34]; p = 0.014), intestinal failure (OR 4.16 [95% CI; 1.69 to 10.28]; p = 0.002), and inflammatory activity (OR 3.83 [95% CI; 1.06 to 12.84]; p = 0.041), were identified as independent risk factors of sarcopenia. A trend was observed for hypermetabolism in multivariate analysis (OR 7.55 [95% CI; 0.79 to 72.03]; p = 0.079). CONCLUSIONS: Patients with intestinal insufficiency and intestinal failure are at immense risk of developing sarcopenia. Associated risk factors are excessive alcohol consumption, intestinal failure, and inflammatory activity.

Osteoporosis in patients with intestinal insufficiency and intestinal failure: Prevalence and clinical risk factors.

BACKGROUND & AIMS: Intestinal insufficiency and intestinal failure are associated with malabsorption of micro- and macronutrients that may negatively influence bone metabolism and increase the risk for developing osteoporosis. However, information regarding prevalence and contribution of individual risk factors is scarce. We investigated the prevalence of osteoporosis in patients with intestinal insufficiency and intestinal failure and identified associated risk factors. METHODS: This was a retrospective cross-sectional study including 167 clinically stable outpatients with intestinal insufficiency or intestinal failure. Bone mineral density (BMD) was measured by dual X-ray absorptiometry and the prevalence of osteoporosis was compared to a gender and age matched population. Several clinical and demographic parameters, including body mass index (BMI), vitamin-D, smoking habits and medications, were analyzed for association with BMD. RESULTS: The prevalence of osteoporosis was 56.9% in the combined patient group compared to 24.1% in the control group (OR 4.2 [95% CI, 2.3 to 7.7]; p < 0.001). BMD in the hip was independently associated with BMI (0.13 [95% CI, 0.09 to 0.18]; p < 0.001) and vitamin-D levels (-0.41 [95% CI, -0.76 to -0.06]; p = 0.03). Similar associations were seen for BMD in the spine (0.15 [95% CI, 0.08 - 0.22]; p < 0.001) and (-0.60 [95% CI, -0.76 to -0.06]; p = 0.02), respectively. Trends for low BMD were observed in smokers, and in patients using glucocorticoids, opioids, and proton pump inhibitors. CONCLUSIONS: Patients with intestinal insufficiency and intestinal failure are at immense risk of developing osteoporosis. Low BMI and vitamin-D deficiency were identified as independent risk factors.

Can We Rely on Predicted Basal Metabolic Rate in Patients With Intestinal Failure on Home Parenteral Nutrition?

BACKGROUND AND AIMS: Intestinal failure (IF) is a serious and common complication of short bowel syndrome with patients depending on parenteral nutrition (PN) support. Effective nutrition management requires an accurate estimation of the patient's basal metabolic rate (BMR) to avoid underfeeding or overfeeding. However, indirect calorimetry, considered the gold standard for BMR assessment, is a time- and resource-consuming procedure. Consequently, several equations for prediction of BMR have been developed in different settings, but their accuracy in patients with IF are yet to be investigated. We evaluated the accuracy of predicted BMR in clinically stable patients with IF dependent on home parenteral nutrition (HPN). METHODS: In total, 103 patients with IF were included. We used indirect calorimetry for assessment of BMR and calculated predicted BMR using different equations based on anthropometric and/or bioelectrical impedance parameters. The accuracy of predicted BMR was evaluated using Bland-Altman analysis with measured BMR as the gold standard. RESULTS: The average measured BMR was 1272 ± 245 kcal/d. The most accurate estimations of BMR were obtained using the Harris-Benedict equation (mean bias, 14 kcal/d [ P = .28]; limits of agreement [LoA], -238 to 266 kcal/d) and the Johnstone equation (mean bias, -16 kcal/d [ P = .24]; LoA, -285 to 253 kcal/d). For both equations, 67% of patients had a predicted BMR from 90%-110% All other equations demonstrated a statistically and clinically significant difference between measured and predicted BMR. CONCLUSIONS: The Harris-Benedict and Johnstone equations reliably predict BMR in two-thirds of clinically stable patients with IF on HPN.

Comparison of complications associated with peripherally inserted central catheters and Hickman™ catheters in patients with intestinal failure receiving home parenteral nutrition. Six-year follow up study.

BACKGROUND & AIM: Patients with intestinal failure (IF) are dependent on parenteral nutrition delivered through central access such as Hickman™ catheters. The peripherally inserted central catheter (PICC) is becoming increasingly popular for the purpose. The aim of the present study was to compare complication rates between the two types of catheters. PATIENTS AND METHODS: Over a six-year period (2008-2014), we included 136 patients with IF receiving home parenteral nutrition (HPN). These patients had a total of 295 catheters (169 Hickman™ catheters and 126 PICCs). Data were collected by reviewing their medical records. Incidences are given per 1000 catheter days. Data are given as means ± standard deviation (SD) and compared using independent student's t-tests, Mann-Whitney-Wilcoxon, and X(2)-tests. A survival analysis for time to the first infection was conducted using Cox regression. RESULTS: The total number of catheter days was 54,912 days for Hickman™ catheters (mean dwell time 325 ± 402) and 15,974 days for PICCs (mean dwell time 127 ± 121), respectively. The incidence of catheter-related blood stream infection (CRBSI) per 1000 catheter days was significantly lower for Hickman™ catheters compared to PICCs (0.56 vs. 1.63, p < 0.05). The mean time to first CRBSI was significantly shorter for PICCs compared to Hickman™ catheters (84 ± 94 days vs. 297 ± 387 days, p < 0.05), which was confirmed with a cox analysis corrected for age and gender. A total of 75 catheters were removed due to CRBSI, 49 Hickman™ catheters and 26 PICCs respectively. In addition, PICCs were more often removed due to local infection/phlebitis and mechanical causes (p < 0.001). CONCLUSION: We found a higher risk and shorter time to first CRBSI in PICCs compared to Hickman catheters supporting that PICCs should mainly be chosen for planned HPN up to 3-6 months. We therefore conclude that the choice of catheter must still be determined on an individual basis.

Environmental Risk Factors for Developing Catheter-Related Bloodstream Infection in Home Parenteral Nutrition Patients: A 6-Year Follow-up Study.

BACKGROUND: Tunneled, cuffed, central venous catheters, including Hickman catheters and peripherally inserted central venous catheters (PICCs), are the most commonly used venous access for home parenteral nutrition (HPN) therapy. Catheter-related bloodstream infection is the most prevalent and severe complication. This study investigated whether environmental risk factors, including smoking, catheter management by a home care nurse, colectomy with stoma, number of infusion days per week, and C-reactive protein at catheter insertion day, influenced the time to first catheter-related bloodstream infection (CRBSI). MATERIALS AND METHODS: In this 6-year (2008-2014) observational cohort study, adult patients with intestinal failure receiving HPN through either Hickman catheters or PICCs were included. Data were obtained by reviewing medical records, and the environmental risk factors were analyzed with the Cox proportional hazards model. RESULTS: A total of 295 catheters (Hickman catheters: n = 169 and PICCs: n = 126) inserted into 136 patients were registered. Using the PICCs, 1 additional infusion day per week showed to significantly decrease the time to first CRBSI by a factor of 2.47. Hickman catheters managed by a home care nurse had a significantly increased mean (SD) incidence of CRBSI of 1.45 (0.68) per 1000 catheter days. Hickman catheters not managed by a home care nurse had a mean (SD) incidence of 0.56 (0.24). CONCLUSION: Using the PICC, 1 additional infusion day per week decreased the time to first CRBSI, while having the Hickman catheter managed by a home care nurse increased the mean CRBSI incidence. No other risk factors were found.

Peripherally inserted central catheter for use in home parenteral nutrition: a 4-year follow-up study.

BACKGROUND: Peripherally inserted central catheters (PICCs) are a relatively new device for home parenteral nutrition (HPN). Usually, tunneled central catheters such as the Hickman catheter are used for this purpose. However, severe complications (eg, pneumothorax) have been reported in association with the insertion of the central catheter. In contrast, PICCs may offer some advantages due to the peripheral insertion. There are only few studies on the use of PICCs for HPN. METHOD: A retrospective study (2008-2012) was performed in our Center for Nutrition and Bowel Disease. Patients receiving parenteral nutrition through PICCs were identified, their files examined, and indication, dwell time, cause of removal, and complications recorded. RESULTS: Fifty-six patients (aged 28-81 years) had a total of 94 lines. Total catheter days were 9859. Mean catheter days per patient were 179.1, and mean dwell time of each line was 104.9 days (longest, 572 days). There were no major complications in relation to the insertion of the catheters. The catheters were removed due to catheter-related sepsis, mechanical reasons, and thrombotic complications in 1.7, 2.1, and 0.2 per 1000 catheter days, respectively. CONCLUSION: This study demonstrates that PICCs are appropriate for use in HPN for at least 3-4 months (a period that sometimes unexpectedly becomes long term). The complications equal those reported for tunneled central catheters. We conclude that PICCs are a relevant alternative to patients receiving HPN, especially if they cannot handle a central line. At present, the choice of catheter must be determined on an individual basis.

Reconstruction of short bowel syndrome after internal hernia in a pregnant woman with previous bariatric surgery.

INTRODUCTION: Bariatric surgery is most often performed with the laparoscopic Roux-en-Y gastric bypass. A complication to the laparoscopic Roux-en-Y gastric bypass is internal hernia, which occurs in up to 16% of the patients. Since the laparoscopic Roux-en-Y gastric bypass is performed in women of fertile age, internal hernia may occur during pregnancy. PRESENTATION OF CASE: A 22-year old woman with a history of laparoscopic Roux-en-Y gastric bypass suffered from massive internal hernia during pregnancy with widespread bowel necrosis. Extensive surgery was performed leaving the patient with an intact duodenum, 15cm of jejunum, 35cm of ileum and colon. Parenteral nutrition was initiated and ten months after the internal hernia, intestinal continuity was re-established. Ten weeks later the patient reached parenteral nutrition independence. DISCUSSION: Internal hernia after laparoscopic Roux-en-Y gastric bypass can be difficult to diagnose, especially during pregnancy and might be severe and life threatening for both mother and child. CONCLUSION: Obstetricians and abdominal surgeons must be aware of this condition. Surgery should be performed on a wide indication. When bowel necrosis is found it should be resected and in case of extensive bowel resection the patient should be evaluated in centres specialized in intestinal failure.