A systematic review of the cost and economic outcomes of home enteral nutrition.

OBJECTIVES: Studies are lacking in the health economic implications of home enteral nutrition (HEN) in home-residing and long-term care/institutionalized patients. The aims of this review were to determine the total costs, the cost-effectiveness and other economic outcomes for HEN. DESIGN: A systematic search of randomized trials and observational studies available from January 2000 to April 2016 was performed using standard literature and electronic databases. Inclusion criteria were adults receiving HEN with economic outcomes in the long-term care or home settings. There was no restriction to the control groups used in the studies. RESULTS: A total of 10 studies met the inclusion criteria. The majority of the studies were not specifically designed for economic evaluation. Cost per QALY was lower in residents residing in home compared to long-term care facilities, and HEN appeared to be cost-effective for those with pressure ulcers. Higher costs were incurred for patients with dementia on HEN. Lower hospitalization costs and infection rates were reported for patients who switched to commercial feeds from blenderized food. The availability of nutritional support teams may decrease overall costs but these studies were of poor study quality. CONCLUSIONS: The lack of good quality economic evaluation studies affected the ability to conclude the overall cost-effectiveness of HEN. There is a trend for cost-saving and improved clinical outcomes in some populations. HEN is unlikely beneficial for patients with dementia. The availability of a nutrition support team may lead to cost savings and improved clinical outcomes for HEN.

Pressure ulcer healing with an intensive nutrition intervention in an acute setting: a pilot randomised controlled trial.

OBJECTIVE: To investigate the feasibility of recruitment, retention, intervention delivery and outcome measurement in a nutritional intervention to promote pressure ulcer healing in an acute setting. METHOD: Some 50 tertiary hospital patients with stage II or greater pressure ulcer were randomised to receive either individualised nutritional care by a dietitian, including prescription of wound healing supplements; or standard nutritional care. Relevant nutritional and pressure ulcer (PU) parameters were collected at day 5, 10, 15, 22 and then weekly or until discharge. RESULTS: The median length of hospital stay was 14 days (1-70) with 29 patients discharged by day 15. There were 24 patients discharged before their PU fully healed. Per cent change in valid PU area and score measures from baseline to day 15 were chosen for outcome data analysis to account for varying initial size and severity of the wound and length of stay. There was a larger percentage reduction in PU measures in the intervention group, but this was not statistically significant. Little difference was found in nutritional intake between the control and intervention groups indicating a requirement to focus on effective delivery of the intervention in future studies. Future studies in the acute setting need to account for length of stay and ideally follow patients until full healing. CONCLUSION: Results indicate a positive association with nutrition intervention and PU healing and that a rigorously designed and adequately powered study is feasible. DECLARATION OF INTEREST: This research was supported by a grant from the Queensland Health, Health Practitioner Research Scheme. The authors have no conflicts of interest to declare.

Validation of an updated evidence-based protocol for proactive gastrostomy tube insertion in patients with head and neck cancer.

BACKGROUND/OBJECTIVES: Evidence-based practice guidelines are available to assist in the decision making for nutrition interventions in patients with head and neck cancer. Re-assessment of guideline recommendations is important with changing demographics, new treatment regimens, advancing radiotherapy techniques, such as helical intensity-modulated radiotherapy, and the emergence of new literature. The aim of this study was to validate the updated high-risk category definition in our local hospital protocol for the swallowing and nutrition management of patients with head and neck cancer to determine the ongoing predictive ability for identifying proactive gastrostomy requirement in a new cohort. SUBJECTS/METHODS: Patients attending a major tertiary hospital for head and neck cancer treatment from 2010 to 2011 were included (n=270). Data were collected on patient demographics (age and gender), clinical factors (tumour site, staging and treatment), nutrition outcome measures (weight, enteral feeding) and protocol adherence. Sensitivity and specificity were calculated and compared with the original validation study. RESULTS: Proactive gastrostomy tubes were inserted in 86 patients. Overall protocol adherence was 93%. Sensitivity improved to 72% (increase of 18%) and specificity improved to 96% (increase of 3%) compared with the original validation study where patients received three-dimensional (3-D) conformal radiotherapy. CONCLUSIONS: The results of this study confirm that the updated high-risk category in the protocol for the swallowing and nutrition management of patients with head and neck cancer remains valid to predict proactive gastrostomy in a mixed population receiving helical intensity-modulated radiotherapy and 3-D conformal radiotherapy. The protocol has an improved sensitivity and specificity and hence remains just as relevant for advanced techniques of radiation treatment delivery.

From Hospital to Home: Limited Nutritional and Functional Recovery for Older Adults.

BACKGROUND: The post-hospital period may be a vulnerable time for elders recovering from acute illness. Few studies have examined nutrition outcomes of older people at nutrition risk after acute hospitalisation. OBJECTIVES: This study aims to describe a) standard nutrition care received by recently discharged older medical patients, b) change in nutritional and functional status at six weeks post-discharge and c) clinical outcomes at twelve weeks post discharge. DESIGN: Prospective cohort study. SETTING: Two metropolitan teaching hospitals in Brisbane, Australia. PARTICIPANTS: Medical patients aged ≥65 years at risk of malnutrition (Malnutrition Screening Score ≥2) and discharged to independent living in the community. MEASUREMENT: Nutritional status (Mini Nutritional Assessment (MNA), weight, lean body mass), functional status (grip strength, walk speed, activities of daily living) and health-related quality of life assessed on discharge and six weeks post-discharge. Inpatient and post-discharge nutrition intervention was recorded. Death and unplanned admissions were measured at 12 weeks. RESULTS: Of the 42 consented participants, only 14% (n=6) received post-discharge dietitian review and 19% (n=8) received practical nutrition supports at home (meal delivery, shopping assistance) as part of standard care. While there was a small improvement in MNA (18.4±4.0 to 20.1±4.2, p=0.004) and walk speed (0.7±0.3 m/s to 0.9±0.3, p=0.004) at six weeks, there was no difference in mean weight, lean body mass, grip strength or activities of daily living. Five (15%) participants lost ≥5% body weight. By twelve weeks, 17 participants (46%) had at least one unplanned hospital admission and four (10%) had died. CONCLUSIONS: Few patients at nutrition risk received nutrition-focussed care in the post-hospital period, and most did not improve nutritional or functional status at 6 weeks.

Cost effectiveness of nutrition support in the prevention of pressure ulcer in hospitals.

BACKGROUND/OBJECTIVES: This study estimates the economic outcomes of a nutrition intervention to at-risk patients compared with standard care in the prevention of pressure ulcer. SUBJECTS/METHODS: Statistical models were developed to predict 'cases of pressure ulcer avoided', 'number of bed days gained' and 'change to economic costs' in public hospitals in 2002-2003 in Queensland, Australia. Input parameters were specified and appropriate probability distributions fitted for: number of discharges per annum; incidence rate for pressure ulcer; independent effect of pressure ulcer on length of stay; cost of a bed day; change in risk in developing a pressure ulcer associated with nutrition support; annual cost of the provision of a nutrition support intervention for at-risk patients. A total of 1000 random re-samples were made and the results expressed as output probability distributions. RESULTS: The model predicts a mean 2896 (s.d. 632) cases of pressure ulcer avoided; 12, 397 (s.d. 4491) bed days released and corresponding mean economic cost saving of euros 2 869 526 (s.d. 2 078 715) with a nutrition support intervention, compared with standard care. CONCLUSION: Nutrition intervention is predicted to be a cost-effective approach in the prevention of pressure ulcer in at-risk patients.

Pharmacological characterization of the N-methyl-D-aspartate (NMDA) receptor recognition site in porcine cerebral cortical membranes using [3H]-CGP 39653.

The high-affinity NMDA receptor competitive antagonist [3H]-CGP 39653 binds to Triton X-100 (0.04%) treated porcine cerebral cortex membranes in a saturable and reversible manner, with a KD of 6.1 +/- 0.97 nM and a Bmax of 944 +/- 55 fmol/mg protein. Association of ligand with the recognition site was rapid (estimated k1 = 1.1 x 10(7) M-1 min-1), and a steady state was reached within 30 min of incubation at 4 degrees C. Dissociation was also rapid (estimated k-1 = 0.2 min-1). The pharmacology of the binding site was similar to that for the rat brain, with mean pIC50 values (Hill slopes in parentheses, *indicating significant difference from unity) of 7.54 (0.51*), 6.99 (0.68*), 6.98 (0.71), 6.63 (0.80*), 6.31 (0.62*) and 5.17 (0.78) for R-CPP, L-glutamate, CGS 19755, cis-2,4-methanoglutamate, L-aspartate and NMDA, respectively. Other compounds (glycine, MK-801, kainate, S-AMPA and magnesium ions), previously observed not to interact competitively with the NMDA binding recognition site, showed a low affinity for the porcine cerebral cortex [3H]-CGP 39653 binding site. It is concluded that the pharmacological properties of the NMDA receptor recognition site labelled by [3H]-CGP 39653 are similar in the pig and rat cerebral cortices.

The effects of two inositol (1,4,5)-trisphosphate 5-phosphatase inhibitors on thyrotropin releasing hormone stimulated inositol (1,4,5)-trisphosphate production in GH3 cells.

The effects of FLA99 and EWP840, two disulfiram analogs which potently inhibit Ins(1,4,5)P3 5-phosphatase, upon basal and thyrotropin-releasing hormone (TRH)-stimulated inositol (1,4,5)-trisphosphate (Ins(1,4,5)P3) levels were investigated. Neither test compound affected the characteristics of the [3H]Ins(1,4,5)P3 binding site used in the competitive protein binding assay of Ins(1,4,5)P3 levels. In rat GH3 pituitary cell suspensions, TRH (100 nM) produced a large and time-dependent increase in Ins(1,4,5)P3 concentration, the maximum response being obtained within 5 seconds of stimulation in these cells. Neither FLA99 (100, 300 and 1000 microM) nor EWP840 (100 microM) produced obvious effects on the Ins(1,4,5)P3 response to TRH stimulation. Higher concentrations of EWP840 (300 and 1000 microM) abolished the Ins(1,4,5)P3 response to TRH stimulation. The lack of effect of the 5-phosphatase inhibition in the cells may indicate that 5-phosphatase is not the major metabolic pathway of this second messenger in this cell line under the assay conditions used.

Topical instillation of doxorubicin hydrochloride in the treatment of recurring superficial transitional cell carcinoma of the bladder.

Thirteen patients with recurring stage A transitional cell carcinoma of the bladder were treated with monthly bladder instillations of doxorubicin hydrochloride. Follow-up at 3-month intervals has shown excellent control of tumor recurrence with complete remissions for up to 21 months in 2 patients. The median for remission in 8 of 13 patients has been 10 months. Two patients with bladder papillomatosis were treated successfully by the same method.

Percutaneous transfemoral embolization of arterio-infundibular-venous fistula.

An arterio-infundibular-venous fistula complicating partial nephrectomy was embolized successfully via transfemoral catheterization of the right renal artery using autologous muscle. The use of autologous material occluded this vascular malformation with preservation of renal function in the remaining portion of the kidney. The technique was lifesaving since this patient was in critical condition and could not tolerate an operation.