Etiology of and predictive factors for chronic intestinal failure requiring long term parenteral support in the last two decades: A retrospective study.

BACKGROUND & AIMS: Chronic intestinal failure (CIF) has been long-recognized, however the underlying etiology and risk factors have not been historically well-studied. We aim to study the underlying etiologies of CIF and predictive factors for long-term parenteral support (PS). METHODS: We retrospectively identified patients with newly diagnosed CIF who received PS to maintain nutrition at the Cleveland Clinic between 2000 and 2017. Long-term PS was defined as a duration of more than 3 months. Univariable and multivariable logistic regression analyses were performed to identify the predictors of the need for long-term PS. RESULTS: We identified 350 patients with CIF, 150 (43%) and 200 (57%) were diagnosed before and after 2010, respectively. The most common etiology was Crohn's disease (CD) in both cohorts (34.7% versus 30.5%, p = 0.41). Graft-versus-host-disease (GVHD) was a less frequent cause of CIF after 2010 (12.7% versus 2.5%, p = 0.0002). The type of PS was mostly total parenteral nutrition before and after 2010, 95% and 96%, respectively (p = 0.55). On univariable analysis, absence of ileocecal valve (p < 0.0001), ischemic bowel disease (p = 0.009), and whole colon resection (p = 0.033) were associated with the need for long-term PS. On multivariable analysis, absence of ileocecal valve (OR 2.19, p = 0.011) and ischemic bowel disease (OR 3.04, p = 0.003) remained statistically significant predictors of long-term PS. CONCLUSION: In our cohort of patients with CIF, CD remains the leading etiology over the last 20 years, whereas GVHD is less common after 2010. The absence of ileocecal valve and ischemic bowel disease were reliable predictive factors for requiring long-term PS.

Effects of Probiotics on Intestinal Failure-Associated Liver Disease in Adult Patients Receiving Prolonged Parenteral Support: A Tertiary Care Center Experience.

BACKGROUND: It has been hypothesized that dysbiosis plays a significant role in the pathogenesis of intestinal failure-associated liver disease (IFALD). Therefore, we aimed to investigate the effect of probiotics on IFALD in patients receiving parenteral support, namely home parenteral nutrition (HPN) and home intravenous fluids (HIVFs). METHODS: We retrospectively reviewed charts of patients with intestinal failure who received HPN or HIVF for >2 weeks at our tertiary center between January 2005 and August 2016. We excluded patients <18 years of age, patients with other causes of liver disease, patients who used probiotics for <30 days, patients with <6 months' follow-up, and those who had long-term antibiotic use (>30 days). Bivariable and multivariable logistic regression analyses were used in this study. RESULTS: A total of 282 patients who received parenteral support were included. Eighty-five percent of our sample received PN. A total of 78 (27.7%) patients used probiotics. The prevalence of IFALD in patients who used probiotics was 35.9% vs 54.4% in patients who did not use probiotics, P = .005. In multivariable analysis, only small-bowel length of 10-90 cm and HPN use showed a significant impact on IFALD, odds ratio (OR) = 4.394 (95% confidence interval [CI], 1.635-11.814; P = .003) and OR = 4.502 (95% CI 1.412-14.351; P = .011), respectively. CONCLUSION: Our study revealed that the prevalence of IFALD was comparable among the probiotic users and nonusers. Only small bowel length of 1090 cm and HPN use showed a significant impact on IFALD.

Feasibility and safety of a novel electromagnetic device for small-bore feeding tube placement.

BACKGROUND: Misplacement of enteral feeding tubes (EFT) in the lungs is a serious and potentially fatal event. A recent Food and Drug Administration Patient Safety Alert emphasized the need for improved technology for the safe and effective delivery of EFTs. OBJECTIVE: We investigated the feasibility and safety of ENvue, a novel electromagnetic tracking system (EMTS) to aid qualified operators in the placement of EFT. METHODS: This is a prospective, single-arm study of patients in intensive care units at two US hospitals who required EFTs. The primary outcome was appropriate placement of EFTs without occurrence of guidance-related adverse events (AEs), as confirmed by both EMTS and radiography. Secondary outcomes were reconfirmation of the EFT tip location at a follow-up visit using the EMTS compared with radiography, tube retrograde migration from initial location and AEs. RESULTS: Sixty-five patients were included in the intent-to-treat analysis. EFTs were successfully placed in 57 patients. In eight patients, placement was unsuccessful due to anatomic abnormalities. According to both the EMTS and radiography, no lung placements occurred. No pneumothoraces were reported, nor any guidance-related AEs. Precise agreement of tube tip location was achieved between the EMTS evaluations and radiographs for 56 of the 58 (96.5%) successful placements (one patient had two placements). Tube tip location was re-confirmed 12-49 hours after EFT insertion by the EMTS and radiographs in 48 patients (84%). For 43/48 patients (89.5%), full agreement between the EMTS and radiography evaluations was observed. For the five remaining patients, the misalignment between the evaluations was within the gastrointestinal tract. Retrograde migration from the initial location was observed in 4/49 patients (8%). CONCLUSION: A novel electromagnetic system demonstrated feasibility and safety of real-time and follow-up tracking of EFT placement into the stomach and small intestine, as confirmed by radiographs. No inadvertent placements into the lungs were documented. LEVEL OF EVIDENCE: Level V (large case series).

Hand-foot Syndrome Secondary to Low-dose Docetaxel in a Breast Cancer Patient.

Docetaxel-induced hand-foot syndrome (HFS) at low doses is a very rare side effect that usually occurs in a dose-dependent manner. HFS can be managed with conservative measures and may need chemotherapy discontinuation. In this report we present a case of HFS in a breast cancer patient after one dose of docetaxel.

Endoluminal Bariatric Interventions: Where do we stand? Where are we going?

BACKGROUND: Obesity is an epidemic leading to high morbidity, mortality, and therefore health-related costs. Thus, there is a huge need for development of safe and effective treatments. Even though success rates of conservative methods are highly limited, the surgical approaches lead to major complications in as many as 25% of the patients. In this study, we aimed to review the currently available, less-invasive, endoscopic bariatric techniques which provides an option to reduce the risks of the patients and the medical costs. METHODS: A systematic literature review through Pubmed and Medline was performed to find the studies on this topic, and all controlled clinical trials, case reports, and case series were reviewed. RESULTS: Endoluminal bariatric interventions include restrictive, malabsorptive approaches, and other techniques including transpyloric shuttle, botulinum toxin, gastric pacing and vagal nerve stimulation. Restrictive procedures act by limiting the gastric volume and leading to early satiety, while malabsorptive procedures create a malabsorption state. Transpyloric shuttle is a device decreasing the rate of gastric emptying. Botox injection causes a delay in gastric emptying, and vagal nerve stimulation modulates eating behavior. CONCLUSION: Endoluminal bariatric techniques can become the primary choice of therapy in the near future for bariatric care.

Skin cancer in immunosuppressed transplant patients: Vigilance matters.

Liver transplantation (LT) is a widely-accepted, definitive therapy of irreversible liver diseases including hepatitis C, alcoholic liver disease and metabolic liver disease. After transplantation, patients generally use a variety of immunosuppressive medications for the rest of their lives to prevent rejection of transplanted liver. Mortality after LT is mainly caused by recurrence of alcoholic hepatitis which is mostly seen in the patients who resume heavy drinking. On the other hand, de-novo malignancies after LT are not seldom. Skin cancers make up 13.5% of the de-novo malignancies seen in these patients. Malignancies tend to affect survival earlier in the course with a 53% risk of death at 5 years after diagnosis. We aimed to report a case who underwent LT secondary to alcoholic liver disease and developed squamous cell carcinoma of the skin eighteen years after transplantation. In summary, transplant recipients are recommended to be educated on self examination for skin cancer; health care providers should be further suspicious during routine dermatological examinations of the transplant patients and biopsies of possible lesions for skin cancer is warranted even many years after transplantation.