Carla Aeberhard

Management of Home Parenteral Nutrition: A Prospective Multicenter Observational Study.

Background: There are no specific Swiss home parenteral nutrition (HPN) data showing patient characteristics, quality of life (QoL) and complications. The goal of this study was to collect representative nationwide data on current adult HPN patients in Switzerland for international comparability and benchmarking. Methods: This was a multicenter, nationwide, observational study. We conducted interviews for demographics, PN characteristics, QoL and complications. The data were assessed at baseline and after a follow-up of 3 months using a questionnaire. Results: Thirty-three adult patients were included. The most common underlying diseases were cancer, radiation enteritis and state after bariatric surgery, and the most prevalent indication was short bowel syndrome. During the 3-month observation period, significant increase or stabilization of body weight occurred in the patients, physical activity scores improved from 34.0 to 39.4 and mental scores improved from 41.9 to 46.4. HPN dependency and traveling restrictions were of the greatest concern. Diarrhea, xerostomia and/or thirst were frequent complaints. Conclusion: Anthropometric parameters and QoL improved during the observational period in this HPN cohort. These Swiss HPN data are prerequisite for evaluation and comparison of HPN recommendations and best clinical practice, status of professional care instructions related to HPN effectiveness, quality of treatment and patient safety.

Physicochemical stability and compatibility testing of levetiracetam in all-in-one parenteral nutrition admixtures in daily practice.

Background: Parenteral antiepileptic drugs are frequently used in critically ill patients for seizure control therapy or prevention. Many of these patients require additional parenteral nutrition (PN). Therefore, a parallel infusion of the frequently used antiepileptic drug levetiracetam (LEV) is interesting in terms of the restricted i.v. lines (e.g., neonates). The potential interactions of the complex PN admixture with the drug product and the appropriate admixing of a drug at effective dosages require physicochemical lab assessments to obtain specific and reliable pharmaceutical documentation for the intended admixing. Aim: To assess the of compatibility and stability of LEV, a neutral and hydrophilic drug, in commercial all‐in‐one (AiO) PN admixtures using simple validated tests to provide necessary data in a timely manner and to allow convenient, documented and safe treatment with PN as the drug vehicle. Methods: Different concentrations of LEV were injected into two different AiO PN admixtures with no further additives. Stability and compatibility tests for the drug and the PN admixtures were performed over seven days at +4 °C, +23 ± 1 °C and +37 °C without light protection. Stability and sample characteristics were observed by visual inspection and the validated light microscope method. Moreover, the pH level of the admixture was checked, as were the concentrations of LEV over time in the PN admixtures, using an established LC‐MS/MS method. Results: The stability controls of LEV at different temperatures were within absolute ±20% of the theoretical value in a concentration range of 98.91–117.84% of the initial value. No changes in pH occurred (5.55 ± 0.04) and no microscopic out of specification data or visual changes were observed. The mean value of the largest lipid droplet in each visual field over seven days was 2.4 ± 0.08 &mgr;m, comparable to that of the drug‐free AiO admixture. Samples stored at +37 °C showed yellowish discolorations after 96 h of storage. Conclusion: LEV showed compatibility and stability over seven days in the selected PN admixtures, and the described methods represented a valuable and timely approach to determine the stability and compatibility of the highly hydrophilic, not dissociated LEV in AiO admixtures under conditions of use. Further studies with clinically relevant and representative examples of physicochemically different drug classes are needed. Graphical abstract Figure. No caption available.

Practical scores for the detection of malnutrition

Malnutrition occurs in 30 - 60 % of hospitalized medical or surgical patients, as well as out-patients. Serious consequences at various levels were observed. Malnutrition influences negatively the quality of life, the immune system, muscle strength and worsens the prognosis of the patient. Interventions for a rapid and simple identification and effective treatment of this condition are essential and cost saving. Screening tools for the identification of patients at nutritional risk are very useful in daily practice. The systematic identification of patients with potential or apparent malnutrition is very important allowing an effective nutritional treatment at an early time. The medical team in charge should perform the nutritional risk screening and the following assessment to recognize the nutritional problems and to solve them in an interdisciplinary and -professional team.

Home parenteral nutrition is beneficial in systemic sclerosis patients with gastrointestinal dysfunction.

Objectives: To assess 12-month changes in nutritional status and quality of life (QoL) in systemic sclerosis (SSc) patients requiring home parenteral nutrition (HPN). Method: We conducted a retrospective, single-centre database analysis of SSc patients regarding a 12-month period of HPN at an interdisciplinary University Unit/team for nutrition and rheumatic diseases. Nutritional status was analysed by nutritional risk screening (NRS) and body mass index (BMI). QoL was evaluated using Short-Form Health Survey (SF-36) questionnaires. Results: Between 2008 and 2013, daily nocturnal HPN was initiated in five consecutive SSc patients (four females and one male, mean age 62.2 years) suffering severe malnutrition due to gastrointestinal tract (GIT) involvement. After 12 months of HPN, the mean NRS score decreased from 4.4 (range 4–5) to 1.4 (range 1–2), the mean BMI increased from 19.1 (range 17.4–20.3) to 21.0 kg/m2 (range 18.3–23.4). QoL improved in all patients, reflected by the summary of physical components with 33.92 points before vs. 67.72 points after 12 months of HPN, and the summary of mental components with 49.66 points before vs. 89.27 points after 12 months of HPN. Two patients suffered one catheter-related infection each with subsequent surgical removal and reinsertion. Conclusions: HPN is a feasible method for improving anthropometric parameters and QoL in SSc patients severely affected by GIT dysfunction. We recommend HPN in malnourished, catabolic SSc patients unable to otherwise maintain or improve their nutritional status.

Not to be taken lightly

A 78 year old patient with type 2 diabetes mellitus was hospitalized because of weakness and poor nutritional status. For several years, he suffered from an unintended weight loss and chronic, pulpy diarrhea. On examination, we found a severe loss of muscle and fat tissue as well as difficulty swallowing. An adequate nutritional therapy with combined parenteral and enteral nutrition was implemented under regular monitoring of electrolytes and volume status, under which the state of health improved noticeably, while steatorrhea improved under substitution of pancreatic enzymes.

Effect of preoperative immunonutrition on postoperative short-term outcomes of patients with head and neck squamous cell carcinoma.

Patients with head and neck squamous cell carcinoma (HNSCC) often acquire an impaired nutritional status resulting in compromised outcomes. Perioperative immunonutrition may have a positive effect on outcomes after elective surgery.

Vitamin-D-Mangel in der Schweizer Sonnenstube?

Zusammenfassung. In dieser Studie wurden die Pravalenz sowie saisonale Fluktuationen des VitD-Mangels bei Bewohnern des Tessins evaluiert. Klinische Indikatoren zur Erkennung eines VitD-Mangelzustands wurden untersucht (Alter, Geschlecht, Hauptdiagnose, Komorbiditaten, Medikamentenanzahl). Beim Eintreffen auf der Notfallstation des Regionalspitals Bellinzona wurde bei je einer Population alterer internistischer Patienten eine einmalige VitD-Serumspiegelbestimmung im Fruhling (n = 58) und im Herbst (n = 49) durchgefuhrt. Die Pravalenz des VitD-Mangels im Fruhling betrug 98 % (Serumspiegelmittelwert 21,4±12,2 nmol/l) versus 63 % im Herbst (Serumspiegelmittelwert 43,7±18,6 nmol/l). Auch nach dem Sommer litten 66 % der Patienten an einem VitD-Mangel. Es konnten keine verlasslichen Indikatoren eruiert werden. Angesichts dieser Ergebnisse und der BAG-Empfehlungen ist eine Prophylaxe mit 800 IE taglich bei allen alteren Schweizern, v.a. im Winter, sinnvoll. Diese Praventionsmassnahme ist kostengunstig, einfach, ...

An Uncommon Diagnosis

We report on a 61-year-old patient who suffered from severe protein-energy malnutrition due to an inadequately treated exocrine pancreatic insufficiency. In this context, a thiamine deficiency was not recognized and there were clinical manifestations of beriberi disease with decompensated biventricular heart failure. In the course of time, a manifest niacin deficiency (pellagra) with dermatitis, diarrhea and persistent delirium occurred, which was recognized and could be treated. We highlight differential diagnostic considerations about the consequences and the treatment of malnutrition, with special focus on the classical deficiency diseases beriberi and pellagra.

Ernährung in der Palliativmedizin

1/14 10 Eine Protein-Energie-Mangelernährung (PEM) lässt sich bei zirka 40 bis 80 Prozent der Krebspatienten beobachten (2). Patienten in der Palliativmedizin weisen eine Vielzahl von ernährungsmedizinischen Problemen auf. Symptome wie Müdigkeit, Schmerzen, Appetitlosigkeit und Gewichtsverlust zeigen sich bei fast allen Patienten, während Übelkeit, Erbrechen, Obstipation und Diarrhöe bei rund der Hälfte der Patienten in den letzten Lebenswochen beobachtet werden (3). Da eine adäquate Nahrungsaufnahme in dieser Patientengruppe zu einem immer grösseren Problem wird und sogar zu sozialen Spannungen zwischen Angehörigen und Therapeuten führt, wird die Ernährung zu einem integralen Bestandteil einer interdisziplinären, interprofessionellen, medizinischen Behandlung (4). Die 3 Phasen der Kachexie bei Tumorpatienten Je nach Art des Tumors sind etwa 10 bis 80 Prozent der Patienten von einer Kachexie betroffen, und bis zu 20 Prozent der Patienten können daran sterben (5). Die vorklinische Kachexie wird von einem mässigen Gewichtsverlust (≤ 5%), einer leichten Inappetenz und metabolischen Veränderungen geprägt. Das multifaktorielle, krankheitsassoziierte Anorexie-Kachexie-Syndrom ist hingegen durch eine stärkere Abnahme des Körpergewichtes (> 5%), durch einen Verlust von Fettund Muskelmasse sowie einer Funktionseinschränkung charakterisiert, die durch einen gesteigerten Proteinabbau und durch eine systemische Entzündung hervorgerufen wird (Abbildung 1) (6). Dem zugrunde liegen sowohl metabolische Veränderungen als auch eine verminderte Nahrungsaufnahme, die zu einer katabolen Stoffwechsellage führen. Diese pathophysiologischen Veränderungen können zu zunehmender Inappetenz, Asthenie, Müdigkeit, Geschmacksund Geruchsveränderungen, Schluckbeschwerden, Mundtrockenheit (Xeros-tomie), Brechreiz, Erbrechen, Gastroparese mit Völlegefühl, Abdominalschmerzen, Verstopfung sowie zu Durchfall führen. Ausserdem kommt dazu, dass eine vorliegende Hypoalbuminämie eine reduzierte Medikamentenwirksamkeit hervorrufen kann. All dies hat eine verminderte Lebensqualität zur Folge (7, 8). Die letzte Phase, die irreversible, späte Kachexie, ist von einem schweren katabolen Metabolismus, einem verminderten Ansprechen auf die Therapie und durch eine kurze Lebenserwartung (< 3 Monate) gekennzeichnet. Adäquate ernährungsmedizinische Massnahmen im Sinne eines multimodalen Ernährungsmanagements sollten bereits in der Phase der vorklinischen Kachexie oder spätestens in der Phase des Anorexie-Kachexie-Syndroms begonnen werden, um schwere Verläufe zu verhindern (Abbildung 2) (9). In der ersten Phase ist eine individuelle Ernährungstherapie mehr als präventive Ernährung zu verstehen mit dem Ziel, einen Gewichtsverlust zu verhindern, um die noch bestehende Ernährung in der Palliativmedizin