Jonathan Shaffer

Home parenteral nutrition in adults: a multicentre survey in Europe in 1993

A retrospective survey was performed in 1994, involving 496 adult home parenteral nutrition (HPN) cases, newly enrolled in the year 1993 from 13 European countries from 75 centres. From the 8 countries having registered more than 80% of cases (423 patients), incidence and prevalence ranged from 0.2 to 4.6 and 0.3 to 12.2 patients/10(6) population/year. In the patients studied, the diagnosis was cancer (42%), Crohns disease (15%), vascular diseases (13%), radiation enteritis (8%), AIDS (4%) and other nonmalignant non-AIDS diseases (18%). Short bowel syndrome and intestinal obstruction were the two major indications for HPN in 31% and 22%, respectively. Seventy-three percent of the centres had a nutrition team. HPN was administered through a tunnelled venous central catheter in 73%, cyclical nocturnal infusions were used in 90% of patients, and intravenous feeding was the sole source of nutrition in 33%. Only 44% undertook HPN unaided. The present report indicates that cancer has now become the main indication for HPN in Europe; there was, however, a heterogeneous distribution of diseases amongst the reporting countries. The observed 9 (6-12)-month probability of survival was poor in AIDS (n = 8; 12%) and cancer patients (n = 78; 29%) but better for the other HPN indications (n = 115; 92%).

Infliximab use in Crohn's disease:impact on health care resources in the UK

Objective To quantify the impact of infliximab therapy on health care resource utilization in the UK. Methods A retrospective audit was undertaken at seven centres in the UK, which reviewed patient notes for a period of 6 months before and 6 months after an initial infliximab infusion. Details of hospital admissions, outpatient visits, operations, diagnostic procedures, drug usage, and overall efficacy were collected. Results were compared for the two 6 month study periods. Results A total of 205 patients (62% female, median age 33 years) with moderate/severe Crohns disease were audited. The majority of patients had chronic active disease (62%) and most received one infusion initially (72%). Clinicians rated 74% of responses as good to excellent and patients 72%. Most patients had concomitant immunosuppression (pre: 75%, post: 75%). Approximately half of the patients (45%) stopped taking steroids, with a further 34% having a dosage reduction. A fall of 1093 inpatient days was seen (1435 vs. 342) in the 6 months following infliximab administration. There were seven fewer operations, 33 fewer examinations under anaesthetic, and 99 fewer diagnostic procedures. Outpatient visits were similar pre- versus post- (555 vs. 534). The total reduction in direct costs amounted to an estimated £591 006. Three hundred and fifty-three infliximab infusions were administered at an estimated cost of £562 719. Thus, there was a net reduction of £28 287 or £137.98 per patient. Conclusions Infliximab appears to be a potentially cost effective treatment for selected patients based on the reduced number of inpatient stays, examinations under anaesthetic, and diagnostic procedures over a 6 month period.

Nutritional status of preoperative colorectal cancer patients

BACKGROUND The present study aimed to determine the extent of malnutrition in preoperative colorectal cancer patients. Malnutrition has been shown to affect post-operative outcome, so it would be beneficial to identify those who are malnourished or who are at risk of becoming so preoperatively. We examine whether weight loss is related to the length of stay or changes in fat free mass. METHODS Patients were enrolled consecutively from outpatients 2-4 weeks prior to surgery. Assessments included body mass index, percentage weight loss, dynamometry, Malnutrition Universal Screening Tool, Subjective Global Assessment and bioelectrical impedance. Cancer staging and hospital length of stay were recorded. RESULTS One hundred and thirty-two patients were eligible and 87 enrolled. Sixty-seven patients were weight losing and 20% had lost >10% of their usual body weight. Handgrip strength was lower in malnourished patients compared to those who had not lost weight (mean 19.4 and 27.3 kg, respectively, P = 0.013). Mean (SD) fat free mass in patients with a weight loss >10% was 39.7 (13.5) kg and, in those with <10% weight loss, was 51.9 (12.0) kg (P = 0.001). This difference was not demonstrated for fat. CONCLUSIONS Over half of these patients had lost weight prior to surgery and one in five were malnourished. Body composition measurements demonstrated that malnourished patients had significantly less fat free mass compared to patients who were not clinically malnourished. Nutritional screening would be beneficial in this group preoperatively to identify weight-losing patients at an early stage in the care pathway when they initially enter the secondary care system.

An unblinded randomised controlled trial of preoperative oral supplements in colorectal cancer patients

BACKGROUND Perioperative oral supplementation has been shown to reduce post-operative complications. However, the use of preoperative standard oral supplements in a cohort of colorectal cancer patients has not been evaluated. The present study examined whether preoperative supplements are beneficial in this group. METHODS In a randomised controlled trial, patients were assigned to receive 400 mL of oral supplement and dietary advice or dietary advice alone. Primary outcome was the number of post-operative complications. One hundred and twenty-five patients were recruited (59 randomised to the intervention group and 66 to the control group) and nine were excluded. RESULTS In the intervention group, 24 (44%) patients had a complication compared to 26 (42%) in the control group (P = 0.780). In the intervention and control groups, there were eight (15%) and 16 (25%) surgical site infections, respectively (P = 0.140) and seven (13%) and 11 (17%) chest infections, respectively (P = 0.470). Subgroup analysis for hypothesis generation included 83 (71%) weight-losing patients, where there was a significant reduction in surgical site infections using the Buzby definition (P = 0.034), although this was not the case for the Centre for Disease Control definition (P = 0.052). CONCLUSIONS There was no evidence that preoperative supplements were beneficial in reducing the number of complications, although there may be some benefit for surgical site infections in selected weight-losing preoperative patients.

What information should lead to a suspicion of catheter sepsis in HPN

BACKGROUND & AIMS The diagnosis of catheter sepsis in patients on home parenteral nutrition can be difficult and patients often do not present with classical symptoms of pyrexia whilst feeding. This study reviews the clinical and diagnostic criteria needed to diagnose catheter sepsis. METHODS A retrospective consecutive notes review of 2 years of patients presenting with catheter infections assessed symptoms, inflammatory markers and some liver function tests. The same data was also collected on those same patients who had successfully under gone line salvage. The two sets were compared using the Mann-Whitney U-test and predictive calculations were carried out using receiver operated characteristic curves. RESULTS Over the two year period there were 37 episodes of CRBSI in 31 patients recorded. Successful catheter salvage was achieved in 30 episodes (in 24 patients) which is an 81% salvage rate. The most significant abnormality seen was a raised C-reactive protein, but less than a third of patients had a raised white cell count. However, there were significant changes in the bilirubin (p=0.0007) and albumin (p=0.0013) in these patients. Almost a third of patients who feel unwell do not present with a raised temperature. CONCLUSIONS The diagnosis of CRBSI remains difficult, but it should be suspected in patients with newly abnormal CRP, albumin or bilirubin and in the non-specifically unwell patient a clinician should not be misled by a normal white cell count and apyrexia.

Management of acute intestinal failure: A position paper from the European Society for Clinical Nutrition and Metabolism (ESPEN) Special Interest Group

Intestinal failure (IF) is the consequence of a reduction of gut function below the minimum necessary for the absorption of nutrients from the gastrointestinal tract. Types I and II comprise acute intestinal failure (AIF). Although its prevalence is relatively low, type II AIF is serious and requires specialist multidisciplinary care, often for prolonged periods before its resolution. The key aspects are: sepsis control, fluid and electrolyte resuscitation, optimization of nutritional status, wound care, appropriate surgery and active rehabilitation. The ESPEN Acute Intestinal Failure Special Interest Group (AIF SIG) has devised this position paper to provide a state-of-the-art overview of the management of type II AIF and to point out areas for future research.

Review article: artificial nutritional support for improved patient care

Malnutrition is common and undiagnosed in the majority of affected hospital patients; it is associated with impaired organ function, morbidity, and increased length of hospital stay. Artifical nutritional support in malnourished patients leads to improvement in nutritional status and clinical outcome.

Hepatic complications of parenteral nutrition

Apart from bone disease, the major metabolic complication of parenteral nutrition is that of hepatobiliary disease) -9 This review concerns only a discussion of hepatic problems. Furthermore, children will not be considered since the problems in this group are somewhat different. The apparent predilection of infants to total parenteral nutrition (TPN) related cholestasis may be based on the relative immaturity of the neonatal biliary excretory system.

Ascorbic acid absorption in Crohn's disease. Studies using L-[carboxyl-14C]ascorbic acid

Total body pool and intestinal absorption of ascorbic acid were studied in 12 patients undergoing operation for Crohns disease (six with fistulae and six without) and in six control patients undergoing operation for reasons other than Crohns disease.l-[caxboxyl-14C]Ascorbic acid, 0.19–0.40 megabecquerels (MBq), was given orally. After a period of equilibration, the labeled ascorbic acid was flushed out of the patients body tissues using large doses of unlabeled ascorbic acid. Intestinal absorption of ascorbic acid, assessed from the total cumulative urinary14C recovery, was found to be similar in patients with fistulizing Crohns disease (73.9±8.45%), those without fistulas (72.8±11.53%), and in controls (80.3±8.11%). Total body pools of ascorbic acid, calculated using the plasma14C decay curves, were similar in patients with Crohns disease with fistulas (17.1±5.91 mg/kg), patients without fistulas (9.6±3.58 mg/kg), and in controls (13.3±4.28 mg/kg). The results indicate that ascorbic acid absorption is normal in patients with both fistulizing and nonfistulizing Crohns disease. The results suggest that routine supplements of vitamin C are not necessary unless oral ascorbic acid intake is low.Total body pool and intestinal absorption of ascorbic acid were studied in 12 patients undergoing operation for Crohns disease (six with fistulae and six without) and in six control patients undergoing operation for reasons other than Crohns disease.l-[caxboxyl-14C]Ascorbic acid, 0.19–0.40 megabecquerels (MBq), was given orally. After a period of equilibration, the labeled ascorbic acid was flushed out of the patients body tissues using large doses of unlabeled ascorbic acid. Intestinal absorption of ascorbic acid, assessed from the total cumulative urinary14C recovery, was found to be similar in patients with fistulizing Crohns disease (73.9±8.45%), those without fistulas (72.8±11.53%), and in controls (80.3±8.11%). Total body pools of ascorbic acid, calculated using the plasma14C decay curves, were similar in patients with Crohns disease with fistulas (17.1±5.91 mg/kg), patients without fistulas (9.6±3.58 mg/kg), and in controls (13.3±4.28 mg/kg). The results indicate that ascorbic acid absorption is normal in patients with both fistulizing and nonfistulizing Crohns disease. The results suggest that routine supplements of vitamin C are not necessary unless oral ascorbic acid intake is low.

Management of intestinal failure in Europe. A questionnaire based study on the incidence and management.

BackgroundIntestinal failure is the outcome of a number of gastrointestinal diseases and characterized by significant reduction in functional gut mass. If not resolved patients often face long-term nutritional support. This study gathered information about how patients referred with intestinal failure are managed in specialised European centres.MethodsA questionnaire was circulated in 7 European countries via representatives of the ESPEN-HAN working group to seek information about experience in treating patients with intestinal failure. We asked about clinical outcome, information about structure and organisation of the department, referral criteria, treatment procedures and guidelines.Results17 centres in 6 European countries completed the questionnaire: UK, n = 6, France, n = 4, Spain, n = 3, Denmark, n = 2, Italy, n = 1, Poland, n = 1. The experience of the centres in treating patients was in the range 12–30 years. The total number of patients on HPN in all centres was 590. The number of patients referred to centres with intestinal failure during the period January to December 2000 was n = 882: UK, n = 375 (range 2–175), France, n = 308 (range 24–182), Italy and Spain, n = 43 (range 9–52), Denmark n = 51 (range 14–37), the centre in Poland included 53 patients. Comparing all centres the following distribution among patients (median % (range%)) with regard to the endpoints were reported: Oral nutrition 32% (23–50%), enteral/tube feeding 11% (4–23%), HPN 36% (15–57%), lost to follow up 10% (0–35%), dead 9% (5–18%). No patients had an intestinal transplant.ConclusionThe study provides information about how patients with intestinal failure are managed across Europe and the data indicates that treatment practice varies between countries.