Lucia Alfonsi

Predictors of survival in terminal-cancer patients with irreversible bowel obstruction receiving home parenteral nutrition

Clinical, anthropometric, hematologic, and biochemical variables, evaluated immediately before starting nutritional treatment, were related to survival in 76 terminal-cancer patients with irreversible bowel obstruction receiving home parenteral nutrition. At baseline, abnormally low values were observed in the following percentages of patients: 40.8% for body mass index, 59.2% for serum albumin, 84.2% for hemoglobin, 48.7% for lymphocyte count, and 60% for serum cholesterol. Survival on home parenteral nutrition ranged between 6 and 301 d, with a median of 74 d. Hemoglobin, serum albumin and serum cholesterol were lower in patients with a survival of less than 3 mo. With regard to Karnofsky performance status, median survival times were 63 d for a score below or equal to 50 and 128 d for a score between 60 and 70. Albumin and a Karnofsky score above 50 (but not age, weight, body mass index, lymphocyte count, or cholesterol) emerged (with a positive sign) as predictors of survival. In conclusion, terminal-cancer patients with irreversible bowel obstruction are often malnourished, showing a high prevalence of anemia and hypoalbuminemia. Survival differs widely and can be predicted only to a limited extent from initial values of serum albumin and Karnofsky performance status.

Central Venous Catheter Infections and Antibiotic Therapy During Long-Term Home Parenteral Nutrition An 11-Year Follow-Up Study

BACKGROUND Catheter-related bloodstream infections are a serious and common complication in patients receiving home parenteral nutrition (HPN). METHODS Prevalence of infections, type of agents, and effectiveness of antibiotic therapy were evaluated in 296 patients (133 males, 163 females; mean age 58.2 +/- 13.5 years) receiving HPN for at least 3 months, from January 1995 to December 2006. Patients underwent 99,969 (331 +/- 552; minimum 91, maximum 4353) days of catheterization, corresponding to 93,236 (311 +/- 489; minimum 52, maximum 4353) days of HPN. RESULTS Fifty-two patients (24 males and 28 females; 35 oncological and 17 nononcological) were diagnosed with 169 infections. The overall corresponding infection rate was 2.0 per 1000 days of catheterization, with a progressive, regular decrease with time. In 30 cases, immediate central venous catheter removal was necessary. Infections were eradicated in 103 of 139 (74%) cases. As to the most common causative agent, 86 (51%) infections were due to Staphylococcus epidermidis. Of these, 64 were treated from 1995 to 2004, 57 of them (89%) successfully; 22 were treated from 2005 onward, only 7 of them (32%) successfully. CONCLUSIONS Although the global infection rate has progressively decreased over the years, S epidermidis has shown an alarming increase in resistance to antibiotic treatment in the last 2 years, suggesting the need for strategies to prevent central venous catheter infection.

Prognostic significance of bioelectrical impedance phase angle in advanced cancer: preliminary observations.

Bioelectrical impedance-derived phase angle is a potentially sensible indicator of protein-energy malnutrition and of fat-free mass loss, frequent in patients with advanced cancer. We evaluated in 13 patients with advanced cancer some biochemical (serum albumin, lymphocyte count, cholesterol, cholinesterase) and clinical (Karnofsky index, Subjective Global Assessment, dietary inquiry) parameters and bioelectrical impedance analysis was performed. In addition to albumin, cholinesterase, and the Karnofsky index, phase angle (R(2)=0.384, P=0.024) was found to be strictly related to survival time and can be therefore considered a prognostic tool in patients with advanced cancer.

Adult Home Parenteral Nutrition: a clinical evaluation after a 3-year experience in a Southern European centre

Aim:To evaluate the current use of Home Parenteral Nutrition (HPN) in a Southern European region.Subjects and methods:A total of 159 (86 m, 73 f) HPN patients, mean age 60.1±14.2 years, BMI 18.8±3.3 kg/m2, consecutively referred to the Artificial Nutrition outpatient Unit of the Federico II University Hospital in Naples (Italy), from January 2000 to December 2002 and treated for at least 4 weeks. Retrospective evaluation of baseline disease, indications and duration of HPN treatment, type of venous access, complications.Results:In all, 140 (88%) were cancer and 19 (12%) noncancer patients. Main indications were carcinosis in 68 for total, and hypophagia/dysphagia in 62 patients for partial/integrative (to oral-enteral nutrition) HPN; mean duration of HPN was 81.45±110.86 days of treatment and infection rate 2.89‰ in the whole population and 2.66‰ in the 36 patients treated for more than 3 months. No other major complications have been observed.Conclusion:HPN is confirmed to be a safe and effective treatment when prescribed and administered by a trained team.

Stable reversal of pathologic signs of primitive intestinal lymphangiectasia with a hypolipidic, MCT-enriched diet

We report on a patient with protein-losing enteropathy due to primitive intestinal lymphangiectasia with an early reversal of clinical and biochemical signs and a stable late reversal of pathologic signs after treatment with a hypolipidic diet enriched with medium-chain triacylglycerols.

Citrulline Blood Levels as Indicators of Residual Intestinal Absorption in Patients with Short Bowel Syndrome

Plasma citrulline is known to be a marker of absorptive enterocyte mass in humans. We evaluated whether citrulline and other blood amino acids are indicators of residual small intestinal length and therefore potential predictors of dependence on parenteral nutrition in the long term. We studied 25 patients with short bowel syndrome (SBS) after at least 18 months since last digestive circuit modification; 24 of them were again evaluated 1 year later. Ten patients were weaned off parenteral nutrition and 15 were dependent on parenteral nutrition. Fifty-four healthy volunteers (28 women and 26 men) served as controls. Amino acid levels were determined on serum with high-performance liquid chromatography (HPLC) as well as on blood and serum with tandem mass spectrometry analysis. Five amino acids (citrulline, leucine, isoleucine, valine and tyrosine) were significantly lower in all SBS patients than in controls, whereas glutamine, measured only by HPLC, was significantly higher. Nevertheless, only serum citrulline measured with HPLC was significantly related to small bowel length. We conclude that HPLC remains the reference methodology to evaluate blood or serum amino acid levels in adult population with SBS.

Long-term medical complications after malabsorptive procedures: Effects of a late clinical nutritional intervention

OBJECTIVE The growing prevalence of severe obesity, combined with the failure of conservative treatments, has led to a significant spread of bariatric surgical procedures. The aim of this study was to emphasize the need of adequate presurgery patient selection and close follow-up after malabsorptive procedures for bariatric surgery. METHODS The study retrospectively evaluated 25 (20 F, 5 M; mean age 43 ± 13 y) obese patients (mean weight before intervention 134 ± 30.7 kg, body mass index 50.7 ± 10.1 kg/m(2)) attending our outpatient clinical nutrition unit for severe malabsorption and secondary malnutrition after surgical intervention that had been performed outside the regional area. RESULTS All patients received personalized dietetic indications; in 12 of 25 (48%) cases integrated by oral protein supplements and in 5 of 25 (20%) by medium chain triglycerides. According to screening exams, patients were prescribed oral/parenteral iron, vitamins A, B group, D, and folate supplementation. In 14 of 25 (56%) patients, parenteral hydration and in 4 of 25 (16%), long-term parenteral nutrition was required. Five patients required hospitalization for severely complicated protein-energy malnutrition. CONCLUSION Nutritional deficiencies are common after malabsorptive procedures for bariatric surgery; these can be present or latent before surgery, frequently going unrecognized and/or inadequately treated particularly when patients are not strictly followed up by the operating center. Despite the adequate-even intensive-intervention, clinical nutritional status moderately improved in all patients.

Composition of personalized and standard nutritional mixtures in patients on home parenteral nutrition

Background/objectives:The compounding of personalized parenteral nutrition mixtures (PPNMs) for home parenteral nutrition (HPN) gives the possibility to better satisfy nutritional requirements for patients in selected clinical conditions. The objective of this study was to compare the composition of PPNMs prescribed in selected cases, by a practitioner nutritionist, with that of industrially manufactured standard parenteral nutrition mixtures (SPNMs).Subjects/methods:Two hundred and ninety-eight patients (151 men, 147 women, aged 17–87 years) on HPN, followed up in 2011 at our Center, were retrospectively recruited.Results:Industrially manufactured SPNMs were prescribed in 230 (77.2%) patients, whereas compounded PPNMs were prescribed in 68 (22.8%). Formulation of PPNMs, adjusted for body weight, did not significantly differ from SPNMs as regards total daily calorie amount, but was significantly different as far as nutrient composition is concerned (P<0.01). Analysis on the daily amount of nutrients per kg of body weight and per patient disease showed that 16/34 (47%) benign chronic intestinal failure (CIF) patients, 47/233 (20%) cancer patients and 5/31 (16%) patients grouped as ‘having other diseases’ needed personalized mixtures (in PPNMs 4–9 nutrients were significantly different from those in SPNMs). Moreover, in CIF patients receiving PPNMs, frequent changes in the formulation (mean 6 times per year, range 1–28) were necessary.Conclusions:Our data suggest that, presently, PPNMs cannot be completely replaced by SPNMs owing to special needs in macro and/or micronutrients of some patients and/or the necessity of frequent changes in the nutritional mixture composition, at least until stabilization of clinical and metabolic conditions.

A patient with oeosinophilic gastroenteritis and severe malnutrition improved with home parenteral nutrition.

Oeosinophilic gastroenteritis is a chronic and rare disorder characterised by massive oeosinophilic tissue infiltration involving one or more segments of the digestive tract. The management of patients with oeosinophilic gastroenteritis is complex and the therapeutic response often poor. Here we discuss the clinical case and management of a 23-year-old man with oeosinophilic gastroenteritis since the first year of life and the decision to prescribe lifelong total parenteral nutrition.

Impaired Enterohormone Response Following a Liquid Test Meal in Gastrectomized Patients

Background: Total gastrectomy (TG) is responsible for symptoms or disturbance of alimentary status (changes in body weight, food intake per meal and frequency of meal per day) which, in turn are responsible for weight loss and malnutrition. The study evaluates the gut hormone responses in totally gastrectomized (TG) patients after a liquid meal test. Methods: Twenty total gastrectomized cancer-free patients (12 M, 8 F, 56.4 ± 10.2 years, BMI 21.4 ± 2.2 kg/m2) and 10 healthy volunteers (4 M, 6 F, 48.0 ± 12.7 years, BMI 26.7 ± 3.0 kg/m2 ) drank a liquid meal (1.25 kcal/mL) at the rate of 50 mL/5′ min for a maximum of 30 min. Satiety score was assessed and blood sample was taken at different time points. Results: The time response course, particularly for insulin, glucose-like pepetide-1, and cholecystokinin, significantly differed between TG patients and controls. Conclusions: Our results may help to better understand hormone responses triggered by the faster arrival of nutrients in the small bowel and to explain some post-TG symptoms.