Comparison of Quality of Life Measurements in Patients Receiving Home Parenteral Nutrition Prior to and During the COVID-19 Pandemic

Background: TheWorld Health Organization declared the outbreak of coronavirus 2 (COVID-19) as a pandemic on March 11, 2020. This led to abundant research to understand nutrition support practices during these unprecedented times. The need for rapid response to a patient's clinical needs, however, left a gap in understanding of the impact the pandemic had on the quality of life (QOL) of patients receiving home parenteral nutrition (HPN). As HPN patients are already vulnerable to having lower QOL scores than the general population, this warrants further exploration. Understanding the HPN patient experience in the setting of the COVID-19 pandemic expands our knowledge so that we can maximize care and support for our patients, resulting in improved patient-reported outcomes. The objective of this study was to determine if there was an association between the COVID-19 pandemic and QOL measurements in patients receiving HPN. Method(s): Inclusion criteria included adult and pediatric patients enrolled in the Total Parenteral Nutrition at Home (HEALTH) registry who completed Short Forms 36 (SF-36) Quality of Life surveys. Data were retrospectively collected from SF-36 surveys and compared between three 12-month time periods: year 1 (March 1, 2019 to February 29, 2020);year 2 (March 1, 2020 to February 28, 2021);and year 3 (March 1, 2021 to February 28, 2022). The primary outcome measure was the difference in mean QOL scores between the 3 time periods for the 8 domains and 2 summary scores. A P value <0.05 was considered statistically significant. The secondary outcome measure was the number of hospitalizations, including length of stay and reason for admission. Result(s): A total of 348 standardized SF-36 surveys from patients across 31 states were included in this study. Clinical and demographic characteristics of the patients are provided in Table 1. QOL measurements for 8 domains and 2 summary scores are provided in Table 2. Six of eight domains and two summary scores were highest during year 1 (pre-COVID pandemic) with a subsequent decrease in year 2 and a slight improvement in year 3. There were no statistically significant differences in QOL scores between any of the three time periods. Role-emotional scores decreased while general health scores improved year over year although again, neither change was statistically significant. Only two hospital admissions were reported as COVID-19 related during year 2. The most prevalent reasons for admission in year 2 and 3 were infection, unrelated to COVID-19 (Table 2). Conclusion(s): SF-36 survey scores in six of the eight domains and two summary scores decreased post pandemic, reflecting a decrease in QOL in HPN patients. As studies have shown the profound influence of the COVID-19 pandemic on both mental health and QOL measurements, clinicians need to consider the impact to our HPN patients who are at risk for overall lower baseline QOL scores. Routinely assessing a patient's QOL during HPN care may help identify areas of support needed to improve both clinical and QOL outcomes. The importance of this practice becomes even more apparent during a challenging experience like the COVID-19 pandemic. (Table Presented).

Initiating Home Parenteral Nutrition Therapy in a Patient at High Risk of Refeeding Syndrome After COVID-19 Infection

Background: An emerging finding about COVID-19 is its effect on nutrition and weight loss. The COVID-19 symptoms of fatigue, altered taste or smell, and lack of appetite are well known. But COVID-19 may have a more profound effect on clinical nutrition status. Two recent studies have identified that approximately one-third of ambulatory COVID-19 patients are at risk of experiencing weight loss >= 5% (Anker, et al;di Filippo, et al). The case study presented here discusses home start total parenteral nutrition (TPN) in a patient recently diagnosed with COVID-19 at high risk for refeeding syndrome. Method(s): N/A Results: Case Study: A 92-year-old patient was diagnosed with COVID-19 on June 8, 2022. Over the next week, she was hospitalized twice to manage symptoms of acute mental status changes, lethargy, aphasia, hypotension, and loss of appetite. The patient received nirmatrelvir/ritonavir, remdesivir, and bebtelovimab to treat COVID-19 at different times between June 9, 2022, and June 18, 2022. She remained COVID positive and continued to deteriorate clinically. On June 20, 2022, the patient began receiving 24/7 homecare, including intravenous (IV) fluids of dextrose 5% in normal saline (D5NS) 1000 mL daily for three days. She continued to experience loss of appetite and had no bowel movement for 3 days. On June 23, 2022, she was referred to this specialty infusion provider to initiate TPN therapy in the home setting. The patient's BMI was 18.2 kg/m2. Lab results revealed potassium 3.0 mmol/L, phosphate 1.6 mg/dL, and magnesium 1.6 mg/dL. High risk of refeeding syndrome was identified by the level of hypophosphatemia and hypokalemia. The specialty infusion provider's registered dietitian recommended to discontinue D5NS and begin NS with added potassium, phosphate, and magnesium. Thiamine 200mg daily was added to prevent Wernicke's encephalopathy. The patient's clinical status and lab values were monitored closely each day until her electrolyte levels stabilized (Table 1). Home TPN therapy was initiated on June 28, 2022, with <10% dextrose and 50% calorie requirement with 85% protein and 1.0 g/kg lipids. Three-day calorie count and nutrition education were performed four days post TPN initiation. Oral intake met only 25% of estimated needs. Over several days, theTPN formula was gradually increased to goal calories and the infusion cycle was slowly decreased. The following week, the patient's oral intake improved to 60%-75% of estimated needs. Her constipation resolved, and she showed improvement in functional status and mobility. Her appetite drastically improved when the TPN was cycled. Another three-day calorie count was performed when TPN calories reached goals. Oral intake demonstrated 100% estimated calorie and protein needs. TPN therapy was ultimately discontinued on July 14, 2022. As of September 30, 2022, the patient has stabilized at her pre-COVID weight of 45 kg with full recovery of appetite, function, and cognition. Discussion(s): The ASPEN Consensus Recommendations for Refeeding Syndrome (da Silva, et al) describe the repletion of electrolyte levels before introducing calories to prevent end-organ damage associated with refeeding syndrome (respiratory muscle dysfunction, decreased cardiac contractility, cardiac arrhythmias, and encephalopathy). Conclusion(s): This case study highlights the successful initiation of home TPN therapy in a patient at high risk of refeeding syndrome post COVID-19 infection. Although home start TPN and the risk of refeeding syndrome are not new concepts, they must be considered in the setting of COVID-19. Given the effects COVID-19 has on taste, smell, and appetite and the recent finding that one-third of patients with COVID infection may experience weight loss of >= 5%, nutrition support and patient education are vital components of overall patient care. (Figure Presented).

COVID-19 infection in patients on long-term home parenteral nutrition for chronic intestinal failure.

BACKGROUND AND AIMS: To investigate the incidence and the severity of COVID-19 infection in patients enrolled in the database for home parenteral nutrition (HPN) for chronic intestinal failure (CIF) of the European Society for Clinical Nutrition and Metabolism (ESPEN). METHODS: Period of observation: March 1st, 2020 March 1st, 2021. INCLUSION CRITERIA: patients included in the database since 2015 and still receiving HPN on March 1st, 2020 as well as new patients included in the database during the period of observation. Data related to the previous 12 months and recorded on March 1st 2021: 1) occurrence of COVID-19 infection since the beginning of the pandemic (yes, no, unknown); 2) infection severity (asymptomatic; mild, no-hospitalization; moderate, hospitalization no-ICU; severe, hospitalization in ICU); 3) vaccinated against COVID-19 (yes, no, unknown); 4) patient outcome on March 1st 2021: still on HPN, weaned off HPN, deceased, lost to follow up. RESULTS: Sixty-eight centres from 23 countries included 4680 patients. Data on COVID-19 were available for 55.1% of patients. The cumulative incidence of infection was 9.6% in the total group and ranged from 0% to 21.9% in the cohorts of individual countries. Infection severity was reported as: asymptomatic 26.7%, mild 32.0%, moderate 36.0%, severe 5.3%. Vaccination status was unknown in 62.0% of patients, non-vaccinated 25.2%, vaccinated 12.8%. Patient outcome was reported as: still on HPN 78.6%, weaned off HPN 10.6%, deceased 9.7%, lost to follow up 1.1%. A higher incidence of infection (p = 0.04), greater severity of infection (p < 0.001) and a lower vaccination percentage (p = 0.01) were observed in deceased patients. In COVID-19 infected patients, deaths due to infection accounted for 42.8% of total deaths. CONCLUSIONS: In patients on HPN for CIF, the incidence of COVID-19 infection differed greatly among countries. Although the majority of cases were reported to be asymptomatic or have mild symptoms only, COVID-19 was reported to be fatal in a significant proportion of infected patients. Lack of vaccination was associated with a higher risk of death.

Unionstagung der Schweizerischen Gesellschaften fur Gefasskrankheiten Gemeinsam mit der Schweizerischen Gesellschaft fur Ultraschall in der Medizin Sektion Gefasse

The proceedings contain 57 papers. The topics discussed include: percutaneous angioplasty and stenting in patients with upper extremity peripheral artery disease (PAD);molecular atlas of the human brain vasculature across development, adulthood and disease at the single-cell level;enoxaparin for symptomatic outpatients with COVID-19: 90-day results from the randomized, open-label, parallel-group, multicenter, phase III OVID trial;quality of warfarin anticoagulation in adults with short bowel syndrome on home parenteral nutrition;mortality rate related to peripheral artery disease: a retrospective analysis of epidemiological data (years 20082019);development and implementation of an ambulatory integrated care pathway tool for peripheral artery disease patients: the vascular passport from knowledge to awareness;late outcomes after fixed-dose ultrasound-assisted catheter-directed thrombolysis for acute pulmonary embolism: single-center experience at a university hospital;and venous thromboembolism and its clinical sequelae in intravenous drug users: systematic review and meta-analysis.

Care of patients on home parenteral nutrition during the first year of the COVID-19 pandemic: Management of central line-associated bloodstream infections.

BACKGROUND AND AIM: The aim of this study was to analyze central line-associated bloodstream infections (CLABSI) in home parenteral nutrition (HPN) patients assisted by an interdisciplinary team during the first year of the COVID-19 pandemic in Argentina. METHODS: Longitudinal, retrospective and analytical study of patients on HPN for ≥90 days during 2020. Data collection included age (adults >18 years, pediatric ≤18 years), gender, diagnosis, type of catheter, number of lumens, venous access, days on HPN, infusion modality and number of CLABSI-associated events. In COVID-19 cases, number of patients, disease progression, mortality rate and microorganisms involved were analyzed. RESULTS: A total of 380 patients were included, 120 (31.6%) pediatric and 260 (68.4%) adult patients. Median age was 44.50 years (10; 62.25). Twelve patients (3.15% of the total) had COVID-19; of these, two pediatric and seven adult patients had no complications, and three adults died of COVID-19 pneumonia. The diagnoses observed were benign chronic intestinal failure (CIF, n = 311), grouped into short bowel (n = 214, 56.3%), intestinal dysmotility (n = 56, 14.7%), intestinal fistula (n = 20, 5.3%), and extensive small bowel mucosal disease (n = 21, 5.5%); malignant tumors (n = 52, 13.7%); other (n = 17, 4.4%). Total catheter days were 103,702. Median days of PN duration per patient were 366 (176.2, 366). The types of catheters used were tunneled (317 patients, 83.4%); peripherally inserted central (PICC) line (55 patients, 14.5%) and ports (8 patients; 2.1%). A total of 111 CLABSI was registered, with a prevalence of 1.09/1000 catheter days (adult, 0.86/1000 days; pediatric, 1.51/1000 days). The microorganisms identified in infectious events were Gram + bacteria (38, 34.5%); Gram-bacteria (36, 32%); mycotic (10, 9%); polymicrobial (4, 3.6%); negative culture and signs/symptoms of CLABSI (23, 20.3%). The odds ratio between pediatric and adult patients was 2.29 (1.35, 3.90). CONCLUSION: The rate of CLABSI during the COVID-19 pandemic was within the ranges reported by international scientific societies. The risk of CLABSI was higher in pediatric patients, and mortality rate in COVID-19 infected patients was higher than in the general population.

Does Frequency of in-Person Clinic Evaluation Impact Central Line-Associated Bloodstream Infections in Pediatric Home Parenteral Nutrition Patients

Background: Home parenteral nutrition (HPN) is the primary treatment for patients with pediatric intestinal failure. It is a complex, life-sustaining therapy requiring a central venous catheter (CVC), and carries high morbidity. Central line-associated bloodstream infection (CLABSI) is a common and potentially fatal complication of HPN. Patients on HPN require a skilled multi-disciplinary team- including physicians, nurses, dietitians and pharmacists-to prevent HPN related complications, provide safe and individualized nutrition support that is evaluated on a regular basis in the ambulatory setting. In-person visits in the clinic setting allow for HPN patients to be evaluated by all disciplines, and full assessment of weight and general condition, fluid status and laboratory values. Importantly, clinic evaluations also allow for close examination of central venous catheter (CVC), discussion with caregivers to identify potential infection risks, and opportunities for education to prevent infections and other complications. Program standard of care is bimonthly clinic and laboratory evaluation, more frequently if clinically indicated. The COVID-19 crisis required transition of many of these evaluations from in-person to telemedicine, which has created new challenges in caring for high-risk pediatric HPN patients and prevention of CLABSI. Multi-disciplinary telemedicine visits including nursing, dietitians and physicians were substituted for in-person evaluations at first exclusively at onset of pandemic, then to every other visit as COVID rates improved and vaccinations became more available. Method(s): HPN clinic encounters from 2019-present were reviewed in a large pediatric HPN program and compared to CLABSI rates. Attention was paid to in-person versus telemedicine evaluations in the setting of COVID-19 pandemic. CLABSI rate was defined as # of ambulatory infections/1000 catheter days, as defined by National Healthcare Safety Network (NHSN) guidelines. Result(s): Despite decreased frequency of in-person clinic evaluation, ambulatory CLABSI rates did not increase during this time. In fact, median CLABSI rate from 2020 to present decreased from 0.81/1000 catheter days to 0.5/1000 catheter days. In 2020, there was a mild trend toward increased CLABSI rate in patients who had higher percentage of telemedicine versus in-person encounters;however, this was not statistically significant. This trend was not observed in 2021. Conclusion(s): Pediatric patients receiving HPN are high-risk and require evaluation by a multidisciplinary team at regular intervals to maintain safety. COVID-19 pandemic interrupted ability to see these complex patients for in-person evaluation with regular frequency;therefore multidisciplinary telemedicine visits were substituted. While in-person evaluation remains the gold standard for management of patients on HPN, intermittent use of multi-disciplinary telemedicine encounters can be utilized to safely care for pediatric HPN patients, without resultant (Figure Presented).

The use of technology to aid the formation of home parenteral nutrition contingency prescriptions

The COVID-19 pandemic represented a substantial risk to the continued supply of compounded home parenteral nutrition (HPN) to patients with intestinal failure. NHS England requested that all patients receiving HPN have a contingency prescription that could be supplied if their homecare provider weren’t able to supply their compounded prescription. The formation of contingency prescriptions and subsequent communication of the plan to both the patients and those involved in their care, was a significant undertaking. Could technology aid in the formation of the contingency prescriptions, improve communication between members of the multidisciplinary team (MDT) and standardise the accompanying written administration plan? An existing spreadsheet developed in-house was used which contained all the commercially available multi-chamber bags (MCBs) and terminally sterilised fluids (TSFs) on the market. A deficits tab was added to the workbook that calculated the weekly differences between the patient’s usual compounded prescription and a proposed contingency prescription. Drop down menus auto populated the contents of the MCBs and TSFs into the spreadsheet. This tab was printed, reviewed by other members of the MDT and was risk-assessed. A tab was created which transferred the selected MCBs and TSFs onto a contingency template to send to homecare providers. This included custom instructions e.g. drug name, dose/volume, form, directions/frequency and total supply per week. Patient information was copied from the compounded formulation request and pasted into the contingency template. The template could then be exported to a separate document, allowing additions of line locks / other medication usually on the prescription. A further tab facilitated the production of a written administration plan for the contingency regimen. Patient information was auto populated from the order template, while drop down menus restricted the bags used to only those that had been selected on the deficits tab. Custom administration instructions were auto populated into the plan. A table showed how many of each bag per week are required, and this counted down as the written plan was populated. Once the written plan was populated, the spreadsheet calculated the number of each type of ancillaries required each week. A breakdown of daily calories and electrolytes supported the user in spreading the prescription as equally as possible across the week. Further alterations were made using an export function prior to sending to the patient and the homecare provider. The development of this spreadsheet has significantly improved the efficiency of the process for creating contingency prescriptions for patients on compounded HPN and produced a robust method for communicating the proposed regimen between members of the MDT. It has successfully standardised our wording on the contingency order templates and written administration plans whilst eliminating transcription errors.

Monitoring bone mineral density in patients with chronic intestinal failure on home parenteral nutrition – a national centre experience

Type 3 intestinal failure (IF) is known to negatively impact bone metabolism contributing to increased prevalence of osteoporosis and associated increases in morbidity and mortality. It has been challenging to appropriately monitor for these pathologies under the restrictions imposed by the ongoing COVID-19 pandemic. We performed a retrospective audit assessing compliance with current guidelines1. All type 3 IF patients receiving home parenteral nutrition (HPN) prescribed at a national centre prior to 1st May 2021 were included. Data was collected from hospital electronic recorded, de-identified and collated on an excel spreadsheet that was securely stored on a departmental computer. 270 patients fulfilled inclusion criteria (35.5% male, mean age 54.0 ± 17.5 years). The mean age at HPN initiation was 45.8 ± 18.5 years and the mean number of years on HPN was 8.2 ± 7.2 years. The maximum duration of HPN administration in this cohort was 37 years. DEXA scan results performed within the preceding 5 years were available for 23.0% of patients. Of these scans 96.8% of patients had evidence of reduced bone density (45.2% osteopenic, 51.6% osteoporotic). Comparing DEXA results at diagnosis and in the last 5 years, a majority (54.2%) of patients progressed or remained osteoporotic, with 8.3% showing improvement in bone density and 4.2% of patients having a return to normal bone density. 59.6% of patients had blood tests performed within the preceding 12 months. 54.4% of patients had undergone plasma vitamin D levels measurement. Vitamin D levels were found to be low (<50nmol/L) in 32.7%. 44.4% of patients were receiving vitamin D supplementation of which 86.7% were prescribed oral supplements and 13.3% intramuscular supplements. 31.3% of patients with osteoporosis were on bisphosphonate therapy. These results demonstrate high prevalence of metabolic bone disease amongst type 3 IF patients on HPN. This highlights a potentially modifiable risk of low-trauma fracture which has a very high morbidity and mortality index. Our findings regarding the prevalence and longitudinal changes in bone density are in agreement with the published ESPEN surveys2,3. The results also demonstrate poor compliance with current guidelines. We believe this reflects the challenges of obtaining non-emergent scans and blood test due to COVID-related restrictions as well as our patients’ very understandable fear of exposure should they attend hospital for a face-to-face review. It is also possible that some of these tests were performed locally, due to many patients living far away from our national referral centre, and thus not visible to the audit team. These findings have highlighted the need for greater education and prompted our group to increase our focus on metabolic bone disease during clinic interactions and to create a subsection of our database for tracking DEXA intervals for this patient cohort. References 1. Pironi L, Arends J, Bozzetti F, et al. ESPEN guidelines on chronic intestinal failure in adults. Clin Nutr 2016;35: 247-307. 2. Pironi L, Labate AM, Pertkiewicz M, et al. Prevalence of bone disease in patients on home parenteral nutrition. Clin Nutr 2002;4: 289-296 3. Pironi L, Tjellesen L, De Francesco A, et al. Bone mineral density in patients on home parenteral nutrition: a follow-up study. Clin Nutr. 2004 Dec;23(6):1288-302

Experiences of the COVID-19 pandemic: A survey of patients on home parenteral nutrition.

Patients on home parenteral nutrition (HPN) have had to endure sweeping changes to their personal lives and medical care during the COVID-19 pandemic. We evaluated the patients' perspectives of these changes at our Intestinal Failure/Rehabilitation centre in order to initiate a debate on improving HPN care. The findings point to high levels of anxiety and depression amongst the 35 patients surveyed with many reporting frustration at conflicting information from different sources. Telephone consultations were well received and most were keen for these to continue. In light of these results, we outline recommendations to enhance our patients' experiences in the coming phases of the pandemic.

Personalized exercise intervention in HPN patients - A feasibility study.

BACKGROUND: Physical health status may be predictive of readmissions, psychological health and mortality in patients with short bowel syndrome. AIMS: This study aimed to investigate the feasibility and effect of an individualized exercise intervention and secondary, oral nutrition intake counseling on Timed-Up-and-Go (TUG) and 30 s Chair Stand Test (CST) as well as body-composition and EuroQol (EQ)-5D-5L, in patients with chronic intestinal failure (IF) type III receiving HPN and/or fluid therapy. METHODS: A 12-week individualized exercise intervention consisting on three weekly home based sessions, and nutrition counselling focusing on protein intake and reducing high stoma output, was performed. Weekly follow-up by phone was done on motivation to exercise. RESULTS: The study invited 71 patients, 44 accepted the invitation (62%), 37(52%) were included, and 31 (84%) completed the intervention. The exercise intervention was well tolerated. TUG improved from 8.9(SD 5.5) to 7.7(SD 3.8) (p = 0.033). CST improved by four repetitions (<0.001∗). A statistical, however not clinically relevant improvement was seen in muscle mass. No improvement was seen in (EQ)-5D-5L total, but insignificantly (p = 0.055) for physical function only. Protein intake improved by 10.6 g/day (p = 0.008). CONCLUSIONS: A 12 weeks individualized exercise intervention showed very feasible and beneficial in HPN patients. Physical function improved statistically and clinically, and oral protein intake improved. QoL overall did not improve, however COVID-19 was an uninvited partner throughout the study period, which may have influenced general QoL. As only 62% accepted the invitation to participate, home based exercise intervention may not apply to all patients.

Organizational issues of home parenteral nutrition during COVID-19 pandemic: Results from multicenter, nationwide study.

OBJECTIVES: Patients on home parenteral nutrition (HPN) are prone to severe complications of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The pandemic requires adaptation of the health care standards, including epidemiologic surveillance, logistics of home supply, and monitoring. Potential lack of medical professionals may worsen the standard of care. The aim of this study was to evaluate the medical staff resources in HPN units. RESULTS: The study was conducted by major Polish scientific societies in clinical nutrition. A questionnaire was distributed among all Polish adult HPN centers concerning statistics from the first 3 mo of the pandemic (March through May 2020). Data on medical staff resources and organizational issues of the units were collected. Modifications of the home procedures, SARS-CoV-2 infection rates of HPN patients and health care workers (HCW) were analyzed. Influence of the pandemic on the rates of new qualifications for home artificial nutrition (HAN) was estimated. Fourteen of 17 adult Polish HPN units took part in the study. The point prevalence of HPN in Poland was 30.75/1 million citizens. Of HCWs, 344 were involved in patient care in Polish HPN units; 18.9% were physicians (49% surgeons, 18.46% internal medicine specialists, 15.38% anesthesiologists, 7.69% pediatricians, 1.54% palliative care specialists), 32.27% nurses, 5.23% dietitians, 9.01% pharmacists, 4.94% pharmacy technicians, 3.2% pharmacy assistants, 5.81% administrative workers, 3.49% physiotherapists. HAN patient-to-HCW ratios for physicians, nurses, pharmacists, dietitians were 49.5, 29.15, 111.6, and 181.6, respectively. Medium ages of physicians and nurses were 45.6 and 44.15 y, respectively. Slightly less than half (53.8%) of physicians and 31.53% of nurses worked parallelly in hospital wards. Thirty-one pharmacists overall were working in all HPN units (2.21 per unit) as were 18 dietitians (1.3 per unit). Nine patients had a confirmed COVID-19 infection (four HPN, five home enteral nutrition). All the units introduced telemedicine solutions in the first months of the pandemic. The number of new qualifications for HPN and home enteral nutrition in the units did not significantly decline from March through May in comparison with a similar period in 2019. CONCLUSIONS: A shortage of HPN medical professionals requires attention when planning health care organization, especially during a pandemic. Severe restrictions in public health systems may not reduce the number of new qualifications for the HPN procedure. There is a need for the continuation of data collection during the evolution of the pandemic as it may have a detrimental effect on HPN including serious issues with access to professional HCWs.

COVID-19 infection in patients with intestinal failure: UK experience.

BACKGROUND: The direct effect of the coronavirus disease 2019 (COVID-19) pandemic on patients with intestinal failure (IF) has not been described. METHODS: We conducted a nationwide study of UK IF centers to evaluate the infection rates, presentations, and outcomes in patients with types 2 and 3 IF. RESULTS: A total of 45 patients with IF contracted COVID-19 between March and August 2020; this included 26 of 2191 (1.2%) home parenteral nutrition (HPN)-dependent adults and 19 of 298 (6.4%) adults hospitalized with type 2 IF. The proportion of patients receiving nursing care for HPN administration was higher in those with community-acquired COVID-19 (66.7%) than the proportion in the entire HPN cohort (26.1%; P < .01). Two HPN-dependent and 1 hospitalized patient with type 2 IF died as a direct consequence of the virus (6.7% of 45 patients with types 2 or 3 infected). CONCLUSION: This is the first study to describe the outcomes of COVID-19 in a large cohort of patients requiring long-term PN. Methods to reduce hospital and community nosocomial spread would likely be beneficial.

An International Survey of Clinicians' Experience Caring for Patients Receiving Home Parenteral Nutrition for Chronic Intestinal Failure During the COVID-19 Pandemic.

BACKGROUND: This survey of centers caring for patients receiving home parenteral nutrition (HPN) was conducted to assess the impact of the coronavirus disease 2019 (COVID-19) crisis on the management of these patients regarding provision of care, monitoring, regular follow-up, and any changes to service infrastructure. METHODS: A survey was devised and publically published on the Research Electronic Data Capture database management system, with individual centers responding to a public link. RESULTS: A total of 78 adult and pediatric centers worldwide contributed to the survey, representing ≥3500 patients' experiences. Centers reported infrastructure maintenance for Parenteral Nutrition (PN) bag deliveries to patients (60, 76.92%) or delivery of ancillary items (57, 73.08%), home delivery and HPN administration (65, 83.33%), and home care nurse shortages (25, 32.05%). Routine follow-up of HPN patients changed to either all telemed or mixed with emergency clinic review (70, 89.74%). In 26 centers (33.33%), HPN for newly discharged patients with benign conditions was reduced or stopped. Based on clinical history, the centers reported psychological distress for patients (52, 66.67%), with anxiety, worry, concern, and apprehension reported most frequently (37 of 52, 71.15%) but also fear (10 of 52, 19.23%), depression (5 of 52, 9.62%), and issues related to isolation/confinement (12 of 52, 23.08%). CONCLUSIONS: The COVID-19 pandemic was reported by clinicians to have had a far-reaching adverse impact on patients receiving HPN, especially their safety in terms of provision of personal protective equipment, PN bags, available nursing staff, and psychological well-being. Healthcare systems responded to the challenge and presented new ways of working.

Considerations for the management of home parenteral nutrition during the SARS-CoV-2 pandemic: A position paper from the Home Artificial Nutrition and Chronic Intestinal Failure Special Interest Group of ESPEN.

The management of patients with chronic intestinal failure requiring home parenteral nutrition has been and will continue to be impaired during the SARS-CoV-2 pandemic. Multidisciplinary intestinal failure teams may have to adapt their clinical approaches to home care, outpatient care as well as hospital admission and discharge in order to keep this vulnerable group of patients as safe and well as possible during the unprecedented challenges that countries are facing during the pandemic. Equally, it is important that expert advice from intestinal failure teams is available when home parenteral nutrition (HPN)-dependent patients require admission with SARS-CoV-2 infection. The Home Artificial Nutrition & Chronic Intestinal Failure Special Interest Group of the European Society for Clinical Nutrition and Metabolism (ESPEN) has developed a position paper to outline areas for intestinal failure teams to consider when managing patients with chronic intestinal failure during the SARS-CoV-2 pandemic.

Home medical nutrition during SARS-CoV-2 pandemic - A position paper.

BACKGROUND: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of a worldwide rapidly spreading illness, Coronavirus Disease 2019 (COVID-19). Patients fed enterally and parenterally at home are exposed to the same risk of infection as the general population, but more prone to complications than others. Therefore the guidance for care-givers and care-takers of these patients is needed. METHODS: The literature search identified no relevant systematic reviews or studies on the subject. Therefore a panel of 21 experts from 13 home medical nutrition (HMN) centres in Poland was formed. Twenty-three key issues relevant to the management of SARS-CoV-2 infection or COVID-19 in the HMN settings were identified and discussed. Some statements diverge from the available nutrition, surgical or ICU guidelines, some are based on the best available experience. Each topic was discussed and assessed during two Delphi rounds subsequently. Statements were graded strong or weak based on the balance between benefit and harm, resource and cost implications, equity, and feasibility. RESULTS: the panel issued 23 statements, all of them were graded strong. Two scored 85.71% agreement, eleven 95.23%, and ten 100%. The topics were: infection control, enrolment to HMN, logistics and patient information. CONCLUSIONS: the position paper present pragmatic statements for HMN to be implemented in places without existing protocols for SARS-CoV-2 pandemic. They represent the state of knowledge available at the moment and may change should new evidence occurs.