Catheter-Related Venous Thrombosis in Patients with Systemic Sclerosis: A Case Series

Background/Aims Systemic sclerosis (SSc) is characterised by endothelial dysfunction and vasculopathy, which may lead to venous thrombosis. Here, we report four cases of extensive venous thrombosis of the upper limbs and right atrium associated with implantable venous access devices (port-a-cath) in patients with a diagnosis of SSc, who presented to our specialist centre between 2018 and 2022. Methods We retrospectively reviewed four patients with SSc and port-a-cathassociated thrombosis who presented to the Department of Rheumatology, Royal Free Hospital NHS Trust between 2018 and 2022. All patients are diagnosed with systemic sclerosis according to the 2013 ACR/EULAR classification criteria. Results Three patients were diagnosed with a port-a-cath-associated thrombosis in 2022, and one in 2018. Two patients had limited cutaneous SSc with positive anti-centromere antibodies, and 2 had diffuse subset with anti-U3RNP antibodies. All patients had a right-sided port-a-cath that had been in-situ for at least 3 years. Two patients were diagnosed with right atrium thrombus (measuring 2.2 and 3cm respectively), one patient with an internal jugular vein and right subclavian thrombosis, and one with a left subclavian thrombosis. None had a history of previous thromboembolic event. A full thrombophilia screen was negative in 2 patients, and is pending in the others. Of note, 2 patients had COVID-19 infection within the 3 months prior the thrombotic event. 1 patient had tocilizumab administered through the line, 1 rituximab and IVIG, the other 2 had prostanoids only. Conclusion We described four recent cases of port-a-cath-associated thrombosis of the upper limbs and right atrium in SSc patients with no previous history of thrombosis. This highlights the increased risk of thrombosis related to long term indwelling catheters in SSc and demonstrates the potential interplay between covid microvasculopathy and the associated thrombotic risks reported with both ACA and antiU3RNP antibodies in SSc. We note that from previous reports the relative lower risk of adverse outcomes in SSc patient receiving parenteral nutrition. Further research into frequency of port-a-cath-related thrombosis in SSc patients is warranted, especially with use of prostanoids, and adequate screening and non-invasive follow up might be needed to avoid life-threatening thromboembolic complications. (Table Presented).

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).

Micronutrients Deficiency in Patients Receiving Parenteral Nutrition: Effect of Multivitamin Supply Shortage

Background: Total parenteral nutrition (TPN) is a life-saving therapy for patients with chronic intestinal failure. TPN typically consists of macronutrients (amino acids, dextrose, and lipids) as well as micronutrients (multi-vitamins [MVI] and trace elements) to meet fluid, calorie, and micronutrient needs. With the early years of PN administration, multiple deficiencies were noted leading to guidelines regarding need for daily use of essential trace element and MVI preparation for parenteral use. Unfortunately, during the last few years we have seen multiple shortages of PN related supplies including the most recent shortage of parenteral MVI preparation. Major organizations such as ASPEN have developed recommendations regarding management of shortages, however their clinical impact has not been fully evaluated. The current study evaluated the impact of MVI shortage on change in clinical practice and the prevalence of deficiency. Method(s): A retrospective review of electronic medical records for patients who received TPN during time of shortage in IV multivitamins supply due to COVID-19 crisis between January 2021 and June 2021. In our program, the shortage affected one TPN supplier. We included patients who received their TPN from affected supplier and who were tested for micronutrients including Vitamins A, B12, C, and D in the 6 months preceding the shortage in supply (period 1) as well as during the shortage period (period 2). Period 1 was defined as from July 1, 2020, to December 31, 2020, and period 2 was defined as from January 1, 2021, to June 30, 2021. In addition to baseline clinical characteristics, we captured changes in studied micronutrients. Result(s): Current retrospective analysis of a prospectively maintained database noted 21 patients (mean age of 63.3 +/- 13.8, 62% female) were impacted by MVI shortage during study period (Table 1). Most common primary diagnosis was Crohn's disease (33.3%) followed by enterocutaneous fistula (19%), and gastrointestinal dysmotility (14.3%). In 19/21 (90%) patients, MVI was administered 3 days per week in PN. In the remaining two patients who had short bowel,MVI was continued 7 days per week. Additionally, 19/21 (90%) patients also were supplemented orally with Vitamin D (17/21), Vitamin B12 (5/21), MVI (3/21), Vitamin C (1/21). There was a decline in average Vitamin C levels between the two study periods (Table 2) with a trend towards a decline in average 25-hydroxy vitamin D levels, while mean vitamin A and B12 levels did not change significantly. There was a significant increase in Vitamin D and C deficiencies, while no increase in deficiencies in Vitamin E, A, and B12 levels was noted (Figure 1). Conclusion(s): Unfortunately, shortages of key PN related supplies have become commonplace in the last few years. The most recent shortage affected MVI supplies. Our group managed the shortage through a combination of reduction of parenteral MVI administration to 3 days per week along with additional supplementation of specific micronutrients orally. Although with this strategy, there was an increase in Vitamin D and C levels falling below reference range, no significant deficiencies were noted. (Table Presented).

Evaluating the Impact of Nutrition Support on Clinical Outcomes in Critically Ill Patients With COVID-19: A Retrospective Study

Background: Patients with COVID-19 experience prolonged ICU stays. The rate of malnutrition in hospitalized patients remains controversial as well as the appropriate nutrition therapy for these patients. The purpose of the study was to evaluate the impact of nutrition support on clinical outcomes in critically ill patients with COVID-19. Method(s): This was a retrospective chart review involving 48 adults, critically ill patients admitted with confirmed SARS-CoV-2 infection. Data extracted included demographic, anthropometric, medical history, biochemical tests, medications, nutrition support protocol, clinical outcomes, length of stay, and ventilator status. We tested associations between aspects of nutrition support (such as early versus delayed feeding, adequacy, and patient positioning) and clinical outcomes (ICU length of stay, weight status, malnutrition status, refeeding syndrome, and ventilator days) using Chi-square, and t-tests, with significance established at the level of p <= 0.05. Result(s): Thirty-eight percent (18) of the patients met the criteria for malnutrition using the Global Leadership Initiative on Malnutrition (GLIM) tool. Approximately 83% of these patients did not have a documented diagnosis of malnutrition in the electronic medical record. More than half of the patients in the study (58.3%) were placed in prone position as part of their treatment and only 7% of these had documented signs of feeding intolerance. None of the patients were switched to total parenteral nutrition (TPN). Only 37% of the patients received adequate protein within the first week of nutrition support while 98% had adequate or exceeded caloric needs. There was no difference in percent weight loss among patients who received inadequate protein compared to those who had adequate protein. Inadequate protein intake was associated with shorter ICU stays (p = 0.04) and fewer ventilator days (p = 0.01) compared to those with adequate protein. Patients who received inadequate or exceeded their calories needs also had shorter ICU stays and fewer ventilator days (p > 0.05). In the context of this study, shorter ICU stays translated into fewer days of life, as 98% of the studied population died before ICU discharge. There were no associations between early nutrition support and selected biochemical parameters. Conclusion(s): The rate of malnutrition was remarkable and largely undocumented. Most patients did not meet the minimum estimated protein needs. Studies with larger sample sizes are needed to examine appropriate protein needs and the effect of nutrition support in patients with COVID-19. Diagnosing and documenting malnutrition warrants heightened attention.

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).

The Association Between Nutritional Status and Outcomes in Patients Infected With COVID-19

Background: The COVID-19 pandemic continues to pose challenges for healthcare systems across the world. Many patients infected with the virus, whether mild or severe, have nutritional complications ranging from poor appetite to the need for nutrition support. Limited research has shown that nutritional status plays a significant role in disease outcomes for COVID-19 patients. Although the American Society for Parenteral and Enteral Nutrition set guidelines for the nutritional management of COVID-19 patients, to date there are few major studies investigating the association between nutritional risk and outcomes in these patients. Thus, the purpose of this study is to assess the association between nutritional status and outcomes in hospitalized patients with COVID-19 and to identify the most common feeding practices among these patients. Method(s): A descriptive research design was used. Researchers reviewed the medical records of a random sample of 300 adult patients diagnosed with COVID-19 admitted to an academic metropolitan healthcare system between March 2020 to March 2021. Nutritional status was obtained from the admission screening and assessment documentation by a clinical dietitian (RD). Patients were then stratified based on admission nutritional status as malnourished or not. Differences in hospital length of stay (LOS), ICU LOS, ventilator dependence (in hours), and mortality were compared between groups using Mann-Whitney U, independent t-test, and chi-square tests. Result(s): Malnourished patients had a longer median (IQR) length of stay compared to non-malnourished patients (8 days (3,16) vs 4 days (3,8), p = 0.001). More patients who were malnourished expired (10/43, 23.3%) compared to patients who were not malnourished (17/ 257, 6.6%) (p = 0.002). No significant differences were observed in ICU length of stay or hours on a ventilator between groups. Most patients in the study were fed orally (87.3%), while 12.7% were fed enterally, and none of the patients were fed through use of parenteral nutrition. Conclusion(s): Results suggest that malnourished patients with COVID-19 experienced several worse outcomes compared to patients with COVID-19 who were not malnourished during hospitalization. Other known factors that influence outcomes of patients with COVID-19 were not considered in this descriptive study. Subsequent analysis to account for race, obesity, and other comorbidities is needed.

Spontaneous Gastro-pancreatic Fistula: A Rare Complication of Acute Pancreatitis

Introduction: Although Gastrointestinal fistula is a well-recognized complication of acute pancreatitis, it has been rarely reported. Here we present a rare case of spontaneous gastro-pancreatic fistula following acute pancreatitis. Case Description/Methods: 42 y/o female with PMH of SLE with a recent prolonged hospitalization for acute drug-induced pancreatitis with pseudocyst came to ED with fever, abdominal pain, nausea, and vomiting. She was tachycardic, had leukocytosis, and was positive for COVID-19. CT Scan A/P showed multiple infected peripancreatic collections with communication of the left upper quadrant collection with the gastric lumen (Figure). The patient was hospitalized, Kept NPO, and started on fluids and antibiotics. IR evaluated and put 2 pigtail catheters for drainage of peripancreatic collections. The tip of the pigtail catheter in the left peripancreatic/retroperitoneal collection was in the gastric lumen. The surgery team recommended continuing with conservative treatment with parenteral nutrition, and IV antibiotics as the patient were nontoxic with no signs of free perforation, and pancreatitis would more likely erode a staple or suture line and would put the patient at further risk of free perforation if repair attempted. IR was successful in pulling the drain out of the gastric lumen on the second attempt to allow gastric perforation to heal. Antibiotics were upgraded as per the culture and sensitivity results of the drain fluid. Repeated multiple bedside leak tests and CT scans with oral contrast continue to be positive for patent gastro-pancreatic fistula. Pigtails catheter continues to drain significant necrotic collection. The patient continues to be hospitalized and is being managed conservatively with Parenteral nutrition, and IV antibiotics. Discussion(s): Fistula of the GI tract following acute pancreatitis can be caused by multiple reasons. Necrosis of the bowel may occur concomitantly with the pancreatic or peripancreatic tissue. Furthermore, enzyme-rich fluid and necrosis can lead to vascular thrombosis, which compromises the blood supply of the segmental GI tract, eventually leading to bowel necrosis. GI fistulas are more common in patients with necrotizing pancreatitis with infected pancreatic necrosis. Despite pharmacologic suppression of pancreatic exocrine secretion and advances in endoscopic and percutaneous therapeutic techniques, pancreatic fistula continues to be a source of morbidity and mortality following pancreatitis and requires multidisciplinary treatment.

Clinical Nutrition and Food Services

Nutrition and food services provide a clinical support for quality nutritional care and treatment for a patient's overall nutritional health and recovery. In response to the crisis of the COVID-19 pandemic initial surge at SBH Health System in Spring 2020, the clinical nutrition team immediately began setting up strategic plans to cope with the unprecedented challenges and the arising logistical and staffing needs as greater demand was put on acute care hospitals worldwide. This chapter highlights those plans and describes how they were implemented during this COVID-19 crisis to ensure the continuity of quality nutrition care provision for all patients in the hospital as well as in the community. A primary challenge throughout the rapidly evolving COVID-19 crisis was rapidly expanding the capacity of the Nutrition Services Department. With proper strategic planning within the team and across the hospital departments, substantial preparations were made to overcome these difficulties and obstacles, despite the many unforeseen circumstances that often evolved unexpectedly. With great teamwork and collaboration, the clinical nutrition team realized there were actually many pathways to negate and minimize the impact of the crisis on nutrition provision allowing continuity of service through the pandemic crisis. © SBH Health System 2022.

Custom parenteral nutrition for critically ill patients with aminoacidopathies

Background: Nutrition therapy is crucial in the management of aminoacidopathies. The goal during critical illness is to reverse catabolism by providing sufficient energy and non-offending amino acids (AAs). If the patient's condition is unstable, tolerance of adequate enteral nutrition (EN) to promote anabolism may not be feasible. Parental nutrition (PN) may be necessary to meet nutrition goals, however standard preparations of PN are contraindicated. Integrity Compounding Pharmacy [Sandy Springs, GA] offers specialty compounding options tailored to provide PN to critically ill patients with aminoacidopathies void of offending AAs. Method(s): Retrospective chart review was performed. Patient Awas a 4-day old twin female born at 31-weeks gestation with phenylketonuria (PKU) hospitalized for prematurity and respiratory failure. Patient B was a 4-day old female, sibling of patient A, also with PKU hospitalized due to prematurity, respiratory failure and ductal dependent pulmonic stenosis. Patient C was a 26 year old male with maple syrup urine disease (MSUD) admitted for metabolic decompensation and respiratory failure in the setting of novel Covid-19 virus. Patient Dwas an 8 year old female with MSUD presenting with nausea and vomiting in the setting of novel Covid-19 virus. All four patients experienced elevated blood levels of offending AAs and inadequate EN intake. Custom PN from Integrity Compounding Pharmacy was utilized in all four patients ranging from 6 to 11 days. Patient A, B and D received custom PN as sole source nutrition for a period of time while transitioning to EN. Patient C tolerated a small amount of EN as well as custom PN to meet nutrition goals. Result(s): The Integrity custom PN provided appropriate AAs to optimize nutrition until full EN could be tolerated. This essential nutrition therapy helped reverse catabolism, achieve metabolic control and prevent further sequelae. Conclusion(s): Custom PN should be considered in critically ill patients with aminoacidopathies that have significant EN intolerance.Copyright © 2022 Elsevier Inc. All rights reserved.

Nutritional assessment of Covid-19 patients admitted in intensive care units in Pakistan

Coronavirus disease 2019 (COVID-19) can be life threating if untreated. Early diagnosis and effective nutritional management can save life. To assess the nutritional status and predict possible outcomes of critical patients Sequential Organ Failure Assessment (SOFA), nutrition risk in critically ill patients (NUTRIC), and acute physiology and chronic health evaluation (APACHE) score has been used. This retrospective observational study was conducted on confirmed COVID-19 cases in Intensive Care Unit (ICU) of Shifa hospital between November 24, 2020 to May 31, 2021. The demographic, clinical and laboratory information was obtained from hospital records. Risk factors for COVID-19 were identified and compared using multivariate logistic regression analysis. The nutritional risk for each patient was assessed. In this study 162 COVID-19 patients with median age of 64 years (IQR: 56-74) were included. Hypertension (59.2%) was found to be the most common comorbidity and the most prevalent symptoms upon admission were fever (54.9%). The patients in critical condition were supplied nutrients through nasogastric route (61.7%) while 37.7% and 0.6 % were assisted through oral and total parenteral nutrition (TPN) route. The Glasgow comma score was found to be mild (72.2%) (GCS>12) with increased creatinine, white blood cell count, C-reactive protein (CRP C), and glycosylated haemoglobin HbA1c level were present. Interestingly based on SOFA, APACHE and NUTRIC score low insignificant malnutrition risk was observed. Our study found different demographic factors and comorbidities have a substantial impact on COVID19 patients, as evidenced by demographic, laboratory, clinical, and nutritional risk factors.

Role of Technology Innovation in Telemedicine: Focus on Sport Nutrition

Due to the COVID-19 pandemic, there has been a significant transformation in the field of telehealth and telemedicine, as systems have been improved to meet the increased demand for remote healthcare services. Many ordinary technologies have been equipped to facilitate the normal relationship between patients and specialists. These technologies were put into action in a short period of time, creating a gap between the limits of common technologies and the special needs of telemedicine patients. Furthermore, focusing the lens on the special needs of sports in terms of nutrition, we see that research demonstrates the possibility of improving athletic performance by introducing technological diet support. This review aims to provide an overview of the technologies successfully implemented in telemedicine systems, a look at new modeling approaches, and a study on the roles of new enabling technologies in the process. It aims to highlight the results of the employment of telemedicine in sports dietary support and present open research challenges and recommendations for future research on a new application of technologies in telemedicine, for both the industrial and academic sectors. Literature was identified through intensive research work, reviewing articles related to the topics of new technologies in telemedicine and sports dietary support systems. The review concludes that it is possible to envisage the design of future models in the eHealth sector related to nutrition and sports, confirming the important role of telemedicine in a healthy lifestyle.

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.

Clinical impact of out-of-ICU non-invasive respiratory support in patients with COVID-19 related pneumonia

In response to the COVID-19 pandemic, health systems attempted to rapidly reorganise their healthcare including implementation of Respiratory Support Units (RSU). Aim(s): To describe the characteristics of the patients admitted to our RSU. Method(s): Observational study including patients admitted to the RSU with bilateral COVID-19 pneumonia from 03/15/2020 to 09/14/2021. Clinical characteristics, gasometrical data on admission, pharmacological treatments, respiratory support therapies, days of stay in the RSU, complications and mortality are described. Result(s): 176 patients (111 men) were included, mean age 64 years. Most frequent comorbidities: hypertension (93 patients), dyslipidaemia (70), obesity (49) and diabetes (45). On admission, the mean respiratory rate was 24 rpm, PaO2/FiO2 143 mmHg. Most used drugs: Enoxaparin > 40mg/day in 126 patients, Dexamethasone in 113, Tocilizumab in 102 and Remdesivir in 53. Parenteral nutrition was received by 26 patients. All patients received oxygen therapy, CPAP was applied to 86 patients and NIV to 55. Mean PEEP applied was 11 cm H2O. Twenty-three patients presented myopathy, 12 pulmonary thromboembolism, 8 haemorrhagic accidents, 3 pneumothorax, 3 venous thromboses, 3 infections due to multiresistant germs, and 2 confussional syndromes. Mean RSU stay was 12 days. Fitting patients required IOT and global mortality was 12%. Conclusion(s): 1. The RSU has allowed us to assume the great demand for care of seriously ill patients derived from the current COVID-19 pandemic. 2. Non-invasive ventilation techniques are a valid alternative for the treatment of hypoxemic respiratory failure refractory to conventional oxygen therapy in these patients.

Deeds and Words

'Complexity chaos high rates of change serious safety and quality issues and workforce shortages in health care are some of the reasons why clinical leadership is important.' Joseph & Huber (2015). Increasingly Practice Education is involved in the early stages of managing an emerging crisis- historically this has not always been the case. We describe key elements used to succeed and in what ways these positively impacted on the teams. Arguably clinical leadership in nursing education reflects that described by Joseph and Huber (2015);'the process of influencing point-of-care innovation and improvement in both organizational processes and individual care practices to achieve quality and safety of care outcomes.' Necessity combined with strong senior leadership during the initial stages of the first wave of the Covid-19 pandemic, led to the Lead Practice Education team taking up leadership positions across the trust to ensure that teams were clinically supported with effective responsive nursing education. This re-modelling of the team coupled with adaptations to workstreams enabled a singular focus on clinical nursing. Whether through upskilling and refreshing those in non-ward based roles disseminating changeable infection control advice or developing education plans for emerging conditions such as PIMS-TS the leadership of this team was highly effective and well received. Since this time Lead Practice Educators have been called upon to support the delivery of high flow humidified oxygen to more patients transferring from ICU and most recently in supporting the Parenteral Nutrition intravenous lines crisis. The 'traditional' educational approach combining clinical leadership with compassion and common sense utilised the following key elements;. Rapid Training Needs Analysis . Wide organisational reach . Rapid translation of policy into practice . Clinical credibility and visibility.

Neurodevelopmental Outcomes in Preterm Infants Receiving a Multicomponent vs. a Soybean-Based Lipid Emulsion: 24 Month Follow-Up of a Randomized Controlled Trial.

BACKGROUND: Few studies in the literature have analyzed the long-term neurodevelopmental outcomes of the administration of a multicomponent versus a soybean-based lipid emulsion (LE) in preterm infants receiving parenteral nutrition (PN). A recent randomized controlled trial conducted in our unit provided evidence of better growth in head circumference during the hospital stay in those who received a multicomponent LE. METHODS: This is a 24 month follow-up study of preterm infants, previously enrolled in a randomized trial, who received a multicomponent LE (SMOFlipid®) or a standard soybean-based one (Intralipid®). We evaluated neurodevelopmental outcomes at 24 months of corrected age (CA) in the two groups. RESULTS: Ninety-three children were followed up to the age of 24 months CA. Due to the peculiar time frame of the SARS-CoV-2 pandemic, neurodevelopmental outcomes were evaluated only in 77 children: 37 in the SMOFlipid® group and 40 in the Intralipid® group. No differences in major disability rates or in Griffith's evaluation were found between the two groups. CONCLUSIONS: In our population study, the administration of a multicomponent LE containing fish oil, compared to a soybean-based LE, had no significant effects on neurodevelopmental outcomes in preterm infants at 24 months CA.

Managing nutrition support product shortages: What have we learned?

Product shortages related to the components of parenteral nutrition (PN) therapy have been well described over the past decade. The situation has more recently worsened and expanded globally because of the impact the COVID-19 pandemic has placed on supply chain issues and workforce demand. The impact of enteral nutrition (EN) product shortages is less well documented when compared with PN, and development of management strategies is often left up to the discretion of individual providers. The recent crisis in infant formula supply has heightened the national awareness of how a nutrition support product shortage can significantly impact patient safety. This review provides a historical perspective of PN and EN product shortages to gain insight into the lessons learned and applies this to strategies for managing current and future product shortages. Strategies for managing PN and EN shortages can best succeed if they are tailored to address aspects that are unique to the inpatient and outpatient care setting. In addition, patients who transition between care settings are vulnerable to harm related to product shortages if measures are not in place to communicate and address these shortages. Teamwork and communication within an organization and among key stakeholders are necessary to develop processes that aim to minimize patient harm related to product shortages.

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.

Nutritional therapy for hospitalized patients with COVID-19: A narrative and integrative review.

Hospitalized patients affected by coronavirus disease 19 (COVID-19) have a sustained pro-inflammatory state and recurrent gastrointestinal symptoms that correlate with a decline in the nutritional status, which is directly related to poor immune response and clinical evolution. Nutritional therapy has proven crucial in COVID-19 treatment through the provision of adequate amounts of nutrients. Since the beginning of the pandemic, medical societies have mobilized to provide practical nutritional guidelines to support decision-making; despite this, there are only a few studies dedicated to compiling the most relevant recommendations. In this narrative review, we aimed to summarize and stratify the current scientific literature on nutritional support for hospitalized COVID-19 patients. We carried out a literature review from three databases between January 2020 and July 2021, using nutrition therapy (or medical nutrition or enteral nutrition or parental nutrition or nutritional support) and COVID-19 (SARS-CoV-2 infection) as the search terms. Only those studies that evaluated adult hospitalized patients with admissions to wards, specific clinics, or intensive care units were included. The nutritional intervention considered was that of specific nutritional support via oral, enteral, or parenteral modes. A total of 37 articles were included. In general, the nutritional care provided to COVID-19 patients follows the same premises as for other patients, i.e., it opts for the most physiological route and meets nutritional demands based on the clinical condition. However, some protocols that minimize the risk of contamination exposure for the health team have to be considered. Energy requirements varied from 15 kcal/kg/day to 30 kcal/kg/day and protein goals from 1.2 g/kg/day to 2 g/kg/day. In both cases, the ramp protocol for increased supply should be considered. In cases of enteral therapy, ready-to-use diet and continuous mode are recommended. Attention to refeeding syndrome is essential when parenteral nutrition is used.

Two-year outcomes of using a stepwise thrombolysis protocol for the management of acute non-malignant portomesenteric thrombosis

IntroductionAcute extensive non-malignant non-cirrhotic portomesenteric thrombosis can lead to bowel infarction and frequently does not resolve with anticoagulation. In 2019 we published our first case series of a stepwise thrombolysis protocol involving the use of low dose tissue plasminogen activator (L-tPa) followed, if indicated, by Catheter-Directed Thrombolysis (CDT) and Transjugular Intrahepatic Portosystemic Shunt (TIPSS). We present an updated series, aiming to explore the recanalization rates, symptom resolution and any adverse events for patients who received this protocol.MethodWe retrospectively reviewed the clinical records of patients who received the stepwise regimen at Royal Free Hospital between December 2019 & March 2022.ResultsA total of 35 patients were included with a mean age of 47 (SD=14) years;63% were males. Thrombophilia was identified in 13 (37%) cases and 14 (40%) had other local or systemic causes for thrombosis (1 had COVID-19;3 received ChAdOx1 vaccination). Three patients had underlying chronic liver disease. All patients had ongoing abdominal pain despite anticoagulation. Occlusive portal vein thrombosis (PVT) was found in 30 (86%) patients with 18 (51%) having thrombosis of all three vessels (PVT + splenic vein + superior mesenteric vein). While all patients received L-tPa within a median of 15 (IQR =18) days of symptoms, CDT was applied in 17 (49%) patients and TIPSS was inserted in 15 (43%). CDT was delivered through EKOS™ endovascular system in 11/17 (65%). A degree of recanalization was observed in 24 (69%). TIPSS was patent at discharge in 14/15 (93%).The majority 28 (80%) were maintained on warfarin and 11 had concomitant anti-platelet therapy. Fifteen patients had imaging follow-up available [median duration of 9 (IQR = 11) months]. Recanalization was maintained in 9/15 (60%) and TIPSS remained patent in 6/9 (67%). At a median follow up of 6.5 (IQR = 9) months, complete symptom resolution was achieved in 30/34 (88%).Nine patients underwent bowel resection within a median duration of 11 (IQR= 10.5) days from presentation;mean length of bowel resected was 67 cm (SD = 50). One patient was discharged on parenteral nutrition and had a stoma. One patient died during the initial admission (related to bowel ischemia) and 1 had intracranial haemorrhage. Minor bleeding was recorded in 8 patients.ConclusionOur protocol resulted in good recanalization and patency rates with the majority achieving symptom resolution. While some patients required surgical intervention, bowel continuity was maintained and only one patient had a stoma.