A comparison of two methods of treatment for central catheter tunnel phlegmon in home parenteral nutrition patients.

INTRODUCTION: The ESPEN guidelines on long-term (> 3 months) parenteral nutrition recommend the use of tunnelled central venous catheters (CVCs) to minimise the risk of insertion site infection. A developed symptomatic infection of the soft tissue tunnel surrounding a CVC may rapidly become directly life threatening if the infection progresses along the catheter tunnel towards its end inserted into the venous system. This requires immediate management to eliminate infection and limit its effects. AIM: To compare two surgical techniques for the treatment of suppurative inflammation of a CVC tunnel: conventional drainage of the infected tissues (surgical technique A) vs. radical en bloc excision of the infected tissues together with the infected central catheter (surgical technique B). MATERIAL AND METHODS: Seventy-three patients hospitalised due to CVC tunnel phlegmon between April 2004 and May 2014 were included in the retrospective study. Thirty-four (46.5%) patients underwent surgical procedure A and another 39 (53.5%) underwent procedure B. RESULTS: The mean duration of antibiotic therapy following procedure A was 8 ±3 days, whereas procedure B required 7 ±2 days of antibiotic therapy (NS). The mean hospitalisation period following procedure B was over 8 days shorter in comparison to that following procedure A (16.54 ±7.59 vs. 24.87 ±10.19, p = 0.009, respectively). CONCLUSIONS: The surgical treatment of CVC tunnel phlegmon involving radical en bloc excision of suppurated tissues along with the infected CVC shortens hospitalisation, expedites the insertion of a new CVC, and potentially reduces treatment costs.

Method of nutrition of patients after major oral and craniofacial surgery and its effects on BMI changes during a half-year period of observation.

UNLABELLED: Injuries, deformations and tumours of the facial part of skull, oral cavity or neck often hamper or prevent normal food consumption. After surgery of these structures food intake may be decreased due to postoperative wounds, pain, swelling and trismus. The aim of the study was to evaluate nutritional state of patients treated surgically in the craniomaxillo- facial surgery department and determination of factors affecting body weight changes after surgery. MATERIAL AND METHODS: The study included 83 patients operated between 2008 and 2010 in the department of cranio-maxillo-facial surgery, due to: maxillo-facial defects (30 individuals), malignant tumours (23 individuals), injuries (19 individuals), benign tumours (11 individuals). The study was prospective. A method of nutrition during the observation period and BMI (Body Mass Index) value on the first day of hospitalization and after 10, 60, 180 days after hospital admission were considered. For statistical analysis of results a general regression analysis was used. RESULTS: Significant reduction of BMI was observed in all patients after 10 and 60 days from the start of hospitalization. A significant increase of this parameter was observed between Day 60 and Day 180 of observation, however the BMI values after 180 days were still significantly lower than the baseline. A dependency between these changes and a cause of hospitalization as well as nutrition during and after the stay at hospital has been shown. CONCLUSIONS: There is a distinct relationship between the worsening of nutritional state after craniofacial surgery and nutrition during and after hospitalization, and therefore special attention should be paid to the issue of nutrition during this period.

Cholelithiasis in home parenteral nutrition (Hpn) patients--complications of the clinical nutrition: diagnosis, treatment, prevention.

UNLABELLED: Long-term home parenteral nutrition (HPN) is an important factor for cholelithiasis. An individualized nutrition program, trophic enteral nutrition and ultrasound bile ducts monitoring is a necessity in those patients. The aim of the study was to evaluate the usefulness of prophylactic cholecystectomy in patients with asymptomatic cholelithiasis requiring HPN. MATERIAL AND METHODS: 292 chronic HPN patients were analyzed in the period from 2005 to 2012. Patients were divided into four groups: A - without cholelithiasis, B - with asymptomatic cholelithiasis, C - urgent cholecystectomy because of cholecystisis caused by gallstones, D - cholecystectomy in patients without cholelithiasis performed during an operation to restore the continuity of the digestive tract. The patients were additionally divided depending on the extent of resection of the small intestine and colon. RESULTS: 36.9% of chronic HPN patients had cholelithiasis confirmed using ultrasonographic examination. Cholecystectomy due to acute cholecystitis symptoms was performed in 14.4% of the patients. The remaining 22.6% patients had asymptomatic cholelithiasis. Prophylactic cholecystectomy was performed in 5.5% patients with no signs of cholelcystisis during the planned operation to restore the continuity of the digestive tract. CONCLUSIONS: Cholelithiasis in chronic HPN patients is a frequent phenomenon. It seems useful to perform prophylactic cholecystectomy during primary subtotal resection of the small intestine, because the risk of cholelithiasis in this group of patients is very high.

Aspergillosis - diagnostic and therapeutic difficulties in critically ill surgical patients.

Improving the effectiveness of the treatment of critically ill and their longer survival has increased the existence of later complications rarely seen before. Among the hospital-acquired infections such complications include infection of mold fungi. The paper presents difficulties in diagnosing and therapy of Aspergillus mold infections illustrating them with the description of cases when Aspergillus infection occurred during the treatment of critically ill, leading with treatment delay to high mortality.

Safety and efficacy of teduglutide after 52 weeks of treatment in patients with short bowel intestinal failure.

BACKGROUND & AIMS: Although home parenteral nutrition (PN) can save the lives of patients with massive bowel loss that results in short-bowel syndrome and intestinal failure, quality of life is impaired by PN and its complications. We examined the 12-month tolerability and efficacy of teduglutide to reduce PN dependency. METHODS: Patients who received teduglutide (0.05 or 0.10 mg/kg/d) for 24 weeks in a randomized controlled trial were eligible for a 28-week double-blind extension study; 52 patients were given 52 weeks of the same doses of teduglutide. We investigated the safety, tolerability, and clinical efficacy (defined as a clinically meaningful ≥20% reduction in weekly PN volume from baseline) at week 52. RESULTS: The most common adverse events reported included headache (35%), nausea (31%), and abdominal pain (25%); 7 patients withdrew because of adverse events (gastrointestinal disorders in 4). Both groups had progressive reduction in PN. At week 52, 68% of the 0.05-mg/kg/d and 52% of the 0.10-mg/kg/d dose group had a ≥20% reduction in PN, with a reduction of 1 or more days of PN dependency in 68% and 37%, respectively. Four patients achieved complete independence from PN. CONCLUSIONS: For patients with short-bowel syndrome intestinal failure, the efficacy of teduglutide was maintained over 52 weeks and the safety profile was sufficient for it to be considered for long-term use. Further studies are needed to determine whether these effects will translate into improved quality of life and reduced PN complications. ClinicalTrials.gov number, NCT00172185.

Teduglutide reduces need for parenteral support among patients with short bowel syndrome with intestinal failure.

BACKGROUND & AIMS: Teduglutide, a glucagon-like peptide 2 analogue, might restore intestinal structural and functional integrity by promoting growth of the mucosa and reducing gastric emptying and secretion. These factors could increase fluid and nutrient absorption in patients with short bowel syndrome with intestinal failure (SBS-IF). We performed a prospective study to determine whether teduglutide reduces parenteral support in patients with SBS-IF. METHODS: We performed a 24-week study of patients with SBS-IF who were given subcutaneous teduglutide (0.05 mg/kg/d; n = 43) or placebo (n = 43) once daily. Parenteral support was reduced if 48-hour urine volumes exceeded baseline values by ≥ 10%. The primary efficacy end point was number of responders (patients with >20% reduction in parenteral support volume from baseline at weeks 20 and 24). RESULTS: There were significantly more responders in the teduglutide group (27/43 [63%]) than the placebo group (13/43 [30%]; P = .002). At week 24, the mean reduction in parenteral support volume in the teduglutide group was 4.4 ± 3.8 L/wk (baseline 12.9 ± 7.8 L/wk) compared with 2.3 ± 2.7 L/wk (baseline 13.2 ± 7.4 L/wk) in the placebo group (P < .001). The percentage of patients with a 1-day or more reduction in the weekly need for parenteral support was greater in the teduglutide group (21/39 [54%]) than in the placebo group (9/39 [23%]; P = .005). Teduglutide increased plasma concentrations of citrulline, a biomarker of mucosal mass. The distribution of treatment-emergent adverse events that led to study discontinuation was similar between patients given teduglutide (n = 2) and placebo (n = 3). CONCLUSIONS: Twenty-four weeks of teduglutide treatment was generally well tolerated in patients with SBS-IF. Treatment with teduglutide reduced volumes and numbers of days of parenteral support for patients with SBS-IF; ClinicalTrials.gov Number, NCT00798967.

Outcome on home parenteral nutrition for benign intestinal failure: a review of the literature and benchmarking with the European prospective survey of ESPEN.

BACKGROUND & AIMS: Indications and timing for referral for intestinal transplantation (ITx) were investigated through a review of the literature on home parenteral nutrition (HPN) for benign intestinal failure and a benchmarking to the results of a prospective European survey which evaluated the appropriateness of the current indications for ITx. METHODS: Manuscripts reporting outcomes of adults and children on HPN were retrieved through a PubMed search. Data from the European survey were compared with those on HPN reported in the literature, and with those on ITx reported by the USA registry and by the Pittsburgh center. RESULTS: HPN is a safe treatment with a high probability of survival. The risk of death during HPN is increased by the absence of a specialist team, and appears greater during the early period of treatment. Survival probability is decreased in patients with: age >40 or <2 years, very short bowel remnant, presence of a stoma, chronic intestinal pseudo-obstruction of myopathic origin, systemic sclerosis, radiation enteritis, intra-abdominal desmoids, necrotizing enterocolitis, congenital mucosal diseases. Liver failure is the HPN-related complication with the greatest risk of death. Death related to venous catheter complications is rare. The benchmarking supported the results of the European survey.

Maintenance of parenteral nutrition volume reduction, without weight loss, after stopping teduglutide in a subset of patients with short bowel syndrome.

BACKGROUND: Teduglutide was discontinued after being tested for ≥ 24 weeks in patients with parenteral nutrition (PN) -dependent short bowel syndrome in a clinical trial for efficacy to reduce PN volume. This study was describes change in body mass index (BMI) and PN volume over 12 months in patients who stopped drug after the clinical trial. METHODS: Prescribed PN volume, weight, and complications were reported. Patients with stable (NEUT, n = 15) or decreased (DEC, n = 7) PN volume by 12 months after stopping drug (NEUT/DEC, n = 22) were compared to those who had increased PN volume (INC, n = 15). With drug response defined by ≥ 20% reduction from pre-drug PN volume to end of drug therapy, 12 INC and 13 NEUT/DEC patients were drug responders. RESULTS: Eleven of 20 eligible sites reported data for 39 of 53 eligible study participants, with follow-up data for 37. INC patients had shorter colon and less frequently had colon in continuity than NEUT/DEC. BMI was decreased at 3, 6, and 12 months relative to the first off-drug visit in INC patients (P = .001), but not in NEUT/DEC patients. Change in BMI off-drug was predicted by colon and small bowel length, baseline BMI, and on-drug change in PN volume (adjusted R2 = 0.708). CONCLUSIONS: Gastrointestinal anatomy, baseline BMI, and PN volume reduction on-drug predicted change in BMI off-drug. Whether this response would be maintained for a longer time or in the context of a challenging clinical situation has not been evaluated.

[Mycological analysis of clinical materials of patients receiving total parenteral nutrition]. / Mikologiczna analiza próbek materialu klinicznego uzyskanego od chorych zywionych pozajelitowo.

The most frequent etiological factors of fungal infections in patients receiving total parenteral nutrition (TPN) belong to Candida genus of the yeastlike fungi. In the TPN patients the several infectious complications can develop: venous catheter infection, catheter candidemia (fungemia), fungal endocarditis or fungal ophtalmitis. The capability of hydrolytic (proteolytic, lipolytic) enzymes secretion as well as biofilm formation on artificial surfaces are the most important factors of fungal strains pathogenity. In the study from clinical materials of 37 patients receiving total parenteral nutrition 31 strains of Candida glabrata (56.4%), 13 strains of Candida albicans (23.6%), 3 Candida tropicalis strains, 2 Candida krusei strains, 2 Candida lusitaniae strains and 1 strain of Candida inconspicua were identified. The phenotypic analysis of isolated strains were performed using API YM (bioMerieux) tests for the enzymatic activity determination. Simultaneously the proteolytic and lipolytic activity analysis were performed. Candida albicans isolates secreted 10 out of 19 enzymes and Candida glabrata 7. The secretion of proteases was demonstrated in 12 C. albicans strains. All Candida glabrata isolates from examined and from control group secreted proteolitic enzymes. Candida glabrata is the dominant species in clinical materials of patients receiving total parenteral nutrition. The numerous isolation of C. glabrata from clinical materials of patients receiving total parenteral nutrition might be connected with the selection of azole resistant strains and also to ability of creatin biofilm on the biomaterial surfaces.

ESPEN Guidelines on Parenteral Nutrition: home parenteral nutrition (HPN) in adult patients.

Home parenteral nutrition (HPN) was introduced as a treatment modality in the early 1970s primarily for the treatment of chronic intestinal failure in patients with benign disease. The relatively low morbidity and mortality associated with HPN has encouraged its widespread use in western countries. Thus there is huge clinical experience, but there are still few controlled clinical studies of treatment effects and management of complications. The purpose of these guidelines is to highlight areas of good practice and promote the use of standardized treatment protocols between centers. The guidelines may serve as a framework for development of policies and procedures.

ESPEN Guidelines on Parenteral Nutrition: central venous catheters (access, care, diagnosis and therapy of complications).

When planning parenteral nutrition (PN), the proper choice, insertion, and nursing of the venous access are of paramount importance. In hospitalized patients, PN can be delivered through short-term, non-tunneled central venous catheters, through peripherally inserted central catheters (PICC), or - for limited period of time and with limitation in the osmolarity and composition of the solution - through peripheral venous access devices (short cannulas and midline catheters). Home PN usually requires PICCs or - if planned for an extended or unlimited time - long-term venous access devices (tunneled catheters and totally implantable ports). The most appropriate site for central venous access will take into account many factors, including the patient's conditions and the relative risk of infective and non-infective complications associated with each site. Ultrasound-guided venepuncture is strongly recommended for access to all central veins. For parenteral nutrition, the ideal position of the catheter tip is between the lower third of the superior cava vein and the upper third of the right atrium; this should preferably be checked during the procedure. Catheter-related bloodstream infection is an important and still too common complication of parenteral nutrition. The risk of infection can be reduced by adopting cost-effective, evidence-based interventions such as proper education and specific training of the staff, an adequate hand washing policy, proper choices of the type of device and the site of insertion, use of maximal barrier protection during insertion, use of chlorhexidine as antiseptic prior to insertion and for disinfecting the exit site thereafter, appropriate policies for the dressing of the exit site, routine changes of administration sets, and removal of central lines as soon as they are no longer necessary. Most non-infective complications of central venous access devices can also be prevented by appropriate, standardized protocols for line insertion and maintenance. These too depend on appropriate choice of device, skilled implantation and correct positioning of the catheter, adequate stabilization of the device (preferably avoiding stitches), and the use of infusion pumps, as well as adequate policies for flushing and locking lines which are not in use.

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

BACKGROUND: Intestinal failure is the outcome of a number of gastrointestinal diseases and characterized by significant reduction in functional gut mass. If not resolved patients often face long-term nutritional support. This study gathered information about how patients referred with intestinal failure are managed in specialised European centres. METHODS: A questionnaire was circulated in 7 European countries via representatives of the ESPEN-HAN working group to seek information about experience in treating patients with intestinal failure. We asked about clinical outcome, information about structure and organisation of the department, referral criteria, treatment procedures and guidelines. RESULTS: 17 centres in 6 European countries completed the questionnaire: UK, n = 6, France, n = 4, Spain, n = 3, Denmark, n = 2, Italy, n = 1, Poland, n = 1. The experience of the centres in treating patients was in the range 12-30 years. The total number of patients on HPN in all centres was 590. The number of patients referred to centres with intestinal failure during the period January to December 2000 was n = 882: UK, n = 375 (range 2-175), France, n = 308 (range 24-182), Italy and Spain, n = 43 (range 9-52), Denmark n = 51 (range 14-37), the centre in Poland included 53 patients. Comparing all centres the following distribution among patients (median % (range%)) with regard to the endpoints were reported: Oral nutrition 32% (23-50%), enteral/tube feeding 11% (4-23%), HPN 36% (15-57%), lost to follow up 10% (0-35%), dead 9% (5-18%). No patients had an intestinal transplant. CONCLUSION: The study provides information about how patients with intestinal failure are managed across Europe and the data indicates that treatment practice varies between countries.

Monitoring of patients on home parenteral nutrition (HPN) in Europe: a questionnaire based study on monitoring practice in 42 centres.

INTRODUCTION & AIM: To gather information about how adult patients on home parenteral nutrition (HPN) are monitored after discharge from the hospital. METHOD: A questionnaire about HPN monitoring practice was circulated to HPN centres in eight European countries through the representative of the ESPEN HAN-working group. Centres were asked about guidelines, home visits and how monitoring and handling of complications were managed. RESULTS: Fourty-two centres in eight European countries completed the questionnaire: UK n=14, France n=9, Belgium n=4, Italy n=4, Poland n=4, Denmark n=4, Spain n=2, Germany n=1. The HPN experience of the centres was in the range 2-30 years. Centres ranged in size from 0 to 125 HPN patients representing a total number of 934 of whom 54% had received HPN for more than 2 years. The primary disease was non-malignant in 90% whilst 10% had been diagnosed with active cancer. Of the centres 92% had a HPN team and 66% had written guidelines for monitoring HPN. Home visits after discharge for monitoring purposes were carried out by 31 of the centres involving the HPN team, general practitioner, community nurse or home care agency. Stable patients on HPN for more than 12 months were monitored at the discharging hospital (73%), at a local hospital (12%), by the General Practitioner (11%) or by a home care agency (4%). Of the centres, 90% reported that the main responsibility for monitoring was assigned to a specific person. The intervals between monitoring visits for the stable HPN patient was in the range 1-6 months, 52% of the centres reported intervals of 2-3 months. In case of complications 76% of centres reported that patients got in touch with the HPN team, 2% the local hospital, 5% the home care agency, and 17% other. Re-admission to hospital was usually to the HPN centre and only occasionally to a local hospital. CONCLUSION: In Europe a specialised team at the discharging hospital monitors HPN patients and 66% of the centres had some kind of written guidelines.

Bone mineral density in patients on home parenteral nutrition: a follow-up study.

BACKGROUND AND AIMS: The variations of bone mineral density (BMD) during home parenteral nutrition (HPN) and their relationship with general, life style, primary disease and HPN risk factors were investigated by a follow-up study. DESIGN: Patients who had BMD assessment in a previous cross-sectional survey underwent a 2nd BMD at femoral neck (FN) and lumbar spine (LS). Data about risk factors were collected by a structured questionnaire. BMD Z-score (number of standard deviations from normal values corrected for sex and age) and the annualized percent BMD change were analysed. RESULTS: Sixty-five adult patients were enrolled (follow-up: 18.1+/-5.5 months). The mean BMD Z-score significantly increased at the LS (P = 0.040) and remained unchanged at FN. In multiple regression analysis, the variations of the LS Z-score during HPN negatively correlated with the female sex (P = 0.021) and the age at starting HPN (P = 0.022). The analysis of the annualized percent BMD change confirmed the results obtained by the analysis of the Z-score. No factor was associated with BMD variation at FN. CONCLUSIONS: HPN was not associated with a decrease of BMD in most of the patients; LS BMD Z-score variations were related to general risk factors rather than to HPN factors, showing a negative association with age and female sex.

[Megacolon imitating emphysema in the course of diaphragmatic hernia]. / Megacolon imitujacy pecherz rozedmowy pluca w przebiegu przepukliny przeponowej.

A 61-year old man with fever, diarrhoea, weight loss has been admitted to the hospital. Nine years earlier an air bubble in the lower part of the left lung was recognised during the chest x-ray, four years later diagnostic studies have shown a megacolon situated in the chest that significantly pressed on the flesh of the left lung and shifted the mediastinum to the right side. At that time the patient did not agree for an operation treatment. He decided for surgery in May 2002. During the operation the presence of an enormous large intestine of the megacolon type has been determined which could be found there due to diaphragm loss. The megacolon and spleen were surgically removed and the injured diaphragm was sutured. After 2 years a clinical and functional examinations of the respiratory system were performed. There was an improvement of the exercise capacity, recession of restriction in functional examinations and an increase in body mass.

Prevalence of bone disease in patients on home parenteral nutrition.

BACKGROUND & AIMS: The epidemiology of bone disease in home parenteral nutrition (HPN) is unknown. The aim of this paper is to evaluate the prevalence and severity of reduced bone mineral density (BMD) in long-term HPN. DESIGN: Cross-sectional, multicentre study including patients who within the last 12 months had their BMD assessed by dual-energy-X-ray absorptiometry after at least 6 months of HPN. Data on bone pain and fractures, the primary gastrointestinal diseases, nutritional and rehabilitation status and HPN regimen were reviewed. Both the T-score (no. of SD below mean BMD of young subjects) and the Z-score (no. of SD from normal BMD values corrected for sex and age) were analysed. RESULTS: A T -score <-1 at any site of assessment was observed in 84% of the 165 patients enrolled (