The prognosis of incurable cachectic cancer patients on home parenteral nutrition: a multi-centre observational study with prospective follow-up of 414 patients.

BACKGROUND: The role of home parenteral nutrition (HPN) in incurable cachectic cancer patients unable to eat is extremely controversial. The aim of this study is to analyse which factors can influence the outcome. PATIENTS AND METHODS: We studied prospectively 414 incurable cachectic (sub)obstructed cancer patients receiving HPN and analysed the association between patient or clinical characteristics and surviving status. RESULTS: Median weight loss, versus pre-disease and last 6-month period, was 24% and 16%, respectively. Median body mass index was 19.5, median KPS was 60, median life expectancy was 3 months. Mean/median survival was 4.7/3.0 months; 50.0% and 22.9% of patients survived 3 and 6 months, respectively. At the multivariable analysis, the variables significantly associated with 3- and 6-month survival were Glasgow Prognostic Score (GPS) and KPS, and GPS, KPS and tumour spread, respectively. By the aggregation of the significant variables, it was possible to dissect several classes of patients with different survival probabilities. CONCLUSIONS: The outcome of cachectic incurable cancer patients on HPN is not homogeneous. It is possible to identify groups of patients with a ≥6-month survival (possibly longer than that allowed in starvation). The indications for HPN can be modulated on these clinical/biochemical indices.

Adaptation of the Psoriatic Arthritis Quality of Life (PsAQoL) instrument for Sweden.

OBJECTIVE: The Psoriatic Arthritis Quality of Life (PsAQoL) questionnaire is the first disease-specific patient-derived instrument for assessing QoL in patients with PsA and has been extensively validated in this population. The aim of the adaptation process reported here was to develop a Swedish version of the PsAQoL that was equivalent to, and met the same psychometric and acceptability standards as, the original instrument, which was developed in the UK. METHOD: Translation of the original questionnaire into Swedish was performed by a professional and a lay panel. Field testing for face and content validity was performed by interviewing 13 patients. Finally, 123 patients with PsA were included in a test-retest postal survey designed to test reproducibility and construct validity. The PsAQoL was administered on two occasions approximately 2 weeks apart. The Nottingham Health Profile (NHP) was used as a comparator instrument. RESULTS: The Swedish version of the PsAQoL questionnaire showed good reliability at both time points and, as expected, correlated with the NHP. The scale was able to distinguish between groups based on self-reported general health and flare-up. Patients with active symptoms of both arthritis and psoriasis had worse QoL. The results also indicated that duration of disease has a progressive impact on PsAQoL scores. CONCLUSIONS: This study provides evidence that the adapted PsAQoL can be used for clinical studies in Swedish patients. The instrument provides valuable information on the long-term effects of PsA on QoL.

Home enteral nutrition in adults: a European multicentre survey.

AIMS: This study was undertaken to report indications and practice of home enteral nutrition (HEN) in Europe. METHODS: A questionnaire on HEN practice was sent to 23 centres from Belgium (B), Denmark (D), France (F), Germany (G), Italy (I), Poland (P), Spain (S) and the United Kingdom (UK). This involved adult patients newly registered in HEN programme from 1 January 1998 to 31 December 1998. RESULTS: A total of 1397 patients (532 women, 865 men) were registered. The median incidence of HEN was 163 patients/million inhabitants/year (range: 62-457). Age distribution was 7.5%, 16-40 years; 37.1%, 41-65 years; 34.5%, 66-80 years and 20.9% >80 years. The chief underlying diseases were a neurological disorder (49.1%), or head and neck cancer (26.5%); the main reason for HEN was dysphagia (84.6%). A percutaneous endoscopic gastrostomy (58.2%) or a naso-gastric tube (29.3%) were used to infuse commercial standard or high energy diets (65.3%), or fibre diets (24.5%); infusion was cyclical (61.5%) or bolus (34.1%). Indications and feeds were quite similar throughout the different centres but some differences exist concerning the underlying disease. There was greater variation in the choice of tubes and mode of infusion. In F, G, I, S, and UK, costs of HEN are fully funded. In B, D, and P patients have to pay part or all of the charges. CONCLUSIONS: In Europe, HEN was utilised mainly in dysphagic patients with neurological disorders or cancer, using a standard feed via a PEG. However, there were important differences among the countries in the underlying diseases treated, the routes used, the mode of administration and the funding.

Vitamin D status and measurements of markers of bone metabolism in patients with small intestinal resection.

BACKGROUND AND AIMS: Vitamin D deficiency is common in patients with small intestinal resection and may lead to secondary hypersecretion of parathyroid hormone (PTH), which in turn may result in increased bone turnover rate and loss of bone mineral. The aims of this study were to investigate the prevalence of vitamin D deficiency, as assessed by low serum concentrations of 25-hydroxyvitamin D (25(OH)D) in patients with small intestinal resection and to explore the relation of 25(OH)D to PTH, markers of bone turnover rate, and bone mineral density (BMD) in these patients. PATIENTS: Forty two patients with small intestinal resection, a faecal energy excretion of more than 2.0 MJ/day, and a mean length of the remaining small intestine of 199 cm were included. Diagnoses were Crohn's disease (n=35) and other (n=7). METHODS: 25(OH)D was analysed by radioimmunoassay and bone turnover rate was assessed by measurement of serum osteocalcin, serum alkaline phosphatase, urine pyridinoline, and urine deoxypyridinoline. BMD was measured by dual energy x ray absorptiometry. RESULTS: Mean 25(OH)D concentration was 13.4 (SD 9.7) ng/ml, which was significantly below the reference mean of 26.4 (SD 13.2) ng/ml (p<0.001). Vitamin D deficiency (25(OH)D concentration

Pyoderma gangrenosum associated with crohn disease: effect of TNF-alpha blockade with infliximab.

Eight patients with pyoderma gangrenosum associated with Crohn disease were treated with infliximab. All had active mucosal inflammation indicated by endoscopic examination. Within 1-4 months, infliximab treatment resulted in complete healing of the pyoderma gangrenosum in 3 cases (1 parastomal, 2 lower limb), partial healing in 3 (2 parastomal, 1 lower limb) and temporary improvement in 2. Adverse effects such as skin rash, pneumonia and diarrhoea were seen in three patients. Our results imply that infliximab has a therapeutic potential on skin manifestations associated with inflammatory bowel disease, even though successful treatment may require repeat courses of infliximab infusions.

Short-term administration of glucagon-like peptide-2. Effects on bone mineral density and markers of bone turnover in short-bowel patients with no colon.

BACKGROUND: Glucagon-like peptide 2 (GLP-2) is a newly discovered intestinotrophic hormone. We have recently reported that a 5-week GLP-2 treatment improved the intestinal absorptive capacity of short-bowel patients with no colon. Additionally, GLP-2 treatment was associated with changes in body composition that included a significant increase in total body bone mass. This article describes the effect of GLP-2 on spinal and hip bone mineral density (BMD) and biochemical markers of bone turnover in these patients. METHODS: In an open-labelled pilot study, eight short-bowel patients (3M, 5F; mean age 49 years) with small-bowel resection and no colon received 400 microg s.c. of GLP-2 twice daily for 5 weeks. Four received home parenteral nutrition (mean length of residual jejunum 83 cm) and 4 did not (mean length of ileum resected 106 cm). The outcome measures were the mean percent change from baseline in spinal and hip BMD measured by dual-energy X-ray absorptiometry, changes in four biochemical markers of bone-turnover, PTH, 25-hydroxy vitamin-D, and the intestinal absorption of calcium. RESULTS: Mean +/- s(x) (SEM) percent changes in spinal and hip BMD were 1.1+/-0.4% (P < 0.05) and 1.9+/-0.8% (P = 0.06), respectively. The intestinal calcium absorption increased by 2.7% (P = 0.87). Serum ionized calcium increased in 5/8 patients with a concomitant decrease in serum PTH values. Three of the four markers of bone turnover decreased. CONCLUSION: A 5-week GLP-2 administration significantly increased spinal BMD in short-bowel patients with no colon. The mechanism by which GLP-2 affects bone metabolism remains unclear, but may be related to an increased mineralization of bone resulting from an improved intestinal calcium absorption.

Clinical, social and rehabilitation status of long-term home parenteral nutrition patients: results of a European multicentre survey.

BACKGROUND: Home parenteral nutrition (HPN) is a lifesaving treatment in patients with intestinal failure. Dependency of nutritional support becomes permanent for the majority of patients who had received HPN for at least 2 years. The alternative to long term HPN in selected patients is intestinal transplantation. AIMS: To study some of the clinical, social and rehabilitation aspects of long-term HPN treatment. METHODS: A survey was performed in nine European HPN centres. The questionnaire covered epidemiologic data, underlying diseases, intestinal anatomy, nutritional support and status, marital status, rehospitalization rate, HPN complications, rehabilitation score, drugs use, coexistent diseases and interest in intestinal transplantation. For some items, data were collected within 12 months prior to the evaluation. RESULTS: This survey included 228 patients with a median age of 49 years. The median duration of HPN was 7 years (range 2--24 years). Short bowel length less than 100 cm was reported in 65% of patients with a predominance of end-jejunostomy or jejuno-colonic anastomosis. Global subjective nutritional status was normal in 79% of the patients, who were supplied with a mean number of 5.6 bags of parenteral nutrition weekly. Rehospitalizations within the 12 months prior to evaluation accounted for a mean period of 23 days and were due to HPN complications in half of the cases. Catheter-related sepsis was the most frequent HPN-complication. Bone metabolism disorders, which seemed to be more common than liver diseases, were directly related to HPN duration. One-third of the HPN patients was regularly consuming analgesics or opiates. HPN impair complete rehabilitation status but may improve the status of patients who had a very low rehabilitation score before starting HPN. An interest of intestinal transplantation was noted in only 10% of medical teams and in 8% of HPN patients. CONCLUSIONS: This study is the largest European survey on long-term HPN patients with long standing or permanent intestinal failure. Data enlighten clinical, social and rehabilitation aspects of patients who could face the option of intestinal transplantation in the future.

Alendronate increases lumbar spine bone mineral density in patients with Crohn's disease.

BACKGROUND & AIMS: Low bone mineral density (BMD) is a common complication of Crohn's disease and may lead to increased morbidity and mortality because of fractures. We investigated the effect of treatment with the bisphosphonate alendronate on bone mass and markers of bone remodeling in patients with Crohn's disease. METHODS: A 12-month double-blind, randomized, placebo-controlled trial examined the effect of a 10-mg daily dose of alendronate. Thirty-two patients with a bone mass T score of -1 of the hip or lumbar spine were studied. The main outcome measure was the difference in the mean percent change in BMD of the lumbar spine measured by dual-energy x-ray absorptiometry. Secondary outcome measures included changes in BMD of the hip and total body and biochemical markers of bone turnover (S-osteocalcin, urine pyridinoline, and urine deoxypyridinoline excretion). RESULTS: Mean (+/-SEM) BMD of the lumbar spine showed an increase of 4.6% +/- 1.2% in the alendronate group compared with a decrease of 0.9% +/- 1.0% in patients receiving placebo (P < 0.01). BMD of the hip increased by 3.3% +/- 1.5% in the alendronate group compared with a smaller increase of 0.7% +/- 1.1% in the placebo group (P = 0.08). Biochemical markers of bone turnover decreased significantly in the alendronate group (P < 0.001). Alendronate was well tolerated, and there was no difference in adverse events among treatment groups. CONCLUSIONS: Treatment with alendronate, 10 mg daily, significantly increased BMD in patients with Crohn's disease and was safe and well tolerated.

[Clinical nutrition in Danish hospitals. A questionnaire study among physicians and nurses]. / Klinisk ernaering på danske hospitaler. En spørgeskemaundersøgelse blandt laeger og sygeplejersker.

Specific nutrition standards have now been developed by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). We investigated the use of clinical nutrition in Danish hospitals and compared it with the standards of JCAHO by doing a questionnaire-based investigation among doctors and nurses randomly selected in 40 hospitals. Overall, 857 (43.4%) responded to the questionnaire (doctors: 395, nurses: 462). Forty percent found it difficult to identify risk-patients, and 52% needed specific screening tools. Eighty-four percent found that a nutrition plan should be described in the patient record, but 39% found it difficult to set up an individual plan, and 79% expressed a need for specific guidelines. The use of clinical nutrition in Danish hospitals did not fulfill the standards for nutrition support according to the criteria established by JCAHO. Special efforts should be aimed at education, specific screening tools and introduction of guidelines in clinical nutrition.

Absorption of calcium and magnesium in patients with intestinal resections treated with medium chain fatty acids.

BACKGROUND: Steatorrhoea is associated with increased faecal loss of calcium and magnesium. Medium chain C8-C10 triglycerides (MCTs) improve fat absorption in patients with small bowel resections but the effects on intestinal absorption of divalent cations are not clear. AIM: To assess the effect of dietary replacement of long chain triglycerides (LCTs) with MCTs on calcium and magnesium absorption in patients with small bowel resections. PATIENTS: Nineteen adult patients with a remaining small intestine averaging 171 cm (range 50-300). METHODS: In a crossover design, patients were randomised to two high fat diets (10 MJ/day, 50% as fat) for four days each separated by one day of washout. Diets were prepared in duplicate and were based on either LCT (LCT period) or equal quantities of LCT and MCT (L/MCT period). Metabolic balances were calculated during the last three days of each period. RESULTS: Mean stool volume increased significantly with the L/MCT diet and was 336 ml more than that with the LCT diet (95% confidence interval of mean difference, 26-649 ml). There was no significant change in the net absorption of calcium and magnesium between the two diets. On average, percentage calcium absorption was 8.6% with the LCT diet and 12.5% with the L/MCT diet. Mean percentage magnesium absorption was 5.4% with the LCT diet and 2.9% with the L/MCT diet. CONCLUSIONS: Dietary replacement of 50% long chain triglycerides with medium chain triglycerides in small bowel resected patients increased faecal volume significantly. No changes in the intestinal net absorption of calcium and magnesium were demonstrated.

Comparison of dual-energy X-ray absorptiometry to four other methods to determine body composition in underweight patients with chronic gastrointestinal disease.

Assessment of body composition may provide important information about the nutritional status. The applicability of two safe and convenient methods for body composition analysis, bioelectrical impedance analysis (BIA) and dual-energy x-ray absorptiometry (DXA), in underweight patients with chronic gastrointestinal disease has been sparsely elucidated. Our objective was to compare measurements by DXA with four other methods. Furthermore, we compared total body water (TBW) by BIA using three different BIA equations with measurement of TBW by tritium dilution (TBW-3H2O). Nineteen clinically stable underweight patients with chronic gastrointestinal disease were included in the study (body mass index [BMI], 19.3 +/- 1.2 kg/m2). Body composition was assessed using total body potassium (TBK), isotope dilution of tritium (3H2O), anthropometry (skinfold thickness [SF]), BIA, and DXA. Fat-free mass (FFM) by DXA was in reasonable agreement with body composition measurements by TBK (mean difference(TBK-DXA) = -1.61 kg, r = .88, standard error of the estimate [SEE] = 4.66 kg) and 3H2O (mean difference(3H2O-DXA) = 0.98 kg, r = .93, SEE = 3.34 kg). Although mean values for FFM by DXA differed significantly versus BIA and SF, we found highly significant correlations between the measurements (r = .97 and r = .97, respectively). The mean TBW by BIA was overestimated by 1.9 and 3.1 L compared with TBW-3H2O when prediction equations for normal-weight subjects were used. We conclude that the DXA method is a valuable addition to the list of methods available for body composition studies in clinically stable underweight patients. Our data show that BIA equations for normal-weight subjects overestimated TBW in the patients studied.

Prophylaxis of postoperative relapse in Crohn's disease with mesalamine: European Cooperative Crohn's Disease Study VI.

BACKGROUND & AIMS: This study investigated if long-term treatment with high-dose mesalamine reduces the risk of clinical relapse of Crohn's disease after surgical resection. METHODS: In a prospective, randomized, double-blind, multicenter study, 4 g of mesalamine (Pentasa; Ferring A/S, Vanlose, Denmark) daily was compared with placebo in 318 patients. Treatment was started within 10 days after resective surgery and continued for 18 months. Primary outcome parameter was clinical relapse as defined by an increase in Crohn's Disease Activity Index, reoperation, septic complication, or newly developed fistula. Risk factors for recurrence were prospectively defined to be analyzed in a stepwise proportional hazards model. RESULTS: Cumulative relapse rates (+/-SE) after 18 months were 24.5% +/- 3.6% and 31.4% +/- 3.7% in the mesalamine (n = 152) and placebo (n = 166) groups, respectively (P = 0.10, log-rank test, 1-sided). Retrospective analysis showed a significantly reduced relapse rate with mesalamine only in a subgroup of patients with isolated small bowel disease (n = 124; 21.8% +/- 5.6% vs. 39.7% +/- 6.1%; P = 0.02, log-rank test). Probability of relapse was predominantly influenced by the duration of disease (P = 0.0006) and steroid intake before surgery (additional risk, P = 0.0003). CONCLUSIONS: Eighteen months of mesalamine, 4 g daily, did not significantly affect the postoperative course of Crohn's disease. Some relapse-preventing effect was found in patients with isolated small bowel disease.

A characterization of vitamin D-independent intestinal calcium absorption in the osteopetrotic (op/op) mouse.

Previous work in our laboratory showed that the osteopetrotic (op/op) mouse possesses a vitamin D-independent mechanism of intestinal calcium absorption. This study was performed in an effort to further characterize the mechanism. The vitamin D-deficient op/op mouse absorbed calcium faster than either a vitamin D-deficient or 1, 25-dihydroxyvitamin D(3)-supplemented wild-type mouse. This increased rate of absorption was not found at concentrations of calcium that result in diffusional calcium absorption. Thus, vitamin D-deficient op/op mice had intestinal calcium absorption similar to that of vitamin D-deficient wild-type littermates when increasing levels of calcium were administered. Also, mRNA and protein levels of calbindin-D9k were similar in vitamin D-deficient wild-type and op/op mice as well as in wild-type and op/op mice treated with 1, 25-dihydroxyvitamin D(3). Therefore, the mechanism of vitamin D-independent intestinal calcium absorption in the op/op mouse is distinct from vitamin D-dependent intestinal calcium absorption.

Clinical nutrition in danish hospitals: a questionnaire-based investigation among doctors and nurses.

Specific nutrition standards are now developed by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in order to improve the nutritional status in hospitalized patients. We investigated the use of clinical nutrition in Danish hospitals and compared it with the standards of JCAHO by doing a questionnaire-based investigation among doctors and nurses randomly selected in 40 hospitals including internal medicine, gastroenterology, oncology, orthopedic departments and intensive care units (ICU).Overall, 857 (43.4%) responded to the questionnaire (doctors: 395, nurses: 462). Seventy-seven percent stated that nutritional assessment ought to be performed on admission, but only 24% stated that it was a routine procedure. Forty percent found it difficult to identify risk-patients, and 52% needed specific screening tools. Twenty-two percent registered body weight in all patients, and 18% registered nutrient intake routinely. Eighty-four percent found that a nutrition plan should be described in the patient record, but 39% found it difficult to set up an individual plan, and 79% expressed a need for specific guidelines. Eighty-four percent would only accept a patient being on isotonic glucose and/or electrolyte infusion for < 5 days (42% for < 2 days), and 33% would only accept a weight loss of 5% before active nutrition was initiated. About 50% would be restrictive in supplying enteral or parenteral nutrition to patients with impaired liver or kidney function. Twenty-seven percent did not use active nutritional therapy at all. Seventy-six percent found that nutritional assessment should be performed during hospital stays, but only 23% monitored the nutritional status. Sixty-eight percent stated that responsibility should be assigned to one or more persons, but this was the case in only 20%The use of clinical nutrition in Danish hospitals did not fulfill the standards for nutrition support according to the criteria established by JCAHO. Special efforts should be aimed at education, specific screening tools and introduction of guidelines in clinical nutrition.

Home parenteral nutrition in adults: a european multicentre survey in 1997. ESPEN-Home Artificial Nutrition Working Group.

A retrospective survey on home parenteral nutrition (HPN) in Europe was performed from January to December 1997. Data were compared to a similar study performed in 1993. A questionnaire of HPN practice was designed by the members of the ESPEN-HAN group. This involved adult patients (older than 16 years) newly registered in an HPN program between 1 January and 31 December 1997 and included: number of patients, underlying diseases and a 6-12 month outcome. Incidence and prevalence (at 1.1.1998) of adult HPN were calculated according to the estimated total population in 1997 for the countries in which more than 80% of HPN patients were reported.A total of 494 patients were registered in 73 centres from nine countries (Belgium (B), Denmark (D), France (F), Poland (P), Spain (S), Sweden (Sw), United Kingdom (UK), The Netherlands (N) and Germany (G). The underlying diseases for HPN in 494 patients were cancer (39%), Crohn's (19%), vascular diseases (15%), radiation enteritis (7%), AIDS (2%), other diseases with intestinal failure (18%). Incidence (patients/million inhabitants/year) were in N (3), F. (2.9), D. (2.8), B. (2.6), UK (1. 2), S (0.7) and P (0.36), respectively. Prevalence were in D. (12.7). U.K. (3.7), N. (3.7), F (3.6), B (3.0), P (1.1), S (0.65). After this 6-12 months follow-up (n=284), the mortality was respectively 4% in Crohn's disease, 13% in vascular diseases, 16% in others, 21% in radiaton enteritis, 34% in AIDS, 74% in cancer. Incidences and prevalences modestly increased in these seven European countries in 1997 in comparison to 1993. The percentages of underlying diseases in these countries remained similar except for AIDS that significantly decreased (from 7% to 2%). Outcomes did not significantly differ in the 4-year period except for AIDS (34% instead of 88% mortality) and could have been related to newer, more efficacious therapy.

Does paracentesis of ascites influence measurements of bone mineral or body composition by dual-energy x-ray absorptiometry?

Measurements of bone mineral content (BMO) and density (BMD) by dual-energy x-ray absorptiometry (DXA) may be affected by changes in soft tissue overlying bone. Furthermore, the accuracy error for body composition determined by DXA may be high in the trunk region due to the complex bone geometry. Our objective was to evaluate the impact of paracentesis on measurements of bone mineral and body composition by DXA. DXA (Norland XR-36; Norland, Fort Atkinson, WI) scans were performed in six patients with cirrhosis of the liver before and after treatment of ascites by paracentesis. There were no significant differences in the spinal BMC (change [delta] = 0.04%) and BMD (delta = -0.9%) (P > .05), nor in total body BMC ([TBBMC] delta = 1.9%) and BMD ([TBBMD] delta = 0.4%) (P > .05). The median volume of ascites drained (6.8 L; range, 1.6 to 14.7) was not significantly different from the median change in total (5.8 kg; range, 2.0 to 16.1) or trunk lean tissue mass ([LTM] 5.8 kg; range, 1.9 to 11.9) (P > .05). The changes in body weight correlated with the changes in trunk LTM (r = .93, standard error of the estimate [SEE] = 1.8 kg, P = .007). Total and regional fat mass were not changed significantly by the paracentesis. We conclude that measurements of total body and spinal bone mineral by DXA are unaffected by large changes in the soft tissue composition and height of the trunk. Furthermore, the change in body composition induced by ascites drainage was accurately determined as a change in total body and trunk LTM on a group level.

Effect of intravenous ranitidine and omeprazole on intestinal absorption of water, sodium, and macronutrients in patients with intestinal resection.

BACKGROUND: H2 receptor blockers and proton pump inhibitors reduce intestinal output in patients with short bowel syndrome. AIMS: To evaluate the effect of intravenous omeprazole and ranitidine on water, electrolyte, macronutrient, and energy absorption in patients with intestinal resection. METHODS: Thirteen patients with a faecal weight above 1.5 kg/day (range 1.7-5.7 kg/day and a median small bowel length of 100 cm were studied. Omeprazole 40 mg twice daily or ranitidine 150 mg twice daily were administered for five days in a randomised, double blind, crossover design followed by a three day control period with no treatment. Two patients with a segment of colon in continuation were excluded from analysis which, however, had no influence on the results. RESULTS: Omeprazole increased median intestinal wet weight absorption compared with no treatment and ranitidine (p<0.03). The effect of ranitidine was not significant. Four patients with faecal volumes below 2.6 kg/day did not respond to omeprazole; in two absorption increased by 0.5-1 kg/day; and in five absorption increased by 1-2 kg/day. Absorption of sodium, calcium, magnesium, nitrogen, carbohydrate, fat, and total energy was unchanged. Four high responders continued on omeprazole for 12-15 months, but none could be weaned from parenteral nutrition. CONCLUSION: Omeprazole increased water absorption in patients with faecal output above 2.50 kg/day. The effect varied significantly and was greater in patients with a high output, but did not allow parenteral nutrition to be discontinued. Absorption of energy, macronutrients, electrolytes, and divalent cations was not improved. The effect of ranitidine was not significant, possibly because the dose was too low.

Selenium depletion in patients with gastrointestinal diseases: are there any predictive factors?

BACKGROUND: Patients with intestinal disease are at risk of developing selenium deficiency due to impaired intestinal absorption. The aim of the present study was to evaluate selenium status and to identify predictive factors of selenium depletion in patients with gastrointestinal disease. METHODS: The concentration of selenium and the activity of glutathione peroxidase in plasma and erythrocytes were measured by fluorometry and by spectrophotometry. Eighty-six patients with Crohn's disease, 40 patients with ulcerative colitis, and 39 patients with various other gastrointestinal diseases were studied. Twenty-seven patients (16%) received home parenteral nutrition. Stool mass, faecal fat, and vitamin B12 absorption were analysed in 100 patients. RESULTS: The plasma selenium concentration was decreased in 85% of the patients receiving supplementary parenteral nutrition and in 20% of the patients receiving oral nutrition, among them in 26% of the patients with Crohn's disease. Almost all patients with ulcerative colitis had normal selenium levels. A statistically significant correlation was found between plasma selenium and vitamin B12 absorption, stool mass, faecal fat excretion, body mass index, P-albumin, P-zinc, and the length of the remaining small bowel. Stepwise regression analyses showed that the strongest predictors of selenium deficiency were stool mass, vitamin B12 absorption, and the length of the small-bowel resection. CONCLUSION: Selenium deficiency is common in patients with severe gastrointestinal disorders. The deficiency is mainly related to malabsorption, and a low selenium level was almost invariably present in patients who needed parenteral supplementation due to gut failure.

Adult patients receiving home parenteral nutrition in Denmark from 1991 to 1996: who will benefit from intestinal transplantation?

BACKGROUND: Small-bowel transplantation is an alternative to home parenteral nutrition (HPN) in patients with gut failure. Our aim was to report the indication, diagnosis, morbidity, mortality, and intestinal adaptation in the total cohort of Danish patients receiving HPN at any time during the 5 years between 1 January 1991 and 31 December 1995. The data were analysed against the option of transplantation. RESULTS: HPN was given to 129 patients; 59 (46%) had inflammatory bowel disease (15% died), 26 (20%) had cured cancers (42% died), and 44 (34%) had other diseases (dysmotility, surgical complications, infarcts, and so forth; 27% died). Of these, 60% were new in the HPN program, but only 19% received HPN all 5 years; 31 % had terminated HPN, 19% permanently, and 25% died. Only four deaths were HPN-related. In December 1995, 73 patients were receiving HPN in Denmark, for a prevalence of 13.9 per million, which is the highest in Europe but 10-fold lower than in the United States. CONCLUSIONS: Gut failure was the only indication for HPN in Denmark. Weight loss without gut failure, such as disseminated cancer and acquired immunodeficiency syndrome, was not an indication for HPN. Survival after small-bowel transplantation should be assessed against a sizeable mortality among candidates receiving HPN, and this depends on diagnosis and age. In an HPN population comparable with the Danish, a quarter is likely to die within a period of 5 years, a quarter will terminate HPN, and the others survive with HPN. Small-bowel transplantation can be a lifesaving procedure in the small fraction of foreseeable HPN-related deaths, mainly caused by liver failure. Transplantation will not improve survival in most adult HPN patients, and only an improved quality of life after transplantation justifies this procedure in most HPN patients.

Body composition by dual-energy X-ray absorptiometry in patients with Crohn's disease.

BACKGROUND: To study body composition at the whole-body level in patients with Crohn's disease and a history of intestinal resection compared with healthy controls, we performed a cross-sectional study using dual-energy X-ray absorptiometry (DXA). METHODS: Thirty-one patients, 13 men and 18 women, were included. They had a history of Crohn's disease for a mean period of 20 years (range, 4-45 years). All patients had undergone intestinal resections. The colon had been resected in 24 patients, and the mean length of the resected small intestine was 97 cm (range, 0-305 cm). At the time of investigation the Crohn's disease had been in remission for at least 24 months. Patients presented with significantly increased faecal volume and faecal fat excretion. A group of 69 women and 19 men were investigated with DXA and used as reference group. The fat-free mass (FFM), fat mass (FM), percentage fat mass (FM%), and total body mineral content (TBMC) were measured by DXA, and the results were expressed as a z-score. RESULTS: The mean z-score of the body mass index (BMI) was significantly reduced to -0.35 (P=0.036). The FFM was significantly reduced with a mean z-score of -1.74 (P=0.0001). The FM was unchanged (z-score, 0.12; P=0.42). However, FM expressed as percentage of body weight was significantly increased, with a z-score of 0.88 (P=0.001). The TBMC was significantly decreased, with a mean z-score of -1.42 (P=0.0001). There was positive direct correlation between the BMI and TBMC z-scores. There was no correlation between malabsorption and body composition variables. CONCLUSION: Patients with clinically quiescent Crohn's disease showed significant changes in body composition, with low BMI, significant loss of FFM, and unchanged FM. However, when expressed as percentage of body weight, FM was significantly increased. The TBMC was significantly reduced.