Catheter-related bloodstream infection in patients With severe anorexia nervosa.

PURPOSE: Anorexia nervosa (AN) may be treated with intravenous hyperalimentation (IVH) that may be associated with catheter-related bloodstream infection (CRBSI). DESIGN AND METHODS: Retrospective chart review was conducted to compare those who developed CRBSI were compared with those who did not. FINDINGS: Of 34 patients, 17 episodes of AN treated with IVH were identified, of which five resulted in CRBSI. The average body mass index at admission was low at 12.2. Patients who needed physical restraint during IVH had a higher (albeit statistically nonsignificant) risk. Also, those with purging had numerically lower risk. PRACTICE IMPLICATIONS: CRBSI complicated IVH in 29.4% instances of severe life-threatening AN in our sample. Whether physical restraints and no purging constitute a risk factor of CRBSI needs to be further investigated.

Long-term prognosis of enteral feeding and parenteral nutrition in a population aged 75 years and older: a population-based cohort study.

BACKGROUND: Enteral feeding and parenteral nutrition (PN) using gastrostomy (GS) and a nasogastric tube feeding (NGT) and PN should be initiated for older patients based on their prognoses. This study aimed to investigate the long-term prognosis of patients aged ≥75 years who underwent enteral feeding via GS and NGT as well as PN. METHODS: A population-based cohort study was conducted using Japan's universal health insurance claims in the Nara Prefecture. This study enrolled 3,548 patients aged ≥75 years who received GS (N=770), NGT (N=2,370), and PN (N=408) during hospital admissions between April 2014 and March 2016. The GS group was further categorized into secondary GS (N=400) with preceding NGT or PN within 365 days and primary GS (N=370) without preceding NGT or PN groups. In the secondary GS group, 356 (96%) patients received NGT (versus PN). The outcome was mortality within 730 days after receiving GS, NGT, and PN. Cox regression analyses in cases with or without malignant diseases, adjusted for sex, age, comorbidity, and hospital type, were performed to compare mortality in the groups. RESULTS: Of the 3,548 participants, 2,384 (67%) died within 730 days after the initiation of GS and NGT and PN. The 2-year mortality rates in the secondary GS, primary GS, NGT, and PN groups were 58%, 66%, 68%, and 83% in patients without malignancies and 67%, 71%, 74%, and 87% in those with malignancies, respectively. In the non-malignant group, Cox regression analysis revealed that secondary GS (hazard ratio (HR) = 0.43, 95% CI: 0.34-0.54), primary GS (HR = 0.51, 95% CI: 0.40-0.64), and NGT (HR = 0.71, 95% CI: 0.58-0.87) were statistically significantly associated with lower mortality compared with PN. CONCLUSIONS: Approximately 58% to 87% patients aged ≥75 years died within 730 days after initiation of nutrition through GS, NGT, or PN. Patients with non-malignant diseases who received secondary GS exhibited better 2-year prognosis than those who received NGT or PN. Healthcare professionals should be aware of the effectiveness and limitations of enteral feeding and PN when considering their initiation.

Automated Self-Adjusting Subcutaneous Insulin Algorithm for Patients NPO or on TPN or Enteral Feedings.

BACKGROUND: Perioperative diabetes patients are often treated with sliding-scale insulin, despite a lack of evidence to support therapeutic effectiveness. We introduced an automated subcutaneous insulin algorithm (SQIA) to improve glycemic control in these patients while maintaining the simplicity of a q4 hour adjustable sliding-scale insulin order set. METHODS: In this pilot study, we implemented a fully programmed, self-adjusting SQIA as part of a structured order set in the electronic medical record for adult patients who are nil per os, or on continuous enteral tube feedings or total parenteral nutrition. The nurse only enters the current glucose in the Medication Administration Record, and then the calculated dose is shown. The new dose is based on previous dose, and current and previous glucoses. The SQIA titrates the glucose to 120-180 mg/dL. For this pilot, this order set was utilized for complex perioperative oncologic patients. RESULTS: The median duration on the SQIA was 58 hours. Glucoses at titration initiation were highest at 206 ± 63 mg/dL, and came down to 156 ± 29 mg/dL by 72 hours. The majority of measured glucoses (66.8%, n = 647) were maintained between 80 and 180 mg/dL. There were no glucoses lower than 60 mg/dL, and only 0.3% (n = 3) were below 70 mg/dL. There was a low rate of errors (1%). CONCLUSIONS: A simple automated SQIA can be used to titrate insulin to meet the changing metabolic requirements of individuals perioperatively and maintain glucose within the target range for these hospitalized patients.

Adolescent eating disorder with catheter-related bloodstream infection.

BACKGROUND: Treatment of adolescent eating disorder requires early improvement of nutritional status. Central venous hyperalimentation is used but catheter-related bloodstream infection (CRBSI) is a complication. There have been no reports examining risk factors for CRSBI in eating disorders. METHODS: The subjects were 51 patients who received nutritional therapy with the use of a peripherally inserted central catheter (PICC) from January 2012 to December 2019. The courses of weight and white blood cell (WBC) count were examined retrospectively during nutritional therapy. Onset factors for CRBSI were determined and a case series of CRBSI caused by Candida parapsilosis is presented. RESULTS: The day of minimum weight occurred on or before day 7 in 37 of the 51 patients, and this day was preceded by the day with the lowest WBC at a significant rate. The minimum weight day was significantly delayed in CRSBI cases compared with non-CRBSI cases (P = 0.02). In the case series of CRBSI caused by C. parapsilosis, the median WBC count before CRBSI decreased to 2,570 (1,680-3,270)/µL at a median of day (12-90) 36. Catheter-related bloodstream infection developed at a median of day (26-133) 38. The PICC was immediately removed and an antifungal drug was started, leading to cure with no after effects in all subjects. CONCLUSIONS: In patients with an eating disorder treated with nutritional therapy using a PICC, prolonged resistance to weight gain became a risk factor for developing CRBSI. White blood cell counts recover after weight gain, which suggests that there is a risk of developing CRBSI, even with improved appetite and weight gain.

Decreasing Use of Percutaneous Endoscopic Gastrostomy Tube Feeding in Japan.

OBJECTIVES: To identify trends in percutaneous endoscopic gastrostomy (PEG) tube placement and intravenous hyperalimentation (IVH) in nonhospital settings (as a potential alternative to tube feeding for nutrition) and to summarize published reports concerning the decision-making process for PEG placement. DESIGN: National survey and systematic review. SETTING: Japan. PARTICIPANTS: All Japanese people. MEASUREMENTS: Data on numbers of individuals with a PEG tube and IVH were obtained from the website of the Japanese Ministry of Health, Labour, and Welfare and published reports concerning the decision-making process for PEG placement in Japan were summarized. RESULTS: The number of PEG tube placements peaked in 2007 and has been decreasing since Japan experienced the Great East Japan Earthquake in 2011. A further decline was seen in 2015 after the Japanese Ministry of Health, Labour and Welfare revised the fee schedule in 2014. More than half of individuals who had tubes were aged 80 and older during the years observed. In contrast, the number of individuals receiving IVH was lowest in the same year as PEG tube placement peaked and has been increasing ever since. Four studies reported that the decision-making process included consideration of not only the underlying disease, but also the individual's age and social barriers and the physician's personal philosophy. CONCLUSION: The number of PEG tube placements has been decreasing since its peak in 2007, and the number of individuals receiving IVH has been increasing. Many factors influence the decision-making process for PEG tube placement. Physicians in Japan may be realizing that there is little evidence to support the use of tube feeding in frail elderly adults.

Extravasation of total parenteral nutrition into the liver from an upper extremity peripherally inserted central venous catheter.

Peripherally inserted central catheters (PICC) are the mainstay of central venous access in preterm infants, and one of the common procedures performed in neonatal intensive care unit (NICU). Complications of PICC include infection, mechanical dysfunction, thrombosis, migration, and extravasation of the infusate. In this report, we describe a case of PICC inserted from an upper extremity with migration into the inferior vena cava (IVC) and the hepatic vein associated with extravasation of the total parenteral nutrition (TPN) into the peritoneum and the liver. This case highlights the vigilance required not only to insert but for the maintenance of PICC to prevent complications associated with migration of PICC.

Fungal endophthalmitis in an elderly woman: differing responses in each eye.

Candida endophthalmitis is caused by hematogenous metastasis of the yeast. To ensure early diagnosis, serodiagnosis, or surveillance culturing is usually performed. If fungemia is apparent upon successive serological testing (in at least two tests: blood culture and/or measurement of ß-d-glucan level), ophthalmic consultation is necessary, even if no ophthalmic complaint is evident. This is because early detection with prompt prescription of systemic antifungal agents inhibits progression of the distinctive cholioretinitis. If the initial fungemia is not promptly diagnosed, or if it is missed, fungal endophthalmitis may develop, associated with a poor prognosis in terms of visual acuity. Here, we report on a case of Candida endophthalmitis in a 92-year-old woman with severe visual disturbance in one eye that was first diagnosed on ophthalmic examination. It was already difficult to recover. Fungemic systemic/ophthalmic symptoms must be checked in the early stage; in addition, prompt ophthalmological consultation is essential.

Severe hypercalcaemia and hypophosphataemia with an optimised preterm parenteral nutrition formulation in two epochs of differing phosphate supplementation.

OBJECTIVE: To compare in two epochs of differing phosphate provision serum calcium, phosphate, potassium, and sodium concentrations and the frequency of abnormality of these electrolytes and of sepsis in preterm infants who received an optimised higher amino acid-content formulation. DESIGN AND SETTING: Retrospective cohort study at a single tertiary-level neonatal unit. PATIENTS: Preterm infants given parenteral nutrition (PN) in the first postnatal week during two discrete 6-month epochs in 2013-2014. INTERVENTIONS: In epoch 1 the Ca2+:PO4 molar ratio of the PN formulation was ~1.3-1.5:1 (1.7 mmol Ca2+ and 1.1 mmol PO4 per 100 mL aqueous phase) and in epoch 2 was 1.0:1 via extra phosphate supplementation (1.7 mmol Ca2+ and 1.7 mmol PO4 per 100 mL). MAIN OUTCOME MEASURES: Peak calcium and nadir phosphate and potassium concentrations, and proportions with severe hypercalcaemia (Ca2+ >3.0 mmol/L), hypophosphataemia (PO4<1.5 mmol/L), and hypokalaemia (K+ <3.5 mmol/L) within the first postnatal week. RESULTS: In epoch 2, peak calcium concentrations were lower than in epoch 1 (geometric means: 2.83 mmol/L vs 3.09 mmol/L, p value<0.0001), fewer babies were severely hypercalcaemic (10/49, 20%, vs 31/51, 61%, p value<0.0001); nadir plasma phosphate concentrations were higher (means: 1.54 mmol/L vs 1.32 mmol/L, p value=0.006), and there were fewer cases of hypophosphataemia (17/49, 35% vs 31/51, 61%, p value=0.009) and hypokalaemia (12/49, 25% vs 23/51, 45%, p value=0.03). CONCLUSIONS: Reverting from a PN Ca2+:PO4 molar ratio of 1.3-1.5:1 to a ratio of 1.0:1 was associated with a lower incidence and severity of hypophosphataemia and hypercalcaemia. For preterm infants given higher concentrations of amino acids (≥2.5 g/kg/day) from postnatal day 1, an equimolar Ca2+:PO4 ratio may be preferable during the first postnatal week.

Co-Managing Patients with Type 1 Diabetes and Cancer.

The life expectancy of people with type 1 diabetes is improving and now approaches that of those without diabetes. As this population ages, a growing number will be diagnosed with and treated for cancer. Cancer treatments can drastically affect insulin requirement and glycemic control through multiple mechanisms including high doses of glucocorticoids and targeted therapies that directly interfere with cellular pathways involved in the action of insulin. Patients with cancer frequently also have alterations in gastrointestinal motility or appetite and require supplemental enteral or parenteral nutrition. Few studies have evaluated these patients directly, but data on patients with and without diabetes suggest that glycemic control may play a larger role in cancer outcomes than is often recognized. Collaboration between the treating oncologist and diabetologist allows people with diabetes to receive the most effective therapies for their cancers without undue risk of hypoglycemia or adverse outcomes due to hyperglycemia.

Maternal super-obesity.

PURPOSE: Pregnant women with a body-mass-index (BMI) above 50 are referred to as "super-obese". For these women adverse pregnancy outcome and a higher risk of fetal congenital defects are major issues. This report focuses on the ratio development of super-obesity in pregnant women, as well as on prenatal ultrasound and pregnancy outcome in the super-obese gravida. METHODS: We reviewed data of all women with a BMI above 30 who delivered at our unit in a 15-year period between January 2000 and December 2014. Data of obese but not super-obese mothers were evaluated in comparison. RESULTS: Final evaluation comprised 69/20,711 pregnancies of super-obese mothers. Forty out of 69 women suffered from a preexisting condition requiring medical treatment. Fetal ultrasound evaluation revealed severe congenital defects in four cases. There were no missed and no false positive diagnoses. Elective cesarean section (c-section) took place in 26/69 cases, 21/69 had a secondary c-section. Twenty-two out of 69 women delivered vaginally. Mean gestational age at delivery was 38(+6) gestational weeks. Pregnancy was complicated by macrosomia in 17/69 pregnancies. Severe neonatal hypoglycemia occurred in 6/69 cases. The number of deliveries by super-obese mothers showed no marked variation during the study period. In contrast the rate of deliveries by obese, but not super-obese, mothers showed an increase. CONCLUSIONS: Maternal super-obesity poses a high-risk situation for mother and child which generally demands a higher amount of perinatal care. The number of deliveries by super-obese mothers remained stable over the study period. Primary c-section was the most frequent mode of delivery. Of the parturients who opted for vaginal delivery nearly half of the deliveries had to be completed by secondary c-section. Over-all peripartal maternal complications did not exceed average.

Prevention of early postnatal hyperalimentation protects against activation of transforming growth factor-ß/bone morphogenetic protein and interleukin-6 signaling in rat lungs after intrauterine growth restriction.

BACKGROUND: Intrauterine growth restriction (IUGR) is intimately linked with postnatal catch-up growth, leading to impaired lung structure and function. However, the impact of catch-up growth induced by early postnatal hyperalimentation (HA) on the lung has not been addressed to date. OBJECTIVE: The aim of this study was to investigate whether prevention of HA subsequent to IUGR protects the lung from 1) deregulation of the transforming growth factor-ß(TGF-ß)/bone morphogenetic protein (BMP) pathway, 2) activation of interleukin (IL)-6 signaling, and 3) profibrotic processes. METHODS: IUGR was induced in Wistar rats by isocaloric protein restriction during gestation by feeding a control (Co) or a low-protein diet with 17% or 8% casein, respectively. On postnatal day 1 (P1), litters from both groups were randomly reduced to 6 pups per dam to induce HA or adjusted to 10 pups and fed with standard diet: Co, Co with HA (Co-HA), IUGR, and IUGR with HA (IUGR-HA). RESULTS: Birth weights in rats after IUGR were lower than in Co rats (P < 0.05). HA during lactation led to accelerated body weight gain from P1 to P23 (Co vs. Co-HA, IUGR vs. IUGR-HA; P < 0.05). At P70, prevention of HA after IUGR protected against the following: 1) activation of both TGF-ß [phosphorylated SMAD (pSMAD) 2; plasminogen activator inhibitor 1 (Pai1)] and BMP signaling [pSMAD1; inhibitor of differentiation (Id1)] compared with Co (P < 0.05) and Co or IUGR (P < 0.05) rats, respectively; 2) greater mRNA expression of interleukin (Il) 6 and Il13 (P < 0.05) as well as activation of signal transducer and activator of transcription 3 (STAT3) signaling (P < 0.05) after IUGR-HA; and 3) greater gene expression of collagen Iα1 and osteopontin (P < 0.05) and increased deposition of bronchial subepithelial connective tissue in IUGR-HA compared with Co and IUGR rats. Moreover, HA had a significant additive effect (P < 0.05) on the increased enhanced pause (indicator of airway resistance) in the IUGR group (P < 0.05) at P70. CONCLUSIONS: This study demonstrates a dual mechanism in IUGR-associated lung disease that is 1) IUGR-dependent and 2) HA-mediated and thereby offers new avenues to develop innovative preventive strategies for perinatal programming of adult lung diseases.

Successful Combined Treatment with Total Parenteral Nutrition Fluid Extravasation Injuries in Preterm Infants

Extravasation injuries in the neonatal intensive care unit are not rare during parenteral hyperalimentation. There have been many different methods of management. We report five premature infants with wounds of hyperalimentation fluid extravasation managed by the antibacterial ointment (Terramycin ophthalmic ointment(TM)) and sesame oil and a antiinflammatory herbal mixture (MEBO(TM)). The mean gestational age of patients was 31(+2) weeks (range, 28(+4) to 35(+6) weeks), and the mean weight at extravasation was 1,930 g (range, 1,140 to 2,680 g). Extravasation occurred within the mean of 32 days (range, 17 to 50 days). The method of dressing was application of a thick layer of this mixture covered by vaseline and wet gauze renewed at an interval of 8-12 hr after irrigating the wounds thoroughly with normal saline. The mean duration of dressing was 30 days (range, 20-50 days). The wounds had healed completely leaving a small size of contracture without functional abnormality. We conclude that this therapy may be considered for an alternative treatment and warrants clinical trials for the confirmation of the local management of extravasation injury.

A case of candida fungemia in acute pancreatitis and hepatitis associated with typhoid fever / 대한내과학회지

Typhoid fever is a bacteremic disease and many organs, including intestine, liver, bone, lung, thyroid, kidney, spleen, heart and pancreas may be invaded by the organism. Acute pancreatitis associated with typhoid fever sometimes needs prolonged total parenteral hyperalimentation and antibiotic treatment. Systemic Candida infections are usually encountered as opportunistic infections in a setting of immunologic depression. The authors report a case of Candida parapsilosis fungemia associated parenteral nutrition in acute pancreatitis associated with typhoid fever. A 17 year-old man was transfered to Pusan national university hospital on May 4th, 1998 under diagnosis of salmonella sepsis. High fever, nausea, vomiting and diarrhea developed 10 days before entery. On admission, serum amylase, lipase and transaminase showed elevation. The patient was treated with antibiotics(ceftriaxon) and total parenteral hyperalimentation was done under diagnosis of acute pancreatitis and hepatitis associated with typhoid fever. On 3rd hospital day, body temperature returned to normal but abdominal pain, nausea and vomiting continued. On 18th hospital day, high fever recurred and ceftriaxon was re-administered. Three days later, body temperature returned to normal. On 25th hospital days, culture of blood and catheter tip was positive for C. parapsilosis. On 27th hospital days, sudden onset high fever, pnumonic infiltration, confusion, hypotension, oliguria and azotemia developed. On 34th hospital day, sudden onset ventricular fibillation developed. On 35th hospital day, the patients died. We report a case of candida fungemia in acute pancreatitis and hepatitis associated with typhoid fever.

The hyperalimentation treatment of peptic ulcer with amino acids (protein hydrolysate) and dextri-maltose

1. A hyperalimentation treatment with a high caloric and high amino acid (protein hydrolysate) mixture has been found to be efficacious in promptly bringing acute peptic ulcers to a state of quiescence2. It is also a prompt method of simultaneously rehabilitating the strength and body weight of the ulcer patient3. The prompt improvement appears to be due to the giving of a substance (protein hydrolysate) that is simultaneously an antacid and an easily assimilable food which can be built into tissues4. The treatment does not insure against recurrences when the patient reverts to old dietary habits5. In the course of this work, a protein deficiency has been demonstrated in a large percentage of peptic ulcer cases6. The suggestion is made that gastroenterologists try this treatment and compare the results with those obtained with other regimens now in use. (Summary and conclusions)

A Prospective Study of Intraocular Candidiasis

Intraocular fungal infection, especially due to candida infection, has become an increasingly important cause of nosocomial infectio. Despite increasing awareness of this complication of candidemia, serious visual impairment due to candida infection remains as a problem. For the determine the frequency of intraocular candidasis and evaluation of risk factor, patients with candidemia were evaluated with indirect ophthalmoscopic examination within ninety six hours ater blood culture. Intraocular candidiasis were found in thirty three Percent of patient with candidemia. Candida chorioretiritis were found in five (27%) patients, candida endophthalmitis was found in one (5%) patients. The candida chorioretinitis was not progressed to candida endophthalmitis in one patients. That patient with candida endophthalmitis was treated with intravitreal amphotericin B injection, pars plana vitrectomy. Among the six intraocular candidiasis patients, five patients got cnadidiasis after long term antibiotics therapy for flame burn injury and one after anticancer therapy combined with intravenous hyperalimentation. The risk factors for the development of intraocular candidiasis can be long-term antibiotic therapy, parenteral hyperalimentation, use of indwelling catheter, or use of immunosupressive drugs in our cases.