Viewpoint: a multidisciplinary approach to the assessment of patients with systemic sclerosis-associated interstitial lung disease.

Systemic sclerosis (SSc) is a rare and heterogeneous disease affecting the skin and internal organs. SSc-associated ILD (SSc-ILD) is a common and often early manifestation of SSc. This article discusses the rationale for a multidisciplinary approach (MDA) to the early identification and assessment of patients with SSc-ILD. Diagnosis of SSc-ILD is often challenging as patients with early disease can be asymptomatic, and SSc-ILD symptoms, such as exertional dyspnea and cough, are non-specific. High-resolution computed tomography (HRCT) of the lungs is the gold standard for diagnosis of SSc-ILD since pulmonary function tests lack sensitivity and specificity, especially in early disease. On HRCT, most patients with SSc-ILD have a non-specific interstitial pneumonia (NSIP) pattern. In addition, findings of pulmonary hypertension and esophageal dysmotility may be present. The multi-organ involvement of SSc and the diverse spectrum of symptoms support an MDA for the diagnosis and assessment of patients with SSc-ILD, with input from rheumatologists, pulmonologists, gastroenterologists, radiologists, and other specialists. Key Points • Interstitial lung disease (ILD) is a common manifestation of systemic sclerosis (SSc). • Early diagnosis is key to reducing the morbidity and mortality associated with SSc-ILD and other manifestations of SSc. • The multi-organ involvement of SSc supports a multidisciplinary approach to the diagnosis and assessment of patients with SSc-ILD, with input from rheumatologists, pulmonologists, gastroenterologists, radiologists, and other specialists.

Disseminating Knowledge in Intestinal Failure: Initial Report of the Learn Intestinal Failure Tele-ECHO (LIFT-ECHO) Project.

BACKGROUND: Intestinal failure (IF) is defined as an ultrarare disease, with an estimated prevalence of ∼25,000 cases in the US. There is a suspicion of disparities in outcomes in IF care, likely related to widespread lack of expertise. The Extension for Community Healthcare Outcomes (ECHO) model originally described by Dr Sanjeev Arora has been used to disseminate knowledge and best practices in many chronic diseases to improve outcomes. We examined our initial experience with using the ECHO model to disseminate learning in IF. METHOD: This is a retrospective review of the launch, growth, and geographic reach of the Learn Intestinal Failure TeleECHO (LIFT-ECHO) program using prospectively collected data. RESULTS: The LIFT-ECHO program has achieved significant geographic reach and clinician engagement. The program has reached close to two-thirds of the states in the US and several countries outside. Clinician engagement in the learning program appears to be growing exponentially. CONCLUSION: It is feasible to use the ECHO model to disseminate knowledge in managing a rare disease like IF while maintaining fidelity to the proven model. Studies are underway to demonstrate direct benefit to patients.

Use of Bedside Ultrasound to Assess Muscle Changes in the Critically Ill Surgical Patient.

BACKGROUND: Critical illness causes hypercatabolism, loss of lean body mass (LBM), and poor outcomes. Evaluating LBM in the critically ill is challenging, and it is uncertain whether nutrition support (NS) impacts LBM. This study measured quadriceps muscle layer thickness (QMLT) by bedside ultrasound (US) to estimate LBM changes in surgical intensive care unit (SICU) patients and healthy controls (HCs). METHODS: Trained RDNs measured QMLT via US at the midpoint and one-third distance between the superior margin of the patella and the anterior superior iliac spine. QMLT measurements were taken upon enrollment and repeated 1-2 times over 10 days. RESULTS: Fifty-two SICU patients and 15 HCs were enrolled. Average SICU percent QMLT loss per day at the midpoint and one-third landmarks was 3.2 ± 3.8 (P < 0.001) and 2.9 ± 5.7 (P = 0.001); and QMLT loss was higher between the second and third measurements (4.0 ± 8.0, P = 0.005 and 4.3 ± 9.8, P = 0.017 at the midpoint and one-third landmarks) compared with that at the first and second measurements (1.7 ± 9.2, P = 0.20 & 1.7 ± 9.4, P = 0.22). Changes were not associated with NS received. No significant QMLT change was found in HCs. CONCLUSIONS: SICU patients significantly lost QMLT over 10 days, with greater losses occurring after 5 days. These results support RDNs performing USs to detect QMLT changes and suggest this technique could be valuable to evaluate LBM changes in critically ill patients.

Short-Bowel Syndrome: Epidemiology, Hospitalization Trends, In-Hospital Mortality, and Healthcare Utilization.

INTRODUCTION: Short-bowel syndrome (SBS) is a common cause of chronic intestinal failure and is associated with increased morbidity, mortality, poor quality of life, and an increased burden on healthcare costs. METHODS: We used the US Nationwide Inpatient Sample database from 2005 to 2014. We identified adult SBS hospitalizations by using a combination of International Classification of Diseases, Ninth Revision, Clinical Modification codes. We studied the demographics of the patients with SBS and analyzed the trends in the number of hospitalizations, in-hospital mortality, and healthcare costs. We also identified the risk factors associated with in-hospital mortality. RESULTS: A total of 53,040 SBS hospitalizations were identified. We found that SBS-related hospitalizations increased by 55% between 2005 (N = 4037) and 2014 (N = 6265). During this period, the in-hospital mortality decreased from 40 per 1000 to 29 per 1000 hospitalizations, resulting in an overall reduction of 27%. Higher mortality was noted in SBS patients with sepsis (6.7%), liver dysfunction (6.2%), severe malnutrition (6.0%), and metastatic cancer (5.4%). The overall mean length of stay (LOS) for SBS-related hospitalizations was 14.7 days, with a mean hospital cost of $34,130. We noted a steady decrease in the LOS, whereas the cost of care remained relatively stable. CONCLUSIONS: The national burden of SBS-related hospitalizations continues to rise, and the mortality associated with SBS has substantially decreased. Older SBS patients with sepsis, liver dysfunction, severe malnutrition, and metastatic cancer had the highest risk of mortality. Healthcare utilization in SBS remains high. healthcare utilization; hospitalization trend; mortality; research and diseases; short-bowel syndrome.

Risks, time trends, and mortality of colonoscopy-induced perforation in hospitalized patients.

BACKGROUND AND AIM: Colonic perforation is a rare complication of colonoscopy and ranges from 0% to 1% in all patients undergoing colonoscopy. The aim of this study was to assess the time trends, risk factors, and mortality associated with colonoscopy-induced perforation (CIP) in hospitalized patients as the data are limited. METHODS: Data are obtained from the Nationwide Inpatient Sample database to identify hospitalized patients between 2005 and 2014 that had CIP. Various factors like age and gender were assessed for association with CIP, followed by univariate and multivariate regression analyses. RESULTS: A total of 2 651 109 patients underwent inpatient colonoscopy between 2005 and 2014, and 4567 (0.2%) of the patients had CIP. Overall, incidence of CIP has increased from 2005 to 2014 (0.1% to 0.3%) (P < 0.001). On multivariate analysis, the adjusted odds ratio (OR) for CIP was highest in Caucasian race (OR: 1.49 [1.09, 2.06]), followed by after polypectomy, history of inflammatory bowel disease, end-stage renal disease, and age > 65 years (OR [95% CI] of 1.35 [1.23, 1.47], 1.34 [1.17, 1.53], 1.28 [1.02, 1.62], and 1.21 [1.11, 1.33], respectively) (all P < 0.05). CIP group had 33% less obesity (OR [95% CI]: 0.77 [0.65-0.9], P = 0.002) and 13-fold higher mortality (0.5% vs 8.1%) (P < 0.001) as compared to patients without CIP. The CIP-associated mortality ranged from 2% to 8% and remained stable throughout the study period. CONCLUSIONS: Our study suggests that the risk of CIP was highest in elderly patients, Caucasians, those with inflammatory bowel disease, end-stage renal disease, and after polypectomy. Recognizing the factors associated with CIP may lead to informed discussion about risks and benefits of inpatient colonoscopy.

Prevalence of cannabis use has significantly increased in patients with cyclic vomiting syndrome.

INTRODUCTION: Cyclic vomiting syndrome (CVS) is a functional gastrointestinal disorder which leads to multiple hospitalizations and causes significant impairment of quality of life. Cannabis use is common in patients with CVS, and there are limited data on the national trends in the prevalence of its use in the United States. METHODS: We used the National Inpatient Sample (NIS) database from 2005 to 2014 and identified hospitalizations with a primary diagnosis of CVS by utilizing the International Classification of Diseases, 9th revision Clinical Modification (ICD-9 CM) coding system. The primary objective of the study was to analyze the prevalence and trends in cannabis use in CVS patients. We also assessed healthcare resource utilization associated with cannabis use. RESULTS: A total of 129 090 hospitalizations with a primary diagnosis of CVS were identified and included in the study. In the United States, the overall rate of cannabis use among these patients was 104 per 1000 hospitalizations (N = 13 460). Over the last decade, the prevalence of cannabis use increased by 10-fold, from 2.2% in 2005 to 21.2% in 2014. CONCLUSION: Our analysis of the national database suggests that nearly 1 in 5 CVS hospitalizations have concurrent cannabis use. This prevalence is significantly rising over the last decade, perhaps due to changing legislation and increased utilization of cannabis. Age younger than 35, male gender, African American and Native American race, personal history of alcohol abuse and tobacco use were some of the strongest predictors of cannabis use.

Bariatric Surgery and Its Complications in Inflammatory Bowel Disease Patients.

Recent data have suggested that bariatric procedures, especially laparoscopic sleeve gastrectomy (SG), are safe and effective weight loss measures in patients with inflammatory bowel disease (IBD). But most of the studies have looked at short-term outcomes, and there is a general lack of awareness of underlying disease processes and baseline comorbidities in IBD patients undergoing bariatric procedures. Postbariatric issues in IBD patients including diarrhea from dumping syndrome, choleretic diarrhea, a high prevalence of small intestinal bacterial overgrowth, gastroesophageal reflux disease, Barrett's esophagus, stomal ulcerations, stenosis, and renal and gallstones can complicate the natural history of IBD. This could lead to unnecessary hospitalizations, change of medical therapy, and poor surgical and quality of life outcomes. In this review, we will discuss major complications after common bariatric procedures (SG, Roux-en-Y gastric bypass, and gastric banding) and suggest possible management strategies.

Feasibility and safety of a novel electromagnetic device for small-bore feeding tube placement.

BACKGROUND: Misplacement of enteral feeding tubes (EFT) in the lungs is a serious and potentially fatal event. A recent Food and Drug Administration Patient Safety Alert emphasized the need for improved technology for the safe and effective delivery of EFTs. OBJECTIVE: We investigated the feasibility and safety of ENvue, a novel electromagnetic tracking system (EMTS) to aid qualified operators in the placement of EFT. METHODS: This is a prospective, single-arm study of patients in intensive care units at two US hospitals who required EFTs. The primary outcome was appropriate placement of EFTs without occurrence of guidance-related adverse events (AEs), as confirmed by both EMTS and radiography. Secondary outcomes were reconfirmation of the EFT tip location at a follow-up visit using the EMTS compared with radiography, tube retrograde migration from initial location and AEs. RESULTS: Sixty-five patients were included in the intent-to-treat analysis. EFTs were successfully placed in 57 patients. In eight patients, placement was unsuccessful due to anatomic abnormalities. According to both the EMTS and radiography, no lung placements occurred. No pneumothoraces were reported, nor any guidance-related AEs. Precise agreement of tube tip location was achieved between the EMTS evaluations and radiographs for 56 of the 58 (96.5%) successful placements (one patient had two placements). Tube tip location was re-confirmed 12-49 hours after EFT insertion by the EMTS and radiographs in 48 patients (84%). For 43/48 patients (89.5%), full agreement between the EMTS and radiography evaluations was observed. For the five remaining patients, the misalignment between the evaluations was within the gastrointestinal tract. Retrograde migration from the initial location was observed in 4/49 patients (8%). CONCLUSION: A novel electromagnetic system demonstrated feasibility and safety of real-time and follow-up tracking of EFT placement into the stomach and small intestine, as confirmed by radiographs. No inadvertent placements into the lungs were documented. LEVEL OF EVIDENCE: Level V (large case series).

Challenges to Delivering Home Parenteral Nutrition in Adult Patients With Limited English Proficiency.

Failure to properly administer parenteral nutrition (PN) solutions can have deleterious effects on patients prescribed such therapies. The last few decades have seen diversification of the general population in the United States and elsewhere, with healthcare systems serving an increasing number of non-English-speaking patients and a more ethnically diverse population. Clinicians who provide care to this patient population encounter challenges in ensuring compliance and safe use of PN because of cultural and language barriers. Here we describe our experience of treating patients with limited English proficiency with respect to the barriers that prevent compliant and safe use of PN, especially in those discharged with home PN. We also describe the methods that we use to navigate these common issues to help clinicians provide the safest level of care to patients regardless of the patient's English proficiency.

Proton Pump Inhibitors: Risks and Rewards and Emerging Consequences to the Gut Microbiome.

In recent years, proton pump inhibitors (PPIs) have been criticized for their various adverse interactions and side effects, creating a dilemma among practitioners regarding their use. Our goal is to review the proper use and possible side effects that might be caused by or associated with PPI use. Conclusions were drawn based on the evidence supporting or refuting short-term and long-term adverse events associated with PPI use. We also looked for the evidence regarding effects of PPIs on gut microbiota and their overall safety profile. Although there are significant discrepancies in the current literature regarding various adverse effects associated with PPI use, current data suggest that PPI use is not associated with an increased risk of bone fractures, community-acquired pneumonia, cardiovascular events, hypocalcemia, and gastric malignancies. A mild increased risk of vitamin B12 deficiency and chronic kidney disease, and a moderate increase in the risk of rebound hypersecretion, small intestinal bacterial overgrowth, and enteric infections, including Clostridium difficile, has been noted with PPI therapy. PPI's link with dementia and spontaneous bacterial peritonitis is not clear and requires further investigation. When used appropriately, PPIs are safe medications and are associated with minimal side effects. A clear indication and potential short-term and long-term side effects should be considered before starting PPI therapy.

Nutritional Interventions in Chronic Intestinal Pseudoobstruction.

Although chronic intestinal pseudo-obstruction (CIPO) is a rare disorder, it presents a wide spectrum of severity that ranges from abdominal bloating to severe gastrointestinal dysfunction. In the worst cases, patients may become dependent upon artificial nutrition via parenteral nutrition or choose to have an intestinal transplant. However, whatever the severity, a patient's quality of life can be seriously compromised. This article defines the disorder and discusses the spectrum of disease and challenges to providing adequate nutrition to help improve a patient's quality of life.

Implications of Celiac Disease Among Patients Undergoing Gastric Bypass.

INTRODUCTION: Bariatric surgery is generally safe and effective, but co-existing malabsorptive processes may increase the risk of complications or nutritional deficiencies. Bariatric surgery has not been well studied in the setting of pre-existing celiac disease. MATERIALS AND METHODS: Patients who underwent Roux-en-Y gastric bypass (RYGB) from January 2002 to December 2015 were retrospectively reviewed for either diagnosis of or serum testing for celiac disease. Identified patients were re-reviewed for adherence to American Gastroenterological Association (AGA) diagnostic criteria. Patient demographics, operative data, and post-operative weight loss and nutritional parameters were collected. RESULTS: Of the > 12,000 patients who underwent bariatric surgery during this study period, there were 342 patients that had abnormal serology or pathology results. Expert review confirmed three patients (0.8%) with celiac disease diagnosed before RYGB procedure. All were female, with an average age of 33 years and a mean BMI of 44.07 kg/m2. At the time of surgery, two of the three patients were following a gluten-free diet. At 6 months follow-up, mean % excess weight loss was 76.5%. The patients following a gluten-free diet preoperatively continued post-operatively. No patients were anemic nor had vitamin B12 or iron deficiencies at 12-month follow-up. Two patients had vitamin D insufficiencies and responded to daily oral supplementation. CONCLUSION: Though many bariatric patients may carry a presumptive diagnosis of celiac disease, a small percentage of these meet AGA diagnostic criteria. RYGB appears safe in this population with comparable weight loss in non-celiac counterparts. Increased attention to vitamin D levels may be warranted post-operatively.

Noncompliance/Nonadherence With Home Nutrition Support: An Underrecognized Clinical Dilemma.

Failure to administer enteral nutrition, intravenous fluids, and/or parenteral nutrition solutions can have deleterious effects on patients who have been prescribed such therapies. However, it is not well understood why patients requiring nutrition support would be noncompliant or nonadherent to these often life-benefiting therapies. This article explores these issues in a large home nutrition support population.

Overview of Home Parenteral Nutrition: An Update.

The trend in modern medicine is to transition care from the hospital to home or other nonacute settings as soon as possible. Increasingly, nutrition support professionals are being asked to help facilitate discharge and/or manage patients who require prolonged intravenous fluid and/or nutrition after having been stabilized during a hospitalization. This updated tutorial reviews many of the concepts and challenges that must be considered for successful care that helps to focus on the patients and their quality of life.

Current status of intestinal and multivisceral transplantation.

Clinical-nutritional autonomy is the ultimate goal of patients with intestinal failure (IF). Traditionally, patients with IF have been relegated to lifelong parenteral nutrition (PN) once surgical and medical rehabilitation attempts at intestinal adaptation have failed. Over the past two decades, however, outcome improvements in intestinal transplantation have added another dimension to the therapeutic armamentarium in the field of gut rehabilitation. This has become possible through relentless efforts in the standardization of surgical techniques, advancements in immunosuppressive therapies and induction protocols and improvement in postoperative patient care. Four types of intestinal transplants include isolated small bowel transplant, liver-small bowel transplant, multivisceral transplant and modified multivisceral transplant. Current guidelines restrict intestinal transplantation to patients who have had significant complications from PN including liver failure and repeated infections. From an experimental stage to the currently established therapeutic modality for patients with advanced IF, outcome improvements have also been possible due to the introduction of tacrolimus in the early 1990s. Studies have shown that intestinal transplant is cost-effective within 1-3 years of graft survival compared with PN. Improved survival and quality of life as well as resumption of an oral diet should enable intestinal transplantation to be an important option for patients with IF in addition to continued rehabilitation. Future research should focus on detecting biomarkers of early rejection, enhanced immunosuppression protocols, improved postoperative care and early referral to transplant centers.

Expediting Transition to Home Parenteral Nutrition With Fast-Track Cycling.

BACKGROUND: Delivery of home parenteral nutrition (PN) is typically cycled over 12 hours. Discharge to home on PN is often delayed due to potential adverse events (AEs) associated with cycling PN. The purpose was to determine whether patients requiring long-term PN can be cycled from 24 hours to 12 hours in 1 day instead of 2 days without increasing the risk of PN-related AEs. METHODS: Hospitalized patients receiving PN at goal calories infused over 24 hours without severe electrolyte or blood glucose abnormalities were eligible. Patients were randomly assigned to a 1-step "fast-track" protocol or 2-step "standard" protocol. AEs were defined as hypoglycemia or hyperglycemia, new-onset or worsening dyspnea, tachycardia, tachypnea, lower extremity or sacral edema, pulmonary edema, or abdominal ascites and were graded as minor or major. RESULTS: In the 63 patients studied, the most prevalent PN-related AE was hyperglycemia, occurring in 24.2% and 30.0% of patients in the fast-track and standard groups, respectively. Overall, there was no significant difference in the prevalence of PN-related minor AEs between fast-track and standard groups (33.3% and 53.3%, P = .5). No major PN-related AEs occurred in the fast-track group, while 1 major PN-related AE (pulmonary edema) occurred in the standard group. CONCLUSIONS: Fast-track cycling is as safe as standard cycling in patients without diabetes mellitus or major organ dysfunction requiring long-term PN. Fast-track cycling could potentially expedite hospital discharge, resulting in decreased healthcare costs and improved patient satisfaction.

Thirty-Day Readmission Rate Is High for Hospitalized Patients Discharged With Home Parenteral Nutrition or Intravenous Fluids.

BACKGROUND: Reducing hospital readmissions decreases healthcare costs and improves quality of care. There are no published studies examining the rate of, and risk factors for, 30-day readmissions for patients discharged with home parenteral support (HPS). OBJECTIVE: Determine the rate of 30-day readmissions for patients discharged with HPS and whether malnutrition and other demographic or clinical factors increase the risk. MATERIALS AND METHODS: Retrospective review of patients discharged with HPS from the Cleveland Clinic between July 1, 2013, and June 30, 2014, and followed by the Cleveland Clinic Home Nutrition Support Service. RESULTS: Of the 224 patients studied, 31.6% (n = 71) had unplanned readmissions within 30 days of hospital discharge. Of these, 21.1% (n = 15) were HPS related, with catheter-related bloodstream infection (n = 5) and dehydration (n = 5) the most common. The majority of patients (84.4%) were diagnosed with malnutrition, but the presence or degree did not influence the readmission rate ( P = .41). According to univariable analysis, patients with an ostomy ( P = .037), a small bowel resection ( P = .002), a higher HPS volume at discharge ( P < .001), and a shorter period between HPS consult and hospital discharge ( P < .026) had a lower risk of 30-day readmission than their counterparts. On multivariable analysis, patients had a higher risk of 30-day readmission if they had a history of heart disease ( P = .048) and for every 1-unit increase in white blood cells ( P = .026). CONCLUSIONS: Patients discharged with HPS have a high 30-day readmission rate, although most readmissions were not related to the HPS itself. The presence and degree of malnutrition were not associated with 30-day readmissions.