Long-term Total Parenteral Nutrition Research Articles

EVALUATION OF THE NUTRITIONAL STATUS AND RESULTS OF PATIENTS FOLLOWED IN THE PALLIATIVE CARE CENTER

OBJECTIVE: The aim of this study is to examine the nutritional status and results of the patients followed in the palliative care center. MATERIAL AND METHODS: 250 consecutive patients who were hospitalized in the palliative care center were included in this study. The patients were grouped according to their nutritional status during hospitalization and discharge. RESULTS: The mean age of the patients subjected to this study is 73±19.22 years. Out of these patients, 125 are female. The average daily calorie requirement of the patients was calculated as 1463.71±21.55 kcal/day, while the maximum tolerated calorie intake was determined to be 1030.54 ±320.54 kcal/day in our patient (P =0.039). No significant change was detected between the calculated calories and the calories consumed by diabetic individuals (P = 0.083). When the nutritional patterns were examined, it was determined that 51.60 % of the patients were orally fed at the time of admission to the palliative care center, the rate of patients fed with a Percutan gastrostomy (PEG)/Percutan jejunostomy (PEJ)/nasogastric tube was 32.05%, and 13.21% of the patients fed total parenteral nutrition (TPN). 67.06% of the patients were discharged with oral feeding, 30.53% with PEG/PEJ/nasogastric tube and 4 (2.39%) with long-term TPN feeding methods. When the patients were divided into percentages according to their calorie consumption, we found that the hospitalization day was significantly shorter in the group consuming 0-25 percentile calories (P = 0.021) but had a significantly higher rate of mortality (%71.42) (P=0.018). In the group with 50-75 percentile calorie intake, mortality was observed significantly at the lowest rate during hospitalization, with 14 (13.59%) patients. (P=0.003). Infections (28.57%) were significantly higher in the 0-25 group (P = 0.051). CONCLUSIONS: At palliative care centers, besides end-of-life management, all needs of patients should be identified. Instead of making strict calorie calculations, it is necessary to develop new nutritional goals compatible with all patients.

Shifting the paradigm of long-term total parenteral nutrition: Lessons from renal dialysis.

Shifting the paradigm of long-term total parenteral nutrition: Lessons from renal dialysis.

Invasive Pulmonary Candidiasis in a Patient Requiring Chronic Total Parenteral Nutrition

ABSTRACT The complications of total parenteral nutrition (TPN) in critically ill patients on short-term supplementation are well-established in the literature. However, data on managing complications, including fungal infections, in those requiring chronic TPN are lacking. The risk of fungal infections in patients requiring long-term TPN is multifactorial, including mechanisms that lead to immune system dysregulation, translocation, and seeding. Current clinical practice favors percutaneous endoscopic gastrostomy formation in patients requiring continued parenteral nutritional support, but in some patients who have undergone extensive abdominal surgeries, a percutaneous endoscopic gastrostomy tube is infeasible. We present a 42-year-old woman requiring chronic TPN who was found to have cavitary pulmonary candidiasis.

Factors associated with the need for long-term total parenteral nutrition in survivors of acute superior mesenteric artery occlusion.

Acute superior mesenteric artery (SMA) occlusion is an uncommon condition associated with high mortality. If extensive bowel resection is performed for patients with acute SMA occlusion and the patient survives, long-term total parenteral nutrition (TPN) may be needed due to short bowel syndrome. This study examined factors associated with the need for long-term TPN after the treatment of acute SMA occlusion. We retrospectively analyzed 78 patients with acute SMA occlusion. Patients were abstracted from a Japanese database from institutions with at least 10 patients with acute SMA occlusive disease from January 2015 through December 2020 RESULTS: Among the initial cohort there were 41/78 survivors. Of these, 14/41 (34%) required permanent TPN who were compared with those who did not require long-term TPN (27/41, 66%). Compared to patients in the non-TPN group, those in the TPN group had significantly shorter remaining small intestine (90.7 cm vs. 218 cm, P<0.01), more patients with time from onset to intervention >6 hours (P=0.02), pneumatosis intestinalis on enhanced computed tomography scan (P=0.04), ascites (Odds Ratio 11.6, P<0.01), and a positive smaller superior mesenteric vein sign (P= 0.03). These were considered significant risk factors for needing long-term TPN. Age, gender, underlying disease, presence of peritoneal sign, presence of shock requiring vasopressors, site of obstruction (proximal vs. distal), and initial treatment (surgery vs. interventional radiology vs. thrombolytic therapy) were not significantly different between the two groups. Long-term TPN was significantly associated with longer hospital stay (52 vs. 35 days, P=0.04). Multivariate analysis identified the presence of ascites as an independent risk factor for needing long-term TPN. The need for permanent TPN after treatment of acute SMA occlusion is significantly associated with longer hospital stay, longer time to intervention, and characteristic imaging findings (pneumatosis intestinalis, ascites, Smaller SMV sign). Ascites is an independent risk factor. III.

Molecular Oxygen Levels and Percentages of DNA Damage in TPN Patients

Total parenteral nutrition (TPN) is a life-saving therapy for patients with intestinal failure, but it carries the risk of complications, including an increase in liver enzymes alanine aminotransferase (ALT) and aspartate aminotransferase (AST) after long-term use. Patients receiving chronic TPN are also exposed to metabolic stress from both the underlying disease and parenteral nutrition. The aim of this study was to compare the concentration of liver transaminases AST and ALT in relation to the rate of oxygen consumption in platelet mitochondria in patients receiving long-term TPN with the degree of oxidative stress induced by lipid emulsions, and to explain their role in cellular energy metabolism and changes in the liver based on the percentage of genomic DNA damage. The study group consisted of 86 TPN patients, while the control group consisted of 86 healthy volunteers who were fed only orally. The results of the study showed that the percentage of molecular oxygen depended on the type of lipid emulsion supplied. Analyzing time on TPN as a factor, we observed a decrease in percentage genomic DNA damage and an increase in percentage molecular oxygen in cells. It remains unclear whether TPN has a direct effect on genomic DNA damage and the level of molecular oxygen in cells during the course of treatment. In conclusion, this study provides important insights into the potential effects of TPN on liver enzymes and cellular metabolism. Further research is needed to better understand the underlying mechanisms and to develop strategies to minimize the risk of complications associated with TPN.

Incidence of Hyponatremia and Associated Factors in Preterm Infants in Saudi Arabia.

Objective: To investigate the incidence of hyponatremia in preterm infants. The secondary aim was to determine the risk factors of late-onset of hyponatremia (LOH) and their influence on neonatal outcomes.Study design: The present study is a retrospective cohort study of 71 preterm infants born before 32 weeks of gestation at King Abdulaziz University Hospital and admitted to the neonatal intensive care unit, level 3, from January to December 2019. Hyponatremia was defined as a sodium level ≤ 132 mEq/L. Retrieved maternal characteristics included age, parity, booking status, medical problems, antenatal steroids, and method of delivery. Retrieved infant characteristics included birth weight, gestational age, Apgar scores, total parenteral nutrition (TPN), breast milk or formula feeding, and body weight. as well as data on early onset of sepsis, chronic lung disease (CLD), patent ductus arteriosus, retinopathy of prematurity, severe intraventricular hemorrhage, and prescribed antibiotics and diuretics.Results: Out of 72 preterm infants, 27% were diagnosed with hyponatremia. Early-onset hyponatremia (EOH) affected 7% (n=5) of the infants while 22.5% (n=16) of preterm neonates developed LOH (two infants developed both EOH and LOH). None of the investigated maternal characteristics were significantly associated with hyponatremia. Some infant characteristics were significantly associated with LOH: lower birth weight, lower gestational age, exclusive breastfeeding, longer duration TPN, and use of diuretics and antibiotics. Infants with LOH had longer hospital stays (p < 0.001) and higher risks of extra-uterine growth retardation (p = 0.007), CLD (p < 0.001), and sepsis (p = 0.001).Conclusion: Twenty-seven percent of preterm infants in King Abdul Aziz University Hospital are born with or develop hyponatremia. Risk factors significantly associated with LOH included lower gestational age, lower birth weight, exclusive breastfeeding, long-term TPN, and prescribed diuretics and antibiotics. Possible outcomes of hyponatremia were long-term hospital stays, growth retardation, sepsis, and CLD.

The Diagnosis and Treatment of Acute Cholecystitis

Acute cholecystitis (AC), defined as inflammation of the gallbladder, is mainly caused by gallstones. Over 90% of AC results from obstruction of the cystic duct by stones or sludge, which subsequently increases the intraluminal pressure within the gallbladder and, in conjunction with the presence of bile supersaturated with cholesterol, activates an acute inflammatory cascade. Clinical features play an important role in the diagnosis of AC. The Tokyo Guidelines 2018 for acute cholecystitis designates the presence of local inflammatory signs and systemic inflammatory signs for a suspected diagnosis. It requires confirmation by radiological imaging along with these two factors for a definitive diagnosis. Thanks to less invasiveness, easy availability, ease of use, and cost-effectiveness, ultrasound (US) is usually accepted as the first choice in suspicious AC patients. A meta-analysis comparing methods of diagnosis for AC reported that the US has 81% of sensitivity and 83% of specificity. Abdominal computed tomography is recommended for diagnosing emphysematous or gangrenous cholecystitis. Meanwhile, acute acalculous cholecystitis (AAC) is a life-threatening disease mainly in severely ill patients. It usually affects the patients hospitalized for multiple trauma, burns, cardiopulmonary bypass surgery, long-term total parenteral nutrition or sepsis. The diagnosis of AAC is quite challenging and requires a high index of suspicion. Currently, cholecystectomy is the treatment of choice for AC, although the optimal time for surgery is still controversial. Due to high morbidity and mortality in high surgical risk groups, percutaneous gallbladder drainage can be a safe and feasible alternative to cholecystectomy, particularly for patients unfit for the surgery.

Mediastinitis Secondary to Peripherally Inserted Central Catheter Migration and Perforation after Minor Trauma: A Case Report.

IntroductionThe use of peripherally inserted central catheters (PICC) has been integral to the advancement of medical care in both in-patient and out-patient arenas.1 However, our knowledge of PICC line complications remains incomplete, particularly in regard to venous perforation and extraluminal migration. Utilization of displaced catheters harbors lethal complications and is an infrequently reported phenomenon, with traumatic etiologies only referenced as possible mechanisms; however, to date no formal cases have been reported.5,6Case ReportWe report a case of a fall associated with extraluminal PICC migration and perforation causing mediastinitis and severe sepsis after total parenteral nutrition (TPN) infusion in a 54-year-old woman. Our patient required a right-sided PICC for long-term home TPN due to severe malnutrition following gastric bypass surgery. During a routine home care visit our patient was found tachypneic, hypoxic, and short of breath. Computed topography imaging in the emergency department (ED) identified the injury, likely related to the recent fall. The patient experienced a complicated hospital course after removal of the PICC. Although rare, PICC line migrations and perforations cause serious complications that should be considered by emergency physicians evaluating patients with chronic indwelling vascular access.ConclusionGiven the efficacy and widespread use of PICC lines, we present this case as a rarely reported but life-threatening complication that requires particular attention. Emergency physicians should be aware of such PICC line complications when encountering patients with chronic indwelling vascular access.

Long bone fractures in neonatal intensive care units of Afyonkarahisar: Five-year's experience.

Objective:To determine the incidence of long bone fractures and the clinical features related with these fractures diagnosed in neonatal intensive care units (ICUs) within the province of Afyonkarahisar in Turkey.Materials and Methods:The incidence of clavicular fractures was 2.4 in 1000 live births, and the incidence of femoral fractures was 0.32 in 1000 live births at the neonatal ICUs of Afyonkarahisar.Results:The incidence of birth trauma-related femoral fracture was 0.16 in 1000 live births, and the incidence of femoral fractures related with osteopenia of prematurity was 1.08 in 1000 live births. The mean gestational age at delivery was 39 weeks, the mean birth weight was 3.308 grams, and the male/female ratio was 3:2 for newborns with birth trauma-related femoral fractures. The mean gestational age at delivery was 30.4 weeks, the mean birth weight was 1256 grams, and the male/female ratio was 2:3 for newborns who had femoral fractures related with osteopenia of prematurity. Breech presentation was present in three newborns (60%), and cesarean section was the type of delivery in all newborns with birth trauma-related femoral fractures.Conclusion:Cesarean delivery does not reduce the risk for birth trauma-associated femoral fractures, and there is a risk for femoral fracture in cases of emergency cesarean performed for malpresentation. In order to overcome osteopenia of prematurity, calcium, phosphorus, and vitamin D should be supplemented in premature newborns with intrauterine growth retardation and receive long-term total parenteral nutrition.

How to perform appropriate flushing after lipid emulsion administration using totally implantable venous access devices in long-term total parenteral nutrition and home parenteral nutrition.

There has been no clear evidence regarding the appropriate method of flushing catheters and totally implantable venous access devices (TIVADs) after lipid emulsion (LE) administration. Therefore, the aim of the study was to identify appropriate methods of flushing to minimize residual LE when using TIVADs to ensure the safety of long-term total parenteral nutrition (TPN) and home parenteral nutrition (HPN). A soybean oil LE containing indocyanine green (ICG) was administered from the injection site of the primary infusion set for flowing TPN, and LE dynamics were evaluated by a fluorescence imaging system. TIVADs were connected to the end of the infusion sets. After LE administration, the tubes and chambers were flushed from the injection site using saline at various speeds (20, 40, 60mL/min), with and without pulsation. The washout effect of TPN solution after LE administration followed by flushing was examined, as was the washout effect of size differences in the infusion sets. When the LE was flushed with 20mL of saline immediately after administering the LE using a standard infusion set (inner diameter 2.5mm), the LE still remained in the tubes and chambers under any flushing condition. Flushing the LE from the injection site with 10mL of saline and then flowing >240mL of TPN solution were effective for minimizing residual LE inside the tubes and chambers. When using an infusion set with a small inner diameter (1.0mm), the LE inside the tubes and chambers was almost discharged with ≥20mL of saline immediately after administering the LE. In all settings, flushing with/without pulsation did not affect LE washout efficacy. Flushing immediately with saline ≥10mL and then flowing >240mL of primary PN solution after soybean oil LE administration using the standard infusion set or flushing with 20mL saline immediately after administering the soybean oil LE using the infusion set with a small inner diameter are effective for minimizing the residual LE in the catheter and TIVAD, ensuring the safety of long-term TPN and HPN.

Iron deposition in autopsied liver specimens from older patients receiving intravenous iron infusion.

Vitamins and minerals are routinely administered by total parenteral nutrition (TPN). However, in Japan, adjustments in iron dosage are difficult because blended mineral preparations are often used. It is therefore unclear whether the iron content is appropriate in cases of long-term TPN. The aim of the study was to assess the influence of iron administration by long-term TPN on iron deposition in post-mortem liver samples isolated from older deceased patients. Liver tissues were collected from post-mortem autopsies of 187 patients over a period of 15 years. Samples were stained with Prussian blue and histologically evaluated from Grade 0-V by at least three different observers. Specimens with positive and negative iron staining were compared, and positive samples were grouped according to the level and distribution of the staining. Post-mortem blood obtained from the subclavian vein during autopsy was also analysed. Samples were collected for the measurement of unsaturated serum iron, serum iron, albumin, prealbumin, hepcidin, and IL-6 concentrations. Iron accumulation in the liver was significantly higher in male patients (p = 0.005) with a history of surgery (p = 0.044) or central vein administration of iron (p<0.001). Additionally, the duration of TPN in the iron-positive group was significantly longer than in the iron-negative group (p = 0.038). Serum analysis revealed that unsaturated serum iron was significantly higher in the iron-negative group and that ferritin and serum iron were significantly higher in the iron-positive group. No other statistically significant differences were observed between the two groups. Chronic intravenous administration of iron was associated with iron deposition in the liver, even when given the minimum recommended dosage. In long-term TPN patients, the iron dose should therefore be carefully considered.

Exogenous Secretin Improves Parenteral Nutrition-associated Liver Disease in Rats.

Intestinal failure-associated liver disease (IFALD) is a feared and life-threatening complication in neonates with intestinal failure (IF) receiving long-term total parenteral nutrition (TPN). This study aims to investigate the effect of exogenous secretin on liver pathology and hepatic function in a rat model of PN-associated liver disease (PNALD). Male Sprague-Dawley rats underwent right jugular venous catheterization to receive 14-day continuous TPN therapy. All rats were allocated into 3 groups: the Control group (n = 8) did not have surgery or TPN and was fed standard rat chow ad libitum; the TPN group (n = 8) underwent catheter insertion and TPN treatment; and the TPN/S group (n = 8) also underwent catheter insertion, TPN treatment, and exogenous secretin treatment (2.5 nmol · kg · day) daily. Fourteen days after initial surgery, we collected the animals' liver and blood samples for further test. The TPN/S group had diminished direct bilirubin (TPN, 2.1 ± 0.7 μmol/L; TPN/S, 1.5 ± 0.2 μmol/L) and liver total bile acid levels (TPN, 144.5 ± 21.2 μmol/L; TPN/S, 123.4 ± 10.4 μmol/L) and improved histological outcomes compared with those in the TPN group. Exogenous secretin also enhanced the canalicular transporter (BSEP, 0.5-fold, P = 0.011) and inhibited the basolateral transporter (OSTA, -0.48-fold, P = 0.002; OSTB, -0.6-fold, P = 0.013) of liver bile acid. In this animal model of PNALD, secretin may improve cholestasis by enhancing canalicular transport, inhibiting the basolateral export of liver bile acid, and eventually decreasing the total bile acid level in the liver. Exogenous secretin treatment may potentially prevent and treat IFALD in IF patients relying on long-term TPN therapy.

2608 Teduglutide Therapy for a Patient With Chronic Intestinal Failure Following Multi-Visceral Transplantation

INTRODUCTION: The use of glucagon-like peptide-2 (GLP-2) agonists, such as Teduglutide, and recombinant human growth hormones (HGH), remain important for making advances in Short Bowel Syndrome and intestinal failure to reduce parenteral nutrition requirements. The efficacy of these agents have yet to be studied in the intestinal transplant population who experience decreased absorption with no evidence of acute rejection. We present a case of Teduglutide therapy for chronic intestinal failure following a multi-visceral transplant including stomach, pancreas and small bowel. CASE DESCRIPTION/METHODS: A 47-year-old Caucasian female presented with a history of corrected, congenital duodenal atresia, complicated by recurrent obstructions, requiring a Whipple procedure with bowel to bowel bypass and anastomosis. She developed short bowel syndrome and began to lose weight. She was placed on long-term total parenteral nutrition (TPN), with consequent hospital admissions for fungemia. She underwent a multi-visceral transplant including stomach, pancreas, and small intestine and placed on immunosuppressive therapy. Years later, she developed ongoing, severe watery diarrhea with recurrent need for TPN. She was placed on Pancrelipase and lipids, without any improvement. Intestinal biopsies repeatedly showed no signs of acute rejection or cytomegalovirus (CMV). Loperamide and Diphenoxylate were also trialed. Given a lack of progress, she was placed on Teduglutide. The patient experienced significant symptomatic improvement after 10 days of therapy. She was able to decrease her intravenous fluids (IVF) needs by 50%. After one month she again experienced worsening symptoms. She was placed on Linaclotide in addition to Teduglutide with the need to maximize TPN requirements. Repeat intestinal biopsies did not show evidence of infection or acute rejection. Teduglutide was discontinued after 10 months as it did not improve symptoms. DISCUSSION: Intestinal absorption can remain an issue in short bowel syndrome until transplant can be achieved. It remains problematic when multi-visceral transplant is performed and patients continue to experience malabsorption. Unfortunately, although our patient had a good initial response, this response did not persist and therefore therapy was discontinued. Research is ongoing to discover pharmacologic treatment options that significantly decrease the necessity of TPN and IVF. HGH and GLP-2 agonists are options at this time, however remain in question if they are effective long term.

P4.59: Pregnancy during long-term total parenteral nutrition in a patient with intestinal failure

P4.59: Pregnancy during long-term total parenteral nutrition in a patient with intestinal failure

Essential Amino Acid Profile in Parenteral Nutrition Mixtures: Does It Meet Needs?

Background and Aims: The study compares the essential amino acid (EAA) composition of different parenteral nutrition (PN) mixtures with whey protein EAA profile and the theoretical daily EAA requirements (set by WHO/FAO/UNU or IAAO method). According to the individual EAA profile, the potential effect of several PN mixtures was evaluated on the skeletal muscle mass (SMM) of patients on home PN. Methods: Eight AA solutions and fifteen complete PN mixtures were considered. Twenty-nine clinically stable patients with short bowel syndrome on home total PN were retrospectively evaluated. SMM was estimated by bioelectrical impedance analysis. Results: The prescribed doses of EAA that showed a significant increase in home PN patients muscle mass were considerably greater than the theoretical ones, showing an EAA profile similar to whey protein. At the daily dose of 1 g of total AA s/kg body weight (BW), the considered PN mixtures mostly failed to improve SMM. Only prescribed doses which included more than 0.25 g/kg BW of total BCAA with at least 0.10 g/kg BW leucine, 0.08 g/kg BW isoleucine, and 0.06 g/kg BW methionine showed a significant increase in SMM. Conclusions: The theoretical daily requirement for each EAA was met by all considered PN solutions when the prescribed daily dose of total AAs was set at 1 g/kg BW. Nevertheless, our data suggest that only an increase in total BCAA, also richer in single AA leucine, isoleucine, and methionine, is associated with the maintenance and/or increase of SMM. According to these preliminary observations, we support the prescription of an EAA composition of PN mixtures close to that of whey protein for the preservation of SMM in patients on long-term total PN.

Developing a Novel Ambulatory Total Parenteral Nutrition-Dependent Short Bowel Syndrome Animal Model

BackgroundShort bowel syndrome (SBS) results from extensive bowel resection. Patients with SBS require total parenteral nutrition (TPN) for survival. Understanding mechanisms contributing to TPN-associated liver injury and gut atrophy are critical in developing SBS therapies. Existing SBS models using tethered animals have significant limitations and are unlike ambulatory human SBS patients. We hypothesized that we could induce SBS in piglets and develop an ambulatory TPN-SBS model. Material and methodsEighteen neonatal pigs received duodenal and jugular catheters. They were fitted with a jacket holding TPN and a miniaturized pump. Six piglets had 90% small bowel resection and catheter placement (SBS group). Non-SBS piglets were randomized into enteral nutrition (EN) or TPN. ResultsBowel resection was successfully accomplished in SBS animals. Weight gain was similar in all groups. SBS animals had increased serum bilirubin compared to EN. Mean conjugated bilirubin ± SD was 0.045 ± 0.01 for EN, (P = 0.03 EN versus TPN and P = 0.03 SBS versus EN) and 1.09 ± 1.25 for TPN, (P = 0.62 TPN versus SBS). Gut density was reduced in the TPN group compared to EN and SBS groups. Mean gut density ± SD was 0.11 ± 0.04 for TPN (P = 0.0004 TPN versus SBS and P = 0.00007 TPN versus EN) and not statistically different for EN versus SBS (P = 0.32). ConclusionsWe created a novel, ambulatory TPN-SBS model using piglets, mimicking long-term TPN delivery in human SBS patients. Our model demonstrated TPN-related conjugated hyperbilirubinemia and compensatory gut hypertrophy, as noted in humans with SBS. This model holds great potential for future research.

A Case of Iatrogenic Wernicke Encephalopathy Following Prolonged Total Parenteral Nutrition

Thiamine is a water-soluble vitamin that plays a role in the metabolism of glucose. Thiamine deficiency affects cardiovascular and nervous systems. Wernicke encephalopathy is characterized by oculomotor abnormalities, ataxia and cognitive deterioration caused by thiamine deficiency. It is most commonly observed in chronic alcoholics. It may also occur in patients who receive long-term total parenteral nutrition. In this study, we present the case of a 50-year-old male patient who underwent surgery for laryngeal cancer, who stayed in the intensive care unit for a prolonged period and received total parenteral nutrition because of the inability of oral intake.

Development and implementation of an antimicrobial lock therapy guideline in a pediatric hospital.

The development and implementation of an antimicrobial lock therapy guideline at a large pediatric hospital are described. Central venous access devices (CVADs) are essential in the medical management of patients requiring long-term total parenteral nutrition, chemotherapy, or hemodialysis. However, the use of a CVAD carries a significant risk of the development of central line-associated bloodstream infection (CLABSI). Antimicrobial lock therapy is indicated for patients with CLABSIs who have no signs of exit site or tunnel infection and for whom catheter salvage is a goal. An antimicrobial lock therapy guideline was developed and implemented at a large pediatric hospital by an interprofessional team consisting of providers specializing in CVAD care. Development and implementation of the guideline included a needs assessment, a literature review, determination of patient selection criteria, addition of compounding formulations, development of administration techniques, and education. In all 10 instances of lock therapy in the 18 months after guideline implementation, the criteria for use were met; in 60% of those instances, patients received care from an infectious diseases physician. Each of the available lock solutions was used at least once during the 18-month period. Overall, implementation of a guideline on administration of antimicrobial lock therapy was successful. Nine patients received antimicrobial lock therapy in the 18 months after policy implementation; although 2 had their line removed (1 due to repeated line infections), neither required line replacement.

Copper deficiency caused by excessive alcohol consumption

Copper deficiency is a disease that causes cytopaenia and neuropathy and can be treated by copper supplementation. Long-term tube feeding, long-term total parenteral nutrition, intestinal resection and ingestion of zinc...

Pre-emptive Intestinal Transplant: The Surgeon's Point of View.

Pre-emptive transplantation is a well-established practice for certain types of end-organ failure such as in the use of kidney transplantation. For irreversible intestinal failure, total parenteral nutrition (TPN) remains the gold standard, due to the suboptimal long-term results of intestinal transplantation. As such, the only role for pre-emptive transplantation, if at all, will be for patients identified to be at high risk of complications and mortality while on definitive long-term TPN. In these patients, the timing of early listing and transplantation could become life-saving, taking into account that mortality on the waiting list is still the highest for intestinal candidates. The development of simulation models or pre-transplant scoring systems could help in selecting patients based on potential outcome on TPN or with transplantation, and recent reports from high-volume centers identify few underlying pathologic conditions and some TPN complications as at higher risk of increased morbidity and mortality. A pre-emptive transplant could be used as a rehabilitative procedure in a well-selected case-by-case scenario, among TPN patients at risk of liver failure, repeated central line infections, mesenteric infarction, short bowel syndrome (SBS) <50cm or with end stoma, congenital mucosal disease, desmoid tumors: These conditions must be carefully evaluated, not to underestimate the clinical stage nor to over-estimate the impact of a temporary situation. At the present time, diseases with a variable and unpredictable course, such as intestinal dysmotility disorders, or quality of life and financial issues are still far from being considered as indications for a pre-emptive transplant.