Publications by authors named "Simon Lal"

115 Publications

Characteristics of adult patients with chronic intestinal failure due to short bowel syndrome: An international multicenter survey.

Clin Nutr ESPEN 2021 10 28;45:433-441. Epub 2021 Jul 28.

Medico-Surgical Department of Gastroenterology, Hôpital Erasme, Free University of Brussels, Belgium.

Background And Aims: The case-mix of patients with intestinal failure due to short bowel syndrome (SBS-IF) can differ among centres and may also be affected by the timeframe of data collection. Therefore, the ESPEN international multicenter cross-sectional survey was analyzed to compare the characteristics of SBS-IF cohorts collected within the same timeframe in different countries.

Methods: The study included 1880 adult SBS-IF patients collected in 2015 by 65 centres from 22 countries. The demographic, nutritional, SBS type (end jejunostomy, SBS-J; jejuno-colic anastomosis, SBS-JC; jejunoileal anastomosis with an intact colon and ileocecal valve, SBS-JIC), underlying disease and intravenous supplementation (IVS) characteristics were analyzed. IVS was classified as fluid and electrolyte alone (FE) or parenteral nutrition admixture (PN). The mean daily IVS volume, calculated on a weekly basis, was categorized as <1, 1-2, 2-3 and >3 L/day.

Results: In the entire group: 60.7% were females and SBS-J comprised 60% of cases, while mesenteric ischaemia (MI) and Crohn' disease (CD) were the main underlying diseases. IVS dependency was longer than 3 years in around 50% of cases; IVS was infused ≥5 days/week in 75% and FE in 10% of cases. Within the SBS-IF cohort: CD was twice and thrice more frequent in SBS-J than SBS-JC and SBS-JIC, respectively, while MI was more frequent in SBS-JC and SBS-JIC. Within countries: SBS-J represented 75% or more of patients in UK and Denmark and 50-60% in the other countries, except Poland where SBS-JC prevailed. CD was the main underlying disease in UK, USA, Denmark and The Netherlands, while MI prevailed in France, Italy and Poland.

Conclusions: SBS-IF type is primarily determined by the underlying disease, with significant variation between countries. These novel data will be useful for planning and managing both clinical activity and research studies on SBS.
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http://dx.doi.org/10.1016/j.clnesp.2021.07.004DOI Listing
October 2021

ESPEN practical guideline: Clinical nutrition in chronic intestinal failure.

Clin Nutr 2021 09 2;40(9):5196-5220. Epub 2021 Aug 2.

Department of Nutritional Medicine and Prevention, University of Hohenheim, Stuttgart, Germany.

Background: This practical guideline is based on the ESPEN Guidelines on Chronic Intestinal Failure in Adults.

Methodology: ESPEN guidelines have been shortened and transformed into flow charts for easier use in clinical practice. The practical guideline is dedicated to all professionals including physicians, dieticians, nutritionists, and nurses working with patients with chronic intestinal failure.

Results: This practical guideline consists of 112 recommendations with short commentaries for the management and treatment of benign chronic intestinal failure, including home parenteral nutrition and its complications, intestinal rehabilitation, and intestinal transplantation.

Conclusion: This practical guideline gives guidance to health care providers involved in the management of patients with chronic intestinal failure.
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http://dx.doi.org/10.1016/j.clnu.2021.07.002DOI Listing
September 2021

Glucagon-like peptide 2 analogues in the treatment of intestinal failure: A qualitative exploration of the views of patients and their families in decision making.

Clin Nutr ESPEN 2021 08 22;44:263-269. Epub 2021 Jun 22.

Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Manchester, M6 8HD, UK.

Background And Aims: Patients with short bowel syndrome and type 3 intestinal failure (SBS-IF) are dependent on parenteral nutrition (PN), a lifesaving treatment but inconvenient and with risks. Glucagon-like peptide 2 analogue (teduglutide) can reduce patients' need for PN. However, it comes with the risk of a number of side effects. This qualitative study investigated patients' decision making process to start teduglutide and how family members contributed to the decision.

Methods: In-depth semi-structured interviews were conducted with nine participants, six patients with SBS-IF and three family members about the decision to take teduglutide. Interviews were transcribed verbatim and analysed using framework analysis.

Results: The prominent motivation for taking teduglutide (Revestive® Takeda Pharmaceuticals Limited) was reducing or stopping PN. Other motivations were to help others by assisting in developing the knowledge base around teduglutide, patients felt that they had nothing to lose by trying the drug and the support of relatives. The reasons patients considered not taking the drug were that they had accepted being on PN, the potential side effects of teduglutide and undergoing extra monitoring. However, the monitoring programme also acted as a motivator providing reassurance that patients would be observed and supported with side effects. Family members were happy to support patients' decision to try teduglutide, although they had more reservations, indicating a higher risk threshold.

Conclusion: Patients considered potential benefits of teduglutide outweighed any disadvantages. Relatives, although supportive, had more reservations.
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http://dx.doi.org/10.1016/j.clnesp.2021.06.005DOI Listing
August 2021

Catheter-related infection rates in patients receiving customized home parenteral nutrition compared with multichamber bags.

JPEN J Parenter Enteral Nutr 2021 Jul 20. Epub 2021 Jul 20.

Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK.

Background: The risk of bloodstream infections may be increased in hospitalized patients receiving ready-made parenteral nutrition (PN) multichamber bags (MCBs) compared with customized PN; however, as highlighted in recent international guidelines, there are no comparable data relating to home PN (HPN).

Methods: Data from a prospectively maintained database were analyzed to compare incidence rates of catheter-related bloodstream infections (CRBSIs) between patients receiving customized HPN compared with MCB HPN at a national UK referral center between May 2018 and August 2020.

Results: Sixty patients with chronic intestinal failure were commenced on MCBs and 45 received customized HPN for a total of 5914 and 7641 catheter days, respectively. No difference in CRBSI incidence was found (0.51/1000 catheter days for MCBs, 0.39/1000 catheter days for customized HPN; incidence rate ratio, 1.29; 95% CI, 0.26-6.37). Eighteen patients were switched from customized HPN to MCB HPN. The study period covered 7401 catheter days receiving customized HPN and 4834 days on MCBs. No significant change was noted in the CRBSI rates following this switch (0.27/1000 catheter days receiving customized HPN vs 0.21/1000 catheter days on MCBs; incidence rate ratio, 1.31; 95% CI, 0.12-14.3).

Conclusion: The use of MCBs for HPN patients is not associated with an increased risk of CRBSI. This study will inform international guidelines and provide reassurance for the continued, safe use of MCB HPN.
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http://dx.doi.org/10.1002/jpen.2225DOI Listing
July 2021

Systematic review with meta-analysis: effects of implementing a nutrition support team for in-hospital parenteral nutrition.

Aliment Pharmacol Ther 2021 09 18;54(5):560-570. Epub 2021 Jul 18.

Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.

Background: Nutrition support teams (NST) may improve parenteral nutrition (PN) outcomes. No previous systematic review has provided conclusive data on catheter-related infection (CRI) occurrence after NST introduction, nor have previous studies performed meta-analysis or graded the evidence.

Aims: To systematically evaluate the effects of implementing an NST for hospitalised adults on PN and compare these with standard care.

Methods: This was a systematic review and meta-analysis, pre-registered in PROSPERO (CRD42020218094). On November 24, 2020, PubMed, Web of science, Scopus, Embase, Cochrane Library, and Clinical Key were searched. Clinical trials and observational studies with a standard care comparator were included. Primary outcome was relative reduction in CRI rate. A random-effects meta-analysis was used to estimate effects, and evidence was rated using Cochrane and GRADE methodologies.

Results: Twenty-seven studies with 8166 patients were included. Across 10 studies, NST introduction reduced the CRI rate (IRR = 0.32, 95% CI: 0.19-0.53) with -8 (95% CI: -12 to -5) episodes per 1000 catheter days compared with standard care. Hypophosphataemia occurred less frequently (IRD = -12%, 95% CI: -24% to -1%) and 30-day mortality decreased (IRD = -6%, 95% CI: -11% to -1%). Inappropriate PN use decreased, both judged by indication (IRD = -18%, 95% CI: -28% to -9%) and duration (IRD = -21%, 95% CI: -33% to -9%). Evidence was rated very low to moderate.

Conclusions: This study documents the clinical impact of introducing an NST, with moderate-grade evidence for the reduction of CRI occurrence compared with standard care. Further, NST introduction significantly reduced metabolic complications, mortality, and inappropriate PN use.
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http://dx.doi.org/10.1111/apt.16530DOI Listing
September 2021

Body composition in patients with type 2 intestinal failure.

Nutr Clin Pract 2021 Jul 16. Epub 2021 Jul 16.

Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, United Kingdom.

Background: Measurement of body composition is a valuable clinical tool for nutrition assessments, but there are no data on the merits of assessment modalities in type 2 intestinal failure (IF). The aim of this study was to evaluate the prevalence of low muscle mass and quality in type 2 IF, comparing bioelectric impedance analysis (BIA) and computed tomography (CT) at the third lumbar vertebra level.

Methods: Patients admitted with acute severe (type 2) IF to a national UK IF center who had BIA measurement and CT scan as part of routine care within 40 days of anthropometric measurement were included in this cross-sectional study. Data were also collected on patient demographics and clinical characteristics.

Results: Forty-four patients meeting inclusion criteria were included. Low muscle mass was detected in 37 out of 44 (84.1%) patients by CT scan and in 30 of out 44 (68.2%) by BIA. Low muscle quality was detected in 22 out of 44 (50%) patients by CT scan and in 40 out of 44 (90.1%) by BIA. Comparison of CT and BIA measurements showed a moderate correlation of muscle, Spearman ρ 0.65 (95% CI, 0.42-0.81; P < 0.001), and a strong correlation of body fat mass measurements, Spearman ρ 0.79 (95% CI, 0.62-0.89; P < 0.001).

Conclusion: This is the first study to demonstrate that low muscle mass is common in patients with type 2 IF, regardless of body composition assessment modality. A larger cohort study is required to validate the impact of low muscle mass and quality on clinical outcomes and the role of targeted interventions to improve the care of patients with type 2 IF.
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http://dx.doi.org/10.1002/ncp.10745DOI Listing
July 2021

Nutritional considerations in severe primary chronic small intestinal dysmotility.

Curr Opin Clin Nutr Metab Care 2021 09;24(5):433-439

Intestinal Failure Unit, Salford Royal Foundation NHS Trust, Salford, UK.

Purpose Of Review: To provide an update on the recent evidence underpinning the approach to nutritional care in patients with severe primary chronic small bowel dysmotility.

Recent Findings: Patients with severe chronic small intestinal dysmotility suffer nutritional and nonnutritional morbidity, both as a result of their underlying polysymptomatic, poorly understood condition and the interventions required. A proportion require artificial nutrition support; however, this is associated with impaired quality of life and associated complications. The approach to nutritional support must therefore engage a multidisciplinary team (MDT) to ensure that decisions to escalate beyond oral nutrition reflect individualised risk-benefit discussions while adopting a holistic approach to symptom management. Since nutritional outcomes are worse in those with the chronic intestinal pseudo-obstruction (CIPO) phenotype, differentiation into CIPO and non-CIPO subgroups, using a pragmatic diagnostic approach rather than invasive/poorly tolerated investigations, can be an important step in achieving nutritional care tailored to the individual.

Summary: Malnutrition in patients with severe chronic small intestinal dysmotility is multifactorial. Early engagement of a broad team that includes dietitians, psychologists and pain management experts is crucial to achieving the most beneficial and least harmful patient-centred nutritional care outcomes.
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http://dx.doi.org/10.1097/MCO.0000000000000775DOI Listing
September 2021

A European survey on the practice of nutritional interventions in head-neck cancer patients undergoing curative treatment with radio(chemo)therapy.

Eur Arch Otorhinolaryngol 2021 Jun 19. Epub 2021 Jun 19.

Medical Oncology, Department of Medical and Surgical Specialties, Radiological Sciences and Public, Health University of Brescia, ASST-Spedali Civili, Brescia, Italy.

Purpose: As the practice of nutritional support in patients with head and neck cancer (HNC) during curative radio(chemo)therapy is quite heterogeneous, we carried out a survey among European specialists.

Methods: A 19-item questionnaire was drawn up and disseminated via the web by European scientific societies involved in HNC and nutrition.

Results: Among 220 responses, the first choice was always for the enteral route; naso-enteral tube feeding was preferred to gastrostomy in the short term, while the opposite for period longer than 1 month. Indications were not solely related to the patient's nutritional status, but also to the potential burden of the therapy.

Conclusion: European HNC specialists contextualize the use of the nutritional support in a comprehensive plan of therapy. There is still uncertainty relating to the role of naso-enteral feeding versus gastrostomy feeding in patients requiring < 1 month nutritional support, an issue that should be further investigated.
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http://dx.doi.org/10.1007/s00405-021-06920-4DOI Listing
June 2021

Comparing success rates in central venous catheter salvage for catheter-related bloodstream infections in adult patients on home parenteral nutrition: a systematic review and meta-analysis.

Am J Clin Nutr 2021 09;114(3):1173-1188

Intestinal Failure Unit, Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands.

Background: Catheter-related bloodstream infection (CRBSI) is a life-threatening complication of parenteral nutrition. Therefore, optimal management, ideally with catheter salvage, is required to maintain long-term venous access.

Objectives: We aimed to evaluate successful catheter salvage rates in patients on home parenteral nutrition (HPN).

Methods: Studies were retrieved from medical databases, conference proceedings, and article reference lists. Data were collected relating to clinical outcomes of 3 treatments: systemic antibiotics, antimicrobial lock therapy (ALT), and catheter exchange. ORs and 95% CIs were calculated from a mixed logistic effects model.

Results: From 10,036 identified publications, 28 met the inclusion criteria (22 cohort studies, 5 case-control studies, and 1 randomized clinical trial), resulting in a total of 4911 CRBSIs. To achieve successful catheter salvage, the addition of an antimicrobial lock solution was superior to systemic antibiotics alone (OR: 1.75; 95% CI: 1.21, 2.53; P = 0.003). Recurrence of infection was less common in studies that used ALT than in those that used systemic antibiotics alone (OR: 0.26; 95% CI: 0.11, 0.61; P = 0.002). The catheter exchange group was excluded from multilevel regression analysis because only 1 included study applied this treatment. Successful salvage rates were highest for coagulase-negative staphylococci, followed by Gram-negative rods and Staphylococcus aureus .

Conclusions: The addition of an antimicrobial lock solution seems beneficial for successful catheter salvage in HPN-dependent patients with a CRBSI. Future prospective randomized studies should identify the most effective and pathogen-specific strategy.This review was registered at www.crd.york.ac.uk/PROSPERO as CRD42018102959.
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http://dx.doi.org/10.1093/ajcn/nqab164DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8408872PMC
September 2021

Recent Advances in the Management of Severe Gastrointestinal Dysmotility.

Clin Exp Gastroenterol 2021 10;14:163-172. Epub 2021 May 10.

Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK.

Severe gastrointestinal motility disorders with small bowel involvement continue to pose a major clinical challenge to clinicians, particularly because of the limitations of diagnostic tests and the lack of efficacious treatment options. In this article, we review current understanding and the utility of diagnostic modalities and therapeutic approaches, and describe how their limitations may potentially exacerbate prolonged suffering with debilitating symptoms, diagnostic delays, the risk of iatrogenic harm and increased healthcare utilisation in this group of patients. Moreover, observations from intestinal failure units worldwide suggest that this problem could be set to increase in the future, with reported trends of increasing numbers of patients presenting with nutritional consequences. Unfortunately, until recently, there has been a lack of consensus recommendations and guidance to support clinicians with their management approach. The aim of this narrative review is to summarise recent developments in this field following publication of an international census of experts, and subsequent clinical guidelines, which have emphasized the importance of holistic, multidisciplinary care. This is particularly important in achieving good clinical outcomes and ensuring the appropriate use of artificial nutritional support, in order to prevent iatrogenic harm. We discuss how these recent developments may impact clinical practice by supporting the development of specialised clinical services to deliver optimal care, and highlight areas where further research is needed.
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http://dx.doi.org/10.2147/CEG.S249877DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8121621PMC
May 2021

Quality of life in patients and in family members of those receiving home parenteral support with intestinal failure: A systematic review.

Clin Nutr 2021 05 13;40(5):3210-3220. Epub 2021 Feb 13.

School of Health Sciences, University of Manchester, Manchester, UK; Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, Manchester, UK; Salford Royal Foundation Trust, Salford, UK. Electronic address:

Background & Aims: People with type 3 intestinal failure require regular home parenteral support (HPS) for survival. Intestinal failure is a long term condition and HPS is a burdensome treatment so understanding quality of life (QoL) and how people live with HPS over time is essential. The aim of this review was to assess the impact of HPS on QoL in adults receiving HPS and their family members.

Methods: A systematic review (PROSPERO 2020 CRD42020166197) of the literature was performed using MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trails, PsycInfo, Web of Science and PROSPERO. Included articles were hand searched to identify any other relevant studies. Eligibility assessment was performed independently by two reviewers in an unblinded standardised manner. Quality was assessed using appropriate Joanna Briggs Institute critical appraisal tools. Data were extracted independently by two reviewers using predefined data fields. Certainty of evidence was assessed using GradePro.

Results: Included in this review were 12 studies with 1236 patients receiving HPS. There were 10 observational studies and 2 randomised controlled trials. Only studies examining QoL in adults receiving HPS were found. There were no studies examining QoL in family carers of these patients. The quality of evidence was graded as low to high and the certainty of evidence for QoL was graded as very low to low. It was not possible to perform a meta-analysis so a narrative review was conducted. All of the studies considered quality of life using validated questionnaires. QoL of patients receiving HPS was lower than the general population regarding physical functioning. Patients had a higher QoL the fewer nights each week they received HPS.

Conclusions: HPS prescriptions seemed to influence QoL. However, the certainty of evidence was very low to low so there is very little to limited confidence about the effect of HPS on patient QoL. Research into family members' QoL is lacking and requires further investigation.
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http://dx.doi.org/10.1016/j.clnu.2021.02.009DOI Listing
May 2021

Factors affecting antidepressant use by patients requiring home parenteral nutrition.

JPEN J Parenter Enteral Nutr 2021 Feb 22. Epub 2021 Feb 22.

Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, and Manchester, UK.

Background: Home parenteral nutrition (HPN) is a life-saving therapy for patients with chronic intestinal failure but can be associated with a degree of psychological distress. The factors associated with the need for antidepressants (ADs) in this cohort have not yet been described.

Methods: The study involved prospective data collection from patients attending an HPN clinic at a national intestinal failure referral center. Patients requiring HPN as a result of active malignancy were excluded. Patients were divided in 2 groups according to AD usage; demographic, anthropometric, socioeconomic characteristics, and intravenous supplementation (IVS) regimens were compared between groups.

Results: A total of 184 patients were recruited between July 2018 and April 2019, with an overall prevalence of AD use of 41.7% (70/168 patients). Daily mean IVS volume was significantly higher among patients taking AD ("AD" group; 2125.48 ± 991.8 ml/day, "no-AD" group; 1828.54 ± 847.0 ml/day, P = .039), with the proportion of patients needing high-volume IVS (≥3000 ml/day) being 3 times higher in the AD group (20.0%(14/70 patients) vs 6.1% (6/98 patients), P = .006). The average energy IVS infusion per day was similar between the groups.

Conclusion: This is the first study to demonstrate that AD use correlates with higher IVS volume rather than energy requirements in HPN patients, suggesting that high IVS volume requirements may be better associated with the patient's disease burden. Early and tailored mental health intervention may be beneficial in those with high IVS volume requirements.
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http://dx.doi.org/10.1002/jpen.2090DOI Listing
February 2021

Reply to the comment by CHEN W et al. on the ESPEN HPN guidelines.

Clin Nutr 2021 02 10;40(2):653. Epub 2020 Dec 10.

Intestinal Failure Unit, Radboud University Medical Center, Nijmegen, the Netherlands.

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http://dx.doi.org/10.1016/j.clnu.2020.12.004DOI Listing
February 2021

An International Survey of Clinicians' Experience Caring for Patients Receiving Home Parenteral Nutrition for Chronic Intestinal Failure During the COVID-19 Pandemic.

JPEN J Parenter Enteral Nutr 2021 01 22;45(1):43-49. Epub 2020 Dec 22.

Medico-Surgical Department of Gastroenterology, Hôpital Erasme, Brussels, Belgium.

Background: This survey of centers caring for patients receiving home parenteral nutrition (HPN) was conducted to assess the impact of the coronavirus disease 2019 (COVID-19) crisis on the management of these patients regarding provision of care, monitoring, regular follow-up, and any changes to service infrastructure.

Methods: A survey was devised and publically published on the Research Electronic Data Capture database management system, with individual centers responding to a public link.

Results: A total of 78 adult and pediatric centers worldwide contributed to the survey, representing ≥3500 patients' experiences. Centers reported infrastructure maintenance for Parenteral Nutrition (PN) bag deliveries to patients (60, 76.92%) or delivery of ancillary items (57, 73.08%), home delivery and HPN administration (65, 83.33%), and home care nurse shortages (25, 32.05%). Routine follow-up of HPN patients changed to either all telemed or mixed with emergency clinic review (70, 89.74%). In 26 centers (33.33%), HPN for newly discharged patients with benign conditions was reduced or stopped. Based on clinical history, the centers reported psychological distress for patients (52, 66.67%), with anxiety, worry, concern, and apprehension reported most frequently (37 of 52, 71.15%) but also fear (10 of 52, 19.23%), depression (5 of 52, 9.62%), and issues related to isolation/confinement (12 of 52, 23.08%).

Conclusions: The COVID-19 pandemic was reported by clinicians to have had a far-reaching adverse impact on patients receiving HPN, especially their safety in terms of provision of personal protective equipment, PN bags, available nursing staff, and psychological well-being. Healthcare systems responded to the challenge and presented new ways of working.
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http://dx.doi.org/10.1002/jpen.2050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7753815PMC
January 2021

Hydrogen and methane breath test results are negatively associated with IBS and may reflect transit time in post-surgical patients.

Neurogastroenterol Motil 2021 06 12;33(6):e14033. Epub 2020 Nov 12.

Department of Gastroenterology, Salford Royal Hospital, Salford, UK.

Background: Contention surrounds hydrogen and methane breath tests as putative measures of small intestinal bacterial overgrowth. We aimed to explore the clinical characteristics associated with positive and negative results to help clarify their role.

Methods: 525 glucose hydrogen/methane breath tests completed over 3 years were analyzed to look for positively and negatively associated predictive factors. Characteristics such as height and weight and underlying medical conditions, medications, and surgical history were collated.

Key Results: There were 85 and 42 positive hydrogen and methane tests, respectively. Patients with irritable bowel syndrome (IBS) (HR = 0.17, p = 0.004) and those with a higher body mass index (HR = 0.93, p = 0.004) were significantly less likely to have a positive test. Patients who underwent the test post-surgically were significantly more likely to have a positive test (HR = 2.76, p = 0.001). A sub-analysis of post-surgical patients by type and region of surgical resection demonstrated that none were statistically more likely than the next to have a positive test. However, for the surgical group as a whole the number of motility-depressing drugs taken (such as opioids) was associated with a significantly decreased likelihood of a positive test (HR = 0.752, p = 0.045).

Conclusion: Our data suggest that patients with a diagnosis of IBS are statistically less likely to have a positive test and it is of limited utility in this group. Post-surgical patients are more likely to have a positive test, possibly secondary to fast transit rather than bacterial overgrowth, as suggested by a significantly negative association with motility-suppressing drugs in this sub-group.
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http://dx.doi.org/10.1111/nmo.14033DOI Listing
June 2021

Nutritional status and predictors of weight loss in patients with systemic sclerosis.

Clin Nutr ESPEN 2020 12 6;40:164-170. Epub 2020 Oct 6.

Division of Diabetes, Endocrinology and Gastroenterology, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9NT, UK; Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK.

Background & Aims: Systemic sclerosis (SSc) commonly affects the gastrointestinal (GI) tract and predisposes to malnutrition. Few studies assessed body composition in outpatients with SSc or used more than one method for comparison over time. The aim of this study was to describe markers of nutrition and body composition in patients with SSc and to identify predictors of unintentional weight loss.

Methods: We consecutively included outpatients with SSc and performed a one-year follow-up. Gastrointestinal (GI) involvement was evaluated from clinical investigations. Patients completed questionnaires for organ involvement and functional status. Clinical assessment included body mass index (BMI), the malnutrition universal screening tool (MUST), inter-incisor distance, anthropometry, and bio-electrical impedance analysis (BIA).

Results: In total, 168 consecutive patients with SSc were included, and 127 (76%) completed one-year follow-up. Thirteen (8%) died before follow-up. Based on MUST scores, 12% of patients were at high and 14% at medium risk of malnutrition. A low BMI was associated with small intestinal involvement (p < 0.0001). Percentage body fat correlated with BMI, both when using four-site anthropometry (r = 0.65, p < 0.01) and BIA (r = 0.49, p < 0.01). Nine (7%) patients had >5% unintentional weight loss at follow-up. Independent baseline predictors of unintentional weight loss included upper GI involvement and disease severity estimated by Health Assessment Questionnaire Disability Index score.

Conclusions: Nutritional risk and GI involvement are frequent and closely correlated in patients with SSc. BIA and four-site anthropometry are comparable in the clinical assessment of patients with SSc. Unintentional weight loss is discrete and related to disease-specific characteristics.
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http://dx.doi.org/10.1016/j.clnesp.2020.09.030DOI Listing
December 2020

Jejunal feeding: when is it the right thing to do?

Frontline Gastroenterol 2020 25;11(5):397-403. Epub 2019 Nov 25.

Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK.

The decision to commence jejunal feeding in patients with structural abnormalities, which prevent oral or intragastric feeding, is usually straightforward. However, decisions surrounding the need for jejunal feeding can be more complex in individuals with no clear structural abnormality, but rather with foregut symptoms and pain-predominant presentations, suggesting a functional origin. This appears to be an increasing issue in polysymptomatic patients with multi-system involvement. We review the differential diagnosis together with the limitations of available functional clinical tests; symptomatic management options to avoid escalation where possible including for patients on opioids; tube feeding options where necessary; and an approach to weaning from established jejunal feeding in the context of a multidisciplinary approach to minimise iatrogenesis.
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http://dx.doi.org/10.1136/flgastro-2019-101181DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7447283PMC
November 2019

Hypophosphatemia in a Specialized Intestinal Failure Unit: An Observational Cohort Study.

JPEN J Parenter Enteral Nutr 2021 Aug 10;45(6):1259-1267. Epub 2020 Sep 10.

Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.

Background: Patients with intestinal failure (IF) are prone to hypophosphatemia and shifts in magnesium and potassium levels. Although these shifts are often attributed to refeeding syndrome (RFS), the incidence of electrolyte shifts among patients with IF is unknown. We evaluated the occurrence of hypophosphatemia and other electrolyte shifts according to the functional and pathophysiological IF classifications.

Methods: We consecutively included all patients' first admission to an IF unit from 2013 to 2017. Electrolyte shifts were defined as severe hypophosphatemia <0.6 mmol/L (mM) or any 2 other shifts below reference range, comprising hypomagnesemia <0.75 mM, hypophosphatemia <0.8 mM, or hypokalemia <3.5 mM. Outcomes included length of stay, central line-associated bloodstream infection, and other infections. Mortality was evaluated 6 months after discharge.

Results: Of 236 patients with IF, electrolyte shifts occurred in 99 (42%), and 127 (54%) of these patients received intravenous supplementation with either phosphate, magnesium, or potassium. In patients who started parenteral nutrition, up to 62% of early-onset shifts (<5 days) related to refeeding, and up to 63% of late-onset shifts (≥5 days) could be ascribed to infections. Derangements occurred in 7 (18%) with type 1 IF, 53 (43%) with type 2 IF, and 39 (53%) readmitted patients with type 3 IF. Of 133 patients with IF secondary to short-bowel syndrome, 65 (49%) developed shifts.

Conclusion: In patients with IF, electrolyte shifts are frequent but not always due to RFS. Electrolyte shifts are common in patients with type 2 and those readmitted with type 3 IF.
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http://dx.doi.org/10.1002/jpen.2006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8451901PMC
August 2021

The management of adult patients with severe chronic small intestinal dysmotility.

Gut 2020 12 21;69(12):2074-2092. Epub 2020 Aug 21.

Gastroenterology and Intestinal Failure Unit, Salford Royal Foundation Trust, Manchester, UK.

Adult patients with severe chronic small intestinal dysmotility are not uncommon and can be difficult to manage. This guideline gives an outline of how to make the diagnosis. It discusses factors which contribute to or cause a picture of severe chronic intestinal dysmotility (eg, obstruction, functional gastrointestinal disorders, drugs, psychosocial issues and malnutrition). It gives management guidelines for patients with an enteric myopathy or neuropathy including the use of enteral and parenteral nutrition.
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http://dx.doi.org/10.1136/gutjnl-2020-321631DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7677490PMC
December 2020

Randomised clinical trial of a gastrointestinal care bundle to reduce symptoms in patients with pelvic cancer undergoing chemoradiotherapy.

BMJ Open Gastroenterol 2020 08;7(1)

Manchester Academic Health Sciences Centre, Health Innovation Manchester, Manchester, UK

Objective: Pelvic radiotherapy is used to treat 17 000 people in the UK each year. Eight in 10 develop difficult bowel problems during pelvic treatment, especially diarrhoea, urgency and incontinence. Some cannot complete treatment, reducing the chance of cancer cure. Undertaking gastroenterologist-led investigation and management during pelvic radiotherapy has never been evaluated. In this study, we aimed to assess whether patients could successfully receive a novel gastrointestinal (GI) care bundle during chemoradiotherapy (feasibility aim) and would experience reduced symptom severity (clinical impact aim).

Design: This randomised controlled trial recruited patients with cervical and bladder cancers undergoing radical chemoradiotherapy. Participants were randomised to intervention or control groups. Questionnaire and anthropometric data were collected. All intervention group patients received individualised dietary counselling weekly throughout treatment, and if bowel symptoms developed they were offered rapid-access investigation and treatment for any identified pathology: lactose intolerance, bacterial overgrowth or bile acid malabsorption.

Results: Feasibility: 50 participants were recruited, 24 were randomised to the intervention group and 26 to the control group. All completed 20 fractions of external beam pelvic radiotherapy. It was possible to perform 57/72 (79%) of proposed intervention tests with no disruption of oncological management.

Clinical Impact: All participants developed GI symptoms during radiotherapy. The median symptom score for each group increased from baseline at 6 weeks. This was from 0.156 (0.000-0.333) to 0.600 (0.250-1.286) in the control group, and from 0.00 (0.000-0.300) to 0.402 (0.000-0.667) in the intervention group.

Conclusion: It was feasible to recruit to and deliver a randomised controlled trial of interventions in patients undergoing pelvic chemoradiotherapy. Lower median bowel scores were reported in the intervention group at 6 weeks, with fewer patients experiencing symptoms overall.

Trial Registration Number: ISRCTN783488.
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http://dx.doi.org/10.1136/bmjgast-2020-000432DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7418694PMC
August 2020

An international survey on clinicians' perspectives on the diagnosis and management of chronic intestinal pseudo-obstruction and enteric dysmotility.

Neurogastroenterol Motil 2020 12 22;32(12):e13937. Epub 2020 Jul 22.

University of Manchester, Manchester, UK.

Background: Chronic intestinal pseudo-obstruction (CIPO) and enteric dysmotility (ED) are small intestinal motility disorders defined by radiological and manometric criteria. In the absence of consensus guidelines, we surveyed opinions on the diagnosis and management of CIPO and ED among experts from different countries.

Methods: A survey questionnaire was circulated electronically to members of the European society for Clinical Nutrition and Metabolism, European Society of Neurogastroenterology and Motility, and United European Gastroenterology. Only responses from participants completing all required components were included.

Key Results: Of 154 participants, 93% agreed that CIPO and ED should be classified separately. Overall, 73% reported an increasing incidence of CIPO and ED, with hypermobile Ehlers-Danlos Syndrome the group with the largest increase in referrals (37%), particularly in the UK (P < .0001). The majority (95%) find diagnosing CIPO and ED difficult. Notably, antroduodenal manometry, a test mandated to diagnose ED, is infrequently used (only 21% respondents use in >50% cases) and full thickness biopsies were reported to seldom influence medical treatment, nutritional management, and prognosis. Respondents reported that very few treatments are useful for most patients, with bacterial overgrowth treatment, prucalopride, and psychological therapies felt to be the most useful. While only 23% of clinicians felt that parenteral nutrition (PN) improves gastrointestinal symptoms in >50% of cases, 68% reported PN dependency at 5 years in the majority of cases.

Conclusions And Inferences: These data highlight the difficulties with diagnosing and managing CIPO and ED and underscore the urgent need for international, multidisciplinary, clinical practice guidelines.
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http://dx.doi.org/10.1111/nmo.13937DOI Listing
December 2020

Patient characteristics and clinical outcomes in a specialised intestinal failure unit: An observational cohort study.

Clin Nutr ESPEN 2020 08 23;38:253-262. Epub 2020 Apr 23.

Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.

Background: Intestinal failure (IF) is defined by a need for intravenous (IV) supplementation. Patients may present with multiple morbidities, and IV treatments carry a risk for catheter-related complications. Few studies described patient characteristics and clinical outcomes according to type of IF.

Methods: We consecutively included patients who were admitted to a newly established inpatient IF unit (IFU) from 2013 through 2017. We evaluated patient characteristics and clinical outcomes of all patients' first admission. Outcomes included IF classification, length of stay, central line-associated blood stream infection (CLABSI), and discharge on home parenteral support (HPS). Follow-up was conducted six months after discharge for mortality and the continued need for HPS.

Results: A total of 236 patients were evaluated, including 39 (17%) with type 1 IF, 123 (52%) with type 2 IF, and 74 (31%) with type 3 IF. Of 91 who had a central venous catheter (CVC) on admission, CLABSI was present in 11 (12%). The CLABSI occurrence during admission was 2 (1%) of 173 patients with a CVC. Mean length of stay declined from mean 33 days (95% confidence interval (CI): 26.2-42.5) in 2013 to 15 days (95% CI: 12.2-17.7) in 2017 (p < 0.0001). Undiagnosed comorbidity was revealed in 165 patients (70%) with unchanged frequency during the study period (p = 0.8). Sixty-seven (28%) patients were discharged with HPS.

Conclusions: Inpatients with IF present with multiple morbidities. CLABSI should be investigated on admission. A low inpatient CLABSI rate may be achieved through the implementation of a specialised IFU.
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http://dx.doi.org/10.1016/j.clnesp.2020.04.002DOI Listing
August 2020

Successful implementation of remote video consultations for patients receiving home parenteral nutrition in a national UK Centre.

Frontline Gastroenterol 2020 14;11(4):280-284. Epub 2019 Oct 14.

Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford, UK.

Rationale: Our intestinal failure unit provides care for patients from a wide geographical area. Patients dependent on home parenteral nutrition (HPN) are routinely reviewed in the clinic at 3-6 monthly intervals. Between March 2008 and 2015, we noted a significant rise in the number of patients under our care, with an associated 51% increase in clinic appointments offered. We evaluated whether telemedicine would provide a strategy to reduce patients' need to travel while maintaining safe clinical standards.

Methods: Implementation began in December 2015 via patient consultation and small tests of change. Clinical data were obtained from a prospectively maintained database. Remote video consultation discussions were carried out via internet video call service (Skype). An anonymous satisfaction questionnaire was offered to patients for completion following consultation. The number of miles saved by obviating the need to attend hospital was calculated for each patient.

Results: During the study period, patients receiving HPN rose by 18% to 288. Twenty-five patients used telemedicine for HPN follow-up, three of these for follow-up with the psychologist. By avoiding hospital attendance, this saved a mean travel distance of 56.7 miles with a total of 18 346.6 cumulative miles saved. Sixty-three per cent of patients rated their satisfaction with the system at ≥90%, with a mean satisfaction of 85%. Eight per cent of the telemedicine cohort was admitted with an HPN complication, compared with an admission rate of 24% for the whole HPN cohort. One emergency admission was avoided.

Conclusion: Telemedicine can obviate the need for clinic attendance in HPN-dependent patients, so reducing the need of individuals with chronic illness to travel while maintaining standards for follow-up.
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http://dx.doi.org/10.1136/flgastro-2019-101257DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7307045PMC
October 2019

Considerations for the management of home parenteral nutrition during the SARS-CoV-2 pandemic: A position paper from the Home Artificial Nutrition and Chronic Intestinal Failure Special Interest Group of ESPEN.

Clin Nutr 2020 07 28;39(7):1988-1991. Epub 2020 May 28.

Clinical Nutrition and Metabolism Unit and Center for Chronic Intestinal Failure, Department of Digestive System, St. Orsola-Malpighi University Hospital, Bologna, Italy.

The management of patients with chronic intestinal failure requiring home parenteral nutrition has been and will continue to be impaired during the SARS-CoV-2 pandemic. Multidisciplinary intestinal failure teams may have to adapt their clinical approaches to home care, outpatient care as well as hospital admission and discharge in order to keep this vulnerable group of patients as safe and well as possible during the unprecedented challenges that countries are facing during the pandemic. Equally, it is important that expert advice from intestinal failure teams is available when home parenteral nutrition (HPN)-dependent patients require admission with SARS-CoV-2 infection. The Home Artificial Nutrition & Chronic Intestinal Failure Special Interest Group of the European Society for Clinical Nutrition and Metabolism (ESPEN) has developed a position paper to outline areas for intestinal failure teams to consider when managing patients with chronic intestinal failure during the SARS-CoV-2 pandemic.
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http://dx.doi.org/10.1016/j.clnu.2020.05.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7253968PMC
July 2020

ESPEN guideline on home parenteral nutrition.

Clin Nutr 2020 06 18;39(6):1645-1666. Epub 2020 Apr 18.

University of Hohenheim, Institute of Nutritional Medicine, Stuttgart, Germany.

This guideline will inform physicians, nurses, dieticians, pharmacists, caregivers and other home parenteral nutrition (HPN) providers, as well as healthcare administrators and policy makers, about appropriate and safe HPN provision. This guideline will also inform patients requiring HPN. The guideline is based on previous published guidelines and provides an update of current evidence and expert opinion; it consists of 71 recommendations that address the indications for HPN, central venous access device (CVAD) and infusion pump, infusion line and CVAD site care, nutritional admixtures, program monitoring and management. Meta-analyses, systematic reviews and single clinical trials based on clinical questions were searched according to the PICO format. The evidence was evaluated and used to develop clinical recommendations implementing Scottish Intercollegiate Guidelines Network methodology. The guideline was commissioned and financially supported by ESPEN and members of the guideline group were selected by ESPEN.
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http://dx.doi.org/10.1016/j.clnu.2020.03.005DOI Listing
June 2020

Infective Endocarditis in Patients With Intestinal Failure: Experience From a National Referral Center.

JPEN J Parenter Enteral Nutr 2021 02 13;45(2):309-317. Epub 2020 Apr 13.

Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK.

Background: Infective endocarditis (IE) is a recognized complication of central line-associated bloodstream infection (CLABSI). Central venous access devices (CVADs) are essential for the delivery of long-term parenteral nutrition (PN), yet there are no published data as to the prevalence, characteristics and outcomes of IE in this population.

Methods: A prospectively maintained database of patients with intestinal failure (IF) types 2 and 3, managed by a national intestinal failure center between January 2010 and December 2018, was analyzed retrospectively and relevant factors extracted from case records.

Results: A total of 745 patients with IF and CVADs in situ on admission, or placed during their stay, were admitted over the duration of this study, 640 with type 2 IF and 105 with type 3 IF. Two hundred eighty-two echocardiograms were performed to investigate potential IE associated with a CLABSI event. Four cases of IE were identified in the entire cohort of 782,666 catheter days (IE incidence rate: 0.005 per 1000 catheter days and 187 per 100,000 person-years for the entire cohort; 0.048 per 1000 inpatient catheter days for acute type 2 IF, 0.0026 per 1000 outpatient catheter days [ie, 99 per 100,000 person-years for outpatients with type 3 IF]).

Conclusion: IE is rare in the type 3 IF population and a rare consequence of CLABSI in inpatient acute type 2 IF. However, mortality and morbidity are high. Routine echocardiography may not be warranted for investigation of CLABSI unless there is a high risk of IE or a virulent organism is involved.
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http://dx.doi.org/10.1002/jpen.1828DOI Listing
February 2021

Causes and Prognosis of Intestinal Failure in Crohn's Disease: An 18-year Experience From a National Centre.

J Crohns Colitis 2020 Nov;14(11):1558-1564

Irving National Intestinal Failure Unit, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK.

Background And Aims: Intestinal failure [IF] is a feared complication of Crohn's disease [CD]. Although cumulative loss of small bowel due to bowel resections is thought to be the dominant cause, the causes and outcomes have not been reported.

Methods: Consecutive adult patients referred to a national intestinal failure unit over 2000-2018 with a diagnosis of CD, and subsequently treated with parenteral nutrition during at least 12 months, were included in this longitudinal cohort study. Data were extracted from a prospective institutional clinical database and patient records.

Results: A total of 121 patients were included. Of these, 62 [51%] of patients developed IF as a consequence of abdominal sepsis complicating abdominal surgery; small bowel resection, primary disease activity, and proximal stoma were less common causes [31%, 12%, and 6%, respectively]. Further, 32 had perianastomotic sepsis, and 15 of those had documented risk factors for anastomotic dehiscence. On Kaplan-Meier analysis, 40% of all patients regained nutritional autonomy within 10 years and none did subsequently; 14% of patients developed intestinal failure-associated liver disease. On Kaplan-Meier analysis, projected mean age of death was 74 years.2.

Conclusions: IF is a severe complication of CD, with 60% of patients permanently dependent on parenteral nutrition. The most frequent event leading directly to IF was a septic complication following abdominal surgery, in many cases following intestinal anastomosis in the presence of significant risk factors for anastomotic dehiscence. A reduced need for abdominal surgery, an increased awareness of perioperative risk factors, and structured pre-operative optimisation may reduce the incidence of IF in CD.
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http://dx.doi.org/10.1093/ecco-jcc/jjaa060DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7648168PMC
November 2020

Advances in chronic intestinal failure management and therapies.

Curr Opin Gastroenterol 2020 05;36(3):223-229

Intestinal Failure Unit, Salford Royal NHS Foundation Trust, Salford.

Purpose Of Review: To summarize changes and recent advances in therapies for chronic intestinal failure (CIF).

Recent Findings: In the last few years, the management of CIF has significantly improved through better prevention and treatment of catheter-related bloodstream infections (CRBSIs) and intestinal failure-associated liver disease (IFALD), as well as improved enteral autonomy by using small bowel growth factors in selected patients. This may have been reflected by a recent reduction in small bowel transplantations.

Summary: Although CIF management has become more established and effective, the long-term implications of parenteral nutrition still place substantial burden on patients such that further work is required to improve patients' quality of life as well as continued efforts to reduce complications relating to CIF management.
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http://dx.doi.org/10.1097/MOG.0000000000000631DOI Listing
May 2020

Intravenous supplementation type and volume are associated with 1-year outcome and major complications in patients with chronic intestinal failure.

Gut 2020 10 21;69(10):1787-1795. Epub 2020 Jan 21.

Flinders Medical Centre, Bedford Park, Adelaide, Australia.

Background And Aim: No marker to categorise the severity of chronic intestinal failure (CIF) has been developed. A 1-year international survey was carried out to investigate whether the European Society for Clinical Nutrition and Metabolism clinical classification of CIF, based on the type and volume of the intravenous supplementation (IVS), could be an indicator of CIF severity.

Methods: At baseline, participating home parenteral nutrition (HPN) centres enrolled all adults with ongoing CIF due to non-malignant disease; demographic data, body mass index, CIF mechanism, underlying disease, HPN duration and IVS category were recorded for each patient. The type of IVS was classified as fluid and electrolyte alone (FE) or parenteral nutrition admixture (PN). The mean daily IVS volume, calculated on a weekly basis, was categorised as <1, 1-2, 2-3 and >3 L/day. The severity of CIF was determined by patient outcome (still on HPN, weaned from HPN, deceased) and the occurrence of major HPN/CIF-related complications: intestinal failure-associated liver disease (IFALD), catheter-related venous thrombosis and catheter-related bloodstream infection (CRBSI).

Results: Fifty-one HPN centres included 2194 patients. The analysis showed that both IVS type and volume were independently associated with the odds of weaning from HPN (significantly higher for PN <1 L/day than for FE and all PN >1 L/day), patients' death (lower for FE, p=0.079), presence of IFALD cholestasis/liver failure and occurrence of CRBSI (significantly higher for PN 2-3 and PN >3 L/day).

Conclusions: The type and volume of IVS required by patients with CIF could be indicators to categorise the severity of CIF in both clinical practice and research protocols.
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http://dx.doi.org/10.1136/gutjnl-2018-318172DOI Listing
October 2020

Discharging Women with Advanced Ovarian Cancer on Home Parenteral Nutrition: Making and Implementing the Decision.

Nutrients 2020 Jan 7;12(1). Epub 2020 Jan 7.

Faculty of Medicine, Biology and Health, and Manchester Academic Health Science Centre, University of Manchester, Oxford Road, Manchester M13 9PL, UK.

Increasingly, patients with advanced ovarian cancer in bowel obstruction are receiving home parenteral nutrition (HPN). Little is known about making and implementing the decision. This study explored the decision-making process for HPN and investigated the barriers and facilitators to implementation. This was a qualitative study underpinned by phenomenology involving 93 longitudinal in-depth interviews with 20 patients, their relatives and healthcare professionals, over 15 months. Participants were interviewed a maximum of four times. Interview transcripts were analysed thematically as per the techniques of Van Manen. We found variance between oncologists and patients regarding ownership of the HPN decision. The oncologists believed they were engaging in a shared decision-making process. However, patients felt that the decision was oncologist-driven. Nevertheless, they were content to have the treatment, when viewing the choice as either HPN or death. In implementing the decision, the principal mutable barrier to a timely discharge was communication difficulties across professional disciplines and organisations. Facilitators included developing a single point-of-contact between organisations, improving communication and implementing standardised processes. Oncologists and patients differ in their perceptions of how treatment decisions are made. Although patients are satisfied with the process, it might be beneficial for healthcare professionals to check patients' understanding of treatment.
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http://dx.doi.org/10.3390/nu12010166DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7019843PMC
January 2020
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