Search

Background: ω-3 Fatty acid (FA)-containing parenteral nutrition (PN) is associated with improvements in patient outcomes and with reductions in hospital length of stay (HLOS) vs standard PN regimens (containing non-ω-3 FA lipid emulsions). We present a cost-effectiveness analysis of ω-3 FA-containing PN vs standard PN in 5 European countries (France, Germany, Italy, Spain, UK) and the US., Methods: This pharmacoeconomic model was based on estimates of ω-3 efficacy reported in a recent meta-analysis and data from country-specific sources. It utilized a probabilistic discrete event simulation model to compare ω-3 FA-containing PN with standard PN in a population of critically ill and general ward patients. The influence of model parameters was evaluated using probabilistic and deterministic sensitivity analyses., Results: Overall costs were reduced with ω-3 FA-containing PN in all 6 countries compared with standard PN, ranging from €1741 (±€1284) in Italy to €5576 (±€4193) in the US. Expenses for infections and HLOS were lower in all countries for ω-3 FA-containing PN vs standard PN, with the largest cost differences for both in the US (infection: €825 ± €4001; HLOS: €4879 ± €1208) and the smallest savings in the UK for infections and in Spain for HLOS (€63 ± €426 and €1636 ± €372, respectively)., Conclusion: This cost-effectiveness analysis in 6 countries demonstrates that the superior clinical efficacy of ω-3 FA-containing PN translates into significant decreases in mean treatment cost, rendering it an attractive cost-saving alternative to standard PN across different healthcare systems., (© 2020 The Authors. Journal of Parenteral and Enteral Nutrition published by Wiley Periodicals, Inc. on behalf of American Society for Parenteral and Enteral Nutrition.)

Background: Use of catheter lock solutions (CLSs) as a strategy to prevent catheter-related bloodstream infections (CRBSIs) has been evaluated in recent clinical trials. Our aim was to identify the most effective CLS formulation in patients receiving home parenteral nutrition (HPN)., Methods: We conducted a systematic review and individual-patient data meta-analysis (IPDMA). Prospective randomized clinical trials in adult HPN patients using CLS were identified from PubMed, EMBASE, Web of Science, CINAHL, Cochrane library, and ClinicalTrials.gov. Primary outcome was the number of CRBSIs per 1000 catheter days for each CLS. Other outcomes included time to CRBSI and identification of patients with a higher risk for CRBSIs., Results: In total, 1107 studies were screened for eligibility, of which three studies comprising 162 HPN patients and 45,695 catheter days were included in the IPDMA. CRBSI rates were significantly decreased in patients using taurolidine (rate 0.13; 95% confidence interval [CI], 0.05-0.32) when compared with saline (rate 0.74; 95% CI, 0.31-1.74; P = .002) or heparin (rate 2.01; 95% CI, 1.03-3.91; P < .001). The cumulative proportion of CRBSI-free patients using taurolidine, saline, and heparin after 1 year was 88%, 56%, and 14%, respectively. Three risk factors for CRBSIs were identified: type of CLS, intestinal dysmotility as underlying condition, and use of central venous catheters., Conclusions: Taurolidine was the most effective CLS formulation in HPN patients for the prevention of CRBSIs. We suggest discussing with patients the benefits and risks when starting taurolidine, especially in patients who are considered to have a higher risk for CRBSIs., (© 2020 American Society for Parenteral and Enteral Nutrition.)

The protein and energy requirements of critically ill patients treated in intensive care units (ICUs) have been actively discussed recently. Currently published clinical recommendations and reviews suggest significant increases of protein provision to 2-2.5 g/kg/d in some populations of ICU patients. However, a detailed analysis of the main sources of these recommendations reveals a number of serious contradictions, as well as an absence of obvious evidence supporting the allotment of high doses of protein. We went through these recommendations and reviewed cited articles and other studies, and we have separated our arguments against excessive protein provision into sections., (© 2020 American Society for Parenteral and Enteral Nutrition.)

In hospitalized patients, lipid emulsions are an integral part of balanced parenteral nutrition. Traditionally, a single lipid source, soybean oil, has been given to patients and was usually regarded as just a source of energy and to prevent essential fatty-acid deficiency. However, mixtures of different lipid emulsions have now become widely available, including mixtures of soybean oil, medium-chain triglycerides, olive oil, and fish oil. Fish oil is high in the ω-3 polyunsaturated fatty acids docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA). There is a growing body of evidence that these ω-3 fatty acids can exert beneficial immunomodulatory, anti-inflammatory, and inflammation-resolution effects across a wide range of patient groups including surgical, cancer, and critically ill patients. At least in part, these effects are realized via potent specialized pro-resolution mediators (SPMs). Moreover, parenteral nutrition including ω-3 fatty acids can result in additional clinical benefits over the use of standard lipid emulsions, such as reductions in infection rates and length of hospital and intensive care unit stay. Clinical and experimental evidence is reviewed regarding lipid emulsion use in a variety of hospitalized patient groups, including surgical, critically ill, sepsis, trauma, and acute pancreatitis patients. Practical aspects of lipid emulsion use in critically ill patients are also considered, such as how to determine and fulfill energy expenditure, how and when to consider parenteral nutrition, duration of infusion, and safety monitoring., (© 2020 The Authors. Journal of Parenteral and Enteral Nutrition published by Wiley Periodicals, Inc. on behalf of American Society for Parenteral and Enteral Nutrition.)

Lipid emulsions are an integral part of parenteral nutrition, and traditionally have been regarded as an energy-dense source of calories and essential fatty acids. For many years, lipids used in parenteral nutrition have been based on vegetable oils (eg, soybean-oil emulsions). However, soybean-oil emulsions may not have an optimal fatty-acid composition under some circumstances when used as the only lipid source, as soybean oil is particularly abundant in the ω-6 polyunsaturated fatty acid (PUFA), linoleic acid. Hence, a progressive series of more complex lipid emulsions have been introduced, typically combining soybean oil with 1 or more alternative oils, such as medium-chain triglycerides (MCTs) and/or olive oil and/or fish oil. The wide range of lipid emulsions now available for parenteral nutrition offers opportunities to alter the supply of different fatty acids, which potentially modifies functional properties, with effects on inflammatory processes, immune response, and hepatic metabolism. Fish oil has become an important component of modern, composite lipid emulsions, in part owing to a growing evidence base concerning its biological effects in a variety of preclinical models. These biological activities of fish oil are mainly attributed to its ω-3 PUFA content, particularly docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA). DHA and EPA have known mechanisms of action, anti-inflammatory, immunomodulatory, and antioxidative properties. Specialized proresolving mediators, such as resolvins, protectins, and maresins, are synthesized directly from DHA and EPA, are key for the resolution of inflammation, and improve outcomes in many cell- and animal-based models and, recently, in some clinical settings., (© 2020 American Society for Parenteral and Enteral Nutrition.)

It is estimated that over 25,000 Americans receive home parenteral nutrition (HPN), mostly because of intestinal failure (IF). Although there is significant variability in the fluid and energy needs of patients receiving HPN, intravenous lipid emulsions (ILEs) are an essential part of the macronutrient composition, serving as an excellent source of non-protein energy, as well as supplying essential fatty acids. However, the long-term use of ILEs in particular may be associated with some detrimental health effects, such as intestinal failure associated liver disease (IFALD). Although there is lack of unifying diagnosis, IFALD can present as cholestasis, steatosis, or fibrosis, with a prevalence that ranges between 5% and 43%. The development of IFALD tends to be multifactorial. Risk factors of IFALD can include those related to IF, inflammation/infection, and long-term parenteral nutrition. Some studies have shown a link between development of IFALD and ILE dose, especially if the dose is >1 g/kg/d, with high ω-6:ω-3 polyunsaturated fatty acid (PUFA) ratio and phytosterol content being theorized as some contributing factors. Thus, efforts have been made to use alternative oils (olive oil, medium-chain triglycerides, and fish oil) to reduce the soybean-oil content of ILE, which tends to be high in ω-6 PUFA and phytosterols. Although additional long-term clinical data are emerging, this strategy, as reviewed in the current manuscript, has shown to provide some benefit in both prevention and treatment of IFALD and other sequelae of HPN., (© 2019 American Society for Parenteral and Enteral Nutrition.)

A number of topics important to the handling of intravenous lipid emulsions (ILEs) were discussed at the international summit. ILE handling includes the preparation and the administration steps in the typical use of parenteral nutrition (PN). The discussion and consensus statements addressed several issues, including standardization of the PN process, use of commercially available multi-chamber PN or compounded PN bags, the supervision by a pharmacist with expertise, limiting ILE repackaging, and infusion duration., (© 2019 American Society for Parenteral and Enteral Nutrition.)

The inclusion of ω-3 fatty acids as part of parenteral nutrition is associated with clinical benefits such as a reduced likelihood of infectious complications and shorter hospital and intensive care unit (ICU) stays. As healthcare resources are limited, pharmacoeconomic analyses have been performed, typically modeling studies, using cost and outcomes data to investigate the cost-effectiveness of parenteral nutrition regimens including ω-3 fatty acids from fish oil compared with standard parenteral nutrition without such ω-3 fatty acids. This review covers pharmacoeconomic studies encompassing Italian, French, German, and UK hospitals for ICU and non-ICU hospitalized patients, and for ICU patients in China. The results show that the use of parenteral nutrition including ω-3 fatty acids more than offsets any additional acquisition costs in all national scenarios investigated to date, indicating that parenteral nutrition including ω-3 fatty acids is a clinically and economically beneficial strategy compared with standard parenteral nutrition., (© 2019 American Society for Parenteral and Enteral Nutrition.)

Background: The 2018 Lipids in Parenteral Nutrition summit involved a panel of experts in clinical nutrition, lipid metabolism, and pharmacology, to assess the current state of knowledge and develop expert consensus statements regarding the use of intravenous lipid emulsions in various patient populations and clinical settings. The main purpose of the consensus statements is to assist healthcare professionals by providing practical guidance on common clinical questions related to the provision of lipid emulsions as part of parenteral nutrition (PN)., Methods: The summit was designed to allow interactive discussion and consensus development. The resulting consensus statements represent the collective opinion of the members of the expert panel, which was informed and supported by scientific evidence and clinical experience., Results: The current article summarizes the key discussion topics from the summit and provides a set of consensus statements designed to complement existing evidence-based guidelines. Lipid emulsions are a major component of PN, serving as a condensed source of energy and essential fatty acids. In addition, lipids modulate a variety of biologic functions, including inflammatory and immune responses, coagulation, and cell signaling. A growing body of evidence suggests that lipid emulsions containing ω-3 fatty acids from fish oil confer important clinical benefits via suppression of inflammatory mediators and activation of pathways involved in the resolution of inflammation., Conclusions: This article provides a set of expert consensus statements to complement formal PN guideline recommendations., (© 2020 American Society for Parenteral and Enteral Nutrition.)

This systematic review and meta-analysis investigated ω-3 fatty-acid enriched parenteral nutrition (PN) vs standard (non-ω-3 fatty-acid enriched) PN in adult hospitalized patients (PROSPERO 2018 CRD42018110179). We included 49 randomized controlled trials (RCTs) with intervention and control groups given ω-3 fatty acids and standard lipid emulsions, respectively, as part of PN covering ≥70% energy provision. The relative risk (RR) of infection (primary outcome; 24 RCTs) was 40% lower with ω-3 fatty-acid enriched PN than standard PN (RR 0.60, 95% confidence interval [CI] 0.49-0.72; P < 0.00001). Patients given ω-3 fatty-acid enriched PN had reduced mean length of intensive care unit (ICU) stay (10 RCTs; 1.95 days, 95% CI 0.42-3.49; P = 0.01) and reduced length of hospital stay (26 RCTs; 2.14 days, 95% CI 1.36-2.93; P < 0.00001). Risk of sepsis (9 RCTs) was reduced by 56% in those given ω-3 fatty-acid enriched PN (RR 0.44, 95% CI 0.28-0.70; P = 0.0004). Mortality rate (co-primary outcome; 20 RCTs) showed a nonsignificant 16% reduction (RR 0.84, 95% CI 0.65-1.07; P = 0.15) for the ω-3 fatty-acid enriched group. In summary, ω-3 fatty-acid enriched PN is beneficial, reducing risk of infection and sepsis by 40% and 56%, respectively, and length of both ICU and hospital stay by about 2 days. Provision of ω-3-enriched lipid emulsions should be preferred over standard lipid emulsions in patients with an indication for PN., (© 2019 The Authors. Journal of Parenteral and Enteral Nutrition published by Wiley Periodicals, Inc. on behalf of American Society for Parenteral and Enteral Nutrition.)

Background: Malnutrition is associated with increased hospital stay and subsequently higher healthcare costs. Early detection of malnutrition among people accessing health services at public hospitals is vital to identify and treat malnutrition effectively and in a timewise and cost-effective manner. The aim of this study was to evaluate the nutrition risk of this population., Materials and Methods: Nutrition screening was performed for 2970 patients (52% male; 55.3 ± 20.1 years old) at 34 hospitals. Nutrition risk was evaluated through 3 nutrition screening tools-Nutritional Risk Screening 2002 (NRS-2002), Malnutrition Universal Screening Tool (MUST), and Mini Nutritional Assessment-Screening Form (MNA-SF)., Results: Malnutrition risk was found: 25.3% with NRS-2002, 22.9% with MUST, and 60.5% with MNA-SF. Nutrition risk among patients accessing health services at public hospitals increases with age (high-risk patients among those ≥80 years old: NRS-2002, 9.8%; MUST, 16.9%; MNA-SF, 43.9%). The highest prevalence of nutrition risk was found at the oncology departments (16.7%, NRS-2002; 23.4%, MUST). According to the NRS-2002 and MUST, surgical patients have a greater risk for malnutrition vs internal medicine patients (adjusted odds ratio [OR] = 1.0, P < .001; adjusted OR = 1.17, P < .001, respectively), whereas according to MNA-SF, surgical patients have 30% lower probability for malnutrition risk against internal medicine patients (adjusted OR = 0.7, P < .001)., Conclusions: A high prevalence of malnutrition risk was reported among patients accessing health services at public hospitals. Early detection of malnutrition is vital to allow the allocation of the needed workforce to manage it effectively., (© 2017 American Society for Parenteral and Enteral Nutrition.)

Aim: Low bone mineral density (BMD) is commonly reported in patients receiving home parenteral nutrition (HPN). Oral and intravenous calcium, vitamin D, and bisphosphonates have been used to treat BMD but with low efficiency due to their limited absorption and patient compliance. Denosumab is a new drug that helps prevent osteoclast development and activation and led to decreased bone resorption in some studies. The aim of this study was to assess its value in HPN patients., Methods: Between November 2011 and March 2013, 49 patients receiving HPN (29 women, 20 men, mean age 55.3 years) who met the eligibility criteria were randomly assigned to a denosumab or control group. Regional dual-energy x-ray absorptiometry of the spine and hip was performed before therapy and after 12 months. BMD, T score, and z score were assessed., Results: Fifteen patients received 2 doses of therapy and were fully reassessed after 1 year. At baseline and after 12 months, the absorptiometry revealed T scores of -3.439 standard deviations (SD) vs -2.33 SD at lumbar segment 2 (L2) and -2.957 SD vs -2.067 SD at lumbar segment 3 (L3), z scores of -2.24 SD vs -1.36 SD at L2 and -1.995 vs -1.067 SD at L3, and BMD of 0.801 vs 0.946 at L2 and 0.857 vs 0.979 at L3, respectively. Two serious outcomes were reported, without any correlation to the intervention. Two patients were weaned off HPN and hence discontinued. One patient experienced sciatica, resulting in discontinuation of the intervention., Conclusions: This study showed that denosumab may be a valuable treatment option for improving BMD in HPN patients., (© 2017 American Society for Parenteral and Enteral Nutrition.)

Background and Aim: Many techniques have been tested to reduce the incidence of catheter-relater bloodstream infections (CRBSIs) during home parenteral nutrition (HPN). One of these methods, taurolidine lock, has shown some potential in several studies, but it has been studied primarily in patients with a relatively high CRBSI rate. Therefore, the aim of this study was to analyze the clinical value of taurolidine in patients receiving HPN who have a low infection rate., Methods: The CRBSI ratio at the Skawina HPN center has remained at 0.3-0.4 episodes/patient/y for the past 7 years. In November 2012, 30 patients (17 men, 13 women, mean age 52.3 years) were randomized to 1 of 3 groups: 2% taurolidine lock (group A), 1.35% taurolidine + citrate lock (B), and control-saline flush (C). Patients were observed for 12 consecutive months for catheter-related complications. Blood cultures were collected in each case in which an infection was suspected., Results: The total number of catheter days reached 10,968, with the following number of days per group: group A, 3658; group B, 3650; and group C, 3660. No complications were observed in the control group, while patients in the study groups had 1 catheter infection (group A) and 1 occlusion (group B). The CRBSIs were treated successfully with antibiotics. The cost of treatment in groups A and B was significantly higher than that in group C (P < .05)., Conclusion: The study did not observe any additional clinical value of taurolidine in patients receiving HPN who have a low infection rate and found low cost-effectiveness. Taurolidine should most likely be used only in patients with a high CRBSI rate., (© 2014 American Society for Parenteral and Enteral Nutrition.)

Background: Disease-related malnutrition (DRM) represents a critical public health concern. Therefore, Fight Against Malnutrition (FAM) should be a state priority, but the degree to which this is true appears to differ considerably among European countries. The aim of this study was to put the problem into perspective by comparing the prevalence of malnutrition in countries from opposite parts of the continent., Methods: Six countries-Croatia, Estonia, Greece, Lithuania, Poland, and Turkey-participated in the study. A short questionnaire was used to assess DRM: its prevalence, the current situation in hospitals, regulations for reimbursement, and general healthcare circumstances. Data from ESPEN's NutritionDay 2006 were used to broaden the perspective., Results: At admission in October 2012, 4068 patients were assessed. The study was performed in 160 hospitals and 225 units with 9143 beds. The highest proportions of patients with 3 or more points on the Nutritional Risk Screening 2002 were observed in Estonia (80.4%) and Turkey (39.4%), whereas the lowest were in Lithuania (14.2%). The provision of nutrition support was best in Turkey (39.4% required intervention, 34.4% received intervention) and Poland (21.9% and 27.8%, respectively). Nutrition support teams (NSTs) are active in some countries, whereas in others they virtually do not exist., Conclusion: The prevalence of malnutrition was quite high in some countries, and the nutrition approach differed among them. It could be the result of the lack of reimbursement, inactive or nonexistent NSTs, and low nutrition awareness. Those facts confirmed that the continuation of FAM activities is necessary., (© 2013 American Society for Parenteral and Enteral Nutrition.)

Background: The benefits of home enteral tube feeding (HETF) provided by nutrition support teams (NSTs) have been questioned recently, given the growing costs to the healthcare system. This study examined the effect of a specialized home enteral nutrition program on clinical outcome variables in HETF patients., Methods: The observational study included 203 patients (103 women, 100 men; mean age 52.5 years) receiving HETF with homemade diets for at least 12 months before starting a specialized home nutrition program for another 12 months consisting of provision of commercial enteral formulas and the guidance of an NST. Both study periods were compared regarding the number of hospital admissions, length of hospital and intensive care unit (ICU) stay, and costs of hospitalization., Results: A specialized HETF program significantly reduced the number of hospital admissions and the duration of hospital and ICU stays. The need for hospitalization and ICU admission was significantly reduced, with odds ratios of 0.083 (95% confidence interval, 0.051-0.133, P < .001) and 0.259 (95% confidence interval, 0.124-0.539, P < .001), respectively. Specialized HETF was associated with a significant decrease in the prevalence of pneumonia (24.1% vs 14.2%), respiratory failure (7.3% vs 1.9%), urinary tract infection (11.3% vs 4.9%), and anemia (3.9% vs 0%) requiring hospitalization. The average yearly cost of hospital treatment decreased from $764.65 per patient to $142.66 per year per patient., Conclusions: The specialized HETF care program reduces morbidity and costs related to long-term enteral feeding at home.