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The emerging field of chrononutrition investigates the effects of the timing of nutritional intake on human physiology and disease pathology. It remains largely unknown when patients receiving home nutrition support routinely administer home parenteral nutrition (HPN) and/or home enteral nutrition (HEN).The present descriptive study included data collected from a patient-oriented survey designed to assess the timing of infusions and sleep habits of patients receiving HPN and HEN in the United States.A total of 100 patients were included. Patients had a mean age of 44.1 years and 81% were female. Among 73 patients supported with HPN and 27 patients supported with HEN, 86% and 44% reported overnight infusions, respectively. The median start and end times of overnight infusions were 2100 (interquartile range [IQR] = 1900-2200) and 0800 (IQR = 0700-1000), respectively, for HPN and 2000 (IQR = 1845-2137) and 0845 (IQR = 0723-1000), respectively, for HEN. Overnight infusions started 2.0 h (IQR = 1.1-3.0) and 2.0 h (IQR = 0.6-3.3) before bedtime for HPN and HEN, respectively, and stopped 12.9 min (IQR = -21.3 to 29.1) and 30.0 min (IQR = -17.1 to 79.3) after wake time for HPN and HEN, respectively. Sleep disruption because of nutrition support or urination was most common among patients receiving infusions overnight compared with those receiving infusions continuously or during the daytime.Our survey study focusing on a novel and medically relevant dimension of nutrition found that most HPN-dependent and HEN-dependent patients receive infusions overnight while asleep. Our findings suggest that overnight infusions coinciding with sleep may result in sleep and circadian disruption.

BACKGROUND Chronic intestinal failure (CIF) is an ultrarare disease, with an estimated national prevalence of ∼25,000 cases. There is a suspicion of widespread lack of expertise in CIF care, but no formal assessment tool or data exist. We developed and validated a knowledge test in CIF and now report our preliminary results from testing CIF knowledge in a cohort of US gastroenterologists. METHOD We developed a 20-question knowledge test in CIF, covering four key components of IF. After internal testing, refinement, and revision, we administered the test to a convenience sample of experts and nonexperts in IF. We then deployed the validated test to a cohort of 100 US gastroenterologists. RESULTS The test had a Cronbach alpha of 0.74, suggesting a reliable test, with a threshold score to discriminate experts and nonexperts of 13.4 (maximum 20) and with a sensitivity of 81.3% and specificity of 86.4%. The overall mean score of 8.2 for the 100 US gastroenterologists was at the level of nonexperts in our convenience sample. CONCLUSION The preliminary results of our validated knowledge test in IF among a broad group of US gastroenterologists demonstrate lack of knowledge in IF.

Intestinal failure (IF) is a rare chronic disease requiring intravenous (IV) fluids or parenteral nutrition (PN) dependency for optimal patient health and sustenance. The complex care is best managed by specialized multidisciplinary teams. Patients who have limited access to intestinal rehabilitation centers often receive IV/PN care from clinicians lacking specialty expertise. An innovative videoconferencing project was launched in May 2019 to provide online telementoring and case-based learning in IF. The Extension for Community Healthcare Outcomes (ECHO) model was adopted to provide education and virtual support via the Learn Intestinal Failure Tele-ECHO (LIFT-ECHO) project. Online clinics include patient case presentations, moderated discussion, best-practice recommendations, and didactic continuing education lectures on IF- and PN-related topics. Participation is interprofessional and international. Via knowledge dissemination and specialty mentorship, LIFT-ECHO is expected to improve healthcare for patients with IF and transform care delivery by overcoming the limitations in access to expertise.

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

BACKGROUND Patient-reported outcome (PRO) measures often address quality of life (QOL) and help improve communication and shared decision-making. The home parenteral nutrition patient-reported outcome questionnaire (HPN-PROQ) was developed for patients to self-assess factors that influence QOL. The aim of this study was to establish construct validity. METHOD Responses were analyzed for 77 HPN-dependent patients with chronic and prolonged acute intestinal failure. General linear modeling was conducted to describe patterns of interactions and association between items included in the HPN-PROQ. RESULTS Most patients (78%) had chronic intestinal failure. Mean HPN duration was 3.3 ± 0.6 years. Underlying illness had a moderate or major effect on QOL for 88%; 59% reported their QOL had been negatively impacted by HPN. There was no difference in QOL among chronic patients, depending on how important they rated "being able to do what I want to do" (P = .1), whereas prolonged acute intestinal failure patients had significantly lower QOL if they rated "being able to do what I want to do" extremely vs very important (adjusted P = .02). Confidence with ability to perform HPN procedures was associated with understanding the need for HPN (P < .01). As ratings increased for emotional difficulty in coping with HPN so did HPN impact on QOL (linear trend P < .01). CONCLUSION Construct validity of the HPN-PROQ was evident. The HPN-PROQ considers the unique experience of living with a complex nutrition therapy.

espanolIntroduccion: el manejo de las fistulas enterocutaneas (FEC) es un reto que requiere enfoque interdisciplinario y plantea un desafio importante. Las guias para optimizar el estado nutricional en estos pacientes estan basadas en estudios que dependen de la experiencia individual y, ocasionalmente, institucional; que se focalizan en el tratamiento integral de las FEC, centrandose en el manejo medico y quirurgico, mientras que la terapia nutricional se revisa solo superficialmente. Los requerimientos nutricionales, via de administracion, uso de inmunonutricion y de analogos de la somatostatina en el tratamiento de estos pacientes no estan bien definidos. El objetivo de esta guia es desarrollar recomendaciones especificas para la terapia nutricional de los pacientes adultos con FEC. Metodo: revision sistematica de la mejor evidencia disponible para responder a una serie de preguntas sobre la terapia nutricional de los adultos con FEC, evaluada utilizando la metodologia GRADE. Se utilizo un proceso de consenso anonimo para desarrollar las recomendaciones de la guia clinica antes de la revision por pares y la aprobacion por las Juntas Directivas de ASPEN y FELANPE. Preguntas: 1) ?Que factores describen mejor el estado nutricional de los adultos con FEC? 2) ?Cual es la mejor via para administrar la terapia nutricional (oral, nutricion enteral o parenteral)? 3) ?Que aporte energetico y proteico proporciona mejores resultados clinicos? 4) ?El uso de la fistuloclisis se asocia a mejores resultados? 5) ?Las formulas inmunomoduladoras se asocian a mejores resultados? 6) ?El uso de la somatostatina proporciona mejores resultados? 7) ?Cuando esta indicada la terapia nutricional parenteral domiciliaria? EnglishBackground: the management of patients with enterocutaneous fistula (ECF) requires an interdisciplinary approach and poses a significant challenge to surgeons, gastroenterologists, intensivists, wound/stoma care specialists, and nutrition support clinicians. Available guidelines for optimizing nutritional status in these patients are often vague, based on limited and dated clinical studies, and typically rely on individual or institutional experience. Specific nutrient requirements, appropriate route of feeding, role of immune-enhancing nutrients, and use of somatostatin analogs in the management of patients with ECF remain a challenge for the clinician. The purpose of this clinical guideline is to develop recommendations for the nutritional care of adult patients with ECF. Methods: a systematic review of the best available evidence to answer a series of questions regarding clinical management of adults with ECF was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Working Group. An anonymous consensus process was used to develop the clinical guideline recommendations prior to peer review and approval by the A.S.P.E.N. and FELANPE Board of Directors. Questions: in adult patients with enterocutaneous fistula: 1) What factors best describe nutritional status? 2) What is the preferred route of nutritional therapy (oral diet, EN or PN)? 3) What protein and energy intake provide best clinical outcomes? 4) Is fistuloclysis associated with better outcomes than standard care? 5) Are immune-enhancing nutrients associated with better outcomes? 6) Does the use of somatostatin provide better outcomes than standard medical therapy? 7) When is home parenteral nutrition support indicated?

Background: The management of patients with enterocutaneous fistula (ECF) requires an interdisciplinary approach and poses a significant challenge to physicians, wound/stoma care specialists, dietitians, pharmacists, and other nutrition clinicians. Guidelines for optimizing nutrition status in these patients are often vague, based on limited and dated clinical studies, and typically rely on individual institutional or clinician experience. Specific nutrient requirements, appropriate route of feeding, role of immune-enhancing formulas, and use of somatostatin analogues in the management of patients with ECF are not well defined. The purpose of this clinical guideline is to develop recommendations for the nutrition care of adult patients with ECF. Methods: A systematic review of the best available evidence to answer a series of questions regarding clinical management of adults with ECF was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development, and Evalu...

Background Home parenteral nutrition (HPN) is a high-cost, complex nutrition support therapy that requires the use of central venous catheters. Central line-associated bloodstream infections (CLABSIs) are among the most serious risks of this therapy. Sustain: American Society for Parenteral and Enteral Nutrition's National Patient Registry for Nutrition Care (Sustain registry) provides the most current and comprehensive data for studying CLABSI among a national cohort of HPN patients in the United States. This is the first Sustain registry report detailing longitudinal data on CLABSI among HPN patients. Objective To describe CLABSI rates for HPN patients followed in the Sustain registry from 2011-2014. Methods Descriptive, χ 2 , and t tests were used to analyze data from the Sustain registry. Results Of the 1,046 HPN patients from 29 sites across the United States, 112 (10.7%) experienced 194 CLABSI events during 223,493 days of HPN exposure, for an overall CLABSI rate of 0.87 episodes/1,000 parenteral nutrition-days. Although the majority of patients were female (59%), adult (87%), white (75%), and with private insurance or Medicare (69%), CLABSI episodes per 1,000 parenteral nutrition-days were higher for men (0.69 vs 0.38), children (1.17 vs 0.35), blacks (0.91 vs 0.41), and Medicaid recipients (1.0 vs 0.38 or 0.39). Patients with implanted ports or double-lumen catheters also had more CLABSIs than those with peripherally inserted or central catheters or single-lumen catheters. Staphylococci were the most commonly reported pathogens. These data support findings of smaller studies about CLABSI risk for children and by catheter type and identify new potential risk factors, including gender, race, and insurance type. Conclusions Additional studies are needed to determine effective interventions that will reduce HPN-associated CLABSI.

Home parenteral nutrition (HPN) is a vital lifesaving therapy for patients who are unable to maintain weight, fluid balance, nutrition, and functional status via oral or enteral nutrition alone. There are few current data sources describing HPN prevalence, patient demographics, or long-term outcomes in the United States.To describe demographics and baseline characteristics of patients receiving HPN therapy.This is a descriptive analysis of data from the first cohort of HPN patients at time of enrollment in the SustainThere were 1251 patients enrolled from 29 sites. Eighty-five percent of patients were adults, with a mean age of 51.3 ± 15.3 years. Fifteen percent were pediatric, with a mean age of 4.9 ± 4.9 years. For both age groups, short-bowel syndrome was the most frequently reported HPN indication (24%). Adults most commonly had a peripherally inserted central catheter (47%) or a tunneled catheter (43%) for HPN administration. In contrast, most pediatric patients (72%) had a tunneled catheter. Most patients received parenteral nutrition daily and consumed some oral nutrition. Twenty-eight percent of all patients were expected to require HPN indefinitely.This is the first report of descriptive data from the Sustain Registry. The data reveal important characteristics of patients receiving HPN in 29 U.S. sites.

Home parenteral nutrition (HPN) is a technologically complex, life-sustaining therapy for individuals who have intestinal failure. Accepting an invasive lifelong therapy like HPN is challenging for patients and their family caregivers. There is a desire to maintain a sense of normalcy in life and to carry on as usual. Using qualitative methodology, the authors explored and described the lived experience of HPN-dependent adults and identified normalization as a repeating and strong theme. Understanding how individuals adapt, cope, or experience this complex therapy provides insight into how they manage their lives in as normal a way as possible. By understanding the perspective of normalization, home infusion nurses and nutrition support clinicians can embrace caregiving strategies and tools consistent with the changing social environment in which the HPN experience is lived.

Patient-reported outcome (PRO) instruments collect information from patients about health conditions and disease management, including quality of life (QOL). Clinicians acknowledge patient concerns about QOL but need guidance to assess the nature and severity of individually experienced problems. The Home Parenteral Nutrition (HPN)-Patient-Reported Outcome Questionnaire (PROQ) was developed for use during medical appointments or homecare visits to address this gap. The purpose of this research was to provide evidence that the HPN-PROQ items and scale possess content validity.A mixed-method study design was used. In phase 1, cognitive interviews (CIs) were conducted with 32 HPN patients. Thematic analysis was used to assess participant understanding of the instructions, items, and response scales and overall utility of the HPN-PROQ. In phase 2, 13 expert clinicians evaluated the relevance of items to the HPN population using the Content Validity Index (CVI) to produce item-level (I-CVI) and scale-level (S-CVI) scores. Items with an I-CVI score ≥0.783 were retained.Fifty-four percent of items were deemed as being comprehensible, acceptable, and clear; 25% were revised; and 11% were deleted. In phase 2, 79% of items were rated highly relevant. The S-CVI score was 0.96. The final HPN-PROQ contains 34 items.This study established acceptable content validity of the HPN-PROQ. This PROQ may help foster patient-clinician communication about lifestyle adaptation and QOL.

Home parenteral nutrition (HPN) is indicated for adults and children who cannot digest and absorb food and who are able to receive therapy safely outside of a hospital. How successful this therapy is depends on the patient's support system and ability to learn and independently administer medically complex procedures. Transition to home is facilitated by identifying all necessary therapies, obtaining information to demonstrate medical necessity, establishing central venous access, reaching goal infusion rate, identifying who will write HPN orders, and coordinating care among all home care providers. An interdisciplinary team provides the most successful process to ensure safe HPN.

Home parenteral nutrition (HPN) provides nourishment and hydration to patients with short bowel syndrome and intestinal failure and is thus a life-sustaining therapy for these patients. However, measures of quality of life (QOL) are lower among the HPN-dependent population than among patients with other intestinal diseases who do not require HPN. Multiple factors contribute to lower QOL in HPN-dependent patients, including fears surrounding the increased risk of HPN-associated adverse events, such as catheter-related complications, parenteral nutrition-associated liver disease, and metabolic bone disease. In addition, HPN-dependent patients report impaired sleep and daytime fatigue because of pump noises, equipment alarms, and nocturia. Psychosocial burdens on families of HPN-dependent patients include decreased social activities, disrupted family relationships and friendships, and depression. These families also face imposing financial constraints, including decreased employment and large out-of-pocket expenses for insurance premiums and nonreimbursed copayments, medications, and supplies. Furthermore, HPN technology and HPN-related complications and sequelae contribute to the rapid overall increase in the costs of healthcare systems. Additionally, family caregivers provide unpaid healthcare services for patients who require HPN, often to the detriment of their own physical and mental well-being. Nonetheless, patients dependent on HPN and their caregivers often demonstrate considerable resilience and are frequently able to normalize their response to illness and disability. Interventions that may improve QOL among HPN-dependent patients and caregivers include patient education, affiliation with support groups, treatment of concomitant symptoms, and pharmacotherapies that decrease HPN requirements.

The management of patients with enterocutaneous fistula (ECF) requires an interdisciplinary approach and poses a significant challenge to physicians, wound/stoma care specialists, dietitians, pharmacists, and other nutrition clinicians. Guidelines for optimizing nutrition status in these patients are often vague, based on limited and dated clinical studies, and typically rely on individual institutional or clinician experience. Specific nutrient requirements, appropriate route of feeding, role of immune-enhancing formulas, and use of somatostatin analogues in the management of patients with ECF are not well defined. The purpose of this clinical guideline is to develop recommendations for the nutrition care of adult patients with ECF.A systematic review of the best available evidence to answer a series of questions regarding clinical management of adults with ECF was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group. An anonymous consensus process was used to develop the clinical guideline recommendations prior to peer review and approval by the ASPEN Board of Directors and by FELANPE.In adult patients with enterocutaneous fistula: (1) What factors best describe nutrition status? (2) What is the preferred route of nutrition therapy (oral diet, enteral nutrition, or parenteral nutrition)? (3) What protein and energy intake provide best clinical outcomes? (4) Is fistuloclysis associated with better outcomes than standard care? (5) Are immune-enhancing formulas associated with better outcomes than standard formulas? (6) Does the use of somatostatin or somatostatin analogue provide better outcomes than standard medical therapy? (7) When is home parenteral nutrition support indicated?

Malnutrition in orthopaedic patients, a condition that is overlooked and understudied, has substantial effects on outcomes1-6. Underweight and malnourished elderly patients are at risk of experiencing reduced well-being and autonomy as well as increased mortality as compared with their counterparts of normal weight7. Malnutrition may be simply defined as an imbalance of energy, protein, and nutrients leading to functional and compositional adverse effects on the body8,9. By this definition, as much as 15% of ambulatory and 65% of hospitalized patients are malnourished10. Without adequate nutrition, orthopaedic patients are more susceptible to infections, slower healing rates, and sarcopenia (reduced lean body mass and muscle function)8. Stratifying malnutrition on the basis of etiology (e.g., “starvation-related,” “chronic disease-related,” and “acute injury or illness-related”) facilitates the formation of a more clinically relevant definition11. In starvation, the primary problem is reduced intake, possibly due to socioeconomic factors or secondary to anorexia6. With chronic disease and acute injury, increases in resting energy expenditure and protein requirements due to the inflammatory response contribute to malnourishment7. The new etiology-based approach to the diagnosis of malnutrition …

The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) developed a Web-based registry for nutrition care launched in early 2011, initially focusing on the home parenteral nutrition (HPN) patient population. The purpose of Sustain is to collect information regarding the patients and populations who require HPN in the United States, measure outcomes associated with HPN, allow institutional benchmarking against the aggregate data, and publish the findings to improve the quality of care for patients receiving HPN. The registry is open to all sites (hospital and home based) who care for new or existing HPN patients. Preliminary data should be available in early 2012.

Using content and interpretative phenomenological analysis, we explored the meaning of food and eating from the perspective of adults receiving home parenteral nutrition (PN). The aim of this research was to obtain a deeper understanding of how issues related to food and eating influence quality of life (QOL). Semistructured telephone interviews were conducted between May 2006 and January 2007 with 24 adults with intestinal failure and home PN dependency. The analysis revealed themes relevant to eating behaviors, hunger and thirst, strategies for dining in restaurants, and a perception of wasting money because of malabsorbed food. Three patterns of eating emerged: eating for survival, eating for health benefits, and eating for socialization. A proposed model illustrates how these eating patterns are linked to QOL. Being able to eat and enjoy food is an important ingredient for good self-reported QOL. Measurements of QOL for this population may be enhanced with inclusion of a food and eating domain. The social and emotional context of food and mealtimes is an important component to address in the nutrition care plan for PN-dependent adults.

Nutrition assessment is a means of identifying critical care patients at greatest risk for complications. It should include manifestations both of disease-related malnutrition and starvation. Critically ill patients are at risk for accelerated loss of lean body mass with even greater loss of weight if nutrient intake is poor or absent. Recognizing those patients who are unable to eat and barriers that interfere with adequate nourishment are important aspects of clinical decision-making. This chapter discusses at risk patient populations, dietary intake analysis, delays and obstacles to feeding, nutrition-focused history and physical examination, laboratory evaluation, and body composition assessment. The multidisciplinary critical care team should discuss relevant components of the nutrition assessment daily. Ongoing evaluation of nutrition adequacy is essential for optimal patient care.

Three issues were highlighted in the 30th Presidential Address to the society: (1) A.S.P.E.N.'s unique interdisciplinary structure; (2) support of the A.S.P.E.N. Rhoads Research Foundation; and (3) the meaning of food from the perspective of the patient who is receiving life-sustaining home enteral or parenteral nutrition. A.S.P.E.N., founded as a multidisciplinary society in the 1970s has evolved into an interdisciplinary society with an expanded and diverse membership of health care professionals and scientists with overlapping interests in clinical nutrition and metabolism. A.S.P.E.N. envisions an environment in which every patient receives safe, efficacious, and high quality patient care. The society is committed to advancing the science and practice of nutrition support therapy. In support of this direction, the A.S.P.E.N. Rhoads Research Foundation exists to fund research grants, promote evidence-based practice, and foster training and mentorship in nutrition and metabolic research. The scientific a...

Background: The purpose of this review is to explore how home technology care affects patients, family caregivers, and quality of life (QOL). Methods: A literature search was conducted to identify studies of home parenteral nutrition (HPN) and other technology prescribed home care. Results: Technology dependence influences health-related QOL. Patients and their family caregivers must balance the positive aspects of being in the home environment with the challenges of administering complex therapies at home. Patients and caregivers need additional support to reduce the physical, emotional, social, and financial burdens they experience. Conclusions: More research is needed to address effective interventions to reduce patient and caregiver burdens and to improve outcomes for technology-dependent individuals. A greater level of preparedness for managing home technology and technology-related problems may improve quality of life.

BACKGROUND Home parenteral nutrition (HPN) is a vital therapy for patients who have the diagnosis of enterocutaneous fistula (ECF), yet little is known about how these patients are managed. This research compares nutrition management of adults with ECF as the indication for HPN therapy to those with other indications. METHODS This is an analysis of data from adult HPN patients in the Sustain registry enrolled between August 2011 and February 2014 who have the diagnosis of ECF or other indication for HPN who served as the control group. Differences between the ECF and control group were assessed by t test, analysis of variance, or χ2 as appropriate. RESULTS There were 141 HPN patients with ECF and 632 control patients. Patients with ECF were older (55 vs 50 years, P < .001), more frequently had a goal for future surgery (30% vs 15%, P = .010), had greater prevalence of overweight/obesity (33% vs 20%, P = .04), and had a lower serum albumin (2.98 ± 0.65 g/dL vs 3.16 ± 0.66 g/dL, P = .006) than controls. The diet order was more frequently nil per os (NPO) in patients with ECF (48% vs 22%, P < .001), and amino acid content of HPN was greater (111.90 ± 29.11 vs 102.06 ± 27.84, P < .001) than in controls. There were no differences in patterns of weight change by ECF or control groups, although underweight patients gained, normal-weight patients maintained, and overweight/obese patients lost weight and serum albumin increased similarly. CONCLUSIONS The HPN management of patients with ECF is similar to other HPN patients other than greater provision of protein, more frequent NPO status, and a goal for future surgery.

Background Accuracy of predictive formulae is crucial for therapeutic planning because indirect calorimetry measurement is not always possible or cost effective. Energy requirements are more difficult to predict in the acutely ill obese patient compared with lean patients because of an increased resting energy expenditure per lean body mass and a variable stress response to illness. Methods A retrospective review of 726 patients identified 57 patients (32 spontaneous breathing, S; 25 ventilator dependent, V) with body mass indexes of 30-50 kg/m2. Limits-of-agreement analysis determined bias (the mean difference between measured and predicted values) and precision (the standard deviation of the bias) to evaluate the accuracy of predictive formulae compared with measured resting energy expenditure (MREE) by a Deltatrac Metabolic Monitor. Predictive accuracy was determined within+/-10% MREE. The predictive formulae examined were: variations of the Harris-Benedict equations using ideal, adjusted weights of 25% and 50% and actual weights with stress factors ranging from 1.0 to 1.5; the Ireton-Jones equation for obesity; the Ireton-Jones equations for hospitalized patients (S and V); and the ratio of 21 kcalories per kilogram actual weight. Results The mean MREE was 21 kcal/kg actual weight. The adjusted Harris-Benedict average weight equation was optimal for predicting MREE for the combined S and V sets (bias = 182+/-123; 67%+/-10% MREE), as well as the S subset (bias = 159+/-112; 69%+/-10% MREE). Conclusions The Harris-Benedict equations using the average of actual and ideal weight and a stress factor of 1.3 most accurately predicted MREE in acutely ill, obese patients with BMIs of 30-50 kg/m2. Predictive formulae were least accurate for obese, ventilator-dependent patients.

Short bowel syndrome (SBS) occurs as a result of intestinal resection, and in many patients is associated with complications, such as diarrhea, dehydration, weight loss, and nutrition deficiencies. Many individuals with SBS develop intestinal failure and require parenteral nutrition (PN) and/or intravenous (IV) fluids (PN/IV). Although PN is essential for survival, some patients with SBS who require long-term PN experience significant complications that contribute to morbidity and mortality. Consequently, therapies that decrease reliance on PN are of considerable importance. Intestinal adaptation, which results in morphologic and functional changes that increase performance of the remnant bowel, occurs spontaneously after intestinal resection. These effects can be enhanced with nutrition and pharmaceutical approaches. For example, oral or tube-fed nutrients stimulate growth and adaptation of intestinal tissues. In addition, prebiotics support growth of beneficial intestinal microbiota that produce short-chain fatty acids, which have been shown in preclinical studies to enhance intestinal structure and function. Finally, glucagon-like peptide 2 (GLP-2) is an endogenous peptide that promotes intestinal rehabilitation and improves intestinal absorption. Teduglutide, a recombinant human GLP-2 analog, has recently been approved in the United States for the treatment of adults with SBS who are dependent on PN. In pharmacodynamic and clinical studies, teduglutide has been shown to promote changes in intestinal structure, such as increases in villus height and crypt depth, and to improve intestinal absorption, as indicated by reduced PN/IV dependence. This article presents a brief overview of SBS, including effects on survival and quality of life and current treatment options.

Support and educational organizations have been shown to improve quality of life of consumers of home nutrition support. One such organization, The Oley Foundation, offers resources for the home parenteral and enteral nutrition (HPEN) consumer. While research has shown proven benefits to HPEN consumers affiliated with The Oley Foundation, no studies have investigated the perceived value of membership to the consumer or the way in which consumers are introduced to the organization.Qualitative methodology was used to gain a deeper understanding of the perceived value of membership in The Oley Foundation. Audiotaped, in-depth, semistructured telephone interviews were conducted to explore participants' experiences with The Oley Foundation and HPEN. Inductive content analysis was used to analyze data and identify themes associated with membership value.The value of The Oley Foundation lies in programs and resources and the competency, inspiration, normalcy, and advocacy gained from membership, helping individuals adjust to life with HPEN dependency. More than half of participants found the organization through self-initiated Internet searches, but all participants clearly expressed the desire "I wish I knew about it sooner."This study identifies the value of membership in The Oley Foundation and the important role the organization has in the lives of HPEN-dependent consumers. Nutrition support clinicians should introduce the organization to patients when the need for HPEN is established and prior to hospital discharge.

The 1995 standards developed by the Joint Commission on Accreditation of Healthcare Organizations are now in effect. In an unprecedented shift, the manual focuses on performance rather than structure and process. It emphasizes the interdisciplinary delivery of care, including nutrition care. This article describes the new standards as they relate to nutrition support professionals.

The aim of this research was to achieve a deeper understanding of the experience of adults living with home parenteral nutrition (PN) and to define their quality of life (QOL).The research design was qualitative, using content and interpretative phenomenological analysis. The sample included adults with intestinal failure, stratified by length of home PN dependency. Sampling continued until data saturation was achieved. A second reviewer independently coded a subset of narratives (kappa = 0.684).Participants included 24 adults receiving home PN because of short bowel syndrome (95.8%) and pseudo-obstruction (4.2%). Twenty-five percent received PN for2 years, 20.8% for 2-5 years, 25% for 5-10 years, and 29.2% for10 years. Respondents viewed home PN as a "lifeline" and "nutritional safety net." QOL was defined as "enjoying life"; "being happy, satisfied, or content with life"; and "being able to do what you want to do, when you want to do it." Participants described their QOL as "good" to "wonderful." Lifestyle was affected by health, stamina, diarrhea, having an ostomy, and the amount of flexibility there was with the infusion schedule. There was a strong desire to achieve normalcy in life among all participants.Qualitative methodology provides new insights and richness of data regarding adults receiving home PN. The positive description of QOL in this study contrasts with the published nutrition literature. It is important for healthcare practitioners to understand and discuss the realities of home PN and lifestyle adaptation.

Selection, care, and management of vascular access devices (VADs) are important components of the nutrition support curriculum. The objectives, content material, learning activities, and evaluation methods used by one hospital's nutrition support service to train dietetic interns, medical students, nurses, and surgical and medical interns and residents are described. An algorithm for selection of VADs and suggested readings for this topic are also presented.

Background: Preclinical and observational studies suggest a relationship between dietary fat intake and breast cancer, but the association remains controversial. We carried out a randomized, prospective, multicenter clinical trial to test the effect of a dietary intervention designed to reduce fat intake in women with resected, early-stage breast cancer receiving conventional cancer management. Methods: A total of 2437 women were randomly assigned between February 1994 and January 2001 in a ratio of 40 : 60 to dietary intervention (n = 975) or control (n = 1462) groups. An interim analysis was performed after a median follow-up of 60 months when funding for the intervention ceased. Mean differences between dietary intervention and control groups in nutrient intakes and anthropometric variables were compared with t tests. Relapse-free survival was examined using Kaplan-Meier analysis, stratified log-rank tests, and Cox proportional hazards models. Statistical tests were two-sided. Results: Dietary fat intake was lower in the intervention than in the control group (fat grams/day at 12 months, 33.3 [95% confidence interval {CI} = 32.2 to 34.5] versus 51.3 [95% CI = 50.0 to 52.7], respectively; P

Home parenteral nutrition (HPN) is life-sustaining therapy in some disease states. Patients, however, report alterations in physical, psychologic, and social function that negatively affect perceived quality of life (QOL). Many generic tools have been used to evaluate QOL during HPN, but there is no gold standard measurement. QOL improvement can only result from identifying and addressing patient-specific problems. The purpose of this study was to identify the tools used by others to measure QOL in adults receiving long-term HPN and to identify factors that affect QOL in this population.An electronic search of CINAHL, MEDLINE, and Health and Psychosocial Instruments databases was conducted to identify studies of HPN and QOL in adults.Thirty-four publications on HPN and QOL were identified. Twenty-four studies of HPN and QOL were included in this review; 10 papers were review articles or editorials. QOL was worse in HPN patients compared with healthy populations. Impaired QOL was associated with decreased physical, psychologic, and social function. Depression, drug dependency, sleep disturbance, frequent urination, fear of therapy-related complications, and inability to eat negatively affected QOL.Use of different QOL instruments, scales, and lifestyle domains limited comparison among studies. QOL is poor in patients receiving HPN and worse in the presence of depression and narcotic dependency. The technical aspects of HPN administration interfere with routine activities. It is difficult to determine whether HPN itself or the impact of the disease affected QOL. Development of an HPN-specific QOL tool may help in this differentiation.

Intestinal failure is a consequence of extensive surgical resection resulting in anatomic loss and/or functional impairment in motility or absorptive capacity. The condition is clinically characterized by the inability to maintain fluid, energy, protein, electrolyte, or micronutri - ent balance when on a conventionally accepted, normal diet. Parenteral nutrition (PN) is the cornerstone of management until intestinal adaptation returns the patient to a PN-independent state. Intestinal length, residual anatomic segments and motility determine the need for and duration of parenteral support. The goals of therapy are to provide sufficient nutrients to enable normal growth and development in children, and support a healthy functional status in adults. This review addresses indications for PN, the formulation of the PN solution, patient monitor- ing, and considerations for prevention of PN-associated complications. With the ultimate goal of achieving enteral autonomy, the important role of diet, pharmacologic interventions, and surgery is discussed.