The Impact of Long-Term Home Parenteral Nutrition on the Patient and the Family: Achieving Normalcy in Life

A Systematic Review of Quality of Life in Patients with Short Bowel Syndrome and Their Caregivers

Purpose

Understanding the quality of life and the factors that influence it for patients with short bowel syndrome (SBS) and their caregivers is of utmost importance in order to enhance their well-being. Therefore, This study aimed to provide a comprehensive understanding of the impact of SBS on patients and their caregivers, as well as its associated factors, by synthesizing the available evidence.

Methods

A systematic review of the literature was done using PubMed, Embase databases, CNKI, and ISPOR conference papers. Included articles were manually searched to identify any other relevant studies. Quality was assessed using appropriate Joanna Briggs Institute critical appraisal tools.

Results

This review included 16 studies, comprising 15 observational studies and 1 randomized controlled trial. The findings revealed that the QoL of patients with SBS was lower than that of the general population regarding physical functioning and psychological domain. Meanwhile, caregivers experienced challenges in maintaining their QoL. The QoL of SBS patients was found to be influenced by various factors such as treatment, age, sex, stoma, and small intestine length. Among them, the treatment is the most noteworthy factor that can be effectively improved through external interventions.

Conclusion

While numerous studies have provided insights into the compromised QoL experienced by individuals with SBS and their caregivers, there remains a scarcity of large-sample quantitative investigations examining the determinants of QoL. The existing body of literature on caregivers is also notably deficient.

The impact of targeted interventions aimed to improve quality of life in patients receiving home parenteral nutrition: A systematic literature review

BACKGROUND

Home parenteral nutrition (HPN) is a specialised therapy offered to people suffering from intestinal failure. Underlying disease, HPN complications and limitations of HPN can significantly impact a person's quality-of-life (QOL). The aim of this review was to evaluate the evidence on existing non-surgical/non-pharmacological interventions aimed at improving QOL, clinical, patient-reported and economic outcomes for patients receiving parenteral nutrition therapy at home across adult and paediatric settings.

METHODS

Online databases Medline (Ovid), Embase and Cinahl were searched to identify studies published between 1937 and 31 March 2022. Identified studies were appraised using the Cochrane Collaboration risk of bias tool and Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessment.

RESULTS

Nine studies were included in this review. Interventions were focused on education (n = 4), telemedicine (n = 2), preparation of infusion mixtures (n = 1), mindfulness-based cognitive therapy (n = 1) and a multi-modal approach (n = 1). Only one study measured QOL before and after the intervention using a validated QOL tool. All studies were assessed at either some, high or critical risk of bias, resulting in low or very low-quality evidence for the interventions evaluated.

CONCLUSIONS

The findings from this review highlight the lack of high-quality non-surgical/non-pharmacological studies seeking to improve QOL for people on HPN. Because the majority of people receiving HPN are not eligible for surgical or pharmaceutical treatments, higher quality research using clinical trial design, and research focused on improving QOL is needed to inform healthcare managers about the effectiveness (and value) of alternative service delivery models for this vulnerable patient group.

Epidemiology, survival, costs, and quality of life in adults with short bowel syndrome

Short bowel syndrome (SBS) is a rare disorder with known physical, psychosocial, and economic burdens and significant morbidity and mortality. Many individuals with SBS require long-term home parenteral nutrition (HPN). The incidence and prevalence of SBS is difficult to determine because it is often based on HPN usage and may not account for those who receive intravenous fluids or achieve enteral autonomy. The most common etiologies associated with SBS are Crohn's disease and mesenteric ischemia. Intestinal anatomy and remnant bowel length are prognostic for HPN dependency, and enteral autonomy confers a survival advantage. Health economic data confirm that PN-related costs are higher for hospitalizations than at home; yet significant healthcare resource utilization is necessary for successful HPN, and patients and families report substantial financial distress that impacts quality of life (QOL). An important advancement in QOL measurement is the validation of HPN- and SBS-specific QOL questionnaires. In addition to the known factors negatively impacting QOL, such as diarrhea, pain, nocturia, fatigue, depression, and narcotic dependency, research has shown that the volume and number of PN infusions per week is associated with QOL. Although traditional QOL measurements describe how underlying disease and therapy influence life, they do not assess how symptoms and functional limitations affect the QOL of patients and caregivers. Patient-centered measures and conversation focused on psychosocial issues helps patients with SBS and HPN dependency better cope with their disease and treatment. This article presents a brief overview of SBS, including epidemiology, survival, costs, and QOL.

Survey of healthcare professionals' experiences of care delivery in patients with chronic intestinal failure: ATLAS of Variance

BACKGROUND AND AIM

Chronic intestinal failure (IF) is a rare but life-altering condition, care delivery of which is complex. The ATLAS Programme was initiated in 2016 to increase disease awareness and address inconsistencies in delivery of care across Europe. We describe the results of a non-interventional study that aimed to explore how adult patients with chronic IF are managed across Europe.

MATERIALS AND METHODS

This mixed-methods, non-interventional, cross-sectional study comprised a desk-based landscape assessment (Phase 1), qualitative interviews (Phase 2), and an online quantitative survey (Phase 3) completed by healthcare professionals (HCPs) involved in the management of adult patients with chronic IF during the period November 2020 to January 2021. Data were collected from 12 European countries. Survey data were anonymised and pooled for analysis at European and country level. Responses were summarised as frequencies, ranks and percentage.

RESULTS

The quantitative survey was carried out on 119 HCPs across an estimated 58 centres. Gastroenterology was the most frequent specialty of respondents (45%). Three-quarters of HCPs (N = 119) reported that their department/unit had a multidisciplinary team for the management of patients with chronic IF. HCPs reported improving quality of life (QoL) to be the most important goal of treatment (39%), followed by reducing mortality (25%), intestinal rehabilitation (20%) and reducing morbidity (9%). Similarly, 63% of HCPs responded that improved QoL was the most important treatment goal from the perspective of their patients. Overall, 87% of HCPs reported that patients with chronic IF routinely receive home parenteral nutrition (HPN) in their country, which was more common in Western versus Eastern Europe. Meeting treatment goals (53%) and achieving better levels of support with HPN (44%) were reported as the main challenges faced by HCPs in the management of patients with chronic IF. A general lack of disease awareness of chronic IF among HCPs (46%), and insufficient accredited patient referral centres (41%) were considered the most important areas for improvement.

CONCLUSIONS

HCPs specialising in treating chronic IF considered that improvement in QoL is needed for their patients. They reported a low level of awareness of chronic IF among non-specialist HCPs.

Impact of a multidisciplinary nutritional support team on quality improvement for patients receiving home parenteral nutrition

Introduction

Home parenteral nutrition (HPN) is essential for patients with intestinal failure requiring long-term nutritional support. The Amerita Quality Improvement Project for HPN Patients (QIP-PN) explored the effect of a physician nutrition expert (PNE)-led multidisciplinary nutritional support team (MNST) on HPN care for patients under its service.

Objective

To determine an MNST effect on adherence to protocols, outcomes and quality of life (QOL) in HPN.

Methods

The study was divided into three phases: data review (phases 1a and 1b), observation (phase 2) and intervention (phase 3). Seven Amerita locations were selected as 'study branches' (population), from which all study patients and controls were drawn. The quality improvement project employed a quasi-experimental case-matched control group (control) design. Data were collected on demographics, treating physicians PNE status, HPN care variables, recommended interventions, quality-of-life assessment, adverse outcomes and hospitalisations. Paired t-test compared continuous data between phases 2 and 3. Comparisons between study and control groups used a negative binomial regression model.

Results

Thirty-four patients were reviewed in phase 1a and 197 in phase 1b. Forty study patients completed phase 2 and progressed into phase 3, of whom 30 completed ≥60 therapy days. Patients were lost to follow-up if they discontinued HPN for any reason. Improvements in weight, body mass index and QOL were seen in the study patients during intervention. Recommendations made and accepted by treating physicians differed based on PNE status. Study patients had fewer adverse outcomes and related hospitalisations than controls.

Conclusion

MNST recommendations improved clinical, biochemical parameters and patients' self-reported overall health. MNST input reduced adverse outcomes, hospitalisation and the length of stay at the hospital. This study highlights the potential for MNST to have a significant impact on the quality and overall cost of HPN management.

Rhoads Research Lecture-Reflections from a clinician scientist: The power of patient voice

Qualitative research is a scientific method that systematically examines a phenomenon with the purpose of understanding and describing human experiences, exploring meanings and patterns, and illuminating the patient's lived experience. The Rhoads Research Lecture will highlight the power of patient voice and its importance to clinicians and researchers in addressing key clinical needs that are most relevant to patients receiving nutrition support. The subjective experience of patients who are dependent on home parenteral nutrition (HPN) will be shared, including how patients view HPN, define their quality of life (QOL), and describe the meaning of food in the context of being intravenously fed. As a result of these exploratory studies, the HPN patient-reported outcome questionnaire (HPN-PROQ) was developed and validated. Incorporating the HPN-PROQ in practice empowers patients to identify and communicate QOL and HPN therapy goals and clinicians to delve deeper in the provision of holistic and empathetic care.

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

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.

Themes of Stressors, Emotional Fatigue, and Communication Challenges Found in Mobile Care Discussion Sessions With Patients Requiring Lifelong Home Parenteral Nutrition Infusions

BACKGROUND

The purpose of this article is to examine themes and topics that emerged from 35 discussion sessions with teens and young adults requiring long-term home parenteral nutrition (HPN) intravenous infusions. The goal was to gain a more detailed understanding of participants' challenges and successes of living with HPN.

METHODS

These patients were invited to attend 3 discussion group sessions facilitated by health professionals. A secure iPad Mini was selected as the mobile tablet device for hosting these encrypted audio-visual group discussions. Content analysis, a standard research data-sorting technique, was used to summarize the anonymous data. Words, phrases, and topics in patients' discussions were coded and grouped together with similar concepts and subsequently categorized into themes.

RESULTS

Themes in these discussions were related to patients' daily, complex management of HPN. These "themes" included having multiple repetitive illness-related stressors and how those stressors were managed; managing emotions; communication challenges with professionals, family, friends, and using social media; and lastly, the least frequent but no less important theme discussed was how HPN effects their daily lives.

CONCLUSION

Teens and young adults living with lifelong HPN face a variety of unique psychological, physical, and emotional stressors and may benefit from numerous methods for managing these challenges.

TRAINING OF CHILDREN'S AND ADOLESCENTS' FAMILY MEMBERS IN HOME PARENTERAL NUTRITION CARE

Objective:

To report the experience of the training in home parenteral nutrition (PN) directed to family members of children and adolescents participating in a multidisciplinary intestinal rehabilitation program of a tertiary public hospital.

Methods:

Cross-sectional descriptive study with family caregivers of patients from the Intestinal Rehabilitation Program of Hospital de Clínicas de Porto Alegre, RS, Brazil, from July/2014 to January/2017. Inclusion criteria: family members of children aged 30 days to 17 years and estimated PN use ≥8 weeks; and family members motivated to care for the child. The training covered: hand washing and disinfection; infusion pump handling; and central venous catheter (CVC) and PN care. Outcomes assessed: catheter-related bloodstream infection (CRBSI) rate, accidental CVC exit, end of PN infusion with more than 60minutes of delay or advance compared to the time predicted, mechanical obstruction, bleeding in the CVC insertion site, and death.

Results:

Twenty-seven family members of 17 children were trained. Their median age was 28 (18-60) years, and 63% were mothers. The mean CRBSI rate was 1.7/1,000 days of CVC use, and 29.4% of patients had at least one episode of accidental CVC exit. There were no complications related to PN infusion, bleeding, or death.

Conclusions:

The training of family caregivers allowed the safe implementation of home PN, with the active participation of families, making the procedure feasible in the public health system in Brazil.

Experiences of Chinese patients with Crohn's disease in the self-administration of nasogastric feeding: A descriptive qualitative study

BACKGROUND

Despite the increasing number of Crohn's disease patients self-administering nasogastric feeding as enteral nutrition support therapy, no studies have reported the experiences of self-administering nasogastric feeding from the perspective of these patients.

OBJECTIVES

To explore the initial trigger factors for the self-administration of nasogastric feeding by Crohn's disease patients and to understand the experiences of self-administration of nasogastric feeding, its effects on various aspects of life and work, and relevant challenges and coping mechanisms encountered during this therapy in order to improve the understanding of this group of patients among medical staff and the public.

DESIGN

This study adopted a descriptive qualitative method. Crohn's disease patients from several tertiary hospitals in Hangzhou, Zhejiang, were recruited to participate through purposive sampling combined with maximum variation and the snowballing technique. Data were collected using semi-structured interviews and analyzed using the conventional content analysis method.

RESULTS

A total of 11 Crohn's disease patients were interviewed. Four themes and eight subthemes emerged from the analysis: rejecting the self-administration of nasogastric feeding (being afraid of inserting the nasogastric tube, having concerns about nasogastric feeding), accepting the reality of nasogastric feeding (health being the most important, followed by having sources of support), nasogastric feeding as a double-edged sword (the disturbances and efficacies of nasogastric feeding), and nasogastric feeding as a part of life (becoming accustomed to tube insertion and taking nasogastric feeding for granted).

CONCLUSIONS

Apart from suffering from physical discomfort, diet and body image disturbances, and inconveniences in daily life, Crohn's disease patients who self-administered nasogastric feeding faced many psychological challenges. Many of these patients eventually adjusted to a life with nasogastric feeding, but not everyone achieved this state. Therefore, health care providers, including physicians and nurses, and the general public should collaborate to help these patients adapt to their "new lives" as soon as possible.

Telemedicine Support Groups for Home Parenteral Nutrition Users

Patients receiving home parenteral nutrition (HPN), a life-sustaining intravenous (IV) infusion that provides nourishment and hydration to patients with short gut or inflammatory bowel diseases, are often isolated and not in visual contact with peers or health providers. One completed clinical trial (Clinical Trials.gov NCT0190028) and 1 ongoing clinical trial (Clinical Trials.gov NCT02987569) are evaluating a mobile videoconferencing-delivered support group intervention for patients on HPN and their caregivers. This home-based telemedicine intervention uses encrypted tablet-based videoconferencing to connect multiple families in real time. The twice-daily IV regimen is challenging for patients who may experience infusion catheter-related bloodstream infections, difficulties with fatigue, loss of sleep, depressive disorders, and worry over the potential life-threatening side effects and the expenses of this therapy. Using secure telemedicine, the facilitated support group intervention aims to enhance HPN home care, daily functioning, and quality of life. The authors provide the rationale for the telemedicine approach with HPN users and caregivers. They provide "how-to" information about the content and process of the facilitated support group sessions via secure videoconferencing. They share lessons learned from the ongoing evaluation of the telemedicine approach.

Identification of Depressive Signs in Patients and Their Family Members During iPad-based Audiovisual Sessions

Home parenteral nutrition requires a daily life-sustaining intravenous infusion over 12 hours. The daily intravenous infusion home care procedures are stringent, time-consuming tasks for patients and family caregivers who often experience depression. The purposes of this study were (1) to assess home parenteral nutrition patients and caregivers for depression and (2) to assess whether depressive signs can be seen during audiovisual discussion sessions using an Apple iPad Mini. In a clinical trial (N = 126), a subsample of 21 participants (16.7%) had depressive symptoms. Of those with depression, 13 participants were home parenteral nutrition patients and eight were family caregivers; ages ranged from 20 to 79 years (with 48.9 [standard deviation, 17.37] years); 76.2% were female. Individual assessments by the mental health nurse found factors related to depressive symptoms across all 21 participants. A different nurse observed participants for signs of depression when viewing the videotapes of the discussion sessions on audiovisual technology. Conclusions are that depression questionnaires, individual assessment, and observation using audiovisual technology can identify depressive symptoms. Considering the growing provision of healthcare at a distance, via technology, recommendations are to observe and assess for known signs and symptoms of depression during all audiovisual interactions.

Molecular impact of omega 3 fatty acids on lipopolysaccharide-mediated liver damage

BACKGROUND

Growing evidence suggests that omega 3 fatty acid containing lipid emulsions have a beneficial effect on parenteral nutrition associated liver disease (PNALD). However, the cellular and molecular mechanisms responsible for this effect are unclear. In this study, we investigated whether Omegaven™ fish oil emulsion could inhibit lipopolysaccharidase (LPS) mediated liver damage.

METHODS

We examined the effects of Omegaven™ and LPS alone and synergistically on hepatic paraoxonase 1 (PON1), a potent antioxidant protein, ERK1/2 activity, and TLR4 regulation.

RESULTS

LPS did not alter PON1 release from HepG2 cells but did significantly decrease PON1 protein synthesis (44%, P<0.05). Omegaven™ alone had no direct effect on PON1 release. However, it did significantly reverse LPS-mediated decrease in PON1 protein levels (control: 100%; LPS alone: 56+/4%; LPS+Omegaven™: 87+/6%, P<0.05). Furthermore, molecular analysis indicated that Omegaven™ blocked LPS-mediated increase in ERK1/2 activity (35% increase), an important LPS signal transduction pathway. TLR4, the receptor for LPS, was down-regulated in the presence of Omegaven™.

CONCLUSION

Omegaven™ may be beneficial in patients with PNAC because of its ability to reverse LPS-mediated inhibition of antioxidant promoting PON1 expression, and this activity may be in part mediated by the ERK1/2 pathway.

A Clinical Trial of Translation of Evidence Based Interventions to Mobile Tablets and Illness Specific Internet Sites

This article describes a method to translate an evidence based health care intervention to the mobile environment. This translation assisted patient participants to: avoid life threatening infections; monitor emotions and fatigue; keep involved in healthy activities. The mobile technology also decreased costs by reducing for example travel to visit health care providers. Testing of this translation method and its use by comparison groups of patients adds to the knowledge base for assessing technology for its impact on health outcome measures. The challenges and workflow of designing materials for the mobile format are described. Transitioning clinical trial verified interventions, previously provided in person to patients, onto tablet and internet platforms is an important process that must be evaluated. In this study, our evidence based guide's intravenous (IV) homeCare interventions (IVhomeCare) were delivered via Apple iPad mini™ tablet audiovisual instruction / discussion sessions and on a website. Each iPad audiovisual session (n = 41), included three to five families, a mental health specialist, and healthcare professionals. Patients and their family caregivers readily learned to use the wireless mobile tablets, and the IVhomeCare interventions, as described here, were successfully translated onto these mobile technology platforms. Using Likert scale responses on a questionnaire (1 = not helpful and 5 = very helpful) participants indicated that they gained problem solving skills for home care through iPad group discussion (M = 4.60, SD = 0.60). The firewall protected videoconferencing in real time with multiple healthcare professionals effectively allowed health history taking and visual inspection of the patient's IV insertion site for signs of infection. Supportive interactions with peer families on videoconferencing were documented during discussions. Discussion topics included low moods, fatigue, infection worry, how to maintain independence, and need for support from others with their same lifelong IV experiences. The visual family interactions, discussions with professionals, and the iPad internet links were highly rated. Mobile distance care delivery can result in saved time and money for both healthcare professionals and families.