Long-term outcomes in critically ill patients who survived COVID-19: The NUTRICOVID observational cohort study

BACKGROUND & AIMS

Malnutrition and sarcopenia may last beyond hospital discharge, especially in patients admitted to intensive care units (ICU), having a negative impact on patient recovery and leading to disability, poor quality of life, and additional morbidity. No prior evidence is available for post-ICU management and follow-up of coronavirus disease 2019 (COVID-19) patients and their long-term evolution. This study reports on the one-year-long evolution of a cohort of COVID-19 survivors after ICU discharge, in terms of nutritional and functional status as well as health-related quality of life (HRQoL).

METHODS

A multicenter, ambispective, observational cohort study (NUTRICOVID study) was conducted in 16 public hospitals located in the Community of Madrid with COVID-19 survivors who were admitted to ICU during the first outbreak. Retrospective and prospective data were collected from hospital admission to one year after discharge. At hospital discharge and at 3, 6 and 12 months post-discharge, the following outcomes were recorded: weight, risk of malnutrition (MUST) and sarcopenia (SARC-F), medical nutrition therapy (MNT), functional status (Barthel index), and HRQoL (EQ-5D-5L).

RESULTS

A total of 199 patients (70.4% male, mean age [SD] of 60.7 [10.1]) were included in the study. At hospital discharge, mean weight loss was 16.4% (8.0%), whereas most patients gained weight after discharge with an increase of 16.5% (14.0%) at 12 months. The proportion of patients at high risk of malnutrition decreased from 83.2% at hospital discharge to 2.1% at 12 months. The proportion at risk of sarcopenia decreased from 86.9% at hospital discharge to 13.4% at 12 months. At hospital discharge, 69 patients received MNT by means of oral nutritional supplements (ONS) while two patients required enteral nutrition (EN). At 12 months, only 12 patients continued taking ONS, with no patients taking EN. Regarding functional status, 72.9% of patients were moderately or severely dependent at hospital discharge, whereas 87.2% showed low dependency or independency after 12 months. The EQ-VAS values increased from hospital discharge (39 [21.2]) to 6 months post-discharge and remained steady up to 12 months (72.7 [19.0]). The mean health value improved from hospital discharge (0.25 [0.41]) to 6 months post-discharge (0.80 [0.24]) and was maintained thereafter.

CONCLUSIONS

Patients' nutritional and functional impairment at hospital discharge was high, with high dependency status and low HRQoL; however, their situation improved progressively during the 12 months following hospital discharge. Nevertheless, there is a need to define early strategies to optimize the nutritional and functional recovery of COVID-19 patients.

Nutrition education in medical schools (NEMS) project: Promoting clinical nutrition in medical schools - Perspectives from different actors

BACKGROUND & AIMS

Nutrition education is not adequately represented in the medical curriculum, and this prompted the European Society for Clinical Nutrition and Metabolism (ESPEN) to launch the Nutrition Education in Medical Schools (NEMS) Project in 2017. The aim of this original paper was to describe the perspectives of different actors in the promotion of nutrition education in medical schools.

METHODS

On 11 November 2021, an online meeting was held on this topic, where nine representatives from different backgrounds participated in the scientific programme. More than 640 participants registered to this webinar.

RESULTS

The different models of Nutrition Education in Medical Schools were introduced by Prof. Cristina Cuerda (Spain) and Prof. Maurizio Muscaritoli (Italy). The students' perspective was given by Ms. Alexandra Archodoulakis (Germany) and Ms. Sila Gürbüz (Turkey), representing the European Medical Students' Association. The dietitian's perspective was given by Dr. Kirsten Berk (The Netherlands), whereas Dr. Matti Aapro (Switzerland) gave the medical doctor (oncology)'s perspective. Ms. Clare Farrand (Australia) gave the WHO perspective and Dr. Kristiina Patja (Finland) explained the healthy lifestyle teaching to medical students. Lastly, Prof. Michael Chourdakis (Greece) and Prof. Zeljko Krznaric (Croatia) hosted the round-table discussion.

CONCLUSIONS

There was strong agreement among the representatives from different settings joining this ESPEN initiative that increasing nutritional knowledge and skills of young doctors is now possible and will launch a virtuous cycle that will proactively involve all the other healthcare professionals working in the nutritional field.

Nutritional management and clinical outcome of critically ill patients with COVID-19: A retrospective study in a tertiary hospital

BACKGROUND & AIMS

Severe COVID-19 infection is characterized by an inflammatory response and lung injury that can evolve into an acute respiratory distress syndrome that needs support treatment in intensive care unit. Nutritional treatment is an important component of the management of critically ill patients and should be started in the first 48 h of ICU admission to avoid malnutrition. This study describes the characteristics of the patients treated in a tertiary hospital in Madrid during the months of March-May 2020 (first wave), the medical nutrition treatment employed and its influence in the clinical outcome of these patients.

METHODS

This is a retrospective study including COVID-19 patients admitted in ICU that needed medical nutrition treatment (MNT). Collected variables included sex, age, BMI, underlying diseases, time from hospitalisation to ICU admission, type of respiratory support (invasive mechanical ventilation (IMV) or high flow nasal cannula (HFNC) or non-invasive ventilation (non-IMV)), caloric and protein requirements (25 kcal/kg adjusted body weight (ABW), 1.3 g/kg ABW/day), MNT type (enteral nutrition (EN), parenteral nutrition (PN), mixed EN + PN), total calories (including propofol) and proteins administered, percentage of caloric and protein goal in ICU day 4th and 7th, metabolic complications, acute kidney failure (AKF), length of stay (LOS) and mortality. Data are expressed as mean ± SD, median (IQR) or frequencies. Statistical analysis was performed with the IBM SPSS Statistics for Windows, Version 25.0. p < 0.05 were considered statistically significant.

RESULTS

A total of 176 patients were included (72.7% male), 60.1 ± 13.5 years, BMI 29.9 ± 5.4 kg/m². Underlying diseases included 47.4% overweight, 39.8% obesity, 49.1% hypertension, 41.4% dyslipidaemia. 88.6% of patients needed IMV, 89.1% prone position, 2.9% ECMO. Time to ICU admission: 2 (4.75) days. Estimated caloric and protein requirements were 1775 ± 202 kcal and 92.4 ± 10.3 g. Calories and proteins administered at days 4th and 7th were 1425 ± 577 kcal and 66 ± 26 g and 1574 ± 555 and 74 ± 37, respectively. Most of the patients received PN (alone or complementary to EN) to cover nutritional requirements (82.4% at day 4th and 77.9% at day 7th). IVM patients received more calories and proteins during the first week of ICU admission. Complications included 77.8% hyperglycaemia, 13.2% hypoglycaemia, 83.8% hypertriglyceridemia, and 35.1% AKF. ICU LOS was 20.5 (26) days. The mortality rate was 36.4%.

CONCLUSIONS

In our series, the majority of patients reached energy and protein requirements in the first week of ICU admission due to the use of PN (total or complementary to EN). Patients with HFNC or non-IMV may be at risk of malnutrition if total or complementary PN to oral diet/ONS/tube feeding is not used to cover nutritional requirements. Therefore, if EN is not possible or insufficient, PN can be safely used in critically ill patients with COVID-19 with a close monitoring of metabolic complications.

Nutrition education in medical schools (NEMS) project: Joining ESPEN and university point of view

BACKGROUND & AIMS

Nutrition education is not well represented in the medical curriculum. The aim of this original paper was to describe the Nutrition Education in Medical Schools (NEMS) Project of the European Society for Clinical Nutrition and Metabolism (ESPEN).

METHODS

On 19 January 2020, a meeting was held on this topic that was attended by 51 delegates (27 council members) from 34 countries, and 13 European University representatives.

RESULTS

This article includes the contents of the meeting that concluded with the signing of the Manifesto for the Implementation of Nutrition Education in the Undergraduate Medical Curriculum.

CONCLUSION

The meeting represented a significant step forward, moved towards implementation of nutrition education in medical education in general and in clinical practice in particular, in compliance with the aims of the ESPEN Nutrition Education Study Group (NESG).

Direct costs of a home parenteral nutrition programme

BACKGROUND & AIMS

Home parenteral nutrition (HPN) is a lifesaving treatment for people with chronic intestinal failure and its cost has been reported to be very high. The purpose of the present paper was to study the direct healthcare and non-healthcare costs associated with the HPN programme managed by a tertiary hospital.

METHODS

Observational, retrospective study of all adult patients on HPN from 11.1.2014 to 10.31.2015 treated at Gregorio Marañón University Hospital (Madrid, Spain). An economic evaluation was undertaken to calculate the direct healthcare (HPN provision, outpatient monitoring and management of complications) and non-healthcare costs (transportation process) of the HPN programme. The variables were collected from medical records, the dispensary and the hospital's financial services. The unit costs were taken from official price lists.

RESULTS

Thirty-two patients met the inclusion criteria. Total direct healthcare and non-healthcare costs amounted to €13,363.53 per patient (€124.02 per patient per day). The direct healthcare costs accounted for 98.32% of overall costs, while the non-healthcare costs accounted for the remaining 1.68%. HPN provision accounted for the majority of the costs (74.25%), followed by management of complications (21.85%) and outpatient monitoring (2.23%).

CONCLUSIONS

The direct healthcare costs accounted for the majority of HPN expenditure, specifically HPN provision was the category with the highest percentage.

[Nutritional support in chronic neurological diseases]

Malnutrition is common in neurodegenerative disorders and is associated with a worse prognosis and an increased risk of complications. Factors leading to malnutrition in these patients are: diseased nutrient intake, due to anorexia, dysphagia and other factors, gastrointestinal symptoms, and energy expenditure alterations. Nutritional evaluation and monitoring is mandatory and should be part of regular clinical evaluation. It will help to identify those patients that need specialized nutritional support. In this paper, relevant aspects regarding nutritional evaluation and support in patients suffering from a neurodegenerative disorder are reviewed, including amyotrophic lateral sclerosis, multiple sclerosis, Parkinson's disease and dementia.

[Persistent chylothorax in patient with lymphangioleiomyomatosis]

Lymphangioleiomyomatosis (LAM) is a rare disease that affects women in fertile age and presents a systemic progressive evolution, being the lung and the mediastinic lymph nodes the most affected organs. The pulmonary disease is characterized by dyspnea, pleural effusion, hemoptysis and spontaneous pneumothorax, being the chylothorax a frequent complication in the course of this disease, appearing in up to 30% of cases. The treatment of chylothorax is not standardized and it is necessary a multidisciplinary approach: nutritional, pharmacological, respiratory and even surgery. These patients present high risk of malnutrition due to the constant loss of chyle, therefore a suitable nutritional management is essential to avoid more complications.

[Catheter occlusion and venous thrombosis prevention and incidence in adult home parenteral nutrition (HPN) programme patients]

In adult home parenteral nutrition (HPN) programme patients up to now no evidence-based recommendations exist on the central venous catheter maintenance nor venous thrombosis prevention. The use of heparin flushes could be linked with long term complications, besides, anticoagulants use is controversial.

OBJECTIVES

To be aware of the usual maintenance practice for HPN central venous catheters, catheter occlusion and related venous thrombosis incidence in our country.

METHODS

Retrospective study of active HPN patients older than 18 years registered by the NADYA- SENPE working group until November 2008.

RESULTS

49 patients were registered (16 males and 33 females), with an average age of 52.1 ± 13.9 years, belonging to 6 hospitals. HPN length was 57.4 ± 73.3 months with 5.8 ± 1.8 PN days a week. The most frequent pathologies were actinic enteritis, intestinal motility disorders and mesenteric ischemia (20.4% each), and neoplasm (16.3%). The reason for HPN provision was short bowel syndrome (49.0%), and intestinal obstruction (28.6%). Neoplasm (16.3%), thrombotic diathesis, thromboembolic syndrome and bed rest (6.1% each) were the main venous thrombosis adjuvant factors. Tunnelled catheters were used in 77.6% of patients, with implanted port-catheters in the remainder. Maintenance of the line was done with saline solution flushes (28.6%) and different concentrations of heparin solutions (69.4%). When heparin was used, it was removed before PN infusion in 63.3% of patients. Catheter occlusion and venous thrombotic events rates were 0.061/10³ and 0.115/10³ HPN days respectively. Eleven patients (22.4%) were treated with anticoagulant drugs due to previous episodes of venous thrombosis or pulmonary embolism.

CONCLUSION

[corrected] The incidence of catheter related thrombotic complications incidence is low in this group of patients on HPN. There is a great variety of practices focused on the prevention of both: line occlusion and catheter related venous thrombosis. In conclusion, it would be necessary to standardize practice.

[Meta-analysis on the role of lycopene in type 2 diabetes mellitus]

INTRODUCTION

lycopene is a carotene with a potent antioxidant effect found in tomato and its derivatives. Given that diabetic patients present an increased oxidative stress, lycopene could be beneficial. The aim of this scientific review has been to analyze the scientific evidence of the role of lycopene as an anti-oxidant agent in diabetes, its prevention and the metabolic control and development of complications.

MATERIALS AND METHODS

We carried out a systematic review and meta-analysis. A literature search was done in Medline and the Cochrane Library, using the MeSH terms "carotenoids" OR "lycopene" AND "type 2 diabetes mellitus". The search was manually completed from the references of the papers found. The quality of the studies was assessed by using the JADAD and STROBE scales. We included a total of 10 articles.

RESULTS

After adjusting for other risk factors, the OR for developing DM2 as similar among the different levels of lycopene intake. The plasma levels of lycopene increase in the intervention groups. Lycopene decreases the malonyldialdehyde and lipid peroxidation. The non-provitamin A/provitamin A carotenoids ratio is negatively associated with the risk for suffering from diabetic retinopathy.

CONCLUSION

Tomato or lycopene intake increases the plasma levels of this compound. However, there is no evidence for the association between lycopene intake and the risk for having diabetes. This compound and other tomato derivatives may have a beneficial effect on the oxidative stress in diabetic patients. The non-provitamin A/provitamin A carotenoids ratio is negatively associated with the risk for suffering from diabetic retinopathy, although there are no data available on the relationship between lycopene and other diabetic complications.

[Home enteral nutrition in Spain: NADYA registry in 2010]

OBJECTIVE

To describe the results of the home enteral nutrition (HEN) registry of the NADYA-SENPE group in 2010.

MATERIAL AND METHODS

We retrieved the data of the patients recorded from January 1st to December 31st 2010.

RESULTS

We registered 6,591 patients (51% males) with 6,688 episodes of HEN, from 32 hospitals. Mean age in those younger than 14 yr (4%) was 1 ± 2 yrs (m ± SD) and 69,9 ± 17,8 yrs in those older than 14 yr. The length of HEN was longer than 2 yrs in 76% of the patients. The most frequent underlying disease was neurological disorders 42%, followed by cancer 28% (mostly head and neck cancer 18%). We had information related to the enteral access route in only 626 cases (9,4%), 51% of them used nasogastric tubes, 27% gastrostomies, 10% oral route and 3% jejunostomies. Only 251 episodes were closed during the year, mostly due to patient death 57% and progress to oral diet 14%. The activity level was limited in 29% of the patients and 39% of them were bed- or chairridden. Total or partial help was needed by 68% of the patients. The hospitals and the private pharmacies delivered the enteral formula in 63% and 34% of the cases, respectively. The hospitals and the primary care centres delivered the disposables in 83% and 16% of the cases, respectively.

CONCLUSIONS

The results of the 2010 HEN registry are similar to those published in previous years regarding the number and characteristics of the patients. We continue finding problems in the entrance of data referred to the enteral access route and the closing of the episodes.

[Home parenteral nutrition registry in Spain for the year 2010: NADYA-SENPE Group]

OBJECTIVES

To report the Group Registry NADYASENPE data about home parenteral nutrition (HPN) in Spain in 2010.

MATERIAL AND METHODS

A descriptive study of the database of the national registry of HPN of NADYA-SENPE (December 10, 2009 to December 10, 2010). For the calculation of prevalence the latest data published by the Institute National Statistics Office (01/01/2009) was used.

RESULTS

There were registered 148 patients from 23 hospitals, 86 women (58.11%) and 9 children (6.08%). The average age of the 139 patients older than 14 years was 53.06 ± 15.41 years. The average duration of HPN was 316.97 days/patient. The most common diagnosis in those younger than 14 years was short bowel traumatic with 5 cases (55.55%) and in those older than 14 years, palliative care cancer with 29 cases (19.59%). The reason for the indication for HPN was short bowel syndrome in 74 cases (47%). The access via most frequently recorded was tunneled catheter in 36 cases (22.78%) followed by implanted port-catheters in 13 cases (8.23%) and other pathways in 3 cases (1.90%). There were 23 catheterrelated infections (82.14%) which represented 0.49 /1,000 days of PN, all of which occurred in cases older than 14 years. During the year 24 episodes of HPN ended, the most frequent cause was the transition to oral nutrition in 12 episodes (50%). It was reported that patients had a normal activity in 70 episodes of HPN (44.30%) with complete autonomy in 88 episodes (55.69%). Some patients 39 (24.68%) were potential candidates for intestinal transplantation.

CONCLUSIONS

The number of registered patients is slightly lower than the previous year, although the number of participating hospitals is the same. The most frequent complication remains catheter-related infection but its incidence has decreased from previous years, presenting the lowest rate since the creation of the record. Differences in participation in the registry observed in the Autonomous Communities causes the development of implementation strategies. There is a gradual increase in day length of HPN over the years, which suggests the chronic treatments of some patients and obliges to study the existence of a possible confounding factor, in case there is an oversight of closing an episode. Therefore, it is necessary to update the registry with warning systems that facilitate periodic review of the patients and optimize the validity of registration.

[Antioxidants and diabetes mellitus: review of the evidence]

INTRODUCTION

An increase in the oxidative stress and a decrease in the antioxidant levels have been described in diabetic patients, that have been related with the etiopathogenesis of diabetes and its chronic complications.

METHODS

We performed a non-systematic review to evaluate the relationship between oxidative stress and diabetes, and the possible effects of antioxidants in the prevention and treatment of diabetes and its complications.

RESULTS

The intervention studies including different antioxidants have not demonstrated any beneficial effect on cardiovascular and global morbimortality in different populations, including diabetic patients. Neither of these studies has demonstrated a beneficial effect of antioxidant supplementation on the prevention of diabetes. According to these studies, these substances can decrease lipid peroxidation, LDL-cholesterol particles oxidation and improve endothelial function and endothelial-dependent vasodilatation, without significant improvement in the metabolic control of these patients.

CONCLUSIONS

The current evidence does not support the use of high doses of antioxidants on the prevention and treatment of diabetes and its complications.

[Home Parenteral Nutrition (HPN) registry in Spain for the years 2007, 2008 and 2009 (NADYA-SENPE Group)]

OBJECTIVE

To report the data of the Home Parenteral Nutrition (HPN) registry of the NADYA-SENPE working group for the years 2007, 2008 and 2009.

METHODOLOGY

We compiled the data from the on-line registry introduced by the responsible Units for the monitoring of HPN from January 1st 2007 to December 31st 2009. Included fields were: age, sex, diagnosis and reason for HPN, access path, complications, beginning and end dates, complementary oral or enteral nutrition, activity level, autonomy degree, product and fungible material supply, withdrawal reason and intestinal transplant indication.

RESULTS

2007: 133 patients with HPN were registered (61 males and 72 females), belonging to 21 hospitals. Average age for the 119 patients older than 13 years old was 53.7 ± 14.9 years, and 3.6 ± 3.6 y. for the 14 patients under 14 years old. Most frequent pathology was neoplasm (24%), followed by intestinal motility disorders and actinic enteritis (14% both). The reason for HPN provision was short bowel syndrome (43%), malabsorption (27%), and intestinal obstruction (23%). Tunnelled catheters were mostly used (69%), followed by implanted port-catheters (27%). Catheter related infections were the most frequent complications, with a rate of 0.92 episodes/103 HPN days. HPN was provided for more than two years in 50% of the cases. By the end of 2007, 71.4% of the patients remained active; exitus was the most frequent reason to end HPN (57.5%). 26% of the patients were eligible for intestinal transplant. 2008: 143 patients with HPN were registered (62 males and 81 females), belonging to 24 hospitals. Average age for the 133 patients older than 13 years old was 54.7 ± 13.9 years, and 3.7 ± 0.6 y. for the 10 patients under 14 years old. Most frequent pathology was neoplasm (20%), followed by actinic enteritis (14%) and intestinal motility disorders (13% ). The reason for HPN provision was short bowel syndrome (44%), malabsorption (28%), and intestinal obstruction (20%). Tunnelled catheters were mostly used (60%), followed by implanted port-catheters (29%). Catheter related infections were the most frequent complications, with a rate of 0.50 episodes/10³ HPN days. HPN was provided for more than two years in 67% of the cases. By the end of 2008, 71.6% of the patients remained active; exitus was the most frequent reason to end HPN (52.4%). 29% of the patients were eligible for intestinal transplant. 2009: 158 patients with HPN were registered (62 males and 96 females), belonging to 24 hospitals. Average age for the 149 patients older than 13 years old was 55.2 ± 13.0 years. Most frequent pathology was neoplasm (25%), followed by actinic enteritis (12%) and intestinal motility disorders (11%). The reason for HPN provision was short bowel syndrome (42%), malabsorption, and intestinal obstruction (23% both). Tunnelled catheters were mostly used (60%), followed by implanted port-catheters (36%). Catheter related infections were the most frequent complications, with a rate of 0.67 episodes/10³ HPN days. HPN was provided for more than two years in 58% of the cases. By the end of 2009, 79.2% of the patients remained active; full oral nutrition was the most frequent reason to end HPN (48%). 23% of the patients were eligible for intestinal transplant.

CONCLUSIONS

We observe an increase in registered patients with respect to previous years, with a very different prevalence among regions. Neoplasia remains as the main pathology since 2003. We observe a decrease in catheter-related infections in the last two years, being the 2008 rate the smallest since the register's beginning.

[The Spanish Home Enteral Nutrition registry of the year 2009: from the NADYA-SENPE group]

OBJECTIVE

To describe the Home Enteral Nutrition Characteristics (HEN) recorded by the group NADYA-SENPE during 2009.

MATERIAL AND METHOD

collection and analysis of the data voluntary recorded in the HEN registry from the NADYA-SENPE group from January 1st to December 31st.

RESULTS

6.540 HEN patients were registered, 5.11% more than the previous year and 6,649 episodes (3,135 in women, 47,93%) from 32 different hospitals. 6,238 of them (95,38%) were over 14 years. The mean age of the patients under 14 yr was 3,67 ± 2,86 and it was 72,10 ± 16,89 in those over 14 yr group. The base illness registered more frequently was the neurological disorders in 2,732 (41,77%) patients, followed by cancer patients in 1,838; 28,10%. The enteral access route was registered in 1,123 (17,17%) of the episodes, being more frequent the administration by nasogastric tube 562 (50,04%). The mean length of nutritional treatment by episode was 323 days (10,77 months). 606 episodes of HEN ended, being the principal reasons for discontinuing treatment the patient death in 295 (48,68%) occasions. The transition to oral feeding occurred in 219 (36,14%) cases. Patients maintained normal activity in 2162 (32,55%) HEN episodes and 2,468 (37,13%) cases were living "bed-couch". The level of dependence was "total" in 2,598 (39,07%) of the episodes recorded. The nutritional formula was provided by the hospital in 4,183 (62,91%) cases and by the reference pharmacy in 2,262 (el 34,02%). Consumables were provided by the hospital in 3,531 (53,11%) cases.

CONCLUSIONS

The number of HEN patients recorded increased from the year 2008, continuing the gradual growth increase since the start of registration. The characteristics of the patients remain in the same profile as in previous years.

[Transversal study on the prevalence of Metabolic Bone Disease (MBD) and Home Parenteral Nutrition (HPN) in Spain: data from NADYA group]

Patients with intestinal failure who receive HPN are at high risk of developing MBD. The origin of this bone alteration is multifactorial and depends greatly on the underlying disease for which the nutritional support is required. Data on the prevalence of this disease in our environment is lacking, so NADYA-SEMPE group has sponsored this transversal study with the aim of knowing the actual MBD prevalence.

MATERIAL AND METHODS

Retrospective data from 51 patients from 13 hospitals were collected. The questionnaire included demographic data as well as the most clinically relevant for MBD data. Laboratory data (calciuria, PTH, 25 -OH -vitamin D) and the results from the first and last bone densitometry were also registered.

RESULTS

Bone mineral density had only been assessed by densitometry in 21 patients at the moment HPN was started. Bone quality is already altered before HPN in a significant percentage of cases (52%). After a mean follow up of 6 years, this percentage increases up to 81%. Due to retrospective nature of the study and the low number of subjects included it has not been possible to determine the role that HPN plays in MBD etiology. Only 35% of patients have vitamin D levels above the recommended limits and the majority of them is not on specific supplementation.

CONCLUSIONS

HPN is associated with very high risk of MBD, therefore, management protocols that can lead to early detection of the problem as well as guiding for follow up and treatment of these patients are needed.

[Spanish home enteral nutrition (HEN) registry of the year 2008 from the NADYA-SENPE group]

AIM

To present the results of the Spanish home enteral nutrition (HEN) registry of the year 2008 from the NADYA-SENPE group.

MATERIAL AND METHODS

We recorded the HEN registry data from January 1st to December 31st 2008.

RESULTS

The number of patients registered in this period was 6206 (51% male) with up to 6,279 episodes of HEN, from 31 Spanish hospitals. Most of the patients (95%) were older than 14 yr. Mean age was 4.83±3.29 yr in the children group, and 70.75±18.14 yr in the adult group (older than 14 yr). Neurological disorders (39%) and cancer (27%) were the two most prevalent diagnoses. The oral route was the most frequently used (43,4%), followed by nasogastric tube (40,4%), and gastrostomy tube (14,7%). Mean length of treatment was 305,36 days (10 months). The principal reasons for discontinuing treatment were death (43%) and progress to oral diet (40%). Only 33% of the patients had a normal activity level, being limited in different grades in the rest of the patients. Most of the patients required partial (25%) or total help (38%). The enteral formula was provided by the hospital in 65% of the cases and by private pharmacies in 32%. The disposables were provided by the hospital (82,4%) and primary care services (17,2%).

CONCLUSIONS

The number and the age of the patients registered have increased comparing to previous years, with little variations in the rest of analyzed variables. The increase in the length of treatment could reflect misreporting of the weaning process in the registry.

[National registry of home enteral nutrition in Spain 2007]

OBJECTIVE

To communicate the results from the registry of Home-Based Enteral Nutrition of the NADYASENPE group in 2007.

MATERIAL AND METHODS

We included every patient in the registry with home enteral nutrition any time from January 1st to December 31st of 2007.

RESULTS

The number of patients with home enteral nutrition in 2007 was 5,107 (52% male) from 28 different hospitals. 95.4% of them were 15 yr or older, with a mean age of 67.96 +/- 18.12, and 4.2 +/- 3.38 among patients aged 14 yr or less. The most common underlying diseases were neurological (37.8%) and neoplastic diseases (29.3%). Enteral nutrition was administered p.o. in most patients (63.5%), followed by nasogastric tube (25.9%), while gastrostomy was only used in 9.2%. The mean time in enteral nutrition support was 9.4 months and the most common reasons for withdrawal were death (58.7%) and switching to oral intake (32%). Activity was limited in 31.4% of patients and 36.01% were house-bound. Most patients needed partial (26.51%) or total (37.68%) care assistance. Enteral formula was provided by hospitals to 69.14% of patients and by pharmacies to 30.17% of them, while disposable material was provided by hospitals to 81.63% and by Primary Care to the remaining patients.

CONCLUSIONS

In 2007, there has been an increase of more than 30% of patients registered with home enteral nutrition comparing with 2006, without any big difference in other data, but a higher proportion of patients with enteral nutrition p.o.

Atrophy of the intestinal villi in a post-gastrectomy patient with severe iron deficiency anemia

BACKGROUND & AIMS

Iron deficiency anemia is a common complication of gastric surgery that in certain patients can be refractory to treatment with oral iron and needs to be treated parenterally.

METHODS

A 48-year woman underwent gastric surgery for a gastric ulcer. She was referred to the nutrition unit for the study and treatment of a 3-year iron deficiency anemia refractory to oral iron supplementation. Blood tests, endoscopy and jejunal biopsy were made to study the case.

RESULTS

Intestinal villi atrophy in the absence of celiac disease was the result. She was treated with intravenous iron, resolving the villous atrophy and thus oral iron supplementation could be effective.

CONCLUSION

This case illustrates that iron deficiency may cause villous atrophy. In this setting, parenteral iron administration is necessary to correct the haematological and non-hematological alterations associated with this deficiency.

Trends in home enteral nutrition in Spain: analysis of the NADYA registry 1992-2007

BACKGROUND

There are few data on trends in home enteral nutrition (HEN) practice in different countries. NADYA is the Spanish home artificial nutrition (HAN) group, and is responsible for the Spanish HAN registry.

METHOD

We performed a 16-year retrospective study (1992-2007) of the Spanish HEN registry by retrieving data from the NADYA database and from publications of the working group. People receiving more than 1000 kcal/d with an enteral formula were included regardless of the access route (oral/tube feeding).

RESULTS

The number of patients registered increased more than 8 times during the study period: the current prevalence is 113 patients/10(6) inhabitants (oral and tube feeding), or 41 patients/10(6) inhabitants (tube feeding). The distribution of the patients was not uniform, and most came from six autonomous communities (Catalonia, Galicia, Castilla-León, Madrid, Andalusia and Extremadura). Gender distribution was nearly 1:1. The number of paediatric patients was very low, representing less than 10% of the total. Mean age in adults was above 65 years in most of the reports. We observed an increase in the age of the patients over the years. The most common underlying diseases were neurological disorders, followed by cancer. We observed an increase in the use of the oral route, from 5.8% in 1992 to 64% in 2007, with a parallel decrease in the use of nasogastric tubes. Gastrostomy tubes were used in 15-20% of the patients. The number of complications was low (less than one complication/patient/year), the most frequent being change of tube, followed by gastrointestinal complications. The principal reasons for discontinuing treatment were death related to the underlying disease (40-50%) and switch to oral diet (30-40%). Most of the patients (75%) were followed by the hospital nutrition unit. Provision of the enteral formula and disposables varied according to the autonomous community. Most of the patients had limited physical activity or were chair- or bed-bound, requiring partial or total help in their daily life.

CONCLUSIONS

The use of HEN has increased dramatically in the last 16 years in Spain. Most of the patients registered were elderly people with neurological disorders and limited physical activity. The oral route was the most frequently used. The number of complications was low. The mortality rate in these patients was highly related to the underlying disease.

[Sea-blue histiocyte syndrome associated with home parenteral nutrition]

A case of a 55 years-old male with long-term Crohn's disease without response to medical treatment and many intestinal fistula is presented. After the last bowel resection, home parenteral nutrition was started. He presented chronic hepatopathy and pancytopaenia. After 9 months of home parenteral nutrition hepatic function and pancytopaenia began to deteriorate. Bone marrow examination revealed an infiltrate of sea-blue histiocytes. He made unsatisfactory progress and died due to a multiorganic failure.

[Registry of home-based enteral nutrition in Spain for the year 2006 (NADYA-SENPE Group)]

OBJECTIVE

To communicate the results obtained from the registry of Home-Based Enteral Nutrition (HBEN) of the NADYA-SENPE group for the year 2006.

MATERIAL AND METHODS

Recompilation of the data from the HBEN registry of the NADYA-SENPE group from January 1st to December 31st of 2006.

RESULTS

During the year 2006, 3,921 patients (51% men) from 27 hospital centers were registered. Ninety-seven percent were older than 14 years. The mean age for those < 14 years was 4.9 +/- 3.9 (m +/- SD) and in those > or = 14 years, it was 68.5 +/- 18.2 years. The most common underlying disease was neurological pathology (42%), followed by cancer (28%). Enteral nutrition was administered p.o. in 44% of the patients, through nasogastric tube in 40%, gastrostomy in 14%, and jejunostomy in 1%. The average time of nutritional support was 8.8 months. The most common reasons for ending the therapy were patient's death (54%) and switching to oral feeding (32%). Thirty-one percent of the patients presented a limited activity and 40% were confined to bed/coach. Most of the patients required partial (25%) or total (43%) care assistance. The nutritional formula was provided by the hospital in 62% of the cases and from the reference pharmacy in 27%. The fungible material was provided by the hospital in 80% of the cases and by primary care in the remaining patients.

CONCLUSIONS

Although the number of registered patients is slightly higher than that from the last years, there are no important changes in the patients characteristics, or way of administration and duration of enteral nutrition.

[Spanish Registry of Home-based Parenteral Nutrition during 2006 (NADYA-SENPE Group)]

OBJECTIVE

To report the data of the Home Parenteral Nutrition (HPN) registry of the NADYA-SENPE working group for the year 2006.

METHODOLOGY

We compiled the data from the on-line registry introduced by the responsible Units for the monitoring of HPN from January 1st to December 31st 2006.

RESULTS

103 patients with HPN were registered (47 males and 56 females), belonging to 19 hospitals. Average age for the 91 patients older than 14 years old was 53.3 +/- 14.9 years old, and that for the 12 patients under 14 years old was 2 +/- 0 years old. Most frequent pathology was neoplasm (29%), followed by intestinal motility disorders (13%). The reason for HPN provision was short bowel syndrome (40%), intestinal obstruction (22%), and malabsorption (21%). Tunneled catheters were mostly used (45%), followed by implanted port-catheters (32%). Catheter related infections were the most frequent complications, with a rate of 0.85 episodes / 10(3) days. HPD was provided for more than two years in 50% of the cases. By the end of 2006, 70.9% of the patients remained active; exitus was the most frequent reason to end HPN (53%). Complementary oral or enteral nutrition was provided to 52% of the patients. 48% of the patients had a normal activity level, and a 55% were autonomous. PN formula was supplied by the hospital in 82% of the cases, while this number was 78% for fungible materials. 27% of the patients were eligible for intestinal transplant.

CONCLUSIONS

We observe an increase in registered patients with respect to previous years, with a very different prevalence among regions. Neoplasia remains as the main pathology since 2003. We observe a decrease in catheter-related infections with respect to the 2004-2005 period.

[Presentation of the new Spanish home artificial nutrition registry]

The registries are databases including information about a treatment or a disease in a definite population. Concerning home artificial nutrition there are registries of patients in different European countries, USA and Japan, collecting data such as the prevalence, indication, follow-up and complications of these treatments. The Spanish group of Home Artificial Nutrition (HAN), NADYA, was established in 1992 with professionals devoted to the practise of artificial nutrition. Since then, one of its wills was the development of the Spanish registry of HAN. This is a voluntary registry accessible through the web page www.nadya-senpe.com. In 2005, this group decided to update the registry according to the Data Protection Law and including other improvements. Thank to the work of all the members of this group we have many data on the practise of HAN in our country. Since 1994, except the years 97-98, the annual registries of patients on home parenteral nutrition and home enteral nutrition have been published periodically, observing an increase in both, the number of patients and collaborating centres, presenting to us the actual practise of HAN in our country.

[Gastric surgery as a nutritional risk factor]

BACKGROUND

The stomach has a role in the digestion and absorption of nutrients, so patients are in nutritional risk after gastric resection. The aim of this work was to study the nutritional status of postgastrectomy outpatients followed in our hospital.

METHODS

We retrospectively studied 54 patients (27 M, 27 F) followed more than 12 months postgastrectomy. Mean age was 61 +/- 14 yr and median follow-up was 35 months. The nutritional assessment included anthropometry, biochemical data and measurement of bone mineral density by dual-energy X-ray absorptiometry. The statistical analysis was performed by non-parametric tests.

RESULTS

Malignancy was the most frequent indication (85%), 63% of patients had total gastrectomy. Patients were supplemented with iron (43%), B12 (87%), calcium (18%) and vitamin D (17%). 13% of patients had a BMI < 18.5. The incidence of 25 OH vitamin D deficiency and secondary hyperparathyroidism was 45% and 76%, respectively. The incidence of osteoporosis at lumbar spine was 46%. Matched with same age-sex people patients had 85.6% of bone mineral density.

CONCLUSIONS

The loss of weight and the metabolic bone disease were the most prevalent impairments after gastric resection. These impairments point to the importance of a nutritional surveillance of patients after gastric resection.

[Spanish registry of Home-Based Parenteral Nutrition for the years 2004 and 2005 (NADYA-SENPE Group)]

OBJECTIVE

To report the results of the Home Parenteral Nutrition (HPN) registry of the NADYA-SENPE working group of the years 2004 and 2005.

MATERIAL AND METHODS

We summarized the data of the new on-line HPN registry of the NADYA-SENPE group for the period 2004-2005.

RESULTS

During the year 2004, 70 HPN-patients (23 males and 47 females) were registered from 14 hospitals. Mean age of adults was 53,7 +/- 14,87 years (m +/- SD) and 6 +/- 2,83 years for those younger than 14 years. The most frequent etiologies of the intestinal failure were neoplasia (24%) and mesenteric ischaemia (19%). Tunnelled catheters were used in 75% of the patients. The catheter-related infections were the most frequent complications, with a rate of 0,98 episodes/10(3) days. In 69% of the cases the nutritional support was maintained for more than 2 years. HPN solutions and disposables were supplied by the hospital pharmacy in 81% and 83%, respectively. Up to 54% of the patients had a normal activity level. The most frequent reasons to end HPN treatment were the transition to oral intake (41%), or exitus (28%). During the year 2005, 79 patients (33 males and 46 females) were registered from 14 hospitals. Mean age of adults was 52,39 +/- 14,21 years and 6,5 +/- 5,21 years for those younger than 14 yrs. The most frequent etiologies of the intestinal failure were neoplasia (22%), and mesenteric ischaemia (15%). Tunnelled catheters were used in 63% of the patients. The catheter-related infections were the most frequent complications, with a rate of 1,14 episodes/10(3) days. In 51% of the cases the nutritional support was maintained for more than 2 years. HPN solutions and disposables were supplied by the hospital pharmacy in 76% and 81%, respectively. Up to 50% of the patients had a normal activity level. The most frequent reasons to end HPN treatment were the transition to oral/enteral feeding (41%) and exitus (31%).

CONCLUSIONS

We have observed a mild decrease in the number of HPN patients registered in the period 2004-2005, probably related to the change of the registry. The characteristics of the patients are similar to previous years. We have observed an increase in the septic catheter-related complications in the year 2005.