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Belluzzi A, Hage K, Abi Mosleh K, Mundi MS, Abu Dayyeh B, Ghanem OM. Long-Term Safety and Efficacy of Bariatric Surgery in Septuagenarians. Obes Surg 2023; 33:3778-3785. [PMID: 37840092 DOI: 10.1007/s11695-023-06882-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/25/2023] [Accepted: 10/04/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Metabolic and bariatric surgery (MBS) has been shown to be safe and effective in the elderly population. Unfortunately, utilization of MBS in patients aged 70 years or older remains low, as MBS was just recently endorsed by the American Society for Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity (IFSO) for septuagenarians. MATERIALS AND METHODS We performed a single-center retrospective cohort study of 103 patients aged ≥ 70 years who underwent sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) from January 2008 until March 2023. The data analyzed included patient demographics, post-operative complications, resolution of obesity-related comorbidities, and weight loss. RESULTS A total of 103 patients (71% female; age 72.1 ± 2.5 years; BMI 43.7 ± 6.8 kg/m2) were included. Sixty-two patients (60.2%) underwent RYGB while the remaining 41 underwent SG (39.8%), with a mean follow-up of 4.7 ± 3.7 years. There was no MBS-related mortality. All-cause mortality rates were 7.3% for the SG group after a mean period of 4.5 ± 3.9 years compared to 8.1% for the RYGB cohort after 7.7 ± 3.5 years (p = 0.601). RYGB was reported to have a higher rate of early and late complications when compared to LSG (p = 0.083 and p = 0.274). T2DM (p = 0.011) and OSA (p = 0.019) resolved significantly after RYGB. CONCLUSION Our study demonstrates that bariatric surgery is safe and effective in patients aged 70 years and older. Bariatric surgery should not be denied to this group of patients based on chronological age alone. Further studies are required to support these findings.
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Affiliation(s)
- Amanda Belluzzi
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
- Padova University Hospital, Bariatric Unit, Week Surgery, 35128, Padua, Italy
| | - Karl Hage
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Kamal Abi Mosleh
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Manpreet S Mundi
- Department of Internal Medicine, Division of Endocrinology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Barham Abu Dayyeh
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Omar M Ghanem
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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2
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Pironi L, Cuerda C, Jeppesen PB, Joly F, Jonkers C, Krznarić Ž, Lal S, Lamprecht G, Lichota M, Mundi MS, Schneider SM, Szczepanek K, Van Gossum A, Wanten G, Wheatley C, Weimann A. ESPEN guideline on chronic intestinal failure in adults - Update 2023. Clin Nutr 2023; 42:1940-2021. [PMID: 37639741 DOI: 10.1016/j.clnu.2023.07.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 07/21/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND & AIMS In 2016, ESPEN published the guideline for Chronic Intestinal Failure (CIF) in adults. An updated version of ESPEN guidelines on CIF due to benign disease in adults was devised in order to incorporate new evidence since the publication of the previous ESPEN guidelines. METHODS The grading system of the Scottish Intercollegiate Guidelines Network (SIGN) was used to grade the literature. Recommendations were graded according to the levels of evidence available as A (strong), B (conditional), 0 (weak) and Good practice points (GPP). The recommendations of the 2016 guideline (graded using the GRADE system) which were still valid, because no studies supporting an update were retrieved, were reworded and re-graded accordingly. RESULTS The recommendations of the 2016 guideline were reviewed, particularly focusing on definitions, and new chapters were included to devise recommendations on IF centers, chronic enterocutaneous fistulas, costs of IF, caring for CIF patients during pregnancy, transition of patients from pediatric to adult centers. The new guideline consist of 149 recommendations and 16 statements which were voted for consensus by ESPEN members, online in July 2022 and at conference during the annual Congress in September 2022. The Grade of recommendation is GPP for 96 (64.4%) of the recommendations, 0 for 29 (19.5%), B for 19 (12.7%), and A for only five (3.4%). The grade of consensus is "strong consensus" for 148 (99.3%) and "consensus" for one (0.7%) recommendation. The grade of consensus for the statements is "strong consensus" for 14 (87.5%) and "consensus" for two (12.5%). CONCLUSIONS It is confirmed that CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for the underlying gastrointestinal disease and to provide HPN support. Most of the recommendations were graded as GPP, but almost all received a strong consensus.
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Affiliation(s)
- Loris Pironi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy; Center for Chronic Intestinal Failure, IRCCS AOUBO, Bologna, Italy.
| | - Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Francisca Joly
- Center for Intestinal Failure, Department of Gastroenterology and Nutritional Support, Hôpital Beaujon, Clichy, France
| | - Cora Jonkers
- Nutrition Support Team, Amsterdam University Medical Centers, Location AMC, Amsterdam, the Netherlands
| | - Željko Krznarić
- Center of Clinical Nutrition, Department of Medicine, University Hospital Center, Zagreb, Croatia
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, United Kingdom
| | | | - Marek Lichota
- Intestinal Failure Patients Association "Appetite for Life", Cracow, Poland
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic College of Medicine, Rochester, MN, USA
| | | | - Kinga Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | | | - Geert Wanten
- Intestinal Failure Unit, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Carolyn Wheatley
- Support and Advocacy Group for People on Home Artificial Nutrition (PINNT), United Kingdom
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, St. George Hospital, Leipzig, Germany
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3
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Patel JJ, Rice TW, Mundi MS, Stoppe C, McClave SA. Nutrition dose in the early acute phase of critical illness: Finding the sweet spot and heeding the lessons from the NUTRIREA trials. JPEN J Parenter Enteral Nutr 2023; 47:859-865. [PMID: 37354044 DOI: 10.1002/jpen.2539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/19/2023] [Accepted: 06/21/2023] [Indexed: 06/26/2023]
Abstract
The landmark NUTRIREA-2 and NUTRIREA-3 trials compared the route and dose of nutrition, respectively, in critically ill patients with circulatory shock. The results of both trials support a "less-is-more" paradigm shift in the early acute phase of critical illness. In this review, the authors outline and appraise the results of the NUTRIREA-2 and NUTRIREA-3 trials, introduce the concept of identifying the "sweet spot" for nutrition dose based on severity of illness/nutrition risk and nutrition dose, and identify the unintended consequences of delivering full-dose nutrition in sicker critically ill patients during the early acute phase of critical illness.
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Affiliation(s)
- Jayshil J Patel
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Christian Stoppe
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital, Wuerzberg, Germany
| | - Stephen A McClave
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Louisville, Louisville, Kentucky, USA
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Mohamed Elfadil O, Shah RN, Hurt RT, Mundi MS. Peptide-based formula: Clinical applications and benefits. Nutr Clin Pract 2023; 38:318-328. [PMID: 36802281 DOI: 10.1002/ncp.10961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 01/08/2023] [Accepted: 01/15/2023] [Indexed: 02/23/2023] Open
Abstract
The use of enteral nutrition (EN) continues to increase given benefits. However, with this increase in use, it is also becoming evident that enteral feeding intolerance (EFI) is also quite prevalent, leading to the inability to meet nutrition needs in many patients. Given the wide variability in the EN population as well as the number of formulas available, there is not a clear consensus regarding the best approach to EFI management. One approach that is emerging to improve EN tolerance is the use of peptide-based formulas (PBFs). PBFs refer to enteral formulas containing proteins that have been enzymatically hydrolyzed to dipeptides and tripeptides. These hydrolyzed proteins are often combined with higher medium-chain triglyceride content to generate an enteral formula that is essentially easier to absorb and utilize. Emerging data demonstrate that the use of PBF in patients with EFI may improve clinical outcomes along with a corresponding reduction in healthcare utilization and potentially the cost of care. This review aims to navigate through key clinical applications and benefits of PBF and to discuss relevant data shared in the literature.
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Affiliation(s)
- Osman Mohamed Elfadil
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Raj N Shah
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Ryan T Hurt
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA.,Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
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5
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Shariq OA, Portela R, Bews KA, Mundi MS, Kellogg T, Habermann EB, Dayyeh BA, Kendrick ML, Ghanem OM. Impact of Early Gastrojejunal Stenosis on Weight Loss in Patients Undergoing Roux-en-Y Gastric Bypass. Surg Laparosc Endosc Percutan Tech 2023; 33:202-206. [PMID: 36971521 DOI: 10.1097/sle.0000000000001165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 02/14/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Gastrojejunal (GJ) anastomotic stenosis is a well-described complication after Roux-en-Y gastric bypass (RYGB); however, its impact on weight loss outcomes is not well elucidated. METHODS We performed a retrospective cohort study of adult patients who underwent RYGB at our institution between 2008 and 2020. Propensity score matching was used to match 30 patients who developed GJ stenosis within the first 30 days post-RYGB with 120 control patients who did not develop this outcome. Short and long-term complications and mean percentage of total body weight loss (TWL) were recorded at 3 months, 6 months, 1 year, 2 years, 3 to 5 years, and 5 to 10 years postoperatively. Hierarchical linear regression modeling was used to analyze the association between early GJ stenosis and the mean percentage of TWL. RESULTS Patients who developed early GJ stenosis had a 13.6% increase in the mean percentage of TWL when compared with controls in the hierarchical linear model [ P < 0.001 (95% CI: 5.7; 21.5)]. These patients were also more likely to present to an intravenous infusion center (70% vs 4%; P < 0.01), require readmission within 30 days (16.7% vs 2.5%; P < 0.01), and/or develop an internal hernia (23.3% vs 5.0%) postoperatively. CONCLUSIONS Patients who develop early GJ stenosis after RYGB have a greater degree of long-term weight loss compared with patients who do not develop this complication. Although our findings support the key contribution that restrictive mechanisms play in maintaining weight loss after RYGB, GJ stenosis remains a complication associated with significant morbidity.
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Affiliation(s)
| | | | - Katherine A Bews
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery
| | | | | | | | - Barham Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
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6
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Mundi MS, Mohamed Elfadil O, Olson DA, Pattinson AK, Epp LM, Miller LD, Seegmiller SL, Schneckloth JM, Baker MR, Abdelmagid MG, Patel A, Wescott BA, Elder LS, Hagenbrock MC, Sefried LE, Hurt RT. Home Enteral Nutrition: A Descriptive Study. JPEN J Parenter Enteral Nutr 2023; 47:550-562. [PMID: 36912121 DOI: 10.1002/jpen.2498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/11/2023] [Accepted: 03/08/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND With data demonstrating benefit, the prevalence of Home Enteral Nutrition (HEN) has increased significantly over the last few decades. Despite this increase, there remains a paucity of data regarding real-world use of HEN including clinical outcomes and complications. METHODS Descriptive analysis of the prospectively maintained database of our specialized HEN program was undertaken. Patients who received care in our program with HEN initiation date between January 1st, 2018, and December 31st, 2020, were included in the analysis. Data regarding demographic information, anthropometrics, EN regimen, electrolytes, and nutrition therapy history were included and tracked until July 31st, 2021. RESULTS During the study period, 1600 patients were initiated on HEN under our care. Majority of study population needed EN therapy due to malignancy and its complications including malignant dysphagia or mechanical obstruction (60.6%) followed by neuro-degenerative diseases (7.5%). By the end of study period, majority of patients (82%) had their HEN stopped. Of these, close to half (44.2%) achieved EN goals and/or oral autonomy. Patients stayed on HEN for median of 100 (IQR 32-301) days. Overall, 53.2% of patients experienced/reported at least one HEN related complication that was addressed and clinically managed by the HEN team. Complications included tube-related, enteral feeding intolerance (EFI), and electrolyte shifts. CONCLUSION In our study population, HEN was most utilized to manage malignancy related complications including dysphagia. Unfortunately, complications including EFI and tube related complications remained quite prevalent. Further evaluation regarding risk factors for complications and preventive mechanisms such as increased education is indicated. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Osman Mohamed Elfadil
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Danelle A Olson
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Adele K Pattinson
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Lisa M Epp
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Lisa D Miller
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Sara L Seegmiller
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jill M Schneckloth
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Margaret R Baker
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Marwa G Abdelmagid
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Ankitaben Patel
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Bethaney A Wescott
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Lindsey S Elder
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Martha C Hagenbrock
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Lindsey E Sefried
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Ryan T Hurt
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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7
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Palchaudhuri S, Mccreary B, Davis J, Mcginnis B, Nyberg S, Mundi MS, Pham A. Discharged on Enteral Nutrition: What Now? The Poor State of Outpatient Support for Patients on Enteral Nutrition Support. Curr Gastroenterol Rep 2023; 25:61-68. [PMID: 36734991 DOI: 10.1007/s11894-023-00864-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2023] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW While the use of enteral nutrition (EN) has increased, and more medical centers have developed inpatient programs to address the unique needs of these patients, our collective experience at a few large institutions indicates that there is very little systemic support for patients after discharge. Here, we discuss what we have observed to be some of the barriers to providing outpatient follow up care, summarize the impact we have seen on patients, and propose some possible solutions. RECENT FINDINGS We have observed and identified some of the root causes to include financial barriers; uncoordinated care transitions; high complexity of care, including medication management; and diffuse leadership to a multidisciplinary problem. Systematic support for outpatient care for patients discharged on enteral nutrition is rare and limited, due to many root causes. There are a few tools and tips that we have summarized here for individual providers, and a few promising methods in development, but a systematic approach is in great need.
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Affiliation(s)
- Sonali Palchaudhuri
- Division of Gastroenterology, Massachusetts General Hospital, Boston, MA, USA.
| | - Brigid Mccreary
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Brenna Mcginnis
- Penn Medicine Center for Health Care Innovation, Philadelphia, PA, USA
| | - Susan Nyberg
- Penn Medicine Center for Health Care Innovation, Philadelphia, PA, USA
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Angela Pham
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL, USA
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8
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Mohamed Elfadil O, Mundi MS, Abdelmagid MG, Patel A, Patel N, Martindale R. Butyrate: More Than a Short Chain Fatty Acid. Curr Nutr Rep 2023:10.1007/s13668-023-00461-4. [PMID: 36763294 DOI: 10.1007/s13668-023-00461-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2023] [Indexed: 02/11/2023]
Abstract
PURPOSE OF REVIEW The mechanistic understanding of the importance and the potential benefits of the gut microbiome has exploded in potential roles in human health and disease. Short chain fatty acids (SCFAs), including butyrate, are one of the key metabolic end products that has been a major focus of microbiome understanding. This brief review aims to describe butyrate's relation to certain biological concepts and their clinical application. RECENT FINDINGS Butyrate has reportedly been described as a potent pro-resolution molecule that has a significant role in maintaining gut immunity, supporting gut barrier function, regulation of histone deacetylase (HDAC), and numerous systemic roles. Further research is needed to explore potential benefits of adding SCFAs for patients receiving total parenteral nutrition. Butyrate plays several biological roles in intestinal epithelium anti-inflammatory pathways with clear benefits in numerous acute and chronic disease states and overall human health helping to maintain homeostasis.
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Affiliation(s)
- Osman Mohamed Elfadil
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, 200 1st St. SW, Rochester, MN, 55905, USA.
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, 200 1st St. SW, Rochester, MN, 55905, USA
| | - Marwa G Abdelmagid
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, 200 1st St. SW, Rochester, MN, 55905, USA
| | - Ankitaben Patel
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, 200 1st St. SW, Rochester, MN, 55905, USA
| | - Nishant Patel
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, 200 1st St. SW, Rochester, MN, 55905, USA
| | - Robert Martindale
- Division of Gastrointestinal and General Surgery, School of Medicine, Oregon Health and Sciences University, Portland, OR, USA
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9
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Katz J, Mercer DF, Schuetz P, Mundi MS, Pimiento J, Morrison C, Mechanick JI, Patel JJ. Case presentation and panel discussion: Transitions in care. JPEN J Parenter Enteral Nutr 2023; 47 Suppl 1:S35-S37. [PMID: 36470242 DOI: 10.1002/jpen.2438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 08/07/2022] [Accepted: 08/08/2022] [Indexed: 12/12/2022]
Abstract
There is evidence that significant quality problems arise as patients transitions in care from one setting to another. Attention to nutrition during transitions of care is important to avoid complication. During the American Society for Parenteral and Enteral Nutrition 2022 preconference course, nutrition during transition of care from pediatric to adult care, from the intensive care unit to the hospital floors and from the hospital to home was addressed.
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Affiliation(s)
- Jennifer Katz
- Division of Gastroenterology and Hepatology, NYU Langone Medical Center, New York, New York, USA
| | - David F Mercer
- Division of Transplantation, Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Philipp Schuetz
- Department of Internal Medicine and Emergency Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Jose Pimiento
- Department of Oncologic Sciences, Moffitt Cancer Center, University of South Florida, Tampa, Florida, USA
| | - Chet Morrison
- Department of Surgery, Central Michigan University School of Medicine, Mount Pleasant, Michigan, USA.,The Marie-Josée and Henry R. Kravis Center for Cardiovascular Health at Mount Sinai Heart, New York, New York, USA
| | - Jeffrey I Mechanick
- Division of Endocrinology, Diabetes and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jayshil J Patel
- Division of Pulmonary Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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10
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Mundi MS, Mohamed Elfadil O, Hurt RT, Bonnes S, Salonen BR. Management of long-term home parenteral nutrition: Historical perspective, common complications, and patient education and training. JPEN J Parenter Enteral Nutr 2023; 47 Suppl 1:S24-S34. [PMID: 36468330 DOI: 10.1002/jpen.2424] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/08/2022] [Accepted: 06/09/2022] [Indexed: 12/12/2022]
Abstract
Intestinal failure (IF) is a rare disease that requires ongoing intravenous supplementation to sustain growth and health. Advancements in parenteral nutrition (PN) and central venous access in the 1960s and 1970s transformed a life-limiting disease to a chronic one in which patients are able to administer hydration, electrolytes, micronutrients, and macronutrients in the comfort of their home. However, despite ongoing advancements in the field of home PN (HPN), complications-whether related to central venous catheters or PN itself-remain common and can be associated with significant morbidity and mortality. Central venous access can be associated with thrombosis, central line-associated bloodstream infection, or damage and can result in loss of access over time. PN can be associated with IF-associated liver disease or hyperglycemia. The key to preserving central venous access and quality of life and maintaining health for patients with chronic IF (CIF) is education focused on prevention and prompt management of CIF complications as they arise. This education typically takes place at the time of initiation of HPN, either in the hospital setting or in the patient's home. The present manuscript describes the historical progression of HPN, prevalence and characteristics of CIF, and an in-depth discussion of the most common catheter-related and PN-related complications and their management, along with a discussion of our education and training process.
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Affiliation(s)
- Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Osman Mohamed Elfadil
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Ryan T Hurt
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA.,Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sara Bonnes
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Bradley R Salonen
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
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11
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Maroun J, Vahibe A, Shah M, Mundi MS, Acosta A, McKenzie TJ, Kellogg TA, Ghanem OM. Impact of Chronic Immunosuppression on Short-, Mid-, and Long-Term Bariatric Surgery Outcomes. Obes Surg 2023; 33:240-246. [PMID: 36469206 DOI: 10.1007/s11695-022-06372-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 11/23/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Bariatric surgical outcomes depend heavily on proper healing of gastrointestinal anatomy, metabolic alterations, and patient lifestyle modifications which are all negatively impacted by immunosuppression and underlying inflammatory diseases. There is a lack of literature exploring how patients with diseases requiring immunosuppression respond to bariatric surgical intervention in the long term. METHODS A retrospective analysis of chronically immunosuppressed patients who underwent primary bariatric surgeries at Mayo Clinic was conducted (2008-2020). Data collected included patient demographics, BMI, underlying disease, and immunosuppression regimen and complications at 3, 6, 12, 24, and 60 months. RESULTS We identified a total of 89 (RYGB = 49, SG = 34, BPD/DS = 6) patients on chronic immunosuppression who underwent bariatric surgery at our center. RYGB (N = 49), 38.2% had a SG (N = 34) and 6.7% had a BPD/DS (N = 6). Rheumatoid arthritis and renal transplantation were the most underlying condition at 20.22% each (N = 18). There were a total of 2 (2.25%) intraoperative complications. In the immediate post-operative period, there were 15 (16.5%) minor complications. In follow-up, 6.1% of RYGB patients experienced marginal ulcerations, while no gastrointestinal leaks occurred. The mean pre-surgical BMI was 48.29 kg/m2 (SD = 18.41). Percent total weight loss (%TWL) and BMI reduction were 30.89% and 14.83 kg/m2 (SD = 9.07) at 12 months and 29.48% and 14.43 kg/m2 (SD = 13.46) at 60 months, respectively. The mean follow-up time was 30.49 months. CONCLUSIONS Bariatric surgery remains safe and effective therapy for chronically immunosuppressed patients with excellent long-term outcomes for patients with moderate to severe obesity.
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Affiliation(s)
- Justin Maroun
- Department of Surgery, Mayo Clinic, 200 1St Street SW, Rochester, MN, USA
| | - Ahmet Vahibe
- Department of Surgery, Mayo Clinic, 200 1St Street SW, Rochester, MN, USA
| | - Meera Shah
- Department of Medicine, Mayo Clinic, 200 1St Street SW, Rochester, MN, USA
| | - Manpreet S Mundi
- Department of Medicine, Mayo Clinic, 200 1St Street SW, Rochester, MN, USA
| | - Andres Acosta
- Department of Medicine, Mayo Clinic, 200 1St Street SW, Rochester, MN, USA
| | - Travis J McKenzie
- Department of Surgery, Mayo Clinic, 200 1St Street SW, Rochester, MN, USA
| | - Todd A Kellogg
- Department of Surgery, Mayo Clinic, 200 1St Street SW, Rochester, MN, USA
| | - Omar M Ghanem
- Department of Surgery, Mayo Clinic, 200 1St Street SW, Rochester, MN, USA.
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12
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Mohamed Elfadil O, Velapati SR, Miller LD, Huiras MF, Stoecker EA, Warner M, Vanderveer L, Adkins A, Chargo C, Kueny K, Bailey MS, Hurt RT, Mundi MS. Dietitian Involvement Improves Consumption of Oral Nutrition Supplements in Hospitalized Patients. CAN J DIET PRACT RES 2022; 83:203-207. [PMID: 36004724 DOI: 10.3148/cjdpr-2022-016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Hospitalized patients are at an increased risk of malnutrition due to multiple factors including, but not limited to, acute and chronic diseases especially those affecting gastrointestinal tract, surgery, appetite, and frequent nil per os while undergoing diagnostic workup. Because of this, guidelines suggest the use of oral nutritional supplements (ONS) in hospitalized patients to reduce the risk of malnutrition and its complications. The current report aims to highlights key findings from a cross-sectional survey of 99 hospitalized patients who were at risk for or diagnosed with malnutrition and prescribed ONS. Data regarding ONS prescriber information as well as number ordered and consumed were collected. Of the 2.4 ± 1.5 supplements ordered per person each day, only 1.3 ± 1.1 were consumed, and there was 48% wastage of prescribed ONS. However, dietitian involvement was associated with significant reduction in wastage. Given the need and benefit, it is imperative for the nutrition community to further explore best practices to improve ONS consumption.
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Affiliation(s)
- Osman Mohamed Elfadil
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Saketh R Velapati
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Lisa D Miller
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Michael F Huiras
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Evan A Stoecker
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Morgan Warner
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Laura Vanderveer
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Ashley Adkins
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Christopher Chargo
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Katherine Kueny
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Molly S Bailey
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Ryan T Hurt
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN.,Division of General Internal Medicine, Mayo Clinic, Rochester, MN.,Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
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13
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Mohamed Elfadil O, Keaveney E, Patel A, Abdelmagid MG, Patel I, Patel J, Hurt RT, Mundi MS. Usability of a Novel Enteral Feeding System: A Summative Study. MDER 2022; 15:253-262. [PMID: 35958115 PMCID: PMC9362904 DOI: 10.2147/mder.s367100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 07/08/2022] [Indexed: 11/23/2022] Open
Abstract
Background Utilization of long-term home enteral nutrition (HEN) for nutrition therapy is increasing across the world. However, HEN can be a mobility-limiting experience affecting quality of life (QoL). Improvement of QoL for patients receiving HEN is a universal goal within the nutrition community. This study evaluated usability of Mobility+®, a novel enteral feeding system (EFS). Methods A summative study evaluating usability of the novel EFS was conducted with novices (NV), non-novices (NN), and healthcare professionals (HCP). Subjects in NV and NN groups received familiarization training where they were introduced to the novel EFS and walked through steps to fill pouch, simulate feeding, flush (rinse), and wear the system, using the Instructions for Use (IFU) booklet, followed by a testing session where they simulated system use on their own. HCP self-trained using the IFU and instructional videos. A fill from ready-to-hang (RTH) formula bag method was also tested in HCP. Participants’ ability to loosely coil the tubing and sit, stand, and move around wearing a filled feeding pouch inside a crossbody bag was also evaluated. Results Forty-five participants completed the study. All participants successfully and safely simulated use of the novel EFS, with 97.8% (44/45) doing so on first attempt. All participants could wear the novel EFS in crossbody bag and move around without any use errors or safety issues. Conclusion The examined novel EFS can be safely used in intended use population, with or without previous experience with enteral nutrition, on provision of basic familiarization training and written IFU. Additionally, HCP can successfully self-train on this system with instructional videos. ![]()
Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/WWR06dCUPts
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Affiliation(s)
- Osman Mohamed Elfadil
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
| | | | - Ankitaben Patel
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Marwa G Abdelmagid
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Ishani Patel
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Jalpan Patel
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Ryan T Hurt
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
- Division of Internal Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
- Correspondence: Manpreet S Mundi, Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA, Tel +1 507-284-0106, Fax +1 507-284-5745, Email
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14
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Mundi MS, Mercer DF, Iyer K, Pfeffer D, Zimmermann LB, Berner-Hansen M, Bishop J, Seidner DL. Characteristics of Chronic Intestinal Failure in the USA Based on Analysis of Claims Data. JPEN J Parenter Enteral Nutr 2022; 46:1614-1622. [PMID: 35726729 DOI: 10.1002/jpen.2426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/06/2022] [Accepted: 06/17/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND This study investigated the prevalence, characteristics, and management of patients with chronic intestinal failure (CIF) in the USA in 2012-2020, based on parenteral support (PS) prescription claims and healthcare utilization. METHODS Patients with CIF were identified from the Integrated DataVerse® claims database if they had at least two PS prescriptions within six months and a relevant diagnosis. Analysis included prevalence and characteristics of patients with CIF, their travel distance to receive PS prescriptions, and the distribution of PS providers and their prescribing history. RESULTS Up to 24,048 patients with CIF were identified, equivalent to 75 patients per million. CIF affected people of all ages, being more prevalent in women than in men. Many providers signed PS orders for small patient groups over short time periods, whereas few providers signed PS orders for large patient groups long term, indicating a lack of centralization. The distribution of PS providers suggested a disparity in healthcare coverage in rural vs urban areas, leading to patients traveling considerable distances to receive PS prescriptions. This may be exacerbated by a decline of providers with expertise in CIF and nutrition. CONCLUSIONS Healthcare disparities for patients with CIF have likely been obscured by the lack of CIF-specific diagnostic and procedure codes, obliging providers to code for their patients under other codes. Effective policy changes, including centralized care, revision of reimbursement models, and expansion of nutrition-focused education in addition to the newly introduced International Classification of Diseases codes, are needed to provide the best care for patients. CLINICAL RELEVANCY STATEMENT CIF affects people of all ages and is more prevalent in women than in men. Healthcare coverage for patients with CIF is largely decentralized. Disparities are evident in rural compared to urban areas, leading to patients traveling considerable distances to receive PS prescriptions, which may be exacerbated by a decline of providers with expertise in CIF and nutrition. These healthcare inequalities necessitate effective policy changes, including introduction of CIF-specific diagnostic and procedure codes, such as the ongoing introduction of unique ICD codes for CIF and associated diseases, revision of reimbursement models and assurance of the continuity of providers with expertise in CIF and nutrition (eg, by expansion of nutrition-focused education in medical schools). Importantly, improvements in healthcare centralization are required to secure management of patients by highly experienced multidisciplinary teams throughout the USA. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - David F Mercer
- Department of Surgery, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, Nebraska, USA
| | - Kishore Iyer
- Recanati Miller Transplant Institute, Department of Surgery, Mount Sinai Hospital, New York, New York, USA
| | | | | | - Mark Berner-Hansen
- Zealand Pharma A/S, Søborg, Denmark
- Digestive Disease Center, Bispebjerg Hospital, Copenhagen, Denmark
| | - Joan Bishop
- The Oley Foundation, Albany Medical Center, Delmar, New York, USA
| | - Douglas L Seidner
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, Ohio, USA
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15
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Mohamed Elfadil O, Linch FB, Seegmiller SL, Hurt RT, Mundi MS, Neisen MJ. Safety and effectiveness of radiologic and endoscopic percutaneous gastrostomy placement: A randomized study. JPEN J Parenter Enteral Nutr 2022; 46:1808-1817. [DOI: 10.1002/jpen.2365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/28/2022] [Accepted: 03/08/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Osman Mohamed Elfadil
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition Mayo Clinic Rochester Minnesota USA
| | - Forrest B. Linch
- Division of Vascular and Interventional Radiology Mayo Clinic Rochester Minnesota USA
| | - Sara L. Seegmiller
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition Mayo Clinic Rochester Minnesota USA
| | - Ryan T. Hurt
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition Mayo Clinic Rochester Minnesota USA
- Division of General Internal Medicine Mayo Clinic Rochester Minnesota USA
- Division of Gastroenterology and Hepatology Mayo Clinic Rochester Minnesota USA
| | - Manpreet S. Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition Mayo Clinic Rochester Minnesota USA
| | - Melissa J. Neisen
- Division of Vascular and Interventional Radiology Mayo Clinic Rochester Minnesota USA
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16
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Affiliation(s)
- Philip C Calder
- School of Human Development and Health, Faculty of Medicine
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton and University of Southampton, Southampton, UK
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
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17
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Ewy MW, Patel A, Abdelmagid MG, Mohamed Elfadil O, Bonnes SL, Salonen BR, Hurt RT, Mundi MS. Plant-Based Diet: Is It as Good as an Animal-Based Diet When It Comes to Protein? Curr Nutr Rep 2022; 11:337-346. [DOI: 10.1007/s13668-022-00401-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2022] [Indexed: 12/12/2022]
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18
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Mundi MS, Mechanick JI, Mohamed Elfadi O, Patel J, Bonnes SL, Blackmer AB, Christian VJ, Hennessy SA, Hurt RT, Jain A, Kaspar MB, Katz J, Labossiere R, Limketkai B, McCarthy PJ, Morrison CA, Newberry C, Pimiento JM, Rosenthal MD, Taylor B, McClave SA. Optimizing the Nutrition Support Care Model: Analysis of Survey Data. JPEN J Parenter Enteral Nutr 2022; 46:1709-1724. [PMID: 35040154 DOI: 10.1002/jpen.2326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 11/30/2021] [Accepted: 12/17/2021] [Indexed: 11/12/2022]
Abstract
BACKGROUND Malnutrition is under-recognized and under-diagnosed, despite high prevalence rates and associated poor clinical outcomes. The involvement of clinical nutrition experts, especially physicians, in the care of high-risk patients with malnutrition remains low, despite evidence demonstrating lower complication rates with nutrition support team (NST) management. To facilitate solutions, a survey was designed to elucidate the nature of NSTs and physician involvement and identify needs for novel nutrition support care models. METHODS This survey assessed demographics of NSTs, factors contributing to the success of NSTs, elements of nutrition education, and other barriers to professional growth. RESULTS Of 255 respondents, 235 complete surveys were analyzed. The geographic distribution of respondents correlated with population concentrations of the United States (r = 90.8%, p-value <0.0001). Most responding physicians (80.7%) reported being a member of NSTs, compared with 56.5% of dietitians. Of those not practicing in NSTs (N = 81, 34.4%), 12.3% reported an NST was previously present at their institution but had been disbanded. Regarding NSTs, financial concerns were common (48.9%), followed by leadership (30.6%), and healthcare professional (HCP) interest (23.4%). A majority (73.6%) of all respondents wanted additional training in nutrition, but reported insufficient protected time, ability to travel, or support from administrators or other HCPs. CONCLUSION Core actions resulting from this survey focused on formalizing physician roles, increasing inter-disciplinary nutrition support expertise, utilizing cost-effective screening for malnutrition, and implementing intervention protocols. Additional actions included increasing funding for clinical practice, education, and research, all within an expanded portfolio of pragmatic nutrition support care models. CLINICAL RELEVANCY STATEMENT Physician engagement in nutrition support continues to remain low despite the increasing prevalence of malnutrition. This problem, and the working solution, is in the context of decreased engagement of other healthcare professionals in nutrition support, as well as declining Nutrition Support Team utilization. To address these issues, the ASPEN Physician Engagement Committee (PEC) conducted a survey of healthcare professionals (HCPs) involved in nutrition support. Key findings include: (1) lack of financial support and physician champions with financial knowledge; (2) inadequate valuation of physicians and other nutrition support HCPs and NSTs, and their impact on clinical outcomes; and (3) significant barriers to primary and supplementary training for physicians in nutrition. Accordingly, the PEC recommends: (1) development of cost-effective screening and intervention for malnutrition; (2) expansion of nutrition support care models appropriately scaled to the available resources and expertise; and (3) development of a knowledge translation platform to foster transmission of novel breakthroughs while addressing research, knowledge, and practice gaps. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Jeffrey I Mechanick
- Kravis Center for Cardiovascular Health at Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Osman Mohamed Elfadi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Jayshil Patel
- Division of Pulmonary & Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wi
| | - Sara L Bonnes
- General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Allison B Blackmer
- American Society for Parenteral and Enteral Nutrition, Silver Spring, MD.,University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO
| | - Vikram J Christian
- Division of Pediatric Gastroenterology, University of Minnesota, Minneapolis, MN
| | - Sara A Hennessy
- Division of Burn, Trauma, Acute & Critical Care Surgery, University of Texas, Southwestern Medical Center, Dallas, Texas
| | - Ryan T Hurt
- General Internal Medicine, Mayo Clinic, Rochester, MN
| | - Ajay Jain
- Division of Pediatric Gastroenterology, Saint Louis University, Saint Louis, Missouri, USA
| | - Matthew B Kaspar
- Department of Internal Medicine, Virginia Commonwealth University Medical Center, Richmond, Virginia, USA
| | - Jennifer Katz
- Division of Gastroenterology and Hepatology, Montefiore Medical Center, Bronx, New York, USA
| | | | - Berkeley Limketkai
- Division of Digestive Diseases, UCLA School of Medicine, Los Angeles, CA
| | - Paul J McCarthy
- Division of Cardiovascular Critical Care, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Chet A Morrison
- Division of Trauma and Critical Care, Central Michigan University College of Medicine
| | - Carolyn Newberry
- Innovative Center for Health and Nutrition in Gastroenterology (ICHANGE), Weill Cornell Medical Center, New York, NY
| | - Jose M Pimiento
- GI Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Martin D Rosenthal
- Division of Trauma and Acute Care Surgery, University of Florida, Gainesville, Florida
| | - Beth Taylor
- Department of Research for Patient Care Services, Barnes-Jewish Hospital, St. Louis, Missouri, USA
| | - Stephen A McClave
- Division of Gastroenterology, Hepatology, and Nutrition, School of Medicine, University of Louisville, Louisville, Kentucky, USA
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19
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Mundi MS, Mechanick JI, Patel JJ, Laviano A, Martindale RG, Zimmers TA. Case presentation and panel discussion: Nutrition issues in cancer. JPEN J Parenter Enteral Nutr 2021; 45:41-46. [PMID: 34897739 DOI: 10.1002/jpen.2220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 07/17/2021] [Indexed: 11/09/2022]
Abstract
Advances in treatment of malignancy including novel pharmacologic therapies and surgical interventions has led to significant improvement in survival. As cancer becomes a chronic disease, nutrition interventions play an increasingly important role in short- and long-term outcomes. The current manuscript presents a case of a 66-year-old male with new diagnosis of pancreatic cancer diagnosed incidentally in the setting of COVID-19. Expert panelists in the field of nutrition discuss optimal strategies for diagnosis of malnutrition along with preoperative, perioperative, and postoperative optimization of nutrition. This discussion focuses on the use of probiotics, immune-modulating nutrition, fish oil, specialized proresolving mediators, and use of enteral and parenteral nutrition support.
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Affiliation(s)
- Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeffrey I Mechanick
- Kravis Center for Clinical Cardiovascular Health at Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jayshil J Patel
- Division of Pulmonary Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Alessandro Laviano
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Robert G Martindale
- Division of Gastrointestinal and General Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Teresa A Zimmers
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Richard Roudebush Veterans Administration Medical Center, Indianapolis, Indiana, USA
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20
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Mundi MS, Mohamed Elfadil O, Patel I, Patel J, Hurt RT. Ketogenic diet and cancer: Fad or fabulous? JPEN J Parenter Enteral Nutr 2021; 45:26-32. [PMID: 34897736 DOI: 10.1002/jpen.2226] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 07/06/2021] [Accepted: 07/17/2021] [Indexed: 12/31/2022]
Abstract
As the prevalence of smoking continues to decline, dietary factors are rapidly becoming the leading preventable cause of disease. Diet and obesity are also leading to a shift in cancer prevalence with increases noted in breast, liver, pancreas, and uterine cancers. Once cancer is detected, obesity is also associated with poorer outcomes with therapy as well as higher morbidity and mortality. Key factors are associated with the link between obesity and cancer including chronic inflammation, change in sex hormones, alteration in insulin-IGF-1 axis, alteration in adipokines, as well as cancer stem cells that are derived from adipose tissue. Because of these associations, a great deal of effort is being placed in implementing lifestyle changes that mitigate obesity-associated factors that contribute to development of cancer, reduce side effects of treatment, and improve survival. Ketogenic diet is emerging as an attractive option in countering obesity-related tumor-promoting factors, as it is associated with weight loss as well as a reduction in insulin resistance and inflammation. Ketogenic diet can also deprive cancer cells of glucose, a fuel source that is predominantly used by many cancer lines through aerobic glycolysis in the setting of dysregulated mitochondria. Current manuscript reviews the theoretical benefits for use of ketogenic diet in cancer as well as the data available from clinical trials.
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Affiliation(s)
- Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Osman Mohamed Elfadil
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Ishani Patel
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jalpan Patel
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ryan T Hurt
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA.,Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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21
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Mundi MS, Mechanick JI, Patel JJ, Al-Kazaz M, Garvey WT, Still CD. Case presentation and panel discussion: Cardiometabolic risk mitigation. JPEN J Parenter Enteral Nutr 2021; 45:93-99. [PMID: 34897733 DOI: 10.1002/jpen.2219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 07/17/2021] [Indexed: 11/10/2022]
Abstract
The worldwide increase in the prevalence of obesity and adiposity-related comorbidities has required a novel approach to cardiometabolic risk mitigation focused on the key mechanistic drivers of disease. The current manuscript presents the case of a 74-year-old male with obesity complicated by coronary artery disease, hypertriglyceridemia, hypertension, nonalcoholic fatty liver disease, obstructive sleep apnea, and type 2 diabetes. Expert panelists discuss optimal diagnostic and treatment strategies focused on lifestyle modifications including dietary interventions such as the Mediterranean dietary pattern, medications that target multiple drivers of disease, as well as procedural options.
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Affiliation(s)
- Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeffrey I Mechanick
- Kravis Center for Clinical Cardiovascular Health at Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jayshil J Patel
- Division of Pulmonary Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Mohamed Al-Kazaz
- Mount Sinai Heart Institute, Icahn School of Medicine, New York, New York, USA
| | - W Timothy Garvey
- Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Christopher D Still
- Department of Nutrition and Weight Management, Division of Medicine, Geisinger Medical Center, Danville, Pennsylvania, USA
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22
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Calderon G, Gonzalez-Izundegui D, Shan KL, Garcia-Valencia OA, Cifuentes L, Campos A, Collazo-Clavell ML, Shah M, Hurley DL, Abu Lebdeh HS, Sharma M, Schmitz K, Clark MM, Grothe K, Mundi MS, Camilleri M, Abu Dayyeh BK, Hurtado Andrade MD, Mokadem MA, Acosta A. Effectiveness of anti-obesity medications approved for long-term use in a multidisciplinary weight management program: a multi-center clinical experience. Int J Obes (Lond) 2021; 46:555-563. [PMID: 34811486 DOI: 10.1038/s41366-021-01019-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 09/30/2021] [Accepted: 11/01/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND AIMS Randomized clinical trials have proven the efficacy and safety of Food and Drug Administration (FDA) approved anti-obesity medications (AOMs) for long-term use. It is unclear whether these outcomes can be replicated in real-world clinical practice where clinical complexities arise. The aim of this study was to evaluate the effectiveness and side effects of these medications in real-world multidisciplinary clinical practice settings. METHODS We reviewed the electronic medical records (EMR) of patients with obesity who were prescribed an FDA-approved AOM for long-term use in academic and community multidisciplinary weight loss programs between January 2016 and January 2020. INTERVENTION We assessed percentage total body weight loss (%TBWL), metabolic outcomes, and side effect profile up to 24 months after AOM initiation. RESULTS The full cohort consisted of 304 patients (76% women, 95.2% White, median age of 50 years old [IQR, 39-58]). The median follow-up time was 9.1 months [IQR, 4.2-14.1] with a median number of 3 visits [IQR, 2-4]. The most prescribed medication was phentermine/topiramate extended-release (ER) (51%), followed by liraglutide (26.3%), bupropion/naltrexone sustained-release (SR) (16.5%), and lorcaserin (6.2%). %TBWL was 5.0%, 6.8%, 9.3%, 10.3%, and 10.5% at 3, 6, 12, 18, and 24 months. 60.2% of the entire cohort achieved at least 5% TBWL. Overall, phentermine/topiramate-ER had the most robust weight loss response during follow-up, with the highest %TBWL at 12 months of 12.0%. Adverse events were reported in 22.4% of patients. Only 9% of patients discontinued the medication due to side effects. CONCLUSIONS AOMs resulted in significant long-term weight loss, that was comparable to outcomes previously reported in clinical trials.
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Affiliation(s)
- Gerardo Calderon
- Precision Medicine for Obesity Program, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Daniel Gonzalez-Izundegui
- Precision Medicine for Obesity Program, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kuangda L Shan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, and Fraternal Order of Eagles Diabetes Research Center, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Oscar A Garcia-Valencia
- Precision Medicine for Obesity Program, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Lizeth Cifuentes
- Precision Medicine for Obesity Program, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Alejandro Campos
- Precision Medicine for Obesity Program, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Maria L Collazo-Clavell
- Division of Endocrinology, Diabetes, Metabolism & Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Meera Shah
- Division of Endocrinology, Diabetes, Metabolism & Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Daniel L Hurley
- Division of Endocrinology, Diabetes, Metabolism & Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Haitham S Abu Lebdeh
- Division of Endocrinology, Diabetes, Metabolism & Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Mayank Sharma
- Precision Medicine for Obesity Program, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kristine Schmitz
- Division of Endocrinology, Diabetes, Metabolism & Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Matthew M Clark
- Division of Endocrinology, Diabetes, Metabolism & Nutrition, Mayo Clinic, Rochester, MN, USA.,Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Karen Grothe
- Division of Endocrinology, Diabetes, Metabolism & Nutrition, Mayo Clinic, Rochester, MN, USA.,Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USA
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism & Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Michael Camilleri
- Precision Medicine for Obesity Program, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Barham K Abu Dayyeh
- Precision Medicine for Obesity Program, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Maria D Hurtado Andrade
- Precision Medicine for Obesity Program, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA. .,Division of Endocrinology, Diabetes, Metabolism & Nutrition, Mayo Clinic Health System, La Crosse, WI, USA.
| | - Mohamad A Mokadem
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, and Fraternal Order of Eagles Diabetes Research Center, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
| | - Andres Acosta
- Precision Medicine for Obesity Program, Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
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Abstract
PURPOSE OF REVIEW The COVID-19 pandemic has been associated with significant morbidity and mortality worldwide. In addition to those with advanced age and co-morbidities such as heart disease or cancer, obese individuals have also had very high rates of hospitalization, critical illness, need for ventilator support, as well as mortality. A number of factors associated with obesity have led to devastating consequences as these two pandemics have interacted. RECENT FINDINGS Obese individuals through a combination of structural and cellular level changes have greater risk of ischemic heart disease, diabetes, cancer, and respiratory disease, which are themselves risk-factors for acquiring COVID-19 disease. These structural changes also result in increased intra-abdominal and intra-thoracic pressure as well as a restrictive lung physiology that leads to reduction in total lung capacity, functional residual capacity, and increase in airway hyper-reactivity. Adipose tissue is also impacted in obese individuals leading to local as well as systemic inflammation, which can contribute to increased release of free fatty acids and systemic insulin resistance. Additionally, angiotensin-converting enzyme 2 and dipeptidyl peptidase 4, which act as receptors for SARS-CoV-2 are also significantly increased in obese individuals. The present manuscript reviews these structural, immune, and molecular changes associated with obesity that make obese individuals more vulnerable to acquiring severe COVID-19 and more challenging to manage associated complications.
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Affiliation(s)
- Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
| | - Jayshil J Patel
- Division of Pulmonary & Critical Care Medicine, Medical College of Wisconsin, WI, Milwaukee, USA
| | - Osman Mohamed Elfadil
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Jalpan Patel
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Ishani Patel
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Sanjeev Nanda
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ryan T Hurt
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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24
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Abstract
PURPOSE OF REVIEW Real-world data suggested that more than half of daily energy intake is coming from processed and ultra-processed foods in most western countries. This high consumption of processed foods is of concern, given laboratory and epidemiological studies' findings that prove overwhelming harms of processed foods on human health. RECENT FINDINGS Data demonstrate that consumption of processed foods is increasing with more reports linking ultra-processed foods to various medical conditions; namely, obesity, metabolic syndrome, atherosclerotic cardiovascular diseases, and certain types of cancer. Scientific community's understanding of the mechanisms and substances by which processed foods are affecting human health is expanding. Holistic approach to the current critical situation is advisable and requires collaborative public health strategies. The current review describes recent classification of processed foods and highlights the pertinent findings in the relationship between processed foods and health. It also outlines key clinical data relevant to the topic.
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Affiliation(s)
- Osman Mohamed Elfadil
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Jalpan Patel
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Ishani Patel
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Matthew W Ewy
- Division of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ryan T Hurt
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
- Division of Internal Medicine, Mayo Clinic, Rochester, MN, USA
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
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25
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Pironi L, Steiger E, Joly F, Jeppesen PB, Wanten G, Sasdelli AS, Chambrier C, Aimasso U, Mundi MS, Szczepanek K, Jukes A, Theilla M, Kunecki M, Daniels J, Serlie M, Poullenot F, Cooper SC, Rasmussen HH, Compher C, Seguy D, Crivelli A, Santarpia L, Guglielmi FW, Kozjek NR, Schneider SM, Ellegard L, Thibault R, Matras P, Matysiak K, Van Gossum A, Forbes A, Wyer N, Taus M, Virgili NM, O'Callaghan M, Chapman B, Osland E, Cuerda C, Udvarhelyi G, Jones L, Won Lee AD, Masconale L, Orlandoni P, Spaggiari C, Díez MB, Doitchinova-Simeonova M, Serralde-Zúñiga AE, Olveira G, Krznaric Z, Czako L, Kekstas G, Sanz-Paris A, Jáuregui MEP, Murillo AZ, Schafer E, Arends J, Suárez-Llanos JP, Youssef NN, Brillanti G, Nardi E, Lal S. Characteristics of adult patients with chronic intestinal failure due to short bowel syndrome: An international multicenter survey. Clin Nutr ESPEN 2021; 45:433-441. [PMID: 34620351 DOI: 10.1016/j.clnesp.2021.07.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 07/08/2021] [Indexed: 01/16/2023]
Abstract
BACKGROUND AND AIMS The case-mix of patients with intestinal failure due to short bowel syndrome (SBS-IF) can differ among centres and may also be affected by the timeframe of data collection. Therefore, the ESPEN international multicenter cross-sectional survey was analyzed to compare the characteristics of SBS-IF cohorts collected within the same timeframe in different countries. METHODS The study included 1880 adult SBS-IF patients collected in 2015 by 65 centres from 22 countries. The demographic, nutritional, SBS type (end jejunostomy, SBS-J; jejuno-colic anastomosis, SBS-JC; jejunoileal anastomosis with an intact colon and ileocecal valve, SBS-JIC), underlying disease and intravenous supplementation (IVS) characteristics were analyzed. IVS was classified as fluid and electrolyte alone (FE) or parenteral nutrition admixture (PN). The mean daily IVS volume, calculated on a weekly basis, was categorized as <1, 1-2, 2-3 and >3 L/day. RESULTS In the entire group: 60.7% were females and SBS-J comprised 60% of cases, while mesenteric ischaemia (MI) and Crohn' disease (CD) were the main underlying diseases. IVS dependency was longer than 3 years in around 50% of cases; IVS was infused ≥5 days/week in 75% and FE in 10% of cases. Within the SBS-IF cohort: CD was twice and thrice more frequent in SBS-J than SBS-JC and SBS-JIC, respectively, while MI was more frequent in SBS-JC and SBS-JIC. Within countries: SBS-J represented 75% or more of patients in UK and Denmark and 50-60% in the other countries, except Poland where SBS-JC prevailed. CD was the main underlying disease in UK, USA, Denmark and The Netherlands, while MI prevailed in France, Italy and Poland. CONCLUSIONS SBS-IF type is primarily determined by the underlying disease, with significant variation between countries. These novel data will be useful for planning and managing both clinical activity and research studies on SBS.
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Affiliation(s)
- Loris Pironi
- CHU Rennes, Nutrition Unit, Clinique Saint Yves, Home Parenteral Nutrition Centre, INRAE, INSERM, Univ Rennes, Nutrition Metabolisms and Cancer, NuMeCan, Rennes, France.
| | - Ezra Steiger
- Home Nutrition Support, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Francisca Joly
- Centre for Intestinal Failure, Department of Gastroenterology and Nutritional Support, Hôpital Beaujon, Clichy, France
| | - Palle B Jeppesen
- Rigshospitalet, Department of Gastroenterology, Copenhagen, Denmark
| | - Geert Wanten
- Intestinal Failure Unit, Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Anna S Sasdelli
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Centre for Chronic Intestinal Failure - Clinical Nutrition and Metabolism Unit, Bologna, Italy
| | - Cecile Chambrier
- Unité de Nutrition Clinique Intensive, Hospices Civils de Lyon, Hôpital Lyon Sud, Lyon, France
| | | | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo College of Medicine, Rochester, MN, USA
| | - Kinga Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | - Amelia Jukes
- University Hospital of Wales, Cardiff, United Kingdom
| | - Miriam Theilla
- Rabin Medical Center, Petach Tikva, Sackler School of Medicine, Tel Aviv University, Israel
| | | | - Joanne Daniels
- Nottingham University Hospital NHS Trust, Nottingham, United Kingdom
| | - Mireille Serlie
- Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Florian Poullenot
- Service de Gastroentérologie, Hôpital Haut-Lévêque, CHU de Bordeaux, Pessac, France
| | - Sheldon C Cooper
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Henrik H Rasmussen
- Centre for Nutrition and Bowel Disease, Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
| | - Charlene Compher
- Hospital of the University of Pennsylvania, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - David Seguy
- Service de Nutrition, CHRU de Lille, Lille, France
| | - Adriana Crivelli
- Unidad de Soporte Nutricional, Rehabilitación y Trasplante de Intestino, Hospital Universitario Fundacion Favaloro, Buenos Aires, Argentina
| | | | | | | | - Stéphane M Schneider
- Gastroenterology and Clinical Nutrition, CHU of Nice, Université Côte D'Azur, Nice, France
| | - Lars Ellegard
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Ronan Thibault
- CHU Rennes, Nutrition Unit, Clinique Saint Yves, Home Parenteral Nutrition Centre, INRAE, INSERM, Univ Rennes, Nutrition Metabolisms and Cancer, NuMeCan, Rennes, France
| | - Przemysław Matras
- Department of General and Transplant Surgery and Clinical Nutrition, Medical University of Lublin, Lublin, Poland
| | - Konrad Matysiak
- Centre for Intestinal Failure, Department of General, Endocrinological and Gastroenterological Surgery, Poznań University of Medical Science, Poznań, Poland
| | - Andrè Van Gossum
- Medico-Surgical Department of Gastroenterology, Hôpital Erasme, Free University of Brussels, Belgium
| | - Alastair Forbes
- Institute of Internal Medicine, University of Tartu, Tartu, Estonia, And Previously at Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Nicola Wyer
- University Hospitals Coventry & Warwickshire NHS Trust, Coventry, United Kingdom
| | - Marina Taus
- SOD Dietetica e Nutrizione Clinica, Centro Riferimento Regionale NAD, Ospedali Riuniti di Ancona, Italy
| | - Nuria M Virgili
- Facultatiu Especialista. Servei D'Endocrinologia I Nutrició, Hospital Universitari de Bellvitge, Barcelona, Spain
| | | | | | - Emma Osland
- Royal Brisbane and Women's Hospital, Herston, Australia
| | - Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | | | - Lynn Jones
- Royal Prince Alfred Hospital, Camperdown, Australia
| | - Andre D Won Lee
- Hospital Das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Paolo Orlandoni
- Nutrizione Clinica-Centro di Riferimento Regionale NAD, IRCCS-INRCA, Ancona, Italy
| | | | - Marta Bueno Díez
- Servei D'Endocrinologia I Nutrició, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | | | | | | | - Zeljko Krznaric
- Centre of Clinical Nutrition, Department of Medicine, University Hospital Centre, Zagreb, Croatia
| | - Laszlo Czako
- First Department of Internal Medicine, Szeged, Hungary
| | | | | | | | | | - Eszter Schafer
- Magyar Honvedseg Egészségügyi Központ (MHEK), Budapest, Hungary
| | - Jann Arends
- Department of Medicine, Oncology and Hematology, University of Freiburg, Germany
| | - José P Suárez-Llanos
- Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Nader N Youssef
- VectivBio AG Basel, Switzerland, Digestive Healthcare Center, NJ, USA
| | - Giorgia Brillanti
- Alma Mater Studiorum, University of Bologna, Department of Medical and Surgical Sciences, Bologna, Italy
| | - Elena Nardi
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford, UK
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26
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Abstract
PURPOSE OF REVIEW Home enteral nutrition (HEN) is a well-established practical nutrition therapy tool that is typically managed by an interdisciplinary team. Prevalence of HEN is increasing across the globe given significant evidence for utility, feasibility, efficacy, safety, and reliability of HEN in helping patients meeting their nutrition needs. The current review highlights the growing use of HEN in the context of what is novel in the field including trends in HEN practice with regards to tubes and connectors, feeding formula and real food blends, and common complications. The review also highlights that the use of HEN is expected to expand further over coming years emphasizing the need for national consensus recommendations and guidelines for HEN management. RECENT FINDINGS The growing use of HEN has always been parallel to adoption of holistic definitions and concept of malnutrition in clinical nutrition practice and more understanding of the need for malnutrition risk stratification, meeting unmet needs in practice and addressing challenges that lead to suboptimal enteral nutrition. SUMMARY Research and advancements in technology as well as in tube feeding formula industry have led to the development of more solutions and have helped identify and implement best HEN practices.
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Affiliation(s)
| | - Matthew Ewy
- Division of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jalpan Patel
- Division of Endocrinology, Diabetes, Metabolism and Nutrition
| | - Ishani Patel
- Division of Endocrinology, Diabetes, Metabolism and Nutrition
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27
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Watt KD, Heimbach JK, Rizk M, Jaruvongvanich P, Sanchez W, Port J, Venkatesh SK, Bamlet H, Tiedtke K, Malhi H, Acosta Cardenas A, Grothe K, Clark M, Mundi MS, Abu Dayyeh BK. Efficacy and Safety of Endoscopic Balloon Placement for Weight Loss in Patients With Cirrhosis Awaiting Liver Transplantation. Liver Transpl 2021; 27:1239-1247. [PMID: 33866660 DOI: 10.1002/lt.26074] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/25/2021] [Accepted: 04/02/2021] [Indexed: 12/13/2022]
Abstract
The efficacy and safety of a fluid-filled intragastric balloon (IGB) for weight loss in patients with cirrhosis on the liver transplantation (LT) waiting list is unknown. We enrolled stable compensated patients with body mass index >35 kg/m2 and on the waiting list for IGB placement endoscopically for a maximum of 6 months. A total of 8 patients (7 men) aged mean ± SD, 56 ± 4.6 years with Model for End-Stage Liver Disease-sodium (MELD-Na) scores 14.1 ± 3.4 experienced weight reduction (146 ± 22.2 kg versus 127 ± 21.6 kg [P = 0.005] with IGB in place and 130 ± 24.6 kg [P = 0.014] at 6 months), with a total body weight loss of 12.2% ± 8.8% with IGBs in place and 10.9% ± 8.9% at 6 months. Body fat decreased from 48.6% ± 5.8% to 40.6% ± 6.4% (P = 0.001) and lean mass increased from 51.3% ± 6% to 59.4% ± 6.4% (P = 0.001). No change in MELD-Na scores occurred (P = 0.770). Early balloon retrieval was attributed to accommodative symptoms (n = 2) and liver decompensation (n = 1). Mallory Weiss tears (n = 3), but no portal hypertensive bleeding, occurred. Liver decompensation and/or hepatocellular carcinoma (HCC) developed in 3 patients. A total of 4 patients with LT ± sleeve gastrectomy maintained overall weight loss. Of 4 patients who did not receive transplants, 2 experienced weight regain. IGB results in short-term weight loss in patients with cirrhosis awaiting LT, with body fat loss without lean mass loss. Adverse effects were common. Decompensation and HCC did occur, with uncertainty of the relation to weight loss, and thus careful patient selection and close follow-up are required.
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Affiliation(s)
- Kymberly D Watt
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | | | - Monika Rizk
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | | | - William Sanchez
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - John Port
- Department of Radiology, Mayo Clinic, Rochester, MN
| | | | - Heather Bamlet
- Department of Clinical Nutrition, Mayo Clinic, Rochester, MN
| | - Kathryn Tiedtke
- Department of Clinical Nutrition, Mayo Clinic, Rochester, MN
| | - Harmeet Malhi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | | | - Karen Grothe
- Department of Psychology, Mayo Clinic, Rochester, MN
| | - Matthew Clark
- Department of Psychology, Mayo Clinic, Rochester, MN
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28
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Spurlock AY, Johnson TW, Pritchett A, Pierce L, Hussey J, Johnson K, Carter H, Davidson SL, Mundi MS, Epp L, Hurt RT. Blenderized food tube feeding in patients with head and neck cancer. Nutr Clin Pract 2021; 37:615-624. [PMID: 34462968 PMCID: PMC9292291 DOI: 10.1002/ncp.10760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Patients with headand neck cancer (HNC) are at high risk for malnutrition before and during chemoradiation treatment. Many will also require tube feeding to address declines in energy intake, weight, and quality of life (QOL) caused by the impact of treatment on gastrointestinal (GI) symptoms. Blenderized tube feeding (BTF) may ameliorate these adverse conditions. Methods In this open‐label, prospective pilot study, 30 patients with HNC who required feeding tube placement were recruited to switch from standard commercial formula after 2 weeks to a commercially prepared BTF formula. Weight, body mass index (BMI), GI symptoms, and QOL scores were tracked for 6 weeks from the first week of feeding tube placement. Results Of the 16 patients who completed the 6‐week assessment period, weights and BMI scores for 15 patients trended upward. For most patients, QOL and oral intake increased and GI symptoms decreased over the 6‐week period, particularly during weeks 3 and 4, when the impact of treatment is particularly exacting on patients with HNC. Conclusion BTF effectively mitigated weight loss, GI symptoms, QOL scores, and total energy intake in this group of patients with HNC who received tube feeding for 6 weeks.
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Affiliation(s)
| | - Teresa W Johnson
- College of Health and Human Services, Troy University, Troy, Alabama, USA
| | | | - Leah Pierce
- Montgomery Cancer Center, Montgomery, Alabama, USA
| | - Jenna Hussey
- School of Nursing, Troy University, Troy, Alabama, USA
| | - Kelly Johnson
- School of Nursing, Troy University, Troy, Alabama, USA
| | - Holly Carter
- School of Nursing, Troy University, Troy, Alabama, USA
| | - Stephen L Davidson
- Alabama Oncology Hematology Associates at The Montgomery Cancer Center, Montgomery, Alabama, USA
| | - Manpreet S Mundi
- Division of Endocrinology, Mayo Clinic, Rochester, Minnesota, USA
| | - Lisa Epp
- Endocrinology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Ryan T Hurt
- Medicine, Mayo Clinic, Rochester, Minnesota, USA
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29
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Phelan SM, Bauer KW, Bradley D, Bradley SM, Haller IV, Mundi MS, Finney Rutten LJ, Schroeder DR, Fischer K, Croghan I. A model of weight-based stigma in health care and utilization outcomes: Evidence from the learning health systems network. Obes Sci Pract 2021; 8:139-146. [PMID: 35388341 PMCID: PMC8976541 DOI: 10.1002/osp4.553] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/19/2021] [Accepted: 07/25/2021] [Indexed: 12/16/2022] Open
Abstract
Objective Obesity is stigmatized and people with obesity report experiencing stigmatizing situations when seeking health care. The implications of these experiences are not well understood. This study tests an indirect effects model of negative care experiences as an intermediate variable between obesity and care avoidance/utilization and switching primary care doctors. Methods A survey was completed by 2380 primary care patients in the Learning Health Systems Network (LHSNet) Clinical Data Research Network with a BMI >25 kg/m2. Measures included scales assessing stigmatizing situations, perceived patient-centered communication, perceived respect, having delayed needed care, and having looked for a new primary doctor in the past 12 months. Sequential and serial indirect effects of care experiences and respect in the association between BMI and care utilization outcomes was modeled. Results The hypothesized model was supported by findings. The associations between BMI and delaying needed care (OR = 1.06, p < 0.001) and attempting to switch primary doctors (OR = 1.02, p = 0.04) was mediated by both stigmatizing situations experienced in a health care context and lower patient-centered communication. Lower perceived respect mediated the association between care experiences and utilization outcomes. Conclusions People with higher BMIs may avoid care or switch doctors as a result of stigmatizing experiences and poor communication with doctors. These outcomes may contribute to morbidity in people with obesity if they delay or avoid care for health concerns when symptoms first present.
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Affiliation(s)
- Sean M. Phelan
- Division of Health Care Delivery ResearchMayo ClinicRochesterMinnesotaUSA,Robert D. and Patricia E. Kern Center for the Science of Health Care DeliveryMayo ClinicRochesterMinnesotaUSA
| | - Katherine W. Bauer
- Department of Nutritional SciencesUniversity of Michigan School of Public HealthAnn ArborMichiganUSA
| | | | - Steven M. Bradley
- Minneapolis Heart Institute and Minneapolis Heart Institute FoundationMinneapolisMinnesotaUSA
| | - Irina V. Haller
- Essentia Institute of Rural Health, Essentia HealthDuluthMinnesotaUSA
| | - Manpreet S. Mundi
- Division of Endocrinology, Diabetes, Metabolism, and NutritionMayo ClinicRochesterMinnesotaUSA
| | | | | | - Kristin Fischer
- Robert D. and Patricia E. Kern Center for the Science of Health Care DeliveryMayo ClinicRochesterMinnesotaUSA
| | - Ivana Croghan
- Robert D. and Patricia E. Kern Center for the Science of Health Care DeliveryMayo ClinicRochesterMinnesotaUSA,Department of Quantitative Health SciencesMayo ClinicRochesterMinnesotaUSA,Department of MedicineDivision of General Internal MedicineMayo ClinicRochesterMinnesotaUSA
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Abstract
Coronavirus disease 2019 (COVID-19), after initially being detected in Wuhan, China in late 2019, quickly spread to most regions of the world, meeting World Health Organization criteria for a pandemic. Social distancing along with other measures implemented to control spread had a drastic impact on the provision of healthcare including deferred elective procedures and surgeries as well as delayed care and evaluation for emergent diagnoses such as heart attacks and strokes. In the home nutrition practice, patients began to delay routine laboratory tests and were canceling or deferring annual visits. Our group soon began to rapidly deploy telehealth to meet the needs of the home nutrition patients. Telehealth is not a new concept with descriptions of healthcare being provided at a distance with the use of telephone in the 1870s. However, widespread adoption has been limited because of regulation (licensure, prescriptions, credentialing, and privileges), lack of reimbursement, as well as adoption and availability of technology needed to carry out telehealth visits. As regulations and limits on reimbursements were waived during COVID-19 pandemic, our home nutrition practice began to evaluate core components of the care we provide for our patients and assess which could be successfully transitioned to telehealth. In addition to the history and regulation of telehealth, the current manuscript provides details regarding successful implementation of telehealth visits such as change management, selection of telehealth platform, scheduling and logistics, as well as carrying out the virtual visit including history and physical exam.
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Affiliation(s)
- Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Osman Mohamed Elfadil
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Sara L Bonnes
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Bradley R Salonen
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ryan T Hurt
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Mohamed Elfadil O, Steien DB, Narasimhan R, Velapati SR, Epp L, Patel I, Patel J, Hurt RT, Mundi MS. Transition to Peptide-Based Diet Improved Enteral Nutrition Tolerance and Decreased Healthcare Utilization in Pediatric Home Enteral Nutrition. JPEN J Parenter Enteral Nutr 2021; 46:626-634. [PMID: 34145597 PMCID: PMC9291947 DOI: 10.1002/jpen.2202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background Home enteral nutrition (HEN) use continues to increase in children unable to meet nutritional needs through oral intake. Some patients do not tolerate standard polymeric formula (SPF), which may lead to malnutrition. Use of peptide‐based diet (PBD) has demonstrated benefits in adults, however there remains a paucity of data in pediatric population. Methods Retrospective review of medical records of children receiving HEN between October 2015 and October 2019 was conducted. Nutrition, tolerance, and healthcare utilization was tracked through May 2020. Children receiving PBD as initial formula or transitioned to PBD from SPF were included. Our objective was to assess gastrointestinal tolerance and impact on healthcare utilization in children receiving PBD. Results During study period, 30 children (mean age, 9 ± 5.44 years; 20 of 30 [66.7%] male) utilized PBDs. Twenty‐one patients started PBD directly with malnutrition as primary indication. Nine patients transitioned from SPF to PBD, most often due to intolerance of SPF (66%). After transition to PBD, no symptoms were reported in 6 of 9 (66.7%) patients, and symptoms of SPF intolerance resolved in 4 of 9 (44.5%) patients. Healthcare utilization declined significantly after transition to PBD, including mean numbers of emergency room visits (0.78 ± 1.09 to 0.11 ± 0.33; P = .025), provider visits (1.67 ± 1.32 to 0.56 ± 0.73; P = .007), and phone calls (1.22 ± 1.39 to 0.33 ± 0.50; P = .026). Conclusions PBD is well tolerated and can result in significant reduction in healthcare utilization in children intolerant to SPF.
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Affiliation(s)
- Osman Mohamed Elfadil
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Dana B Steien
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Ramya Narasimhan
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Saketh R Velapati
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Lisa Epp
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Ishani Patel
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Jalpan Patel
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Ryan T Hurt
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA.,Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
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Nanda S, Chacin Suarez AS, Toussaint L, Vincent A, Fischer KM, Hurt R, Schroeder DR, Medina Inojosa JR, O'Horo JC, DeJesus RS, Abu Lebdeh HS, Mundi MS, Iftikhar S, Croghan IT. Body Mass Index, Multi-Morbidity, and COVID-19 Risk Factors as Predictors of Severe COVID-19 Outcomes. J Prim Care Community Health 2021; 12:21501327211018559. [PMID: 34024181 PMCID: PMC8150439 DOI: 10.1177/21501327211018559] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Purpose The purpose of the present study was to investigate body mass index, multi-morbidity, and COVID-19 Risk Score as predictors of severe COVID-19 outcomes. Patients Patients from this study are from a well-characterized patient cohort collected at Mayo Clinic between January 1, 2020 and May 23, 2020; with confirmed COVID-19 diagnosis defined as a positive result on reverse-transcriptase-polymerase-chain-reaction (RT-PCR) assays from nasopharyngeal swab specimens. Measures Demographic and clinical data were extracted from the electronic medical record. The data included: date of birth, gender, ethnicity, race, marital status, medications (active COVID-19 agents), weight and height (from which the Body Mass Index (BMI) was calculated, history of smoking, and comorbid conditions to calculate the Charlson Comorbidity Index (CCI) and the U.S Department of Health and Human Services (DHHS) multi-morbidity score. An additional COVID-19 Risk Score was also included. Outcomes included hospital admission, ICU admission, and death. Results Cox proportional hazards models were used to determine the impact on mortality or hospital admission. Age, sex, and race (white/Latino, white/non-Latino, other, did not disclose) were adjusted for in the model. Patients with higher COVID-19 Risk Scores had a significantly higher likelihood of being at least admitted to the hospital (HR = 1.80; 95% CI = 1.30, 2.50; P < .001), or experiencing death or inpatient admission (includes ICU admissions) (HR = 1.20; 95% CI = 1.02, 1.42; P = .028). Age was the only statistically significant demographic predictor, but obesity was not a significant predictor of any of the outcomes. Conclusion Age and COVID-19 Risk Scores were significant predictors of severe COVID-19 outcomes. Further work should examine the properties of the COVID-19 Risk Factors Scale.
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Salonen BR, Mundi MS, Hurt RT, Bonnes SL. The Role of Parenteral Nutrition for Incurable Cancer: Bridging Expectations and Reality. Curr Nutr Rep 2021; 10:226-231. [PMID: 34047939 DOI: 10.1007/s13668-021-00361-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW In this review, we examine the role for parenteral nutrition (PN) for nutritional support of patients with advanced, incurable cancer with an emphasis on bridging the divide between expectations and reality. RECENT FINDINGS As the rates of cancer have continued to rise worldwide, the utility of PN has continued to be studied. Due to multiple reasons, high-quality research studies have been scarce, and much of the data is based on observational studies. The recent trend appears to support the use of PN in carefully selected patients. Importantly, the effect on quality of life also should be considered when deciding to initiate PN. PN can be a supportive lifeline for patients with advanced, incurable cancer. The medical team should consider each patient individually to decide if PN should be offered. It is of paramount important for the medical team to engage in shared decision-making with the patient and caregiver(s) to ensure that PN is aligned with their goals and wishes.
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Affiliation(s)
- Bradley R Salonen
- Division of General Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Ryan T Hurt
- Division of General Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.,Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA.,Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.,Division of Gastroenterology, Hepatology and Nutrition, University of Louisville, Louisville, KY, USA
| | - Sara L Bonnes
- Division of General Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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Nanda S, Toussaint L, Vincent A, Fischer KM, Hurt R, Schroeder DR, Chacin Suarez AS, Medina Inojosa JR, O'Horo JC, DeJesus RS, Abu Lebdeh HS, Mundi MS, Iftikhar S, Croghan IT. A Midwest COVID-19 Cohort for the Evaluation of Multimorbidity and Adverse Outcomes from COVID-19. J Prim Care Community Health 2021; 12:21501327211010991. [PMID: 33855875 PMCID: PMC8053748 DOI: 10.1177/21501327211010991] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective To describe the process and outcome of creating a patient cohort in the early stages of the COVID-19 pandemic in order to better understand the process of and predict the outcomes of COVID-19. Patients and Methods A total of 1169 adults aged 18 years of age or older who tested positive in Mayo Clinic Rochester or the Mayo Clinic Midwest Health System between January 1 and May 23 of 2020. Results Patients were on average 43.9 years of age and 50.7% were female. Most patients were white (69.0%), and Blacks (23.4%) and Asians (5.8%) were also represented in larger numbers. Hispanics represented 16.3% of the sample. Just under half of patients were married (48.4%). Common comorbid conditions included: cardiovascular diseases (25.1%), dyslipidemia (16.0%), diabetes mellitus (11.2%), chronic obstructive pulmonary disease (6.6%), asthma (7.5%), and cancer (5.1%). All other comorbid conditions were less the 5% in prevalence. Data on 3 comorbidity indices are also available including the: DHHS multi-morbidity score, Charlson Comorbidity Index, and Mayo Clinic COVID-19 Risk Factor Score. Conclusion In addition to managing the ever raging pandemic and growing death rates, it is equally important that we develop adequate resources for the investigation and understanding of COVID-19-related predictors and outcomes.
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Mundi MS, Klek S, Martindale RG. Use of Lipids in Adult Patients Requiring Parenteral Nutrition in the Home Setting. JPEN J Parenter Enteral Nutr 2021; 44 Suppl 1:S39-S44. [PMID: 32049397 DOI: 10.1002/jpen.1755] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 09/24/2019] [Accepted: 11/11/2019] [Indexed: 12/27/2022]
Abstract
It is estimated that over 25,000 Americans receive home parenteral nutrition (HPN), mostly because of intestinal failure (IF). Although there is significant variability in the fluid and energy needs of patients receiving HPN, intravenous lipid emulsions (ILEs) are an essential part of the macronutrient composition, serving as an excellent source of non-protein energy, as well as supplying essential fatty acids. However, the long-term use of ILEs in particular may be associated with some detrimental health effects, such as intestinal failure associated liver disease (IFALD). Although there is lack of unifying diagnosis, IFALD can present as cholestasis, steatosis, or fibrosis, with a prevalence that ranges between 5% and 43%. The development of IFALD tends to be multifactorial. Risk factors of IFALD can include those related to IF, inflammation/infection, and long-term parenteral nutrition. Some studies have shown a link between development of IFALD and ILE dose, especially if the dose is >1 g/kg/d, with high ω-6:ω-3 polyunsaturated fatty acid (PUFA) ratio and phytosterol content being theorized as some contributing factors. Thus, efforts have been made to use alternative oils (olive oil, medium-chain triglycerides, and fish oil) to reduce the soybean-oil content of ILE, which tends to be high in ω-6 PUFA and phytosterols. Although additional long-term clinical data are emerging, this strategy, as reviewed in the current manuscript, has shown to provide some benefit in both prevention and treatment of IFALD and other sequelae of HPN.
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Affiliation(s)
- Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Stanislaw Klek
- Department of General and Oncology Surgery with Intestinal Failure Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | - Robert G Martindale
- Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
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Martindale RG, Berlana D, Boullata JI, Cai W, Calder PC, Deshpande GH, Evans D, Garcia-de-Lorenzo A, Goulet OJ, Li A, Mayer K, Mundi MS, Muscaritoli M, Pradelli L, Rosenthal M, Seo JM, Waitzberg DL, Klek S. Summary of Proceedings and Expert Consensus Statements From the International Summit "Lipids in Parenteral Nutrition". JPEN J Parenter Enteral Nutr 2021; 44 Suppl 1:S7-S20. [PMID: 32049392 DOI: 10.1002/jpen.1746] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 09/24/2019] [Accepted: 10/25/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND The 2018 Lipids in Parenteral Nutrition summit involved a panel of experts in clinical nutrition, lipid metabolism, and pharmacology, to assess the current state of knowledge and develop expert consensus statements regarding the use of intravenous lipid emulsions in various patient populations and clinical settings. The main purpose of the consensus statements is to assist healthcare professionals by providing practical guidance on common clinical questions related to the provision of lipid emulsions as part of parenteral nutrition (PN). METHODS The summit was designed to allow interactive discussion and consensus development. The resulting consensus statements represent the collective opinion of the members of the expert panel, which was informed and supported by scientific evidence and clinical experience. RESULTS The current article summarizes the key discussion topics from the summit and provides a set of consensus statements designed to complement existing evidence-based guidelines. Lipid emulsions are a major component of PN, serving as a condensed source of energy and essential fatty acids. In addition, lipids modulate a variety of biologic functions, including inflammatory and immune responses, coagulation, and cell signaling. A growing body of evidence suggests that lipid emulsions containing ω-3 fatty acids from fish oil confer important clinical benefits via suppression of inflammatory mediators and activation of pathways involved in the resolution of inflammation. CONCLUSIONS This article provides a set of expert consensus statements to complement formal PN guideline recommendations.
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Affiliation(s)
- Robert G Martindale
- Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - David Berlana
- Pharmacy Service, Vall d'Hebron Barcelona Hospital Campus and Department of Nutrition, University of Barcelona, Barcelona, Spain
| | - Joseph I Boullata
- Department of Nutrition Sciences, Drexel University, Philadelphia, Pennsylvania, USA.,Clinical Nutrition Support Services, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Wei Cai
- Department of Pediatric Surgery, Division of Pediatric Gastroenterology and Nutrition, Xin Hua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Philip C Calder
- Faculty of Medicine, University of Southampton, Southampton General Hospital, Southampton, UK.,NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
| | - Girish H Deshpande
- Neonatal NICU, Nepean Hospital, Kingswood, NSW, Australia.,Sydney Medical School, Nepean, University of Sydney, Australia
| | - David Evans
- Department of Surgery, Ohio State University Medical Center, Columbus, Ohio, USA
| | | | - Olivier J Goulet
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Intestinal Failure Rehabilitation Center, National Reference Center for Rare Digestive Diseases, Hospital Necker-Enfants Malades, University of Paris-Descartes, Paris, France
| | - Ang Li
- Department of General Surgery, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Konstantin Mayer
- Vidia Kliniken Karlsruhe, Medizinische Klinik IV, Karlsruhe, Germany
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Martin Rosenthal
- Department of Surgery, Division of Trauma and Acute Surgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Jeong-Meen Seo
- Division of Pediatric Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Dan L Waitzberg
- Department of Gastroenterology, Lim 35, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Stanislaw Klek
- Department of General and Oncology Surgery, Intestinal Failure Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
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Mundi MS, Hurt RT, Phelan SM, Bradley D, Haller IV, Bauer KW, Bradley SM, Schroeder DR, Clark MM, Croghan IT. Associations Between Experience of Early Childhood Trauma and Impact on Obesity Status, Health, as Well as Perceptions of Obesity-Related Health Care. Mayo Clin Proc 2021; 96:408-419. [PMID: 33549259 DOI: 10.1016/j.mayocp.2020.05.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 05/10/2020] [Accepted: 05/27/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate the association between obesity and history of childhood trauma in an effort to define implications for the provider-patient relationship and possible causes of failure of obesity treatment. METHODS Multisite survey developed by the Patient-Centered Outcomes Research Institute Learning Health Systems Obesity Cohort Workgroup consisting of 49 questions with 2 questions focusing on history of being a victim of childhood physical and/or sexual abuse was mailed to 19,964 overweight or obese patients. Data collection for this survey occurred from October 27, 2017, through March 1, 2018. RESULTS Among the 2211 surveys included in analysis, respondents reporting being a victim of childhood abuse increased significantly with obesity (23.6%, 26.0%, 29.1%, and 36.8% for overweight, class I, class II, and class III obesity, respectively; P<.001). A higher percentage of those who reported being a victim of childhood abuse noted that their weight issues began at an earlier age (P=.002) and were more likely to have weight-related comorbidities (P<.001), even after controlling for body mass index. Impacting physician counseling on weight loss, patients who were childhood victims of abuse reported lower self-esteem (P<.001), were more likely to feel judged by their health care providers (P=.009), and less likely to feel being treated with respect (P=.045). CONCLUSION Overall, being a victim of childhood abuse was significantly associated with obesity, lower self-esteem and negative experiences interacting with health care providers. Health care providers should receive training to ensure open and nonjudgmental visits with obese patients and consider the role of trauma survivorship issues in patients' development of obesity and health care experiences.
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Affiliation(s)
- Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN.
| | - Ryan T Hurt
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN; Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN; Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Sean M Phelan
- Robert D. and Patricia E. Kern Center of Science and Health Care Delivery, Mayo Clinic, Rochester, MN
| | - David Bradley
- Diabetes and Metabolism Research Center, Division of Endocrinology, Diabetes & Metabolism, Department of Internal Medicine, The Ohio State University, Columbus, OH
| | - Irina V Haller
- Department of Psychiatry and Psychology, Essentia Institute of Rural Health, Essential Health, Duluth, MN
| | - Katherine W Bauer
- Department of Nutritional Sciences, University of Michigan School of Public Health, Ann Arbor, MI
| | - Steven M Bradley
- Center for Healthcare Delivery Innovation, Minneapolis Heart Institute and Minneapolis Heart Institute Foundation Minneapolis, MN
| | - Darrell R Schroeder
- Division of Biomedical Statistics and Informatics, Department of Health Science Research, Mayo Clinic, Rochester, MN
| | - Matthew M Clark
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN; Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN
| | - Ivana T Croghan
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN; Robert D. and Patricia E. Kern Center of Science and Health Care Delivery, Mayo Clinic, Rochester, MN; Division of Community Internal Medicine, Mayo Clinic, Rochester, MN; Division of Epidemiology, Department of Health Science Research, Mayo Clinic, Rochester, MN
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Maselli DB, Alqahtani AR, Abu Dayyeh BK, Elahmedi M, Storm AC, Matar R, Nieto J, Teixeira A, Al Khatry M, Neto MG, Kumbhari V, Vargas EJ, Jaruvongvanich V, Mundi MS, Deshmukh A, Itani MI, Farha J, Chapman CG, Sharaiha R. Revisional endoscopic sleeve gastroplasty of laparoscopic sleeve gastrectomy: an international, multicenter study. Gastrointest Endosc 2021; 93:122-130. [PMID: 32473252 DOI: 10.1016/j.gie.2020.05.028] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 05/07/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Laparoscopic sleeve gastrectomy (LSG) facilitates significant and durable weight loss; however, weight recidivism and need for revisional surgery occur in a subset of patients. Reduction of a dilated LSG using the revisional endoscopic sleeve gastroplasty (R-ESG) approach is an appealing and minimally invasive alternative to surgical revision that is congruent with obesity as a chronic relapsing disease model. In this study, we examine the safety and efficacy of the technique in a large multicenter international cohort. METHODS Prospectively collected data from 9 centers for 82 consecutive adults who underwent R-ESG for weight regain after LSG using the OverStitch device (Apollo Endosurgery, Austin, Tex, USA) from March 2014 to November 2019 were reviewed. Total body weight loss (TBWL) and adverse events were reported up to 12 months. Univariable logistic regression was used to identify predictors of response at 12 months. RESULTS Eighty-two adults (92.7% female) experienced 27.9 ± 20.7 kg weight regain from post-LSG nadir weight, prompting R-ESG (mean age, 42.8 ± 10.4 years) at a mean weight of 128.2 ± 57.5 kg. Mean R-ESG procedure duration was 48.3 ± 20.5 minutes, and the median number of sutures used was 4 (interquartile range, 3-4). After R-ESG, TBWL (follow-up %) was 6.6% ± 3.2% at 1 month (81.7%), 10.6% ± 4.4% at 3 months (74.4%), 13.2% ± 10.1% at 6 months (63.4%), and 15.7% ± 7.6% at 12 months (51.2%). In a per-protocol analysis, ≥10% TBWL was achieved by 37 of 51 patients (72.5%) at 6 months and 34 of 42 patients (81.0%) at 12 months; ≥15% TBWL was achieved by 20 of 46 patients (43.5%) at 6 months and 22 of 42 patients (52.4%) at 12 months. Only 1 moderate adverse event occurred in the form of a narrowed gastroesophageal junction, which resolved after a single endoscopic dilation. CONCLUSIONS R-ESG is a safe and effective means of facilitating weight loss for weight recidivism after LSG, with sustained results at 1 year. R-ESG should be considered before pursuing more-invasive surgical revisional options.
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Affiliation(s)
- Daniel B Maselli
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Aayed R Alqahtani
- Department of Surgery, College of Medicine, King Saud University, and New You Medical Center, Riyadh, Saudi Arabia
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamed Elahmedi
- Department of Surgery, College of Medicine, King Saud University, and New You Medical Center, Riyadh, Saudi Arabia
| | - Andrew C Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Reem Matar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jose Nieto
- Borland Groover Clinic, Jacksonville, Florida
| | - Andre Teixeira
- Orlando Regional Medical Center, Orlando Health, Orlando, Florida, USA
| | - Maryam Al Khatry
- Department of Gastroenterology, Obaidulla Hospital, Ras Al Khaimah, United Arab Emirates
| | | | - Vivek Kumbhari
- Division of Gastroenterology, Johns Hopkins Medicine, Baltimore, Maryland
| | - Eric J Vargas
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | | | - Mohamad I Itani
- Division of Gastroenterology, Johns Hopkins Medicine, Baltimore, Maryland
| | - Jad Farha
- Division of Gastroenterology, Johns Hopkins Medicine, Baltimore, Maryland
| | - Christopher G Chapman
- University of Chicago Medicine, Center for Endoscopic Research and Therapeutics, Chicago, Illinois
| | - Reem Sharaiha
- Department of Gastroenterology, Weill Cornell Medicine, New York, New York, USA
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Holgerson AA, Clark MM, Frye MA, Kellogg TA, Mundi MS, Veldic M, Grothe K. Symptoms of bipolar disorder are associated with lower bariatric surgery completion rates and higher food addiction. Eat Behav 2021; 40:101462. [PMID: 33307467 DOI: 10.1016/j.eatbeh.2020.101462] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 11/11/2020] [Accepted: 11/17/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Bipolar disorder (BP) is highly comorbid with obesity, however, little is known about how BP might be associated with bariatric surgery outcomes. METHODS In this retrospective clinical cohort study, 1034 patients completed a psychological evaluation, and screening positive for possible BP was defined as a score ≥7 and moderate disability on the Mood Disorders Questionnaire. Food addiction (FA), subthreshold binge eating disorder (BED), and illegal drug use were also assessed using standardized questionnaires. RESULTS The 54 (5.2%) patients screening positive for BP were less likely to have bariatric surgery compared to 980 (94.8%) patients who screened negative for BP (5 patients or 9.3% vs 273 patients, or 27.9%). Patients with possible BP also had significantly higher prevalence of FA (37% vs 13.2%), subthreshold BED (29.6% vs 8.3%) and illegal drug use (7.4% vs 2.1%). CONCLUSIONS In this retrospective clinical cohort study, patients who screened positive for BP had a higher prevalence of food addiction, subthreshold binge eating disorder and recent illegal drug use. They also demonstrated lower completion rates for having bariatric surgery. Clearly, more needs to be learned about how to help patients with symptoms of bipolar disorder manage their obesity and behavioral challenges.
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Affiliation(s)
- Allison A Holgerson
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN 55905, USA.
| | - Matthew M Clark
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN 55905, USA.
| | - Mark A Frye
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN 55905, USA.
| | - Todd A Kellogg
- Department of Subspecialty General Surgery, Mayo Clinic, Rochester, MN 55905, USA.
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, & Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA.
| | - Marin Veldic
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN 55905, USA.
| | - Karen Grothe
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN 55905, USA.
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Wescott B, Seegmiller S, Mohamed Elfadil O, Schneckloth J, Hurt RT, Mundi MS. Seeding of Gastrostomy Tube Site in Patient With Squamous Cell Carcinoma of the Tongue: A Case Report. Nutr Clin Pract 2020; 36:648-653. [PMID: 33615591 DOI: 10.1002/ncp.10606] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Enteral nutrition (EN) is a widely used therapeutic tool to provide nutrition support for patients with various clinical conditions, including different types of cancer. Head and neck cancers, often complicated by dysphagia, are among leading indications for enteral feeding. Percutaneous endoscopic gastrostomy (PEG) and percutaneous endoscopic jejunostomy (PEJ) tubes are typically used to deliver EN. This article presents a case report of a young male with squamous cell carcinoma of the tongue. Unfortunately, he developed metastasis of his cancer at the right lateral side of the PEG placement site, requiring surgical resection of seeded growth at the PEG site. This rare complication can be challenging, as it requires a high index of suspicion to diagnose and can potentially limit nutrition support options. A number of theories have been proposed to explain seeding during PEG/PEJ placement, including direct repositioning of malignant cells during instrumentation. A specific placement technique has not been shown to be superior, as seeding was reported with all placement techniques. However, given the lack of statistically powerful studies to describe this entity, there are still gaps we need to explore to better understand seeding of feeding tubes and best practices around diagnosis and early treatment. EN continues to be an important part of caring for patients with cancer during active or palliative treatments. Understanding potential risks in the setting of cancer metastasis is beneficial to the patients and multidisciplinary teams involved. Early recognition of possible seeding of feeding tube sites is necessary to ensure subsequent timely surgical intervention.
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Affiliation(s)
- Bethaney Wescott
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Sara Seegmiller
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Osman Mohamed Elfadil
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Jill Schneckloth
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Ryan T Hurt
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA.,Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
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Velapati SR, Schroeder SE, Schroeder DR, Buttar NS, Mohamed Elfadil O, Hurt RT, Mundi MS. Use of Home Enteral Nutrition in Malnourished Post-Bariatric Surgery Patients. JPEN J Parenter Enteral Nutr 2020; 45:1023-1031. [PMID: 32997355 DOI: 10.1002/jpen.1973] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/14/2020] [Accepted: 07/22/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Bariatric surgery is by far the most effective treatment option available for successfully achieving and maintaining weight loss in the obese population, but it can also be associated with complications that lead to malnutrition. There is limited data on how enteral nutrition (EN) can be used to provide nutrition support in such cases. METHODS Retrospective review of our Home Enteral Nutrition (HEN) database was conducted from February 2013 to April 2018 to identify patients who received HEN because of bariatric surgery-related complication. RESULTS During the study period, 72 patients (86% female, mean age 50.3 ± 11.6 years) initiated HEN because of bariatric surgical complication. Most common bariatric surgery was Roux-en-Y (74%) and most common indication for HEN was malnutrition/failure to thrive (33%). HEN was most commonly provided through nasojejunal feeds and resulted in an average increase in body weight and body mass index from 74.8 kg and 26.5, respectively, before HEN to 76.9 kg and 27.2, respectively, at the end of the HEN period. Through HEN, patients received 22.2 ± 7.9 kcal/kg/d and 1.0 ± 0.3 g/kg/d protein, meeting 94% ± 17% of their energy goals and 95% ± 29% of their protein goals. Vitamin deficiencies were noted in 69% of patients at the time of HEN initiation, which improved to 10% after enteral feeds and appropriate vitamin supplementation. CONCLUSION HEN is safe and effective in treating malnutrition and vitamin deficiencies that might occur as a complication of bariatric surgery, leading to avoidance of parenteral nutrition support in most cases.
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Affiliation(s)
- Saketh R Velapati
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Darrell R Schroeder
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota, USA
| | - Navtej S Buttar
- Division of Gastroenterology, Hepatology and Nutrition, University of Louisville, Louisville, Kentucky, USA
| | - Osman Mohamed Elfadil
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Ryan T Hurt
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
- Division of Gastroenterology, Hepatology and Nutrition, University of Louisville, Louisville, Kentucky, USA
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
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42
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Mundi MS, Bonnes SL, Salonen BR, McMahon MM, Martindale R, Hurt RT. Clinical application of fish-oil intravenous lipid emulsion in adult home parenteral nutrition patients. Nutr Clin Pract 2020; 36:839-852. [PMID: 32970359 DOI: 10.1002/ncp.10581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/23/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND High-ω-6 polyunsaturated fatty acids (PUFAs) are noted to contribute to development of intestinal failure-associated liver disease (IFALD) in home parenteral nutrition (HPN). Fish oil (FO) has been added to latest generation of lipid injectable emulsion (ILE) to increase ω-3:ω-6 PUFA ratio; however, appropriate dose of FO to treat IFALD is unknown. METHODS After approval of exclusive FO ILE in the US for pediatric patients, we noted 2 adult patients with ongoing IFALD despite transition to mixed-oil (MO) ILE. They were transitioned to off-label FO ILE after review of literature regarding use of FO ILE in adult HPN patients was conducted to guide management. RESULTS The first case involves a 40-year-old female receiving HPN with IFALD refractory to MO ILE. MO ILE (with 15% FO) was provided at 50 g/d for 3 d/wk and combined with FO ILE at 50 g/d for 4 d/wk. This combination resulted in improvement in liver studies and allowed for decrease in dextrose calories. The second case involves a 49-year-old male receiving HPN (secondary to complications of necrotizing pancreatitis) who developed IFALD. FO ILE was used as the sole source of lipids and led to improvement in liver function tests. No evidence of essential fatty acid deficiency was found in either case. CONCLUSIONS Current case presentations and review of literature support the use of FO ILE to increase ω-3 PUFAs in patients with IFALD refractory to MO ILE. Additional research is necessary to delineate the dose of FO ILE necessary to achieve benefit.
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Affiliation(s)
- Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Sara L Bonnes
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Bradley R Salonen
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - M Molly McMahon
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert Martindale
- Division of Gastrointestinal and General Surgery, Oregon Health Science University, Portland, Oregon, USA
| | - Ryan T Hurt
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA.,Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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43
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Hurt RT, Ebbert JO, Croghan I, Nanda S, Schroeder DR, Teigen LM, Velapati SR, Mundi MS. The Comparison of Segmental Multifrequency Bioelectrical Impedance Analysis and Dual-Energy X-ray Absorptiometry for Estimating Fat Free Mass and Percentage Body Fat in an Ambulatory Population. JPEN J Parenter Enteral Nutr 2020; 45:1231-1238. [PMID: 32794583 DOI: 10.1002/jpen.1994] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 08/07/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Despite malnutrition being associated with increased mortality and morbidity, there continues to be great difficulty in defining criteria and implementing widespread screening. Tools used to diagnose decreased fat-free mass (FFM [sarcopenia]) should be easy to use, relatively inexpensive, and safe. Bioelectrical impedance analysis (BIA) has the potential to meet these criteria, but reliability across body mass index (BMI) classes is a concern. METHODS A total of 176 healthy ambulatory participants (aged 18-65 years) were recruited equally (n = 44) in 4 BMI categories: (1) 18.5-24.9, (2) 25.0-29.9, (3) 30-34.9, and (4) ≥35.0. Participants were fasting overnight and had S-MFBIA (InBody 770) measurements the next morning, with DXA being performed subsequently within 30 minutes. RESULTS The measurement (mean ± SD) for FFM with DXA was 52.8 ± 11.0, and BIA was 53.6 ± 11.0. Delta (S-MFBIA vs DXA) was 0.8 ± 2.2 (5% limits of agreement -3.5 to +5.2), and concordance correlation coefficient (CCC) was 0.98 (95% CI, 0.97-0.98). The measurements (mean ± SD) for PBF with DXA was 37.5 ± 10.6% and S-MFBIA was 36.6 ± 11.3%. Delta (S-MFBIA vs DXA) was -0.9 ± 2.6 (5% limits of agreement 6.0 to +4.2), and CCC was 0.97 (95% CI, 0.96-0.98). The CCC according to the 4 BMI groups for FFM and PBF was between 0.96-0.98 and 0.90-0.94, respectively. CONCLUSIONS FFM and PBF measured by S-MFBIA had good agreement with DXA across all BMI categories measured in the current study of ambulatory participants.
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Affiliation(s)
- Ryan T Hurt
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA.,Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jon O Ebbert
- Division of Community Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ivana Croghan
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Division of Community Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Sanjeev Nanda
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Levi M Teigen
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Saketh R Velapati
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
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Abstract
PURPOSE OF REVIEW Obesity and its related comorbidities make up a large part of healthcare expenditures. Despite a wide array of options for treatment of obesity, rates of sustained weight loss continue to be low, leading patients to seek alternative treatment options. Although the first medically utilized ketogenic diet was described nearly 100 years ago, it has made a resurgence as a treatment option for obesity. Despite increased popularity in the lay public and increased use of ketogenic dietary strategies for metabolic therapy, we are still beginning to unravel the metabolic impact of long-term dietary ketosis. RECENT FINDINGS There are a number of recent trials that have highlighted the short- and long-term benefits of ketogenic diet on weight, glycemic control, and other endocrine functions including reproductive hormones. This review is a summary of available data on the effectiveness and durability of the ketogenic diet when compared to conventional interventions. Ketogenic dietary strategies may play a role in short-term improvement of important metabolic parameters with potential for long-term benefit. However, response may vary due to inter-individual ability to maintain long-term carbohydrate restriction.
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Affiliation(s)
| | - Meera Shah
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
| | - Saketh Velapati
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA
| | - Victoria M Gershuni
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Tamim Rajjo
- Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sanjeev Nanda
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ryan T Hurt
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA.,Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA.,Division of Gastroenterology, Mayo Clinic, Rochester, MN, USA
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA.
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45
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Mohamed Elfadil O, Bonnes SL, Salonen BR, Vellapati S, Patel J, Narasimhan R, Hurt RT, Mundi MS. New Uses for a New Oil: Clinical Applications of Fish Oil Lipid Emulsion. Curr Surg Rep 2020. [DOI: 10.1007/s40137-020-00259-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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46
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Lal S, Van Gossum A, Joly F, Bozzetti F, Cuerda C, Lamprecht G, Mundi MS, Staun M, Szczepanek K, Wanten G, Wheatley C, Pironi L. Considerations for the management of home parenteral nutrition during the SARS-CoV-2 pandemic: A position paper from the Home Artificial Nutrition and Chronic Intestinal Failure Special Interest Group of ESPEN. Clin Nutr 2020; 39:1988-1991. [PMID: 32487434 PMCID: PMC7253968 DOI: 10.1016/j.clnu.2020.05.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 05/15/2020] [Accepted: 05/18/2020] [Indexed: 12/29/2022]
Abstract
The management of patients with chronic intestinal failure requiring home parenteral nutrition has been and will continue to be impaired during the SARS-CoV-2 pandemic. Multidisciplinary intestinal failure teams may have to adapt their clinical approaches to home care, outpatient care as well as hospital admission and discharge in order to keep this vulnerable group of patients as safe and well as possible during the unprecedented challenges that countries are facing during the pandemic. Equally, it is important that expert advice from intestinal failure teams is available when home parenteral nutrition (HPN)-dependent patients require admission with SARS-CoV-2 infection. The Home Artificial Nutrition & Chronic Intestinal Failure Special Interest Group of the European Society for Clinical Nutrition and Metabolism (ESPEN) has developed a position paper to outline areas for intestinal failure teams to consider when managing patients with chronic intestinal failure during the SARS-CoV-2 pandemic.
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Affiliation(s)
- Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust and University of Manchester, Manchester, Stott Lane, Salford, M6 8HD, UK.
| | - Andre Van Gossum
- Medico-Surgical Department of Gastroenterology, Hˆopital Erasme, Free University of Brussels, Belgium
| | - Francisca Joly
- Centre for Intestinal Failure, Department of Gastroenterology and Nutritional Support, Hˆopital Beaujon, Clichy, France
| | | | - Cristina Cuerda
- Nutrition Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Georg Lamprecht
- Division of Gastroenterology and Endocrinology, University Medical Center Rostock, Germany
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Michael Staun
- Rigshospitalet, Department of Gastroenterology, Copenhagen, Denmark
| | - Kinga Szczepanek
- General and Oncology Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland
| | - Geert Wanten
- Intestinal Failure Unit, Department of Gastroenterology and Hepatology, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | | | - Loris Pironi
- Clinical Nutrition and Metabolism Unit and Center for Chronic Intestinal Failure, Department of Digestive System, St. Orsola-Malpighi University Hospital, Bologna, Italy
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47
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Mundi MS, Velapati S, Kuchkuntla AR, Hurt RT. Reduction in Healthcare Utilization With Transition to Peptide-Based Diets in Intolerant Home Enteral Nutrition Patients. Nutr Clin Pract 2020; 35:487-494. [PMID: 32149433 DOI: 10.1002/ncp.10477] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Since the introduction of percutaneous endoscopic gastrostomy in the 1980s, the prevalence of home enteral nutrition (HEN) support has increased significantly. Despite these increases, many patients are unable to tolerate standard polymeric formulas (SPFs), resulting in significant healthcare resource utilization. Peptide-based diets (PBDs) have emerged as a viable option in SPF-intolerant patients; however, data in the HEN population are lacking. METHODS Retrospective review of our prospectively maintained HEN database was conducted to assess tolerance, efficacy, and impact on healthcare utilization in patients on PBDs. RESULTS From January 1, 2016, to May 1, 2018, 95 patients were placed on PBDs, with 53 patients being started directly and 42 patients being transitioned from SPFs. In patients transitioned to PBDs, symptoms of nausea and vomiting, diarrhea, abdominal pain, and distention improved significantly. Healthcare utilization also declined significantly, including mean number of phone calls (1.8 ± 1.6 to 1.1 ± 0.9, P = 0.006), mean number of emergency room visits (0.3 ± 0.6 to 0.09 ± 0.3, P = 0.015), and mean number of provider visits (1.3 ± 1.3 to 0.3 ± 0.5, P < 0.0001). CONCLUSIONS Overall, PBDs were well tolerated and resulted in significant improvements in symptoms of gastrointestinal distress and healthcare utilization in patients intolerant to SPFs.
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Affiliation(s)
- Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Saketh Velapati
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Aravind R Kuchkuntla
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Ryan T Hurt
- Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
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48
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Milton DL, Johnson TW, Johnson K, Murphy B, Carter H, Hurt RT, Mundi MS, Epp L, Spurlock AY, Hussey J. Accepted Safe Food‐Handling Procedures Minimizes Microbial Contamination of Home‐Prepared Blenderized Tube‐Feeding. Nutr Clin Pract 2020; 35:479-486. [DOI: 10.1002/ncp.10450] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Debra L. Milton
- Department of Biological and Environmental Sciences Troy University Troy Alabama USA
| | | | | | - Brie Murphy
- Department of Biological and Environmental Sciences Troy University Troy Alabama USA
| | - Holly Carter
- School of Nursing, Troy University Troy Alabama USA
| | | | | | - Lisa Epp
- Mayo Clinic Rochester Alabama USA
| | | | - Jenna Hussey
- School of Nursing, Troy University Troy Alabama USA
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Abstract
The global prevalence of nonalcoholic fatty liver disease (NAFLD) is estimated to be 25% and continues to rise worldwide in the setting of the obesity epidemic. This increase is especially concerning because NAFLD is often a progressive disease that can be associated with significant complications such as liver cirrhosis, hepatocellular carcinoma, and an increase in liver-related and overall mortality. Because of the devastating complications and comorbidities, NAFLD is a very costly disease for the healthcare system, with estimated annual direct medical costs exceeding $100 billion in the United States alone. Given this progressive course, it is imperative to make the diagnosis in patients with risk factors (metabolic syndrome, weight gain, and insulin resistance/diabetes). Once the diagnosis is made, the focus should shift to treatment and monitoring for the development of associated complications. Given that currently no pharmaceutical intervention is approved for the treatment of NAFLD, focus shifts instead to mitigation of risk factors through avoidance of foods that are rich in red meat, trans fats, refined carbohydrates, and high-fructose corn syrup; are low fiber; and have high energy density. The landmark of treatment, however, continues to be weight loss and improvement of insulin resistance, often through a multimodality approach. The current manuscript reviews the clinical phenotypes of NAFLD, its risk factors, and pathogenesis, as well as treatment options including lifestyle modifications and dietary interventions, medical therapies, endoscopic bariatric interventions, and bariatric surgery.
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Affiliation(s)
- Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Saketh Velapati
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Janki Patel
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA
| | - Todd A Kellogg
- Division of Breast, Endocrine, Metabolic, and GI surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ryan T Hurt
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota, USA.,Division of Breast, Endocrine, Metabolic, and GI surgery, Mayo Clinic, Rochester, Minnesota, USA.,Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA.,Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville, Louisville, Kentucky, USA
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50
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Affiliation(s)
- Jayshil J Patel
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee
| | - Manpreet S Mundi
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota
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