[Show abstract][Hide abstract] ABSTRACT: Background and aims
Inoperable bowel obstruction is the most common and judicious indication for long term parenteral nutrition in patients with palliative malignancy. Considerable uncertainty exists about the survival length, quality of life (QOL) and associated health economics of home parenteral nutrition (HPN) for this patient group.
A systematic review was carried out for survival length and QOL of adult patients treated with HPN due to malignancy causing inoperable bowel obstruction in the palliative phase. Whenever possible, individual patient data were extracted to allow meta-analyses. Health economic evaluation was undertaken to calculate cost and incremental cost effectiveness ratio (ICER).
Twelve studies involving 437 patients, met the inclusion criteria. Meta-analyses of extracted survival length data, representing the largest published cohort of HPN patients with palliative malignancy and inoperable bowel obstruction (n = 244 patients), revealed a mean survival of 116 days, median 83 days, with 45% and 24% still alive at 3 and 6 months, and only 2% survival at one year. Limited evidence suggests QOL deteriorated before death in a highly symptomatic group. The ICER is £176,587 per quality adjusted life year.
This is the first health economic evaluation and systematic review of survival and QOL for patients with inoperable bowel obstruction receiving HPN during the palliative phase of malignancy. Meta-analyses reveal a short survival and health economic analysis demonstrates high associated costs. This information can be used by clinicians to inform and guide selection of patients in this cohort for HPN treatment.
[Show abstract][Hide abstract] ABSTRACT: Background
Malnutrition is common amongst hospitalised older patients and associated with increased morbidity and mortality. Poor dietary intake results from factors including acute illness and cognitive impairment but additionally patients may have difficulty managing at mealtimes. Use of volunteers to help at mealtimes is rarely evaluated.Objectives
To obtain multiple perspectives on nutritional care of older inpatients, acceptability of trained volunteers and identify important elements of their assistance.DesignA qualitative study 1 year before and after introduction of volunteer mealtime assistants on one ward and parallel comparison with a control ward in a Medicine for Older People department at a UK university hospital.Participants and methodsSemi-structured interviews and focus groups, in baseline and intervention years, with purposively sampled nursing staff at different levels of seniority; patients or close relatives; and volunteers.ResultsAt baseline staff felt under pressure with insufficient people assisting at mealtimes. Introducing trained volunteers was perceived by staff and patients to improve quality of mealtime care by preparing patients for mealtimes, assisting patients who needed help, and releasing nursing time to assist dysphagic or drowsy patients. There was synergy with other initiatives, notably protected mealtimes. Interviews highlighted the perceived contribution of chronic poor appetite and changes in eating patterns to risk of malnutrition.Conclusions
Improved quality of mealtime care attributed to volunteers’ input has potential to enhance staff morale and patients’/relatives’ confidence. A volunteer mealtime assistance scheme may work best when introduced in context of other changes reflecting commitment to improving nutrition.Implications for practice(i) A mealtime assistance scheme should incorporate training, supervision and support for volunteers; (ii) Good relationships and a sense of teamwork can develop between wards staff and volunteers; (iii) Impact may be maximised in the context of ‘protected mealtimes’.
International Journal of Older People Nursing 08/2014; 10(2). DOI:10.1111/opn.12064
[Show abstract][Hide abstract] ABSTRACT: Background: Recommendations effectively restrict the infusion duration of lipid-containing parenteral nutrition (PN) from a single bag, purportedly because it encourages growth of potential microbial contaminants more than lipid-free PN. Since other variables, including osmolarity, may independently affect microbial growth, this study examined variables affecting growth of Escherichia coli and Enterococcus durans in PN infusates. Materials and Methods: Growth of E coli and E durans was assessed in quadruplicate in 12 different PN infusates, with and without lipid, in varying glucose concentrations. Results: Results are presented as mean log10 colony-forming units (cfu)/mL ± SEM at 48 hours. The log10cfu/mL of both E coli and E durans in PN increased considerably after adjustment for baseline log10cfu/mL and pH, from 1.093 to 2.241 (P < .001) and from 0.843 to 3.451 (P < .001) respectively. Growth of each microorganism was independently increased by lipid inclusion, or increasing the proportion of nonnitrogen energy from lipid, and reduced by raising the glucose concentration or energy density. Increasing the osmolarity of lipid-PN with glucose or sodium chloride reduced growth but only significantly for sodium chloride (E coli, P = .025; E durans, P = .045). Induced changes in pH affected the growth of the 2 organisms differently. Conclusion: The presence of lipid and an increasing proportion of energy from lipid in PN favored the growth of E coli and E durans. Osmolarity changes and the nutrient type causing these changes independently affect the growth of these microbes. Each effect needs to be considered when establishing guidelines based on the growth of potential contaminants in different types of PN.
Journal of Parenteral and Enteral Nutrition 06/2014; DOI:10.1177/0148607114538456 · 3.14 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: There is controversy about the indications for home parenteral nutrition (HPN) during the palliative phase of malignancy causing inoperable gastrointestinal obstruction (IBO). This is partly due to uncertainty about the survival of patients. This study aimed to establish the survival characteristics of these patients in order to inform decisions about the use of HPN.
Gut 06/2014; 63(Suppl 1):A12-A13. DOI:10.1136/gutjnl-2014-307263.25 · 13.32 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To determine the feasibility and acceptability of using trained volunteers as mealtime assistants for older hospital inpatients.
Poor nutrition among hospitalised older patients is common in many countries and associated with poor outcomes. Competing time pressures on nursing staff may make it difficult to prioritise mealtime assistance especially on wards where many patients need help.
Mixed methods evaluation of the introduction of trained volunteer mealtime assistants on an acute female medicine for older people ward in a teaching hospital in England.
A training programme was developed for volunteers who assisted female inpatients aged 70 years and over on weekday lunchtimes. The feasibility of using volunteers was determined by the proportion recruited, trained, and their activity and retention over one year. The acceptability of the training and of the volunteers' role was obtained through interviews and focus groups with 12 volunteers, nine patients and 17 nursing staff.
Fifty-nine potential volunteers were identified: 38 attended a training session, of whom 29 delivered mealtime assistance, including feeding, to 3911 (76%) ward patients during the year (mean duration of assistance 5·5 months). The volunteers were positive about the practical aspects of training and ongoing support provided. They were highly valued by patients and ward staff and have continued to volunteer.
Volunteers can be recruited and trained to help acutely unwell older female inpatients at mealtimes, including feeding. This assistance is sustainable and is valued.
This paper describes a successful method for recruitment, training and retention of volunteer mealtime assistants. It includes a profile of those volunteers who provided the most assistance, details of the training programme and role of the volunteers and could be replicated by nursing staff in other healthcare units.
[Show abstract][Hide abstract] ABSTRACT: Background:Mosttechniquesformeasuringbodycompositionare basedon2-componentmodels(2-CMs)anddependonassumptions relating to the constancy of the density (DFFM) and hydration frac- tion (HFFFM) of fat-free mass (FFM). Objectives: The objectives were to determine whether these as- sumptions are systematically violated in patients with cirrhosis and to assess the validity of the estimates of body composition obtained in these patients by using 2-CM techniques. Design: Body composition was assessed by using a 4-component model (4-CM), which was based on data obtained from densitome- try,deuteriumdilution,anddual-energyX-rayabsorptiometry,in20 patients with cirrhosis who had no evidence of fluid retention and in 20pair-matchedhealthycontrolsubjects.Theresultswerecompared with those obtained by using "reference" and "bedside" 2-CM tech- niques. Results: The mean (SD) DFFM was significantly lower in the patientswithcirrhosis(1.0910.008comparedwith1.1000.006 kg/L; P 0.001); no significant difference in HFFFM was observed betweenthepatientsandcontrolsubjects(74.52.6comparedwith 73.5 2.1), although there was greater variability in the patients. Significantdifferenceswereobservedinthebody-compositionvari- ables obtained by using the "reference" 2-CM techniques compared with the 4-CM—the 95% limits of agreement in the patients with cirrhosis exceeded 5% body fat and 3 kg FFM; the corresponding valuesforthe"bedside"2-CMtechniqueswere11%bodyfatand7.5 kg FFM. Conclusions: Assumptions relating to the constancy of the DFFM and HFFFM are violated in patients with cirrhosis. Thus, standard 2-CM techniques provide inaccurate body composition estimates in this patient population. Am J Clin Nutr 2006;84:1151-62.
[Show abstract][Hide abstract] ABSTRACT: The adverse effects of disease-related malnutrition (DRM) on health care use and costs are well substantiated. However, the impact of managing DRM with nutritional support on health care use, including hospital (re)admissions requires exploration. This systematic review (9 RCT, n=1190) examined the effects of oral nutritional supplements (ONS) on hospital (re)admissions. Meta-analysis of 6 RCT (n=852) with data on the proportion of patients (re)admitted to hospital showed significant reductions with ONS vs. routine care (OR 0.59, 95% CI 0.43 to 0.80, P=0.001), including 5 RCT (n=826) that recorded readmissions (OR 0.59, 95% CI 0.43 to 0.80), P=0.001). The significant reduction in (re)admissions was found in meta-analyses of ONS trials in various settings and in patients with DRM or of varied nutritional status. A larger meta-analysis (8 RCT, n=999) that combined other (re)admissions data using standardised differences also showed a significant reduction with ONS (effect size -0.23, 95% CI -0.36 to -0.10, P=0.001). Most of these trials (75%) were in older people aged ≥65 years (6 RCT, n=834, effect size -0.18, 95% CI -0.31 to -0.04, P=0.011). This systematic review shows that ONS significantly reduce hospital (re)admissions, particularly in older patient groups, with economic implications for health care.
Ageing research reviews 07/2013; 12(4). DOI:10.1016/j.arr.2013.07.002 · 7.63 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Because lipid putatively encourages contaminant growth it has been proposed that infusion of lipid-containing parenteral nutrition (PN) bags should be restricted to 24 h (48 h or longer if lipid free). This study aimed to examine this proposal by identifying factors affecting Candida albicans growth in PN.
C. albicans growth was assessed in quadruplicate in 12 PN infusates, with and without lipid and varying glucose concentrations.
The results are presented as mean ± SEM. Baseline log10 colony forming units (cfu)/mL (1.806 ± 0.015) increased substantially by 48 h in the PN infusates (to 3.731 ± 0.059). In PN infusates (pH 6.14 ± 0.01) growth was unaffected by the presence of 5% w/v lipid (0.246 ± 0.156 log10 cfu/mL decrease; P = 0.127), and independently suppressed by increasing glucose concentration (0.438 ± 0.174 log10 cfu/mL decrease per 10% increase in w/v glucose; P = 0.018). In a separate analysis growth was suppressed by increasing energy density (0.520 ± 0.179 log10 cfu/mL decrease per 1000 kcal non-nitrogen energy in 2 L; P = 0.007), without a significant effect of % non-nitrogen energy from lipid (0.056 ± 0.036 log10 cfu/ml increase per 10%; P = 0.082).
Using a framework developed to examine growth of potential contaminants in PN, the inclusion of lipid emulsion in PN produced no specific effect on the growth of C. albicans, other than by increasing energy density. Growth was independently suppressed by increasing either glucose concentration or non-nitrogen energy density.
[Show abstract][Hide abstract] ABSTRACT: This study examined an electronic nutritional self-screening procedure for feasibility and for reliability, rapidity, and ease of use by hospital outpatients.
One hundred sixty consecutive patients (ages 18-87 y) attending a gastroenterology clinic measured their weight and height using a modified digital weight and height machine, which transmitted results to a computer. Following input of reported weight loss in the previous 3 mo to 6 mo, malnutrition risk by the Malnutrition Universal Screening Tool (MUST) was instantaneously calculated. The duration and ease of undertaking screening were noted. Screening also was undertaken by a health care professional.
Of the patients in the study, 21.3% were at risk for malnutrition (medium + high risk). There was perfect agreement (kappa = 1.00) between self-screening and health care professional screening, between test-retest self-screening, and between two methods of measuring height (facing toward and away from the stadiometer). A low within-patient coefficient of variation was found for measurement of weight (<0.2%), height (<0.35%) and body mass index (<0.4%), except for two measurements in which height was recorded before correct positioning of the sliding headpiece. The overall time to self-screen was 1.29 ± 0.57 min but it was 2.81 ± 0.92 min in those aged ≥ 75 y. Of the participants, 96.2% rated self-screening as very easy (71.9%) or easy (24.3%) and 3.8% (predominantly patients ages ≥ 75 y) difficult.
The study provides evidence that electronic nutritional self-screening can be rapid, easy, reliable, and feasible in a clinical setting. Equipment specifically designed for self-screening and use in other types of patients and settings could facilitate appropriate and routine implementation of self-screening.
[Show abstract][Hide abstract] ABSTRACT: Background: Handwritten recycled paper prescription for parenteral nutrition (PN) may become a concentrated source of viable contaminants, including pathogens. This study examined the effect of using fresh printouts of electronic prescriptions on these contaminants. Materials and Methods: Cellulose sponge stick swabs with neutralizing buffer were used to sample the surfaces of PN prescriptions (n = 32 handwritten recycled; n = 32 printed electronic) on arrival to the pharmacy or following printing and PN prescriptions and bags packaged together during delivery (n = 38 handwritten recycled; n = 34 printed electronic) on arrival to hospital wards. Different media plates and standard microbiological procedures identified the type and number of contaminants. RESULTS: Staphylococcus aureus, fungi, and mold were infrequent contaminants. Nonspecific aerobes more frequently contaminated handwritten recycled than printed electronic prescriptions (into pharmacy, 94% vs 44%, Fisher exact test P < .001; onto wards, 76% vs 50%, P = .028), with greater numbers of colony-forming units (CFU) (into pharmacy, median 130 [interquartile range (IQR), 65-260] vs 0 [0-75], Mann-Whitney U test, P < .001; onto wards, median 120 [15-320] vs 10 [0-40], P = .001). Packaging with handwritten recycled prescriptions led to more frequent nonspecific aerobic bag surface contamination (63% vs 41%, Fisher exact test P = .097), with greater numbers of CFU (median 40 [IQR, 0-80] vs 0 [0-40], Mann-Whitney U test, P = .036). Conclusion: The use of printed electronic PN prescriptions can reduce microbial loads for contamination of surfaces that compromises aseptic techniques.
Journal of Parenteral and Enteral Nutrition 03/2013; 38(2). DOI:10.1177/0148607113480182 · 3.14 Impact Factor