Differences in essential fatty acid requirements by enteral and parenteral routes of administration in patients with fat malabsorption.
BACKGROUND: Essential fatty acid (EFA) requirements of patients receiving home parenteral nutrition (HPN) are uncertain. OBJECTIVE: The objective was to evaluate the influence of the route of administration (enteral compared with parenteral) on plasma phospholipid EFA concentrations. DESIGN: Intestinal absorption, parenteral supplement of EFAs, and plasma phospholipid EFA concentrations were investigated in balance studies in 4 groups (A, B, C, and D) of 10 patients with short-bowel syndrome and a fecal loss of >2000 kJ/d. Groups A (fat malabsorption <50%) and B (fat malabsorption >50%) did not receive HPN, whereas group C received HPN containing lipids (7.5 and 1.2 g/d linoleic and linolenic acids, respectively) and group D received fat-free HPN. RESULTS: Intestinal absorption of linoleic and linolenic acids was 8.9 and 1.3 g/d and 2. 6 and 0.4 g/d in groups A and B, respectively, whereas EFA absorption was negligible in groups C and D. Thus, intestinal absorption of EFAs in group A corresponded to parenteral EFA supplements in group C, whereas group D was almost totally deprived of EFAs. The median plasma phospholipid concentration of linoleic acid decreased by 21.9%, >16.3%, >13.8%, 11.0%, and >7.7% and linolenic acid by 0.3%, 0.2%, 0.2%, >0.2%, and 0.1%, respectively, in 10 healthy control subjects and groups A, B, C, and D (P < 0.001). CONCLUSIONS: Intestinally absorbed EFAs maintained plasma EFA status better than did an equal quantity of parenterally supplied EFAs. Intravenous requirements of EFAs in patients with negligible absorption of EFAs are probably higher than the amounts recommended to patients with preserved intestinal absorption of EFAs. (+info)
Intestinal failure defined by measurements of intestinal energy and wet weight absorption.
BACKGROUND AND AIMS: Intestinal failure defined by the minimal energy and wet weight absorption required to avoid home parenteral nutrition (HPN) is not well described. Thus the aim of this study was to identify the minimal level of gut function necessary to avoid parenteral support using objective measurements of intestinal function. METHODS: Energy (bomb calorimetry) and wet weight absorption were measured during 48 hour balance studies in 45 HPN patients with intestinal failure and in 44 non-HPN borderline patients with a short bowel or malabsorption exceeding 2 MJ/day. RESULTS: In the non-HPN patients, the lower 5% confidence interval of the absorption of energy was 84% of the basal metabolic rate (BMR, the Harris-Benedict equations), equivalent to 4.9 MJ/day. Wet weight absorption was 1.4 kg/day. The HPN patients absorbed less of either or both. The non-HPN patients absorbed 24-86% (range) of the energy and 23-95% of the wet weight. Absorption in the HPN patients ranged from below 0% (net secretion) in patients with very short bowels to 100% absorption of an insufficient oral intake in patients with pseudo-obstruction. Non-HPN patients who absorbed less than half of their intake avoided HPN by hyperphagia (200-400% of BMR equivalent to 10-24 MJ/day, and 3-7 kg/day of wet weight). CONCLUSION: Intestinal failure was accurately measured as absorption below 1.4 kg/day of wet weight and 84% of the calculated BMR (depending on weight, sex and age), which is equal to 4.9 MJ/day. Intestinal absorption, expressed as a percentage of intake, did not discriminate between patients with and without intestinal failure, except for patients who absorbed less than 25% of their intake. (+info)
Nutritional support at home and in the community.
Technical developments in feeding, together with the growth of support structures in the community has lead to a steady increase in the number of children receiving home enteral tube feeding and home parenteral nutrition. In many cases the adverse nutritional consequences of disease can be ameliorated or prevented, and long term parenteral nutrition represents a life saving intervention. Careful follow up of children receiving home nutritional therapy is necessary to establish the ratio of risks to benefits. A considerable burden is sometimes placed on family or other carers who therefore require adequate training and ongoing support. The respective responsibilities of different agencies relating to funding and support tasks require more clear definition. (+info)
Evaluation of indexes of in vivo manganese status and the optimal intravenous dose for adult patients undergoing home parenteral nutrition.
BACKGROUND: There are no accurate indexes for determining the status of manganese in humans, and there is no clear recommended daily dose of this essential trace element to be administered in total parenteral nutrition solutions. OBJECTIVE: The objectives were to evaluate accurate indexes of manganese status and elucidate the optimal manganese dose to be administered to adult patients undergoing home parenteral nutrition. DESIGN: Patients were administered total parenteral nutrition solutions providing 0, 1, 2, or 20 micromol Mn/d according to an on-off design, after which manganese concentrations in whole blood and plasma were determined. Magnetic resonance imaging (MRI) was performed to determine the intensity on T(1)-weighted images (MRI intensity) and T(1) values in the globus pallidus. Hematologic and biochemistry tests were also performed. RESULTS: High degrees of correlation were found between whole-blood manganese concentrations and both MRI intensity (r = 0.7728) and T(1) values (r = -0.7519) in the globus pallidus. A strong negative correlation was found between MRI intensity and T(1) values (r = -0.8407). The dose of 1 micromol Mn/d caused no change in MRI intensity or T(1) values, and the whole-blood manganese concentration remained within the normal range in all patients. CONCLUSIONS: Whole-blood manganese concentrations and MRI intensity and T(1) values in the globus pallidus are useful indexes of the status of manganese in humans. The optimal dose of manganese may be 1 micromol/d for adult patients undergoing home parenteral nutrition. (+info)
Effect of cyclical intravenous clodronate therapy on bone mineral density and markers of bone turnover in patients receiving home parenteral nutrition.
BACKGROUND: Patients receiving home parenteral nutrition (HPN) because of intestinal failure are at high risk of developing osteoporosis. OBJECTIVE: We studied the effect of the bisphosphonate clodronate on bone mineral density (BMD) and markers of bone turnover in HPN patients. DESIGN: A 12-mo, double-blind, randomized, placebo-controlled trial was conducted to study the effect of 1500 mg clodronate, given intravenously every 3 mo for 1 y, in 20 HPN patients with a bone mass T score of the hip or lumbar spine of less than -1. The main outcome measure was the difference in the mean percentage change in the BMD of the lumbar spine measured by dual-energy X-ray absorptiometry. Secondary outcome measures included changes in the BMD of the hip, forearm, and total body and biochemical markers of bone turnover, ie, serum osteocalcin, urinary pyridinoline, and urinary deoxypyridinoline. RESULTS: The mean (+/-SEM) BMD of the lumbar spine increased by 0.8 +/- 2.0% in the clodronate group and decreased by 1.6 +/- 2.0% in the placebo group (P = 0.43). At all secondary skeletal sites (ie, hip, total body, and distal forearm), we observed no changes or small increases in the BMD of the clodronate group and decreases in the BMD of the placebo group. In the clodronate group, biochemical markers of bone resorption decreased significantly (P < 0.05). CONCLUSIONS: Clodronate significantly inhibits bone resorption as assessed by changes in biochemical markers of bone turnover. Although the mean BMD increased in the clodronate group, cyclic clodronate therapy failed to increase spinal BMD significantly at 12 mo. (+info)
Patients' perspectives on high-tech home care: a qualitative inquiry into the user-friendliness of four technologies.
BACKGROUND: The delivery of technology-enhanced home care is growing in most industrialized countries. The objective of our study was to document, from the patient's perspective, how the level of user-friendliness of medical technology influences its integration into the private and social lives of patients. Understanding what makes a technology user-friendly should help improve the design of home care services. METHODS: Four home care interventions that are frequently used and vary in their technical and clinical features were selected: Antibiotic intravenous therapy, parenteral nutrition, peritoneal dialysis and oxygen therapy. Our qualitative study relied on the triangulation of three sources of data: 1) interviews with patients (n = 16); 2) interviews with carers (n = 6); and 3) direct observation of nursing visits of a different set of patients (n = 16). Participants of varying socioeconomic status were recruited through primary care organizations and hospitals that deliver home care within 100 km of Montreal, the largest urban area in the province of Quebec, Canada. RESULTS: The four interventions have both a negative and positive effect on patients' lives. These technologies were rarely perceived as user-friendly, and user-acceptance was closely linked to user-competence. Compared with acute I.V. patients, who tended to be passive, chronic patients seemed keener to master technical aspects. While some of the technical and human barriers were managed well in the home setting, engaging in the social world was more problematic. Most patients found it difficult to maintain a regular job because of the high frequency of treatment, while some carers found their autonomy and social lives restricted. Patients also tended to withdraw from social activities because of social stigmatization and technical barriers. CONCLUSIONS: While technology contributes to improving the patients' health, it also imposes significant constraints on their lives. Policies aimed at developing home care must clearly integrate principles and resources supporting the appropriate use of technology. Close monitoring of patients should be part of all technology-enhanced home care programs. (+info)
Crohn's disease over 20 years after diagnosis in a referral population.
OBJECTIVES: Patients frequently ask questions about the lifetime prognosis of Crohn's disease. The aim of this study was to describe the outcomes of Crohn's disease more than 20 years after diagnosis. METHODS: Data from all patients with Crohn's disease whose diagnosis had been performed before 1st January 1978 were analyzed. All referred patients filled in a medical and health-related quality-of-life questionnaire. RESULTS: Among 273 patients with Crohn's disease diagnosed more than 20 years ago, 141 (52%) patients answered our questionnaire, 45 (16%) patients were alive but did not wish to answer our questionnaire, 51 (19%) could not be traced and 36 (13%) died before July 1998. At the end of follow-up, 25.7 (20.0-59.3) years after diagnosis, 24% had a relapse in the previous 12 months, and 48% and 28% had quiescent disease with and without treatment, respectively. These ratios were not different from those observed three years after Crohn's disease diagnosis. Sixteen patients died within 20 years after CD diagnosis, including 11 from CD-related causes. The risk of death estimated by Kaplan-Meier life-tables analysis was non-significantly higher if death was related to CD. An ileal or colic adenocarcinoma was noted in 6 (3.4%) patients. CONCLUSIONS: Crohn's disease activity does not burn out with time, and roughly one-quarter of the patients had active disease 20 years after diagnosis. (+info)
Efficacy and safety of an olive oil-based intravenous fat emulsion in adult patients on home parenteral nutrition.
BACKGROUND: The most frequently used intravenous lipid emulsions are composed of 100% long chain triacylglycerols from soybean oil or of 50% long chain triacylglycerols-50% medium chain triacylglycerols. A newer emulsion, ClinOleic 20% containing 80% olive oil and 20% soybean oil, was suggested to reduce lipid peroxidation and immune function impairment. AIM: To assess ClinOleic 20%'s efficacy, safety and effect upon systemic inflammatory parameters in adults on home parenteral nutrition. METHODS: In stable home parenteral nutrition patients, the initial intravenous lipid emulsion was changed for ClinOleic 20%. Nutritional status, clinical and biological tolerance, and systemic inflammatory markers were analysed before and after 1 and 3 months of home parenteral nutrition, with ClinOleic 20% as intravenous lipid emulsion. RESULTS: Clinical and biological nutritional markers and inflammatory parameters did not differ between day 0 and month +3. There was no essential fatty acids deficiency. No side-effects were reported. Three of five patients presenting with migraine during home parenteral nutrition infusion at day 0 felt consistently better at month +3. CONCLUSIONS: ClinOleic 20% is safe and efficient in adult home parenteral nutrition. It maintains normal essential fatty acids status and did not influence inflammatory parameters. In contrast to studies in preterm infants or paediatric patients, no effect on vitamin E concentration or lipid peroxidation was observed. (+info)