Increased Anti‐Flagellin and Anti‐Lipopolysaccharide Immunoglobulins in Pediatric Intestinal Failure

Background: Central line–associated bloodstream infections (CLABSIs) pose a significant challenge in the lives of patients with intestinal failure (IF). We hypothesized that plasma immunoglobulins against flagellin (FLiC) and lipopolysaccharide (LPS) would be able to differentiate CLABSIs from nonbacterial febrile episodes and that levels would increase with infection and decline following appropriate antibiotic treatment. Materials and Methods: Patients with IF, due to short bowel syndrome, between the ages of 3 months and 4 years of age, were recruited at Cincinnati Children's Hospital Medical Center. Anti‐FLiC and anti‐LPS plasma antibody levels were measured in 13 children with IF at baseline, during febrile events, and also following treatment with antibiotics. These were also measured in 11 healthy children without IF who were recruited as controls. Results: Plasma anti‐FLiC IgA levels increased during febrile episodes in all patients with IF (baseline mean of 1.10 vs febrile episode mean of 1.32 optical density units, respectively; P = .046). Neither plasma anti‐FLiC nor anti‐LPS IgA or IgG levels distinguished CLABSI from nonbacterial febrile episodes compared with baseline levels. Compared with controls, patients with IF had significantly higher plasma levels of anti‐FLiC and anti‐LPS IgA at baseline. Conclusion: Plasma anti‐FLiC IgA antibody levels rise during febrile episodes but do not differentiate between nonbacterial febrile illnesses and CLABSIs in pediatric IF. However, the upregulation of these antibodies in IF suggests the baseline systemic presence of Gram‐negative bacterial products.     

Small bowel bacterial overgrowth and rice malabsorption in healthy and physically disabled older adults

Aim To determine whether there are differences in small bowel bacterial overgrowth (SBBO) and rice digestion between healthy and disabled older adults and to estimate the influence of physical activity on these nutritional statuses. Method Fifteen disabled adults who commute to a day‐care centre and 11 healthy older adults participated in this study. SBBO and rice absorption were judged using a breath hydrogen test. Physical activity was estimated using a pedometer. Results The average number of steps taken per day by the disabled was 1056 ± 243, which was statistically lower than that of the healthy, 6904 ± 782 (P < 0.001). No SBBO‐positive subject was seen in the healthy group, whereas five (33.3%) of 15 disabled older adults were SBBO‐positive. After ingesting glucose solution, the ?H₂ of disabled subjects was higher than that of the healthy subjects (7.6 ± 2.7 versus 0.5 ± 0.3 p.p.m., P < 0.05). Rice malabsorption was seen in one (9.1%) of 11 in the healthy and two (14.3%) of 14 in the disabled groups, which was not statistically significant. Conclusions Disabled older people who have a physically inactive lifestyle are at risk of SBBO, probably because of a reduction in their intestinal motility. SBBO has no influence on absorption of rice, and some older adults, independent of physical condition, can not absorb rice adequately.     

Vitamin D Deficiency in Children With Intestinal Failure Receiving Home Parenteral Nutrition

Background: Vitamin D plays important roles in both skeletal and nonskeletal health. Limited data suggest that patients with intestinal failure (IF) receiving home parenteral nutrition (PN) are at risk for vitamin D deficiency due to inadequate oral intake, poor absorption, and chronic illness. The purpose of this study was to document vitamin D status in pediatric patients with IF receiving home PN. Materials and Methods: We performed a 2‐year retrospective review of children with IF followed at our center who had been on home PN for ≥6 months and had ≥1 serum 25‐hydroxyvitamin D (25‐OHD) level checked as part of routine clinical care. Patients were then categorized as deficient (<20 ng/mL), insufficient (20–29 ng/mL), or normal (≥30 ng/mL) based on their lowest vitamin D level. Demographic data and clinical characteristics were also assessed. Results: Eleven of 27 children (41%) had ≥1 insufficient 25‐OHD level, including one child with vitamin D deficiency. Diagnosis of short bowel syndrome (compared with dysmotility or malabsorption syndromes) was associated with decreased likelihood of suboptimal vitamin D status, with an odds ratio of 0.12 (95% confidence interval, 0.02–0.8, P = .028). Osteopenia was noted in 59% of the cohort. There was a trend toward higher risk for osteopenia in patients with low 25‐OHD levels compared with those with normal 25‐OHD levels (82% vs 44%, P = .109). Conclusion: Suboptimal 25‐OHD levels are common in children with IF on home PN. This emphasizes the critical importance of routine surveillance of serum vitamin D levels and consideration of enteral supplementation when indicated.     

Single‐Center Experience with the Use of Teduglutide in Adult Patients with Short Bowel Syndrome

Background

Teduglutide is a glucagon‐like peptide 2 (GLP‐2) analog that has been approved for the treatment of adult short bowel syndrome (SBS)–associated intestinal failure (IF; SBS‐IF). Teduglutide increases villus height and crypt depth in the small bowel mucosa, promoting nutrition absorption and enteral independence from parenteral nutrition (PN). We aim to report our single‐center experience with teduglutide in adult patients with SBS to provide real‐world context to its use.

Method

We conducted a retrospective analysis on patients managed within our tertiary‐level intestinal rehabilitation program to identify patients with SBS‐IF treated with teduglutide from 2009–2015. The current report includes all patients at our center who had any exposure to teduglutide, including those who received commercial drug after approval by the Food and Drug Administration (FDA) and outside the scope of clinical trials.

Results

A total of 18 patients were treated with teduglutide. Eleven patients (61%) achieved complete enteral independence from PN and/or intravenous fluids (IV) at a median time of 10 months (range: 3–36 months). PN/IV volume requirement was reduced in all patients except two. Ten of the 11 patients (91%) who achieved enteral autonomy had colon. All patients off PN/IV required additional oral vitamins and electrolyte supplementations.

Conclusion

Our preliminary experience is consistent with prior reports of successful partial or complete weaning from PN/IV with teduglutide treatment in adult patients with SBS. The presence of colon appears to be favorable in obtaining enteral independence from PN/IV, regardless of residual small bowel length. Patients on teduglutide may remain at high risk of micronutrient deficiencies.     

Fasting and Postprandial Plasma Citrulline and the Correlation to Intestinal Function Evaluated by 72‐Hour Metabolic Balance Studies in Short Bowel Jejunostomy Patients With Intestinal Failure

Background: Fasting plasma citrulline (p‐citrulline) is a marker of functional enterocyte mass. However, the optimal timing of measurement in relation to meals has yet to be clarified. Furthermore, p‐citrulline has been proposed to be a surrogate marker for small bowel length and intestinal absorption parameters in short bowel syndrome patients with intestinal failure (SBS‐IF). Materials and Methods: Eight patients with SBS‐IF and 8 healthy controls (HCs) were given a standardized mixed test meal, and p‐citrulline was measured 15 minutes before and 60, 120, and 180 minutes after completion of the meal. The patients with SBS‐IF had their intestinal absorption of wet weight, energy, macronutrients, and electrolytes measured in relation to 72‐hour metabolic balance studies. We investigated the possible correlations between p‐citrulline and short bowel length, absorptive parameters, and the dependence on parenteral support (PS). Results: In the patients with SBS‐IF, we found a 12% (P = .041) reduction in postprandial citrulline levels after 180 minutes. In the HCs, there was a 13% postprandial reduction at 60 minutes (P = .018). No significant correlations between fasting p‐citrulline and bowel length, bowel absorptive function, or the dependence on PS were found. Even when excluding 2 patients in whom the intestinal absorption was adjacent to the intestinal insufficiency borderlines, these correlations were not significant. Conclusion: Based on findings in this small study, the optimal timing of p‐citrulline measurement is on fasting samples. However, p‐citrulline seems insufficiently discriminative to serve as a valid biomarker of bowel length, bowel absorptive function, or dependence on PS in patients with SBS‐IF.     

Longitudinal Bone Mineralization Assessment in Children Treated With Long‐Term Parenteral Nutrition for Severe Intestinal Failure

Background: Metabolic bone disease is common in children receiving home parenteral nutrition (HPN) for intestinal failure (IF). Long‐term evolution of bone mass in pediatric IF is poorly documented. The aims of this study were (1) to determine the prevalence of low bone mass (LBM) in children receiving HPN for IF, (2) to evaluate the evolution of total bone mineral content (TBMC) during HPN with dual‐energy x‐ray absorptiometry (DXA), and (3) to identify related factors. Methods: All children referred in our HPN center from 2004 to 2014 were eligible. Inclusion criteria were HPN dependence due to noninflammatory IF, at least 2 TBMC assessments, and HPN duration of at least 2 years at last DXA. TBMC was expressed in z score for ideal weight for height (WFH). LBM was defined by a TBMC WFH z score ≤–2 standard deviations (SD). Results: A total of 175 DXAs for 31 children were performed, mean of 5.6 ± 2.9 assessments per child. The median time between first and last DXA recorded was 6.2 years (0.7–16.6). At the first DXA, 14 children (45%) had a LBM. TBMC increased by +0.1 ± 0.04 SD per year of HPN (P = .012). The risk of LBM decreased with an odds ratio of 0.9 per year of HPN (95% confidence interval, 0.92–0.99; P = .018). Lean mass z score and calcium parenteral intakes were related to the TBMC improvement. Conclusion: LBM is common in pediatric IF, but bone status could improve during HPN in these children.     

Long‐Term Fish Oil Lipid Emulsion Use in Children With Intestinal Failure–Associated Liver Disease

Background: Fish oil lipid emulsion (FOLE) and multidisciplinary care for infants with intestinal failure (IF) have been associated with reduced morbidity and mortality due to IF‐associated liver disease (IFALD). With increased survival, a greater proportion of infants with IF are now able to remain on parenteral nutrition (PN) in the long term. The purpose of this study was to examine outcomes in children with IFALD who have required long‐term PN and FOLE therapy due to chronic IF. Materials and Methods: A review of prospectively collected data was performed for children with IFALD who required at least 3 years of PN and FOLE therapy due to chronic IF. Outcomes examined include the incidence of death, transplantation, and essential fatty acid deficiency (EFAD), as well as growth parameters and the biochemical markers of liver disease. Results: Of 215 patients with IFALD treated from 2004–2015, 30 required PN and FOLE therapy for at least 3 years (median, 4.6 years). To date, no patients have died, required transplantation, or developed EFAD. Biochemical markers of liver disease normalized within the first year of therapy with no recurrent elevations in the long term. Weight‐for age and length‐for‐age z scores improved and PN dependence decreased in the first year of therapy, with a stable rate of growth in the long term. Conclusions: Children with IFALD who required long‐term PN and FOLE for chronic IF had no mortality, need for transplantation, EFAD, or recurrence of liver disease in the long term, allowing for continued intestinal rehabilitation.     

Decreased Bone Turnover Markers in Children on Long‐Term Parenteral Nutrition (PN) for Intestinal Failure (IF)

Background: Metabolic bone disease (MBD) is a well‐recognized but poorly understood complication of long‐term parenteral nutrition (PN). Bone histomorphometry in adults has provided useful information but does not provide quantitative measures of bone resorption and is to invasive for children. Measurement of bone turnover markers provides an alternative less invasive approach. We therefore aimed to measure bone turnover markers in children on long‐term PN for intestinal failure (IF), and to compare them to age‐ and gender‐matched controls. Methods: Serum concentrations of osteocalcin (OC), bone‐specific alkaline phosphatase (BSAP), and c‐telopeptide (CTx) were measured in IF patients treated at a multidisciplinary intestinal rehabilitation and home PN program at the Hospital for Sick Children, Toronto, Canada. Age‐ and gender‐matched control participants were recruited for comparison. Results: A total of 13 IF patients and 20 control participants were recruited. IF patients had lower serum OC and CTx concentrations when compared with controls: 42.43 ± 11.54 vs 68.39 ± 20.95 µg/L (P < .01) and 7.454 ± 2.17 vs 9.246 ± 1.92 (P < .05; mean ± SD) µg/L for OC and CTx, respectively. In a subgroup of 9 IF patients for whom BMD was available, OC and CTx concentration were negatively correlated to BMD (g/cm²) and BMD z score. Conclusion: Bone turnover markers may be useful indicators for identifying children on long‐term PN at risk of MBD. Further studies are needed to validate the current results and determine the factors that influence the occurrence and evolution of MBD in children on PN.     

Intestinal Microbiota Signatures Associated With Histological Liver Steatosis in Pediatric‐Onset Intestinal Failure

Background: Intestinal failure (IF)–associated liver disease (IFALD) is the major cause of mortality in IF. The link between intestinal microbiota and IFALD is unclear. Methods: We compared intestinal microbiota of patients with IF (n = 23) with healthy controls (n = 58) using culture‐independent phylogenetic microarray analysis. The microbiota was related to histological liver injury, fecal markers of intestinal inflammation, matrix metalloproteinase 9 and calprotectin, and disease characteristics. Results: Overabundance of Lactobacilli, Proteobacteria, and Actinobacteria was observed in IF, whereas bacteria related to Clostridium clusters III, IV, and XIVa along with overall diversity and richness were reduced. Patients were segregated into 3 subgroups based on dominating bacteria: Clostridium cluster XIVa, Proteobacteria, and bacteria related to Lactobacillus plantarum. In addition to liver steatosis and fibrosis, Proteobacteria were associated with prolonged current parenteral nutrition (PN) as well as liver and intestinal inflammation. Lactobacilli were related to advanced steatosis and fibrosis mostly after weaning off PN without associated inflammation. In multivariate permutational analysis of variance, liver steatosis, bowel length, PN calories, and antibiotic treatment best explained the microbiota variation among patients with IF. Conclusions: Intestinal microbiota composition was associated with liver steatosis in IF and better predicted steatosis than duration of PN or length of the remaining intestine. Our results may be explained by a model in which steatosis is initiated during PN in response to proinflammatory lipopolysaccharides produced by Proteobacteria and progresses after weaning off PN, as the L plantarum group Lactobacilli becomes dominant and affects lipid metabolism by altering bile acid signaling.     

Laboratory Monitoring of Children on Home Parenteral Nutrition: A Prospective Study

Background: The primary hypothesis of this article is that a team approach in creating a protocolized laboratory monitoring schedule for home parenteral nutrition (PN) patients improves patient safety by decreasing the occurrence of nutrition deficiencies and is cost‐effective. Methods: In this prospective cohort study of home PN patients, each patient followed an established protocol of laboratory monitoring and weekly review by an interdisciplinary team of dietitians, nurses, and physicians. Data collected included anthropometric measurements, laboratory results, deviations from laboratory protocols, laboratory charges, PN shortage information, and means of ameliorating such shortages. Cost‐effectiveness analysis was only performed for nonmicronutrient laboratory tests. Results: Fifteen children (male, n = 6) with a median age of 59 months (range, 19–216) were included in this study. Primary diagnoses included short bowel syndrome (47%) and intestinal pseudo‐obstruction (40%). Patients received PN mixtures from 6 different infusion companies and experienced 60 different shortages in the PN formulation requiring adjustments or substitutions (mean, 4 shortages per patient). All patients had appropriate growth and complete micronutrient monitoring. No patient experienced any clinical symptoms due to shortages. The median number of laboratory draws/patient per month was 2.9 preprotocol compared with 1.14 postprotocol (P = .003). The median per patient per month charges were $2014 (interquartile range [IQR], 1471–2780) preprotocol compared with $792 (IQR, 435–1140) postprotocol (P = .002). Conclusions: A structured team approach to laboratory monitoring of home PN patients can simplify PN management, significantly decrease monthly laboratory costs, and lead to fewer laboratory draws while improving micronutrient monitoring and preventing deficiencies.     

Long-term impact of infantile short bowel syndrome on nutritional status and growth

Short-term bowel adaptation has been documented, but data on long-term effects are scarce. The aim of the present study was to evaluate the long-term consequences of infantile short bowel syndrome (SBS). A cross-sectional assessment (2005-7) of growth, nutritional status, defecation pattern and health status in individuals with a history of infantile SBS, born between 1975 and 2002, were performed. Data were compared with reference values of healthy controls and presented as means and standard deviations or median and ranges. A total of forty subjects (sixteen male and twenty-four female; mean age 14·8 (SD 6·8) years) had received parenteral nutrition during a median of 110 (range 43-2345) d, following small bowel resection. The mean standard deviation scores (SDS) for weight for height and target height (TH) of the children were normal; mean SDS for height for age was - 0·9 (SD 1·3). The median BMI adults was 19·9 (range 17-26) kg/m2; mean SDS for height for age was - 1·0 (range - 2·5 to 1·5). Height in general was significantly shorter than TH, and 53 % of children and 78 % of adults were below TH range. Most subjects had normal body fat percentage (%BF). SDS for total body bone mineral density were generally normal. The SDS for bone mineral content (BMC) of the children were - 1·0 (SD 1·1). Mean energy intake was 91 % of the estimated average requirements. The frequencies of defecation and bowel complaints of the subjects were significantly higher than in healthy controls. In conclusion, infantile SBS results in shorter stature than was expected from their calculated TH. BMC was lower than reference values, but the subjects had normal weight for height and %BF.     

Effect of Recombinant Human Growth Hormone on Intestinal Absorption and Body Composition in Children With Short Bowel Syndrome

This prospective study aimed to establish the effect of recombinant human growth hormone (rhGH) on intestinal function in children with short bowel syndrome (SBS). Eight children with neonatal SBS were included. All were dependent on parenteral nutrition (PN) for >3 years (range, 3.8–11.6 years), with PN providing >50% of recommended dietary allowance for age (range, 50%–65%). The subjects received rhGH (Humatrope) 0.13 mg/kg/d subcutaneously over a 12‐week period. The follow‐up was continued over a 12‐month period after rhGH discontinuation. Clinical and biological assessments were performed at baseline, at the end of the treatment period, and 12 months after the end of treatment. No side effects related to rhGH were observed. PN requirements were decreased in all children during the course of rhGH treatment. Between baseline and the end of treatment, significant increases were observed in concentrations (mean ± standard deviation) of serum insulin‐like growth factor 1 (103.1 ± 49.9 µg/L vs 153.5 ± 82.2 µg/L; P < .01), serum insulin‐like growth factor–binding protein 3 (1.7 ± 0.6 mg/L vs 2.5 ± 0.9 mg/L; P < .001), and plasma citrulline (16.5 ± 14.8 µmol/L vs 25.2 ± 18.3 µmol/L; P < .05). A median 54% increase in enteral intake (range, 10%–244%) was observed (P < .001) and net energy balance improved significantly (P < .002). It was necessary for 6 children to be maintained on PN or restarted after discontinuation of rhGH treatment, and they remained on PN until the end of the follow‐up period. A 12‐week high‐dose rhGH treatment allowed patients to decrease PN, but only 2 patients could be definitively weaned from PN. Indications and cost‐effectiveness of rhGH treatment for SBS pediatric patients need further evaluation.     

Iodine status of UK women of childbearing age

Background: Iodine deficiency in pregnant women can lead to impaired foetal brain development, linked to reduced intelligence quotient scores and impaired motor skills in the offspring (Haddow et al., 1999). As a result, the WHO (2007) has raised iodine requirements during pregnancy to 250 μg day^?1 (compared was 150 μg day^?1 for non‐pregnant adults). It is important that women meet this requirement to provide an adequate supply of thyroid hormones to the foetus. Historically, the UK was considered to have a sufficient iodine intake (Lee et al., 1994) but concern has recently been expressed about the iodine status of UK women (Kibirige et al., 2004). This study aimed to assess a cohort of UK women of childbearing age to identify the extent of any inadequacy in iodine intake. Methods: Twenty‐six women of childbearing age were recruited from the student and staff population of a university.Twenty‐four hour urine collections were obtained and total volumes measured. Iodide concentrations were measured using inductively coupled plasma mass spectrometry (ICP‐MS), considered the ‘gold standard’ technique (Vanderpas, 2006). Twenty‐four hour iodide excretion was calculated and used to assess the individual risk of deficiency using cut‐off values defined by Thomson et al. (1997). Iodine intake was estimated by extrapolation of 24‐h urinary iodide excretion (assuming 90% excretion rate) and this was compared to the reference Nutrient Intake (RNI) for adults and pregnant women. Ethical approval was obtained from The University Ethics Committee Results: The median value for urinary iodide concentration was 66 μg L^?1 (IQR 42), classifying the group as mildly deficient (WHO et al., 2001). Twenty‐four iodide excretion showed that five (19%) subjects were mildly iodine deficient as urinary iodide excretion was between 50 and 100 μg in 24 h. Iodine intake (estimated from urinary iodide excretion) indicated that seven subjects (27%) did not meet the adult requirement of 150 μg day^?1 and, should these subjects become pregnant, 17 subjects (65%) would not meet the 250 μg day^?1 requirement. Discussion: The findings of this small study give cause for concern as almost a fifth of individuals were classified as mildly deficient in iodine. This could have serious consequences if these women were to become pregnant. Various limitations of the study (selection of subjects and season) suggest that this is likely to be a best‐case scenario. It may be prudent to advise pregnant women to increase their intake of iodine‐rich foods during pregnancy. Conclusions: This study needs to be repeated in larger and more diverse cohorts to assess the prevalence of iodine insufficiency in the UK and the subsequent risk to foetal development. References Haddow, J.E., Palomaki, G.E., Allan, W.C. et al. (1999) Maternal thyroid deficiency during pregnancy and subsequent neuropsychological development of the child. N. Engl. J. Med. 341, 549–555. Kibirige, M.S., Hutchison, S., Owen, C.J. & Delves, H.T. (2004) Prevalence of maternal dietary iodine insufficiency in the north east of England: implications for the fetus. Arch. Dis. Child. Fetal. Neonatal. Ed. 89, 436–439. Lee, S.M., Lewis, J., Buss, D.H. et al. (1994) Iodine in British foods and diets. Br. J. Nutr. 72, 435–446. Thomson, C.D., Colls, A.J., Conaglen, J.V., Macormack, M., Stiles, M. & Mann, J. (1997) Iodine status of New Zealand residents as assessed by urinary iodide excretion and thyroid hormones. Br. J. Nutr. 78, 901–912. Vanderpas, J. (2006) Nutritional epidemiology and thyroid hormone metabolism. Annu. Rev. Nutr. 26, 293–322. WHO, ICCIDD & UNICEF. (2001) Assessment of Iodine Deficiency Disorders and Monitoring their Elimination. A guide for Programme Managers, 2nd edn [Online] ed: World Health Organization. Available at http://www.who.int/reproductive‐health/docs/iodine_deficiency.pdf (accessed on 18 January 2007). WHO Secretariat (2007) Prevention and control of iodine deficiency in pregnant and lactating women and in children less than 2‐years‐old: conclusions and recommendations of the Technical Consultation. Public Health Nutr. 10, 1606–1611.     

Challenging the 48‐Hour Rule‐Out for Central Line–Associated Bloodstream Infections in the Pediatric Intestinal Failure Population

Introduction: While parenteral nutrition (PN) has revolutionized the management of patients with intestinal failure (IF), central line–associated bloodstream infections (CLABSIs) remain a leading cause of mortality and morbidity in this population. The objective of this study is to characterize the presentation of CLABSIs in pediatric IF and to determine the time to positivity of blood cultures. Methods: A retrospective cohort study of children with IF who presented to our institution for evaluation of a possible CLABSI from January 1, 2012, to December 31, 2012, was performed. Results: Sixty patients with IF were identified. There were 33 cases of CLABSI in 16 patients, with a rate of 1.5 infections per 1000 catheter days. There were no significant differences in age, growth parameters, or catheter days between patients with or without CLABSI. Fever was documented in 85% of patients with CLABSI. These patients demonstrated an increased percentage of neutrophils and higher C‐reactive protein levels compared with patients without CLABSI. The mean time to culture positivity was 13.2 hours, and 97% of cultures were positive within 24 hours. Conclusion: Our data suggest that most pediatric patients with IF who have CLABSI develop positive cultures within 24 hours, and the absence of fever and leukocytosis does not necessarily indicate the absence of infection. These findings may support clinical practice guidelines in favor of shorter hospital stay when CLABSI is suspected; however, a prospective analysis of CLABSI in this population is recommended to determine the safety and appropriate setting prior to any practice change.     

Small bowel bacterial overgrowth may not affect bone mineral density in older people

BACKGROUND & AIMS: Small bowel bacterial overgrowth (SBBO) may be associated with malnutrition, diarrhea, and weight loss. Recently, bone mineral density (BMD) in patients with SBBO was reported to be lower, and SBBO may be an important factor in the development of metabolic bone disease. However, the subjects in these studies were relatively young patients with intestinal diseases. There is no information on the effect of SBBO on BMD in older people. METHOD: Seventeen relatively active and 33 disabled older people participated in this study. SBBO was determined by a breath hydrogen (H2) test after ingestion of a glucose solution. BMD of the lumbar spine and femur were measured using a dual energy X-ray absorptiometry scan (DEXA). RESULTS: One healthy control and 11 disabled subjects were SBBO-positive. The Z-scores of the lumbar spine were not statistically different between groups, and a high incidence of disorders, >70%, was seen in all groups. On the other hand, there were significant differences in the femoral BMD between the healthy controls and the SBBO-negative (P<0.001) and SBBO-positive (P<0.05) groups. No significant difference was seen in femoral BMD between SBBO-positive and SBBO-negative institutionalized people. CONCLUSION: SBBO seems to have little effect on BMD in people approximately 80 years old.     

Ethanol Lock Efficacy and Associated Complications in Children With Intestinal Failure

Background: Prophylactic ethanol lock therapy (ELT) reduces central line–associated bloodstream infections (CLA‐BSIs) in children with intestinal failure (IF). However, the risk of associated complications is unclear. We aim to describe our experience with prophylactic ethanol locks in a cohort of patients with IF. Materials and Methods: Thirty patients on ELT from 2010–2013 were identified by review of our intestinal rehabilitation registry. Patient demographics, CLA‐BSI events, and line complications were extracted. Comparisons in infection and complication rates when on and off ELT were made using a Poisson mixed‐effect regression model. Results: CLA‐BSIs when on and off ELT were 3.1 and 5.5 per 1000 catheter days, respectively (P < .015). Overall complication rates were similar in both groups. In those patients who experienced a complication, the complication rates on ELT compared with time off ELT were significantly lower (P < .003). Line perforation or breakage rates declined significantly when on ELT, from 1.8 to 1.53 per 1000 catheter days (P < .006). Line occlusion rates also decreased on ELT, from 0.6 to 0.3 per 1000 catheter days (P = .056). Infecting organisms were not different on and off ELT, and patients experienced a similar number of polymicrobial infections on or off therapy. Klebsiella pneumoniae was the most common infecting organism in both groups. Conclusions: Ethanol lock therapy use reduces both CLA‐BSI and central line complication rates in children with IF. These results underscore the safety and efficacy of ELT use in this population.     

Severe Gut Microbiota Dysbiosis Is Associated With Poor Growth in Patients With Short Bowel Syndrome

Background: Children with short bowel syndrome (SBS) can vary significantly in their growth trajectory. Recent data have shown that children with SBS possess a unique gut microbiota signature compared with healthy controls. We hypothesized that children with SBS and poor growth would exhibit more severe gut microbiota dysbiosis compared with those with SBS who are growing adequately, despite similar intestinal anatomy. Materials and Methods: Stool samples were collected from children with SBS (n = 8) and healthy controls (n = 3) over 3 months. Gut microbiota populations (16S ribosomal RNA sequencing and metagenomic shotgun sequencing) were compared, including a more in‐depth analysis of SBS children exhibiting poor and good growth. Statistical analysis was performed using Mann‐Whitney, Kruskal‐Wallis, and χ² tests as appropriate. Results: Children with SBS had a significant deficiency of the commensal Firmicutes order Clostridiales (P = .025, Kruskal‐Wallis) compared with healthy children. Furthermore, children with SBS and poor growth were deficient in beneficial bacteria known to produce short‐chain fatty acids and had expansion of proinflammatory Enterobacteriaceae (P = .038, Kruskal‐Wallis) compared with children with SBS who were growing adequately. Using metabolic function analyses, SBS/poor growth microbiomes were deficient in genes needed for gluconeogenesis but enriched in branched and aromatic amino acid synthesis and citrate cycle pathway genes. Conclusions: Patients with SBS, particularly those with suboptimal growth, have a marked gut dysbiosis characterized by a paucity of beneficial commensal anaerobes, resulting in a deficiency of key metabolic enzymes found in the gut microbiomes of healthy children.     

Home Parenteral Nutrition in Adult Patients With Chronic Intestinal Failure: The Evolution Over 4 Decades in a Tertiary Referral Center

Background/Aims: In Denmark, the public healthcare system ensures patients with intestinal failure (IF) the same rights for a life‐saving treatment as patients with other organ failures. This study reports the epidemiological data from the largest Danish IF center. As one of the pioneering centers in treating IF with home parenteral nutrition (HPN), this study documents the HPN evolution and describes the demographics and outcome in one of the world's largest single‐center cohorts. Methods: We included patients with IF discharged with HPN from 1970–2010. Data were extracted according to European Society for Clinical Nutrition and Metabolism classifications from the Copenhagen IF database. Results: Over the decades, we observed an exponential increase in the number of HPN patients. The 508 patients with IF collectively received HPN for 1751 years. While receiving HPN, 211 patients with IF (42%) died. Only 24 deaths were HPN related: sepsis (n = 10), liver disease (n = 12), central venous thrombosis (n = 1), and a complicated catheter placement (n = 1). The HPN‐related mortality was as low as 0.014 deaths/HPN year. In the first decade, HPN was mainly provided to younger, intestinally resected adult patients with IF with inflammatory bowel disease (IBD), but numerically, they were subsequently outnumbered by elderly patients with IF with cancer or complications from non‐IBD, noncancer abdominal surgery. Despite these demographic changes, the HPN‐related mortality has decreased in the past decade. Conclusion: Evolving from being a rare, experimental treatment in the 1970s, HPN at present is safe with a low treatment‐related mortality in the experienced center, despite HPN being more widely used in a more elderly population.