Prevalence of home artificial nutrition in Italy in 2005: a survey by the Italian Society for Parenteral and Enteral Nutrition (SINPE)

AIM: To determine the prevalence (cases per million inhabitants) of home artificial nutrition (HAN), enteral (HEN) and parenteral (HPN), in Italy, grouped according to administrative regions, patient age and primary disease, and to analyze the impact both of the presence of an HAN regional regulation and of demographic characteristics. METHODS: In April 2005, the Regional Coordinators of the Italian Society for Parenteral and Enteral Nutrition (SINPE) recorded all the ongoing cases of HAN using a structured questionnaire and were asked to estimate the representativeness of the collected sample with respect to the total expected HAN. RESULTS: A total of 6955 cases of HAN (93.5% adults, 6.5% pediatric patients < or = 18 years) were recorded in 16 of the 20 Italian regions (80% of the Italian population; sample representativeness 78%). HAN prevalence 152.6 (83.9% HEN, 16.1% HPN); the HAN range among the regions was: prevalence 28.1-519.8; oncological disease 13.8-75.7%, neurological disease 15.5-79.9%, intestinal failure 1.3-14.0%. An HAN regulation was present in 11 regions. A positive association (P=0.012) was found between the number of years since the regulation was issued and the HAN prevalence, and also between the % neurological patients and the population density (P=0.130) and the % inhabitants > or = 75 years (P=0.040). CONCLUSIONS: The need for HAN regards a great number of patients throughout the country; there are substantial differences between the regions with respect to both the prevalence and the use of HAN in various disease categories. A specific regulation may favor the development of HAN.     

Economic analysis model for inpatient parenteral nutrition: A pilot study

Aim: Parenteral nutrition is a high‐cost but essential support service in contemporary health care, yet no model exists to determine the total cost. This study aimed to create a cost analysis model identifying both direct and indirect costs of parenteral nutrition inpatient care. Methods: A health economics analysis model was constructed and used to create an audit tool for measuring parenteral nutrition costs in seven predefined categories. This tool was piloted on a cohort of 21 consecutive patients commencing parenteral nutrition at a large city hospital between March and April 2008. These patients were prospectively audited for a maximum 12 days or until parenteral nutrition cessation (192 patient days). Costs and adherence to evidence‐based guidelines were compared across the seven categories and between patient subgroups determined by ward locality upon commencement. Results: The mean total cost for all parenteral nutrition patients was $1579(NZD)/day, of which non‐parenteral hospital costs comprised 85%. For patients treated solely outside the intensive care unit, cost was $1045 per day, of which 24% was directly attributed to provision of parenteral nutrition. Formula accounted for nearly two‐thirds (63%) of parenteral nutrition direct costs and 8.5% of that prescribed was wasted. Return to oral or enteral nutrition was achieved in 57% patients within 12 days of commencing parenteral nutrition. Conclusions: Direct costs involved in providing parenteral nutrition appear to be less than previously reported, and represent a relatively small proportion of the total cost of care. This cost category analysis may have application in measuring and comparing parenteral nutrition service delivery in other institutions.     

Nutrition given to critically ill patients during high level/complex care (on Italian ICUs)

BACKGROUND & AIMS: Within a prospective study on costs in 45 Italian intensive units we reviewed nutrition support practice given during critical illness. METHODS: From June to October 1999, patients with an ICU stay longer than 47 h were studied. Nutrition (i.e. fasting, parenteral, enteral and mixed) and calorie supply by the enteral route were monitored during the first consecutive days (up to seven) of invasive support of organ failure (high-care). RESULTS: 388 patients received high-care for at least 1 day, 200 patients had seven consecutive high-care-days. Some form of nutrition was given in 90.7% of patients, 9.3% were never fed (25.8% of the cardiac patients). Parenteral nutrition was given in 13.9% of patients (78.9% of the abdominal surgery patients), 39.7% received only enteral nutrition, and 36.4% received mixed nutrition. Finally, 77.1% of the patients received nutrient by gut. Nutrition was given in 78.5% of 2115 collected days, 44.1% of the first high-care-days and 93.5% of the 7th days were positive for nutrition. Enteral calorie load on the first day was similar for enteral and mixed nutrition (range 8-14 kcal/kg), it was higher for exclusive enteral nutrition between the 4th and the 7th day (15-19 vs. 11-14 kcal/kg). It differed according to diagnosis group. CONCLUSIONS: In Italian ICUs, in complex critically ill patients, nutrition is consistently given in critical illness, gut is widely used except in abdominal surgery patients.     

Early nutrition support in critical care: a European perspective

PURPOSE OF REVIEW: Today, early nutrition support is considered standard care in most ICUs. The recommended method is the enteral route, although there is only minor evidence for this. Often inadequate delivery of energy and a cumulative energy deficit are implied. The purpose of this paper is to evaluate the indication for early enteral nutrition or immunonutrition and to discuss the application of additional parenteral nutrition. RECENT FINDINGS: The indication for early enteral nutrition is also supported by guidelines for enteral nutrition recently published by the European Society for Clinical Nutrition and Metabolism. Some more recent results strengthen the indication for a special formula in acute respiratory distress syndrome and septic patients. A recent metaanalysis has shown that parenteral nutrition is superior to delayed enteral nutrition. Additional parenteral nutrition thus seems to be the way to avoid cumulative energy deficit associated with insufficient or no enteral nutrition. SUMMARY: Early enteral nutrition is recommended for critically ill patients, with special formulas indicated in specific subgroups of patients. If enteral nutrition is insufficient or fails, parenteral nutrition should be instituted, respecting the often reduced demand for exogenous substrates in critically ill patients.     

Quality of Life of Cancer Patients Receiving Enteral Nutrition: A Systematic Review of Randomized Controlled Trials

Most studies confirm the beneficial effects of enteral nutrition on the quality of life, but some studies indicate an inverse association and its detrimental impacts. However, there are insufficient data on the effects of enteral nutrition on the quality of life of cancer patients. This systematic review aimed to describe the influence of applied enteral nutrition on the quality of life of cancer patients, based on the results of randomized controlled trials. It was registered in the PROSPERO database (CRD42021261226) and conducted based on the PRISMA guidelines. The searching procedure was conducted using the PubMed and Web of Science databases, as well as Cochrane Library, and it included studies published until June 2021. It was conducted to select randomized controlled trials assessing the influence of enteral nutrition (compared with the other model of nutrition) on the quality of life of cancer patients. A general number of 761 records were screened and a final number of 16 studies were included in the systematic review. The studies were included and assessed by two independent researchers, while the risk of bias was analyzed using the Newcastle–Ottawa Scale (NOS). Studies compared patients treated with and without enteral nutrition, patients treated with various methods of enteral nutrition or with enteral diets of various content, as well as patients treated with enteral and parenteral nutrition. Within the included studies, the majority were conducted in patients with cancers located in various parts of the body, or diverse areas within the gastrointestinal system, while some studies were conducted in specific populations of patients with a defined cancer location—esophagus, stomach, or ovary. The duration of applied enteral nutrition within the included studies was diversified—from two weeks or less to half a year or even more. The vast majority of studies used well-known and validated tools to assess the quality of life, either developed for a specific group of head/neck, esophagus/stomach, and ovary cancer patients or developed for more general patient populations. Most studies concerning patients treated with and without enteral nutrition supported applying enteral nutrition, which was concluded in seven studies out of ten (including four studies with a low risk of bias). The other important observations to be emphasized—formulated based on the studies with a low risk of bias—presented the role of oral supportive nutrition guided by a dietitian, as well as the beneficial role of enteral and parenteral nutrition, combined. In spite of a relatively low number of randomized controlled trials assessing the influence of enteral nutrition on the quality of life of cancer patients, which should be considered as a limitation, the results were promising. Most studies supported the positive influence of enteral nutrition on the quality of life, either assessed based on the psychological measures of the quality of life or by considering the other potential determinants (e.g., malnutrition, complications, etc.). Taking this into account, enteral nutrition should be applied whenever possible, both to prevent and treat malnutrition in cancer patients. However, considering the limited number of studies conducted so far, further research conducted in homogenic populations of patients is necessary.     

42例胃癌根治术后早期肠内营养效果分析

目的探讨胃癌根治术后早期肠内营养的应用效果及护理方法。方法观察2008年1月～2010年12月在我院行胃癌根治术后接受早期肠内营养支持的42例患者,并总结其护理经验。结果接受早期肠内营养支持及精心护理的42例患者中,发生腹痛腹泻或胃管脱出者共6例,其中改用肠外营养者2例。余36例患者均能耐受肠内营养,无术后严重并发症及肠内营养并发症发生,无死亡病例,平均住院日为11.5±2.2 d。结论胃癌根治术后早期肠内营养可促进患者的早日康复,护理工作在肠内营养的实施中具有重要意义。     

Home Artificial Nutrition in Polish Children: An Analysis of 9-Year National Healthcare Provider Data

Background: Home artificial nutrition (HAN) is a developing method of treatment that reduces the need for hospitalizations. The epidemiology of pediatric HAN in Poland has not yet been covered in detail. This study is a longitudinal nationwide analysis of incidence, prevalence, and patients’ profile for HAN in Polish children. Methods: Assessment of National Health Fund (NFZ) data covering all pediatric patients treated with HAN in Poland between 2010 and 2018. Results: HAN was received by 4426 children, 65 patients were on home enteral nutrition (HEN) or home parenteral nutrition (HPN) at different times (HEN n = 3865, HPN n = 626). HAN was most frequently started before the child was 3 years old and long-term HAN programs (5–9 years) were reported. The most common principal diagnosis in HEN was food-related symptoms and signs. In HPN, it was postoperative gastrointestinal disorders. A regionally differentiated prevalence of HAN patients and centers was demonstrated. Mortality among patients was 24.9% for HEN, and 9.6% for HPN, and the main in-hospital cause of death was cardiac arrest. Conclusions: HAN’s use is increasing and evolving in Poland. Uneven distribution of patients and centers results in difficult access to the nutritional procedure which, together with the increasing number of patients, highlights the need for data analysis and development of nutrition centers.     

Home parenteral nutrition: a hospital-based program with commercial logistic support

Since home parenteral nutrition was introduced in the 1970's, a number of medical centers have formed successful home parenteral nutrition programs which have reduced expenses to the patient and third party payers by 50 to 73% over in hospital costs. However, the cost of maintaining these programs for training and follow-up has largely been absorbed by the hospital as a nonreimbursable teaching expense. To offset the costs of our growing program in these times of budget "caps," we have established an agreement between our hospital and commercial home care company which provides for patient instruction and follow-up by the hospital parenteral and enteral nutrition team and logistic support by the home care company. We used the average cost of our first five patients to establish a fee schedule which the commercial company agreed to pay the hospital parenteral and enteral nutrition team for its services. This agreement reduces the number of nurses and pharmacists that the commercial company would otherwise have to hire for teaching and follow-up of home care patients, and supports the concept of regional care in medical centers where parenteral and enteral nutrition teams maintain quality control, continuity of care, and efficient teaching programs for patients requiring home parenteral nutrition.     

非要素经肠营养剂在胃癌围手术期的应用

目的　应用非要素经肠营养剂改善进展期胃癌病人的营养状况和免疫功能 ,提高其手术及术后放、化疗的耐受力。方法　用经肠营养剂经口服或管饲对进展期胃癌病人围手术期进行营养支持 ,并设等能量等氮的肠外营养组进行对照 ,观察血浆蛋白等营养指标及免疫球蛋白等免疫指标。结果　营养支持后 ,实验组病人营养指标的改善与对照组相近 ,但 Ig G、Ig A、Ig M等多项免疫指标明显优于对照组。结论　用非要素经肠营养剂对进展期胃癌病人在围手术期进行营养支持 ,其疗效明显优于等能量等氮的肠外营养支持。     

胃肠道肿瘤患者术后早期肠内营养支持的疗效观察

[目的]探讨胃肠道肿瘤患者术后早期肠内营养支持的临床疗效。[方法]选择某院2009年6月～2010年9月期间收治的胃肠道肿瘤手术患者98例,随机将患者分为观察组和对照组,每组49例。两组患者经手术治疗后,对照组患者行肠外营养支持等治疗,而观察组患者则给予早期肠内营养支持治疗,并对两组患者的临床治疗效果等相关指标进行对比分析。[结果]与对照组患者相比,观察组患者的血浆前白蛋白和血浆视黄醇结合蛋白均显著增高,差异均具有统计学意义(P﹤0.05);观察组患者的肛门排气时间和胃排空恢复时间以及住院时间均显著减少,差异均具有统计学意义(P﹤0.05);观察组患者并发症的发生比率显著降低,而未发生并发症的比率则显著提高,差异均具有统计学意义(P﹤0.05)。[结论]早期肠内营养支持在胃肠道肿瘤患者术后中的应用,其疗效确切效果显著,对于改善患者的营养状况和减少并发症的发生具有极其重要的临床价值。     

术后早期肠外联合肠内营养支持治疗对老年胃癌病人临床预后的影响

目的:观察术后早期肠外联合肠内营养支持治疗对老年胃癌病人临床预后的影响。方法:96例老年胃癌病人随机分为观察组和对照组,每组48例。术后分别行肠外营养(PN)+肠内营养(EN)和PN支持,持续7 d。测定两组病人手术前后血清C反应蛋白(CRP)、清蛋白(ALB)、转铁蛋白(TF)水平和术后疲劳指数,并观察两组病人术后肛门排气、并发症和住院时间的变化。结果:与对照组比,观察组老年胃癌病人术后第7天血清CRP水平和疲劳指数均明显下降(P<0.05),血清TF水平显著增加(P<0.05),并且术后肛门排气和术后住院时间缩短(P<0.05),术后感染发生率降低(P<0.05)。结论:PN联合EN治疗有助于调节老年胃癌病人术后机体的创伤应激,促进病人康复。     

Is enteral nutrition optimally used in hospitalized patients? A study of the practice of nutrition in a Swedish hospital

Thirty patients with parenteral nutrition were studied in order to evaluate if they could be given enteral nutrition instead. Based upon absolute and relative contraindications for enteral nutrition, we calculated that 80% of the patients were possible candidates for enteral nutrition. Long-term use of parenteral nutrition may cause complications. Besides metabolic and other advantages when enteral nutrition is used, economical gains are also important. We have calculated an estimated annual net profit of US$ 357,000 in our hospital, if enteral instead of parenteral feeding is used in patients suitable for the former type of feeding. This implies that it is really cost-beneficial to consider enteral nutrition in hospitalized patients. Although parenteral nutrition will continue to have its place in the management of different occasions, increased use of enteral nutrition may result in improved patient outcomes and improved cost-effectiveness.     

低热量营养支持对肝癌术后营养和免疫功能的影响

目的:比较低热量肠内、外营养支持对肝癌术后营养和免疫功能的影响.方法:将49例可切除肝癌的病人随机分为两组,术后第2 d始分别接受低热量肠内营养(HEN组)和低热量肠外营养(HPN组),比较两组术后的免疫和营养指标.结果:HEN组术后前清蛋白、转铁蛋白、IgA、IgG、IgM下降幅度小,CD3和CD4/CD8易恢复至术前水平,与HPN组比较,差异有显著性意义(P＜0.05).结论:HEN支持有利于肝癌术后营养和免疫功能的改善.     

早期肠内营养对急性重症胰腺炎炎症介质及营养指标的影响简

目的：探讨早期肠内营养对急性重症胰腺炎患者炎症介质、营养指标及临床恢复的影响。方法2006年1月至2010年3月收治的急性重症胰腺炎患者患者59例,随机分成早期肠内营养组31例,肠外营养组28例,观察上述两组治疗后1、3、7天血清中TNF-α、IL-1β、前白蛋白、清蛋白的水平;外周血淋巴细胞数;并观察两组血清淀粉酶恢复时间,全身炎性反应综合征（ Systemic infammactery response syndrome ,SIRS）、腹腔脓肿及肝功能异常例数,治疗费用等指标的差异。结果早期肠内营养组治疗后3、7天血清TN F-α、IL-1β浓度明显低于肠外营养组（ P＜0．05）,前白蛋白、清蛋白的水平、外周血淋巴细胞数明显高于肠外营养组（P＜0．05）,治疗费用低于肠外营养组（P＜0．05）,两组血清淀粉酶恢复时间,SIRS、腹腔脓肿及肝功能异常例数无明显差异（P＞0．05）。结论早期肠内营养在改善急性重症胰腺炎患者营养状态方面明显优于肠外营养,有利于提高机体的抗感染能力和各系统机能的恢复,是可靠、安全、经济的营养支持手段。     

Prise en charge nutritionnelle à domicile des malades cancéreuxHome artificial nutrition in cancer patients

Cancer is the first indication for home artificial nutrition in France, with rising figures. Survival of cancer patients on home parenteral nutrition is lower than that of other patients on home parenteral nutrition, due to the evolution of the underlying disease, and cancer is also associated with lower survival figures in home enteral nutrition patients. More than half of cancer patients die within the first year of home artificial nutrition. Home artificial nutrition seems to improve health-related quality of life, and may improve life expectancy in some patients. It is prescribed in patients during treatment (supportive care) or with therapeutic sequels, the indications being comparable to those in the hospital setting. Home artificial nutrition as a palliative care is much more debated, as it has not proved to increase quality of life or survival. It should be banned for patients with a life expectancy lower than three months and a Karnofsky index lower than 50. There is no specific nutrition technique for cancer patients.     

Clinical Pathways in Home Nutrition Support

In home-care settings, physicians with various medical specialties may order home enteral and/or parenteral nutrition support. Clinical pathways may be used to provide a clear, concise, standardized method for ordering and monitoring home nutrition support. The clinical pathways should be appropriate for 80% of the patients placed on the pathways, allowing for a 20% variance, or deviation, from the pathway. In one home-care facility, disease-specific clinical pathways have been used for longer than 1 year for patients with a variety of diseases requiring home nutrition support. To determine the usefulness of the home nutrition support clinical pathways, data obtained from 20 patients were analyzed. Patients were followed up while being treated using home nutrition support clinical pathways designed for oncology (9 patients), human immunodeficiency virus/acquired immunodeficiency syndrome (2 patients), short bowel syndrome (6 patients), and hyperemesis (3 patients) for 191 weeks. Overall, an average variance (deviation from the pathway) of 22% (the number of variances divided by the total weeks of therapy) was observed. The use of the pathways to provide enteral or parenteral nutrition facilitated more cost-effective care by following pathway guidelines for obtaining laboratory values and patient visits. Communication between the home-care staff and the physician was also improved. Clinical pathways can enable standardization of care for patients receiving nutrition support at home.     

Effect of recombinant human growth hormone and enteral nutrition on short bowel syndrome

BACKGROUND: Studies showed that bowel rehabilitation therapy, including recombinant human growth hormone (rhGH), nutrition support, glutamine, and dietary fiber, promotes intestinal adaptation in patients with short bowel syndrome. The aim of the current study was to determine if enteral nutrition and rhGH are effective in weaning short bowel patients off total parenteral nutrition (TPN). METHODS: Thirty-seven patients with short bowel syndrome received bowel rehabilitation therapy for 4 weeks. Thirty-four patients were treated within 2 years after short bowel syndrome. Treatment included nutrition support from enteral nutrition 500 to 1500 kcal/d, oral glutamine 0.6 g/kg/d, plus a high-carbohydrate and low-fat diet. Once patients were in positive nitrogen balance, rhGH 0.05 mg/kg/d was administered for 3 weeks. RESULTS: All patients completed the treatment; there were no deaths caused by malnutrition. Intestinal absorptive capacity and plasma levels of proteins were significantly improved after treatment (p < .05). Of the 23 patients who have been followed for >2 years after bowel rehabilitation therapy, 21 patients (57%) weaned off parenteral nutrition, among which 18 (49%) patients lived on a high-carbohydrate and low-fat diet supplemented with enteral nutrition, and 3 patients were free of enteral nutrition and relied on high-carbohydrate and low-fat diet alone. The minimal intestinal length for these patients was 15 cm with ileocecal valve and intact colon in adults. CONCLUSIONS: Providing patients with enteral nutrition, glutamine, dietary fiber, and rhGH during howel rehabilitation therapy allows weaning from TPN in a sign;ficant number of patients.     

Enhanced Enteral and Parenteral Nutrition Practice and Outcomes in an Intensive Care Unit with a Hospital-Wide Performance Improvement Process

To improve patient outcomes at a 455-bed community health care facility, a performance improvement process was implemented for the delivery of enteral and parenteral nutrition in a 28-bed intensive care unit (ICU). In 1992, the study group consisted of all patients who were started on either enteral or parenteral nutrition while in the ICU during a 2-month period. These patients were followed up until discharge from the hospital or death to determine practice patterns and outcomes. Three actions were identified as opportunities to change practice and improve outcomes: increase use of the enteral route of alimentation compared with the parenteral route; start alimentation sooner, especially via the enteral route; and meet protein and energy needs of patients. Educational programs were developed targeting physician and nursing staff. Through an interdisciplinary approach, a nutrition support decision tree and patient outcome statement were developed. In 1994, evaluation of a group meeting the same criteria as the original group indicated that the goals for nutrition support practice improvement were met in all three areas identified. Providing a systematic approach to an interdisciplinary performance improvement process, as part of an organization-wide plan, enhanced nutrition support practice in a community hospital and resulted in quality improvement and cost savings. J Am DietAssoc. 1996; 96:484-489.     

胃癌全胃切除术后肠内营养和肠外营养临床研究

目的：探讨早期肠内营养与肠外营养对胃癌全胃切除术后的营养效果比较。方法：选择本院收治的2008年3月-2012年7月的胃癌全胃切除术患者共62例作为研究对象,随机分成早期肠内营养组（EEN）和肠外营养组（PN）,比较两组患者营养效果。结果：EEN组患者营养支持术后7d其BWI、ALB、PA、HGB、TF等营养指标均明显优于PN组（P〈0．05）;EEN组患者肛门排气时间、排便时间以及住院时间等明显少于PN组（P〈0．05）;两组不良反应发生情况比较差异无统计学意义（P〉0．05）。结论：早期肠内营养支持可有效改善患者的营养状态,促进患者的康复,值得临床推广。     

Improved nutritional management reduces length of hospitalization in intractable diarrhea

Sixteen patients were managed by one of two specific refeeding protocols to compare the efficacy of two enteral formulas in the nutrition restoration of infants with intractable diarrhea (IDI). The protocols outlined specific nutritional therapy including transition from parenteral to enteral nutrition; concentration, volume, and steps of advancement of formulas. Patient progress was monitored daily. Average length of stay, number of days on parenteral nutrition support, and number of formula changes for the IDI protocol groups were compared with a retrospective chart audit group of 29 IDI patients. The protocol groups had substantially fewer days of parenteral nutrition support, significantly fewer formula changes (p less than 0.01), and fewer days of hospitalization. The differences resulted in $14,750 of charges saved per protocol patient.