Economics of home parenteral nutrition

The past 30 years have seen long term parenteral nutrition evolve from a novel technique to an accepted intervention for gastrointestinal failure. The development of home parenteral nutrition (HPN) has parallelled a shift in resources from hospital to community care and has been driven by technological advances, the growth of commercial home care companies and patient choice. Costs for HPN per patient year have been estimated to range from $US 150,000 to $US 250,000 in the US, and are around 55,000 pounds in the UK, perhaps only 25 to 50% of in-hospital costs. In the absence of any alternative treatment for many patients with gastrointestinal disease, parenteral nutrition is life saving and offers the prospect of maintaining a good quality of life. The cost of 1 quality-adjusted life-year for HPN has been estimated as 69,000 pounds in the UK (1995 values), and $Can 14,600 in Canada (1984 values), making HPN relatively cost effective compared with other ways of spending money to improve health. HPN is also given to patients in whom life expectancy is unlikely to be influenced, such as those with cancer or AIDS. Although there is considerable heterogeneity between countries in the proportion of HPN patients with a particular disease, malignancy is now the single most common indication. HPN can be expected to improve quality of life over a short period of terminal care, and whilst a strong case can be made for use of HPN in some of these patients, its use has not been subjected to detailed medical or economic appraisal.     

Parenteral nutrition in the management of gastrointestinal Kaposi's sarcoma in a patient with AIDS

A patient with acquired immunodeficiency syndrome (AIDS) who required aggressive nutritional intervention via home parenteral nutrition therapy is described, and nutritional status, etiology and therapeutic management of AIDS-associated malnutrition, role of nutrition support, and factors for consideration in using parenteral nutrition in AIDS patients are discussed. Parenteral nutrition therapy was initiated in a 30-year-old AIDS patient with Kaposi's sarcoma lesions of the gastrointestinal tract because of rapid weight loss, low serum protein levels, and malnutrition. He had previously undergone a small-bowel resection and a jejunojejunostomy, and radiation and antineoplastic-drug therapy was planned. During parenteral nutrition therapy, the patient demonstrated increased physical strength and was able to care for himself during most of the time spent at home or in a long-term-care facility. Aggressive measures, including parenteral nutrition therapy, were discontinued 11 days before the patient's death. Complications of therapy included one episode of sepsis and a tear in the external catheter tubing. Malabsorption and diarrhea mainly caused by gastrointestinal disease, reduced food intake because of oral and esophageal infections, adverse effects from medication, and depression are factors that can contribute to AIDS-associated malnutrition. Also, hypermetabolism resulting from infections and fevers may contribute to malnutrition in AIDS. The extent to which this malnutrition affects the underlying immune dysfunction occurring in the syndrome and the response to other more direct drug therapies in AIDS is not known. Available methods for nutritional intervention are based on clinical experience and anecdotal reports. Because of gastrointestinal disease, an oral diet, supplements, and enteral tube feedings may not meet nutritional goals for an AIDS patient.(ABSTRACT TRUNCATED AT 250 WORDS)     

营养支持在心衰病人治疗中的作用研究

目的　观察营养支持在慢性心衰治疗中的作用。方法　随机选择 4 0例病人 ,将其分为自由饮食组 (F组 )和营养支持组 (N组 )。F组病人随意进食 ,N组按计算的总能量消耗进行营养支持。观察血白蛋白、淋巴细胞总数、体重和三角肌皮皱厚度的变化。结果　 4 0例病人入院时均有不同程度的营养不良 ,入院第 10d ,F组血白蛋白、体重和淋巴细胞计数明显下降 ,N组血白蛋白、体重和淋巴细胞计数明显上升 ,两组病人的三角肌皮皱厚度并无显著变化。结论　心衰治疗同时给予积极的营养支持 ,可提高血白蛋白的浓度 ,增加体重 ,改善免疫状态 ,提高心衰的治疗效果 ,防止进一步发展为心源性恶液质。     

肠内营养在脑血管意外患者营养支持治疗中的作用

目的探讨肠内营养在脑血管意外患者营养支持治疗中的临床价值。方法将我院收治的48例脑血管意外患者,随机分成两组,其中24例采用肠内营养支持(实验组),24例采用肠外营养支持(对照组),比较肠内营养与肠外营养支持治疗脑血管患者的营养指标及并发症。结果两组患者在营养支持治疗10d后血红蛋白、转铁蛋白、淋巴细胞计数、血浆总蛋白等指标无显著性差异,但实验组腹胀、腹泻、消化道出血、高血糖的发生率低于对照组(P<0.05)。结论早期肠内营养支持治疗可更好地改善患者营养状况,并发症较肠外营养少,在脑血管意外患者的支持治疗中有重要的临床价值。     

临床药师对1例克罗恩病患者营养治疗的药学监护

目的:通过该病例探讨肠外肠内营养专业临床药师在克罗恩病综合治疗的营养支持治疗中发挥的作用。方法:在1例克罗恩病患者全程治疗过程中,临床药师协助临床医师制订合理的营养治疗方案:给予患者整蛋白型肠内营养剂口服治疗,同时监护患者营养治疗全过程,并在患者急性消化道出血时,停用肠内营养改为肠外营养支持。结果:在临床药师参与下,患者营养治疗方案的制订与调整真正做到了个体化,患者营养指标白蛋白、前白蛋白均恢复至正常范围。结论:临床药师通过对克罗恩病患者的药学监护可以优化营养治疗方案,确保良好的治疗效果。     

1例新型冠状病毒肺炎危重型患者的营养支持分析及药学监护

目的探讨新型冠状病毒肺炎(COVID-19)危重型患者营养支持的药学监护要点,为后续治疗提供参考。方法以医院收治的1例COVID-19危重型患者为研究对象,关注其营养方案的制订和调整,监护其症状体征、相关营养和生化指标变化,分析药师的药学监护要点。结果该患者的营养治疗方案制订做到了个体化,经过肠内外营养的支持治疗,其前白蛋白(PA)、白蛋白(ALB)等营养指标恢复正常;通过鼻饲给药的药物种类较多,用药过程中避免了药物的相互作用;治疗过程中发生了轻微腹泻、腹胀、便秘不适及三酰甘油(TG)升高的情况,均经干预后改善。结论 COVID-19危重型患者治疗措施复杂,药师在进行药学监护时除了要关注患者的营养方案外,还需评估其用药依从性,做好用药及饮食教育,监测肠内外营养与其他治疗药物间的相互作用,防治胃肠道、代谢性等并发症。     

经鼻肠管早期肠内营养治疗重症急性胰腺炎的临床价值

目的总结经鼻肠管早期肠内营养治疗重症急性胰腺炎的临床价值。方法将124例患者随机分为两组,每组62例。对照组营养治疗只给全胃肠外营养（TPN）,肠内营养组在胃肠外营养基础上适时给予肠内营养（EN）。结果肠内营养组在并发症总体发病率、死亡率、住院时间及医疗费用方面均低于对照组。结论经鼻肠管早期肠内营养治疗重症急性胰腺炎安全性高,疗效好,实用性强。     

低热量胃肠外营养治疗普外营养不良患者的疗效分析

目的研究低热量胃肠外营养治疗的效果,为临床提供可供参考的依据。方法按照入组的先后随机分为治疗组(低热量肠外营养)和对照组,两组均在第1天开始给予相应方案的肠外营养支持治疗,持续5～7d。于营养前1d及后第8天,检测体质量、血清白蛋白、以及进行与营养状态相关疲劳评分。结果治疗前后,两组患者的体质量、白蛋白均有降低,但对照组降低有统计学意义(P<0.05);疲劳评分显示,两组治疗后分质均有升高,出现疲劳程度加重,但对照组治疗前后有统计学意义(P<0.05);治疗组与对照组治疗后评分比较也有显著差异(P<0.05)。结论采用低热量方式的治疗,对患者的营养状态有显著的治疗作用,值得临床进一步推广和研究。     

不同营养支持方式对AECOPD患者营养状态影响的研究

目的 探讨不同营养支持方式对慢性阻塞性肺疾病急性加重期(AECOPD)患者营养状态的临床研究。方法 随机选取556例AECOPD患者进行回顾性分析,其中肠内营养(EN)组36例、肠内联合肠外营养(EN PN)组45例、肠外营养(PN)组201例、对照组274例。对照组给予常规治疗,营养支持组在此基础上分别给予不同的营养支持方式,比较四组患者治疗前后营养、免疫、肝肾功能指标变化。结果 (1)营养及免疫状态：治疗后各营养支持组患者总蛋白、前白蛋白、血红蛋白均较对照组明显升高(p<0.05),PN组白蛋白、淋巴细胞数均较对照组明显升高(p<0.05);治疗后PN组血红蛋白较EN组升高(p<0.05);治疗后EN组、EN PN组总蛋白均较PN组升高(p<0.05)。(2)肝肾功能：治疗后PN组ALT、AST和CR均较对照组明显增高(p<0.05),治疗后EN PN组CR较对照组明显增高(p<0.05),各营养组BUN较对照组改善不明显(p>0.05)。结论 在常规治疗基础上应用营养支持治疗可以明显改善AECOPD患者的营养状态,肠外营养对患者肝肾功能有一定的影响。     

胃癌术后肠内肠外营养联合应用分析

目的探讨胃癌术后肠内肠外营养联合应用分析。方法将邯郸市第一医院2009年6月—2012年6月之间收录的58例胃癌手术后的患者随机分为三组,A组19例患者采取肠内营养方法给予补充,B组19例患者采取肠外营养方法给予补充,C组20例患者采取肠内肠外联合的营养方法给予补充,观察三组的临床应用效果。结果c组患者肛门排气时间和胃肠的恢复时间以及住院时间与术后并发症情况均明显低于A组和B组,比较具有统计学意义（P〈0．05）;其中三组给予营养支持8d后的患者体内的转铁蛋白和血清白蛋白以及前白蛋白均明显的高于治疗后1d的情况,数据比较具有统计学意义（P〈0．05）,三组营养支持8d后的组间比较无统计学意义（P〉0．05）。结论对于胃癌手术后的患者采取肠内肠外联合营养方法支持能够有效的降低术后的并发症和缩短胃肠功能的恢复时间。并且安全可靠．操作简单．佰得临床中府用和椎广．     

肠内外营养对肝硬化患者的治疗价值

目的：探讨肠内外营养治疗对肝硬化患者的临床价值。方法肝硬化患者77例,随机分为两组,实验组给予肠内外营养治疗,对照组给予营养膳食指导,对比两组患者治疗后营养指标及肝功能的变化情况。结果治疗结束后,实验组谷草转氨酶、谷丙转氨酶和血浆前白蛋白等肝功能指标得到明显改善,与对照组比较差异具有统计学意义（P〈0.05）。结论对肝硬化患者实施肠内外营养支持,有助于缓解患者的临床症状,提高治疗效果,具有十分积极的临床意义。     

重症脑卒中患者营养风险筛查与营养支持现状调查

目的 探讨营养风险筛查（nutritional risk screening,NRS）用于评估重症脑卒中患者营养状态的意义,比较肠内外营养支持治疗对该类患者的临床应用价值。方法 采用回顾性调查方法,对267例重症脑卒中患者根据营养风险筛查2002版[2002年欧洲肠外肠内营养学会（ESPEN）推荐的成人营养风险筛查方法,NRS 2002]进行营养评估,并根据营养支持类型分为3组,包括肠内营养（EN）组、肠外营养（PN）组和联合营养（EN+PN）组,通过比较使用前后各项指标的变化情况,对各组的临床疗效和不良反应进行评价。结果 通过比较患者入院第1天与第10天的营养状况、肝肾功能及并发症情况,发现EN组、EN+PN组相对用药前的总蛋白、白蛋白水平有显著性提高（P<0.05）,且EN组肝肾功能指标变化较小,合并感染的发生率为16.67%。结论 肠内营养支持能有效改善重症脑卒中患者的营养状况,降低患者感染及胃肠道并发症的发生率,明显改善患者预后。     

肠内营养支持在中晚期食管癌贲门癌围手术期的临床应用

目的探讨中晚期食管癌患者围手术期营养支持的效果及肠内、肠外营养的优缺点。方法将40例中晚期食管癌患者随机分为肠内营养组（EN组）和肠外营养组（PN组）各20例,分别给予不同方式的营养支持。结果EN和PN均改善了机体的营养状况,短期应用效果近似,但EN在促进肠道功能与体力的恢复、保护肠黏膜屏障、改善细胞免疫功能、减少对肝功能损害、降低住院费用方面优于PN。结论两种营养方式对改善营养状况、降低蛋白质分解均有作用,与PN比较,EN可明显促进肠道功能的恢复,具有符合生理、安全、有效、价廉等特点。     

鼻肠管早期肠内营养辅以肠外营养支持在重型颅脑损伤中的临床研究

目的观察鼻肠管早期肠内营养辅以肠外营养对重型颅脑损伤患者的治疗效果。方法将72例重型颅脑损伤患者随机分为实验组与对照组各36例,实验组留置鼻肠管,对照组留置鼻胃管,均给予早期肠内营养辅以场外营养的营养支持方式,观察两组生活指标、胃肠道耐受及并发症情况。结果营养支持后7d血清蛋白呈上升趋势,但两组比较无差异（P〉0．05）;两组血糖均较营养支持前下降,两组比较差异具有统计学意义（P〈0．01）;实验组并发症发生率比对照组明显降低（P〈0．05）。结论重型颅脑损伤病患者鼻肠管早期肠内营养辅以场外营养支持方式,可以明显改善营养状况,减少并发症的发生。     

临床药师参与制订1例T细胞淋巴瘤患者化疗期间营养支持方案的分析

目的:探讨临床药师在T细胞淋巴瘤患者化疗期间营养支持中发挥的作用,为营养支持在恶性肿瘤患者中的临床应用提供参考。方法:临床药师根据病情变化对1例T细胞淋巴瘤患者营养支持方案进行制订与调整:减少TPN中20%中/长链脂肪乳注射液(C6-24)用量至125 ml,10%浓氯化钠至6 g,同时加用整蛋白型肠内营养剂(粉剂)口服营养支持,并加用丁二磺酸腺苷蛋氨酸保肝治疗,并对患者实施药学监护。结果:9 d后,患者由全肠外营养支持过渡至全肠内营养支持,营养状况改善,继续行下一步化疗方案。结论:临床药师参与到临床治疗团队中,协助医师制订和调整营养支持方案,并加强药学监护,可以确保营养支持的安全、有效。     

早期肠内营养对胃癌根治术后患者恢复的影响

目的:探讨早期肠内营养对胃癌根治术后患者恢复的影响。方法:将22例胃癌术后患者随机分为肠内营养组与肠外营养组,于术后20 h开始分别给予肠内与肠外营养,比较2组患者术后肛门首次排气时间、住院时间及并发症情况。结果:与肠外营养组比较,肠内营养组患者术后肛门首次排气时间早,住院时间短,2组均无严重并发症发生。结论:早期肠内营养可加快胃癌根治术后患者胃肠功能的恢复,是一种安全可行的营养支持方式。     

肠内外营养对肺癌化疗患者营养状况及不良反应的影响

目的 研究对原发性肺癌化疗患者使用肠内外营养联合支持对其营养状况和化疗不良反应的影响。方法 选取2018年6月—2019年6月在我院接受化疗的原发性肺癌住院患者90例,随机分为对照组和观察组,各45例。两组均进行化疗治疗,对照组患者采用肠外营养支持,观察组患者进行肠内外营养联合支持。分别在每个化疗周期记录两组患者营养状况及不良反应并进行比较。结果 两组患者营养支持前（T₀）的营养状况无显著差异（P>0.05）。化疗T₁-T₄周期内,观察组的营养状况显著优于对照组,不良反应发生率显著低于对照组,差异均有统计学意义（P<0.05）。结论 肠内外营养联合支持能够改善原发性肺癌化疗患者的营养状态,减少化疗期间的不良反应,值得临床推广。     

Economic burden of chronic obstructive pulmonary disease. Impact of new treatment options

The incidence, morbidity and mortality of chronic obstructive pulmonary disease (COPD) is rising throughout the world. The total economic cost of COPD in the US in 1993 was estimated to be over $US15.5 billion, with $US6.1 billion for hospitalisation, $US4.4 billion for physician and other fees, $US2.5 billion for drugs, $US1.5 billion for nursing home care and $US1.0 billion for home care. Office visits, hospital outpatient visits and emergency department visits accounted for 17.3% of the direct costs for COPD in the US. When stratified by severity, COPD treatment costs strongly correlate with disease severity. The American Thoracic Society, the European Respiratory Society and the British Thoracic Society have developed guidelines for the pharmacological treatment of COPD. However, the guidelines establish inhaled bronchodilators (anticholinergic agents and beta 2-adrenergic agonists) as the mainstay of therapy for patients with COPD. The guidelines were not based on cost analyses and thus are not a priori cost-effective guidelines. Since the publication of these guidelines, several new pharmacological products have been approved for use in patients with COPD including a combination of an anticholinergic and selective beta 2-adrenergic agonist [ipratropium/salbutamol (albuterol)] and a long-acting beta 2-adrenergic agonist (salmeterol). Both products are effective bronchodilators in COPD. The purpose of this report is to place these new agents in an updated pharmacological guideline scheme, utilising recently published data on clinical efficacy as well as pharmacoeconomics. The annualised healthcare costs were computed to be $US788/patient/year for the combination ipratropium/salbutamol inhaler and $US1059/patient/year for salmeterol (1999 values). Based upon an improved understanding of the complexity of COPD, the response of patients to newer bronchodilators (given individually or in combination), and recent pharmacoeconomic data for COPD treatment, a new treatment algorithm with associated costs is proposed. The use of an algorithm, based on medical and pharmacoeconomic data, will improve lung function in patients with COPD, improve patient satisfaction (e.g. quality of life, dyspnoea) and outcomes (e.g. exacerbations). It will also result in a positive effect on healthcare costs.