Care Coordination to Enhance Management of Long‐Term Enteral Tube Feeding

Background: A systematic review and meta‐analysis was completed to summarize care delivery models that used care coordination and/or team approach methods in the management of patients requiring long‐term enteral tube feeding. Our aim was to evaluate team composition, implementation strategies, and the effectiveness of these methods. Methods: We conducted a broad search of 7 databases from inception to May 2012, cross‐referenced clinical reviews and medical guidelines, and consulted clinical experts. Independent reviewers screened eligible studies, extracted data, and assessed study quality. Results: Fifteen studies enrolling 2145 patients were included in this review. The studies described multidisciplinary teams composed of primary care physicians, specialists, nurses, dietitians, and language or speech specialists. Patients and their families/caregivers were also an important part of the care team. The interventions were multifaceted and employed multiple simultaneous strategies that particularly included patient and family education, staff education, and continuous auditing and feedback methods. Meta‐analysis suggested no significant reductions in complications (incidence rate ratio [IRR], 0.53; 95% confidence interval [CI], 0.27–1.05), infections (IRR, 0.77; 95% CI, 0.48–1.24), and overall hospital admissions (IRR, 0.36; 95% CI, 0.13–1.00) most likely due to lack of statistical power. We found significant reduction of total hospital costs (estimates in US dollars: ?623.08; 95% CI, ?745.64 to ?500.53; P < .01) after the interventions. Conclusion: Studies suggested a positive association of care coordination by a multidisciplinary team approach and improved patient outcomes for long‐term enteral feeding patients. However, the available evidence does not allow estimating the effectiveness of a particular intervention or team composition.     

What Are Adults With Inflammatory Bowel Disease (IBD) Eating? A Closer Look at the Dietary Habits of a Population‐Based Canadian IBD Cohort

Background: A comprehensive study of what individuals with inflammatory bowel disease (IBD) are eating that encompasses food avoidance, dietary sugar consumption, and a comparison with the non‐IBD Canadian population has not been documented. The aim was to analyze these interrelated dietary components. Methods: Food avoidance and sugar intake data were collected from 319 patients with IBD enrolled in the University of Manitoba IBD Cohort Study. Diets of those with IBD (n = 256) were compared with a matched, non‐IBD Canadian cohort using the nutrition questions obtained from the Canadian Health Measures Survey (CHMS). Results: Food avoidance among IBD is prevalent for alcohol, popcorn, legumes, nuts, seeds, deep‐fried food, and processed deli meat, with a higher prevalence among those with active IBD. Patients with active IBD also consumed significantly more portions of sports drinks and sweetened beverages compared with those with inactive disease. Compared with the non‐IBD Canadian population, patients with IBD consume significantly less iron‐rich food but more milk. Conclusions: Food avoidance is common among those with IBD but may be due more to personal preferences, while sugar‐laden beverages may be displacing other foods higher in nutrients. The overall diet of patients with IBD differed from that of the non‐IBD Canadian population, but deficiencies were observed in both groups. Considering malnutrition among persons living with IBD, nutrition education by trained dietitians as part of the IBD team is imperative to address food avoidance and overall balance nutrition as part of treating and preventing nutrition deficiencies.     

Association Between Serum 25(OH)D Level and Nonspecific Musculoskeletal Pain in Acute Rehabilitation Unit Patients

Objective: Nonspecific musculoskeletal pain can be difficult to manage in acute rehabilitation unit (ARU) patients. We investigated whether vitamin D status is a potential modifiable risk factor for nonspecific musculoskeletal pain in ARU patients. Materials and Methods: This cross‐sectional study focused on 414 adults from an inpatient ARU in Mission Viejo, California, between July 2011 and June 2012. On ARU admission, all patients had serum 25‐hydroxyvitamin D (25(OH)D) levels measured and were assessed for nonspecific musculoskeletal pain. We performed multivariable logistic regression to test the association of serum 25(OH)D level with nonspecific musculoskeletal pain while adjusting for clinically relevant covariates. Results: Among these 414 patients, mean (SD) 25(OH)D level was 29 (12) ng/mL, and 30% had nonspecific musculoskeletal pain. After adjustment for age, sex, race, body mass index, Functional Independence Measure score, Deyo‐Charlson Comorbidity Index, fractures, steroid use, history of osteoporosis/osteomalacia, and patient type (orthopedic, cardiac, neurological, spinal cord injury, or traumatic brain injury), serum 25(OH)D level was inversely associated with nonspecific musculoskeletal pain (odds ratio [OR] per 10 ng/mL, 0.67; 95% confidence interval [CI], 0.48–0.82). When 25(OH)D level was dichotomized, patients with levels <20 ng/mL had higher odds of nonspecific musculoskeletal pain (OR, 2.33; 95% CI, 1.23–4.17) compared with patients with levels ≥20 ng/mL. Conclusions: In adult patients, serum 25(OH)D level on admission to ARU was inversely associated with nonspecific musculoskeletal pain. These data support the need for randomized, controlled trials to test the role of vitamin D supplementation to improve nonspecific musculoskeletal pain in ARU patients.     

Impact of the Nationwide Intravenous Selenium Product Shortage on the Development of Selenium Deficiency in Infants Dependent on Long‐Term Parenteral Nutrition

Background: For patients dependent on parenteral nutrition (PN), selenium must be supplemented intravenously. A nationwide intravenous selenium shortage began in April 2011. The impact of this shortage on PN‐dependent infants was evaluated by examining the provision of selenium, development of biochemical deficiency, and costs associated with the shortage. Materials and Methods: This single‐center, retrospective study included PN‐dependent infants aged ≤1 year who weighed ≤30 kg, received PN for ≥1 month, and had ≥1 serum selenium measurement. The primary outcome was the incidence of biochemical selenium deficiency. Secondary outcomes included severity of biochemical deficiency, clinical manifestations, costs, and relationship between serum selenium levels and selenium dose. Results: The average selenium dose decreased 2‐fold during the shortage (2.1 ± 1.2 µg/kg/d; range, 0.2–4.6 µg/kg/d) versus the nonshortage period (3.8 ± 1 µg/kg/d; range, 2.4–6 µg/kg/d; P < .001). A linear relationship between serum selenium concentration and selenium dose was observed (r² = 0.42), with a dose of 6 µg/kg/d expected to result in normal serum levels in most cases. Similar proportions of patients developed biochemical deficiency in both groups: shortage period, 59.1%; nonshortage, 66.7%; P = .13. The severity of biochemical deficiency was similar between groups. A significant increase in incremental cost during the shortage was observed. Conclusion: This is the first study examining the impact of the intravenous selenium shortage on PN‐dependent infants. Both groups exhibited similarly high incidences of biochemical selenium deficiency, suggesting higher empiric doses may benefit this population. However, ongoing shortages limit the ability to provide supplementation.     

Teduglutide for Safe Reduction of Parenteral Nutrient and/or Fluid Requirements in Adults

Background: Teduglutide (Gattex; NPS Pharma, Bedminster, NJ), a recombinant analogue of human glucagon‐like peptide 2 (GLP‐2), is the first long‐term medical therapy approved for the treatment of adults dependent on parenteral nutrition (PN). Objective: To assess the efficacy and safety of teduglutide in reducing PN (parenteral nutrient and/or fluid) requirements in PN‐dependent adults. Methods: Studies were identified using predefined search criteria and multiple databases, including Medline and Embase. The search was completed to November 30, 2014, in the absence of date or study design restrictions. Citation inclusion criteria and methodological quality were assessed by 2 independent reviewers. Outcomes of interest were changes in parenteral nutrient or fluid requirements and adverse event incidence. From 2693 unique citations, 76 abstracts were reviewed. Fourteen reports met the inclusion criteria, including data from 2 phase III, double‐blind, placebo‐controlled clinical trials and their respective extension studies. Data extraction was performed by 2 reviewers using a standardized form. Results: Teduglutide reduced PN requirements compared with placebo, whereas adverse event incidence was similar. Limitations: Number of subjects studied and length of follow‐up. Conclusions: Teduglutide appears to be a safe and well‐tolerated means to reduce PN dependence in adults, regardless of PN dependence duration.     

Changes in Resting Energy Expenditure Following Orthotopic Liver Transplantation

Background:There is no consensus whether resting energy expenditure (REE) following orthotopic liver transplantation (OLT) is altered. Methods: The objectives of this investigation were to describe changes in measured REE (mREE) using indirect calorimetry in 25 OLT patients on days 5, 10, and 15 after baseline (within 72 hours following OLT) and compare mREE changes with those calculated with 2 predicted equations for energy expenditure (pREE): the Harris‐Benedict and Schofield equations. Results: Patients were 57 ± 5.4 years of age, 44% were male, 36% were black, and 72% had liver disease of viral etiology. Measured REE (at baseline and days 5, 10, and 15, per kcal/d: 1832 ± 952, 1565 ± 383, 1538 ± 345, 1578 ± 418) and kcal per kilogram of body weight (22.7 ± 12.8, 18.4 ± 4, 18.7 ± 3.8, 21 ± 6.5) did not change over time. In contrast, changes in pREE based on either the Harris‐Benedict (P < .001) or Schofield (P = .006) equation using measured weights at each corresponding time point and lowest body weight during the study to estimate dry weight were significant. Conclusions: Wide ranges in both mREE and mREE expressed per kilogram of body weight at each study time point were observed in contrast to pREE, which declined by day 15. The observed differences in mREE over time suggest indirect calorimetry is indicated if available following OLT. Additional research is warranted to determine the most appropriate predictive equation with suitable stress factors to use when indirect calorimetry is not available.