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Background & aims: Subjects with short bowel syndrome (SBS) have impaired quality of life (QoL). No disease-specific instrument has been available to measure treatment-induced changes in QoL over time. Therefore, the aim was to develop and validate an SBS-specific QoL scale. Methods: Classical test theory and Food and Drug Administration (FDA) guidance were applied for development and validation of the SBS-QoL™. Procedures included item generation and raw scale construction. Factor analysis, construct validity and internal consistency were assessed in a non-interventional observation, test re-test reliability and responsiveness in a randomised clinical study. Results: The SBS-QoL™ comprises 17 items including two subscales. Subjects assessed the scale as easy to handle and comprehensible. Good construct validity was shown by comparison with the Home Parenteral Nutrition-Quality Of Life questionnaire as an external scale, which yielded moderately high correlation (r≥0.7). High internal consistency was demonstrated (Cronbach's alpha: 0.94). Also the test re-test reliability was high (r≥0.95), indicating reliable reproducibility of results. The Responsiveness Index (1.84) indicated the ability of the scale to detect changes in QoL over time. Conclusions: The SBS-QoL™ is an easy to handle and comprehensible SBS-specific subject-reported QoL scale. It is valid, reliable and sensitive with excellent psychometric characteristics to measure treatment-induced changes in QoL over time in subjects with SBS. © 2012 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism.

Teduglutide was discontinued after being tested for ≥ 24 weeks in patients with parenteral nutrition (PN) -dependent short bowel syndrome in a clinical trial for efficacy to reduce PN volume. This study was describes change in body mass index (BMI) and PN volume over 12 months in patients who stopped drug after the clinical trial.Prescribed PN volume, weight, and complications were reported. Patients with stable (NEUT, n = 15) or decreased (DEC, n = 7) PN volume by 12 months after stopping drug (NEUT/DEC, n = 22) were compared to those who had increased PN volume (INC, n = 15). With drug response defined by ≥ 20% reduction from pre-drug PN volume to end of drug therapy, 12 INC and 13 NEUT/DEC patients were drug responders.Eleven of 20 eligible sites reported data for 39 of 53 eligible study participants, with follow-up data for 37. INC patients had shorter colon and less frequently had colon in continuity than NEUT/DEC. BMI was decreased at 3, 6, and 12 months relative to the first off-drug visit in INC patients (P = .001), but not in NEUT/DEC patients. Change in BMI off-drug was predicted by colon and small bowel length, baseline BMI, and on-drug change in PN volume (adjusted R2 = 0.708).Gastrointestinal anatomy, baseline BMI, and PN volume reduction on-drug predicted change in BMI off-drug. Whether this response would be maintained for a longer time or in the context of a challenging clinical situation has not been evaluated.

Background and aims Teduglutide, a GLP-2 analogue, may restore intestinal structural and functional integrity by promoting repair and growth of the mucosa and reducing gastric emptying and secretion, thereby increasing fluid and nutrient absorption in patients with short bowel syndrome (SBS). This 24-week placebo-controlled study evaluated the ability of teduglutide to reduce parenteral support in patients with SBS with intestinal failure. Methods In 83 patients randomised to receive subcutaneous teduglutide 0.10 mg/kg/day (n=32), 0.05 mg/kg/day (n=35) or placebo (n=16) once daily, parenteral fluids were reduced at 4-week intervals if intestinal fluid absorption (48 h urine volumes) increased ≥10%. Responders were subjects who demonstrated reductions of ≥20% in parenteral volumes from baseline at weeks 20 and 24. The primary efficacy end point, a graded response score (GRS), took into account higher levels and earlier onset of response, leading to longer duration of response. The intensity of the response was defined as a reduction from baseline in parenteral volume (from 20% to 100%), and the duration of the response was considered the response at weeks 16, 20 and 24. The results were tested according to a step-down procedure starting with the 0.10 mg/kg/day dose. Results Using the GRS criteria, teduglutide in a dose of 0.10 mg/kg/day did not have a statistically significant effect compared with placebo (8/32 vs 1/16, p=0.16), while teduglutide in a dose of 0.05 mg/kg/day had a significant effect (16/35, p=0.007). Since parenteral volume reductions were equal (353±475 and 354±334 ml/day), the trend towards higher baseline parenteral volume (1816±1008 vs 1374±639 ml/day, p=0.11) in the 0.10 mg/kg/day group compared with the 0.05 mg/kg/day group may have accounted for this discrepancy. Three teduglutide-treated patients were completely weaned off parenteral support. Serious adverse events were distributed similarly between active treatment groups and placebo. Villus height, plasma citrulline concentration and lean body mass were significantly increased with teduglutide compared with placebo. Conclusions Teduglutide was safe, well tolerated, intestinotrophic and suggested pro-absorptive effects facilitating reductions in parenteral support in patients with SBS with intestinal failure. ClinicalTrials.gov number NCT00172185.

Placement and care of central venous catheter by qualified personnel and adherence to protocols for care and maintenance of the access site decreases the risk of complications. Adequate hydration, coagulopathy correction, examination of venous anatomy by Doppler scan before and proper patient’s position, reducing PEEP, using small-gauge needle to locate the vein and the use of the Seldinger technique during insertion are also important.

Aims: This study was undertaken to report indications and practice of home enteral nutrition (HEN) in Europe. Methods: A questionnaire on HEN practice was sent to 23 centres from Belgium (B), Denmark (D), France (F), Germany (G), Italy (I), Poland (P), Spain (S) and the United Kingdom (UK). This involved adult patients newly registered in HEN programme from 1 January 1998 to 31 December 1998. Results: A total of 1397 patients (532 women, 865 men) were registered. The median incidence of HEN was 163 patients/million inhabitants/year (range: 62–457). Age distribution was 7.5%, 16–40 years; 37.1%, 41–65 years; 34.5%, 66–80 years and 20.9% >80 years. The chief underlying diseases were a neurological disorder (49.1%), or head and neck cancer (26.5%); the main reason for HEN was dysphagia (84.6%). A percutaneous endoscopic gastrostomy (58.2%) or a naso-gastric tube (29.3%) were used to infuse commercial standard or high energy diets (65.3%), or fibre diets (24.5%); infusion was cyclical (61.5%) or bolus (34.1%). Indications and feeds were quite similar throughout the different centres but some differences exist concerning the underlying disease. There was greater variation in the choice of tubes and mode of infusion. In F, G, I, S, and UK, costs of HEN are fully funded. In B, D, and P patients have to pay part or all of the charges. Conclusions: In Europe, HEN was utilised mainly in dysphagic patients with neurological disorders or cancer, using a standard feed via a PEG. However, there were important differences among the countries in the underlying diseases treated, the routes used, the mode of administration and the funding.

Background & aims: The epidemiology of bone disease in home parenteral nutrition (HPN) is unknown. The aim of this paper is to evaluate the prevalence and severity of reduced bone mineral density (BMD) in long-term HPN. Design: Cross-sectional, multicentre study including patients who within the last 12 months had their BMD assessed by dual-energy-X-ray absorptiometry after at least 6 months of HPN. Data on bone pain and fractures, the primary gastrointestinal diseases, nutritional and rehabilitation status and HPN regimen were reviewed. Both the T -score (no. of SD below mean BMD of young subjects) and the Z -score (no. of SD from normal BMD values corrected for sex and age) were analysed. Results: A T -score

UNLABELLED Injuries, deformations and tumours of the facial part of skull, oral cavity or neck often hamper or prevent normal food consumption. After surgery of these structures food intake may be decreased due to postoperative wounds, pain, swelling and trismus. The aim of the study was to evaluate nutritional state of patients treated surgically in the craniomaxillo- facial surgery department and determination of factors affecting body weight changes after surgery. MATERIAL AND METHODS The study included 83 patients operated between 2008 and 2010 in the department of cranio-maxillo-facial surgery, due to: maxillo-facial defects (30 individuals), malignant tumours (23 individuals), injuries (19 individuals), benign tumours (11 individuals). The study was prospective. A method of nutrition during the observation period and BMI (Body Mass Index) value on the first day of hospitalization and after 10, 60, 180 days after hospital admission were considered. For statistical analysis of results a general regression analysis was used. RESULTS Significant reduction of BMI was observed in all patients after 10 and 60 days from the start of hospitalization. A significant increase of this parameter was observed between Day 60 and Day 180 of observation, however the BMI values after 180 days were still significantly lower than the baseline. A dependency between these changes and a cause of hospitalization as well as nutrition during and after the stay at hospital has been shown. CONCLUSIONS There is a distinct relationship between the worsening of nutritional state after craniofacial surgery and nutrition during and after hospitalization, and therefore special attention should be paid to the issue of nutrition during this period.

UNLABELLED Long-term home parenteral nutrition (HPN) is an important factor for cholelithiasis. An individualized nutrition program, trophic enteral nutrition and ultrasound bile ducts monitoring is a necessity in those patients. The aim of the study was to evaluate the usefulness of prophylactic cholecystectomy in patients with asymptomatic cholelithiasis requiring HPN. MATERIAL AND METHODS 292 chronic HPN patients were analyzed in the period from 2005 to 2012. Patients were divided into four groups: A - without cholelithiasis, B - with asymptomatic cholelithiasis, C - urgent cholecystectomy because of cholecystisis caused by gallstones, D - cholecystectomy in patients without cholelithiasis performed during an operation to restore the continuity of the digestive tract. The patients were additionally divided depending on the extent of resection of the small intestine and colon. RESULTS 36.9% of chronic HPN patients had cholelithiasis confirmed using ultrasonographic examination. Cholecystectomy due to acute cholecystitis symptoms was performed in 14.4% of the patients. The remaining 22.6% patients had asymptomatic cholelithiasis. Prophylactic cholecystectomy was performed in 5.5% patients with no signs of cholelcystisis during the planned operation to restore the continuity of the digestive tract. CONCLUSIONS Cholelithiasis in chronic HPN patients is a frequent phenomenon. It seems useful to perform prophylactic cholecystectomy during primary subtotal resection of the small intestine, because the risk of cholelithiasis in this group of patients is very high.

Background: Home parenteral nutrition (HPN) is a lifesaving treatment in patients with intestinal failure. Dependency of nutritional support becomes permanent for the majority of patients who had received HPN for at least 2 years. The alternative to long term HPN in selected patients is intestinal transplantation. Aims: To study some of the clinical, social and rehabilitation aspects of long-term HPN treatment. Methods: A survey was performed in nine European HPN centres. The questionnaire covered epidemiologic data, underlying diseases, intestinal anatomy, nutritional support and status, marital status, rehospitalization rate, HPN complications, rehabilitation score, drugs use, coexistent diseases and interest in intestinal transplantation. For some items, data were collected within 12 months prior to the evaluation. Results: This survey included 228 patients with a median age of 49 years. The median duration of HPN was 7 years (range 2–24 years). Short bowel length less than 100 cm was reported in 65% of patients with a predominance of end-jejunostomy or jejuno-colonic anastomosis. Global subjective nutritional status was normal in 79% of the patients, who were supplied with a mean number of 5.6 bags of parenteral nutrition weekly. Rehospitalizations within the 12 months prior to evaluation accounted for a mean period of 23 days and were due to HPN complications in half of the cases. Catheter-related sepsis was the most frequent HPN-complication. Bone metabolism disorders, which seemed to be more common than liver diseases, were directly related to HPN duration. One-third of the HPN patients was regularly consuming analgesics or opiates. HPN impair complete rehabilitation status but may improve the status of patients who had a very low rehabilitation score before starting HPN. An interest of intestinal transplantation was noted in only 10% of medical teams and in 8% of HPN patients. Conclusions: This study is the largest European survey on long-term HPN patients with long standing or permanent intestinal failure. Data enlighten clinical, social and rehabilitation aspects of patients who could face the option of intestinal transplantation in the future.

Rationale: Home Artificial Nutrition (HAN) has been an expanding area over the last 30 years. HAN programs have been often developed prior to the regulation by the National Health Systems (NHS) leading to different policies within European countries. The aim of this study was to compare legislation regarding HAN in Europe. Method: The Group elaborated two structured questionnaires (one for Home Enteral Nutrition – HEN - and one for Home Parenteral Nutrition – HPN) which were presented to all the members of the HAN-Working group and to the 21 ESPEN Council members. Results: Twelve questionnaires were returned, covering for more than 375 million inhabitants. HEN: regulated in seven countries, Italy and France being the first to implement reimbursement policy in 1988. Except in France, Croatia and the Czech Rep almost any physician can prescribe HEN. NHS totally or partially fund HEN, although in Austria and Israel expenses are paid for the patients. Provision of enteral diets and equipment varies widely within countries. As in HPN, most of the countries have written guidelines for health care workers and for patients. HPN: legislated in six countries, Denmark being the first in 1975. HPN programs are restricted to a few hospitals and patients are followed by Nutrition Support Teams (NST). The budget for HPN is 100% supported by NHS. Hospital pharmacy, private pharmacists and Home Care companies are involved in a different degree in providing and distributing solutions and disposables. Conclusions: HPN regulation preceded HEN regulation by 10–20 years. Due to this longer experience and high level of care, HPN patients are usually followed by NST. Despite different policies, funding is relatively uniform, NHS supporting most of the expenses for HAN. ESPEN could play a key role developing common standards for HAN all over Europe.

Improving the effectiveness of the treatment of critically ill and their longer survival has increased the existence of later complications rarely seen before. Among the hospital-acquired infections such complications include infection of mold fungi. The paper presents difficulties in diagnosing and therapy of Aspergillus mold infections illustrating them with the description of cases when Aspergillus infection occurred during the treatment of critically ill, leading with treatment delay to high mortality.

PN admixtures are sterile large volume parenteral infusions aseptically manufactured/compounded/prepared from required nutritional components (e.g. amino acids, glucose, lipid, electrolytes, trace elements and vitamins). The individual components (sterile injections/infusions) are transferred into a single sterile plastic container, providing the user with a complex pharmaceutical formulation in the form of a single easy to use infusion system. PN admixtures are usually referred to as Two-in-One (TIO) or Allin-One (AIO) where these refer to admixtures that are (Fig. 1)

AIO admixtures are parenteral nutrition formulations containing water, glucose, 15–20 amino acids, lipids, 10–12 electrolytes, 9 trace elements and 11–12 vitamins in a single container. For practical reasons some medications (e.g. insulin, cimetidine and ranitidine) may be added to the admixture in order to maintain acting concentration in serum, decreasing total volume of fluids infused, reducing the risk of contamination and the cost of equipment. All these ingredients and additives and order in which they are added and ways of delivery influence the overall TPN admixture stability. Stability means that the admixture maintains the same status throughout the defined period of time (storage and delivery). Features of stability are

The concept of PPN first described in 1945 by Brunschwig and colleagues, who fed a patient withmultiple fistulas parenterally, for eight weeks using a protein hydrolysate and 10% glucose solution. When Wretlind first introduced his amino acid solution and lipid emulsion, he and Schubert administered these peripherally in the 1950s and 1960s. When Dudrick introduced hyperalimentation in 1968, PPN was regarded as erroneously hypocaloric.

A retrospective survey on home parenteral nutrition (HPN) in Europe was performed fromJanuary to December 1997. Data were compared to a similar study performed in 1993. A questionnaire of HPN practice was designed by the members of the ESPEN-HAN group. This involvedadult patients (older than 16 years) newly registered in an HPN program between 1 January and 31 December 1997 and included: number of patients, underlying diseases and a 6–12 month outcome. Incidence and prevalence (at 1.1.1998) of adult HPN were calculated according to the estimated total population in 1997 for the countries in which more than 80% of HPN patients were reported. A total of 494 patients were registered in 73 centres from nine countries (Belgium (B), Denmark (D), France (F), Poland (P), Spain (S), Sweden (Sw), United Kingdom (UK), The Netherlands (N) and Germany (G). The underlying diseases for HPN in 494 patients were cancer (39%), Crohn's (19%), vascular diseases (15%), radiation enteritis (7%), AIDS (2%), other diseases with intestinal failure (18%). Incidence (patients/million inhabitants/year) were in N (3), F. (2.9), D. (2.8), B. (2.6), UK (1.2), S (0.7) and P (0.36), respectively. Prevalence were in D. (12.7). U.K. (3.7), N. (33), F (3.6), B (3.0), P (1.1), S (0.65). After this 6–12 months follow-up (n=284), the mortality was respectively 4% in Crohn's disease, 13% in vascular diseases, 16% in others, 21% in radiators enteritis, 34% in AIDS, 74% in cancer. Incidences and prevalences modestly increased in these seven European countries in 1997 in comparison to 1993. The percentages of underlying diseases in these countries remained similar except for ADS that significantly decreased (from 7% to 2%). Outcomes did not significantly differ in the 4-year period except for AIDS (34% instead of 88% mortality) and could have been related to newer, more efficacious therapy.

Une enquete retrospective a ete realisee en 1994, incluant 496 patients adultes qui ont debute une nutrition parenterale a domicile (NPAD) au cours de l'annee 1993, au sein de 75 centres repartis dans 13 pays europeens. Pour les pays ayant enregistre plus de 80% des nouveaux cas (423 patients), l'incidence et la prevalence furent estimees dans une echelle de 0,2 a 4,6 patients et de 0,3 a 12,2 patients pour 1 000 000 habitants par an, respectivement. Chez les patients etudies, la maladie sous-jacente etait soit un cancer (42%), une maladie de Crohn (15%), une maladie vasculaire (13%), une enterite radique (8%), un syndrome d'immunodeficience acquise (4%) ou autre (18%), Le syndrome du grele court et l'obstruction intestinale etaient les deux indications majeures pour la NPAD, respectivement dans 31% et 22% des cas. Soixante-trois pour cent des centres avaient une equipe de nutrition. La NPAD etait le plus souvent administree via un catheter central tunnelise (73%) et sous le mode cyclique nocturne (90%), alors qu'elle etait la seule source de nutrition dans 33% des cas. Seulement 44 % de patients prenaient en charge de maniere autonome leur NPAD. La presente etude indique que le cancer est devenu actuellement l'indication majeure pour la NPAD en Europe ; il existe cependant une grande heterogeneite dans les indications parmi les pays europeens ayant participe a l'enquete. La probabilite de survie apres une duree allant de 6 a 12 mois etait faible en cas de SIDA (n = 8; 12%) et de cancer (n = 78; 29%) mais tres satisfaisante dans les autres indications de NPAD (n = 115 ; 92%).

Summary Background & aims Short bowel syndrome (SBS)-intestinal failure (IF) patients have impaired quality of life (QoL) and suffer from the burden of malabsorption and parenteral support (PS). A phase III study demonstrated that treatment with teduglutide, a glucagon-like peptide 2 analogue, reduces PS volumes by 32% while maintaining oral fluid intake constant; placebo-treated patients had reduced PS by 21%, but oral fluid intake increased accordingly. As effects of teduglutide on QoL are unknown, they were investigated here. Methods QoL analyses from a double-blind, randomised Phase III study in 86 SBS-IF patients receiving teduglutide (0.05 mg/kg/day s.c.) or placebo over 24 weeks. At baseline and every 4 weeks, QoL was assessed using the validated SBS-QoL™ scale. Results PS reductions were associated with QoL improvements (ANCOVA, p = 0.0194, SBS-QoL per-protocol). Compared to baseline, teduglutide significantly improved the SBS-QoL™ total score and the score of 9 of 17 items at week 24. These changes were not significant compared to placebo. Teduglutide-treated patients with remaining small intestine >100 cm experienced more gastrointestinal adverse events (GI-AE), unfavourably affecting QoL. Conclusions Overall, PS volume reductions were associated with improvements in SBS-QoL™ scores. The short observation period, imbalances in oral fluid intake in relation to PS reductions, large patient and effect heterogeneity and occurrence of GI-AE in a subgroup of teduglutide-treated patients may account for the inability to show statistically significant effects of teduglutide on SBS-QoL™ scores compared to placebo. ClinicalTrials.gov identifier: NCT00798967.

Background & Aims Although home parenteral nutrition (PN) can save the lives of patients with massive bowel loss that results in short-bowel syndrome and intestinal failure, quality of life is impaired by PN and its complications. We examined the 12-month tolerability and efficacy of teduglutide to reduce PN dependency. Methods Patients who received teduglutide (0.05 or 0.10 mg/kg/d) for 24 weeks in a randomized controlled trial were eligible for a 28-week double-blind extension study; 52 patients were given 52 weeks of the same doses of teduglutide. We investigated the safety, tolerability, and clinical efficacy (defined as a clinically meaningful ≥20% reduction in weekly PN volume from baseline) at week 52. Results The most common adverse events reported included headache (35%), nausea (31%), and abdominal pain (25%); 7 patients withdrew because of adverse events (gastrointestinal disorders in 4). Both groups had progressive reduction in PN. At week 52, 68% of the 0.05-mg/kg/d and 52% of the 0.10-mg/kg/d dose group had a ≥20% reduction in PN, with a reduction of 1 or more days of PN dependency in 68% and 37%, respectively. Four patients achieved complete independence from PN. Conclusions For patients with short-bowel syndrome intestinal failure, the efficacy of teduglutide was maintained over 52 weeks and the safety profile was sufficient for it to be considered for long-term use. Further studies are needed to determine whether these effects will translate into improved quality of life and reduced PN complications. ClinicalTrials.gov number, NCT00172185.

Teduglutide, a glucagon-like peptide 2 analogue, might restore intestinal structural and functional integrity by promoting growth of the mucosa and reducing gastric emptying and secretion. These factors could increase fluid and nutrient absorption in patients with short bowel syndrome with intestinal failure (SBS-IF). We performed a prospective study to determine whether teduglutide reduces parenteral support in patients with SBS-IF.We performed a 24-week study of patients with SBS-IF who were given subcutaneous teduglutide (0.05 mg/kg/d; n = 43) or placebo (n = 43) once daily. Parenteral support was reduced if 48-hour urine volumes exceeded baseline values by ≥ 10%. The primary efficacy end point was number of responders (patients with20% reduction in parenteral support volume from baseline at weeks 20 and 24).There were significantly more responders in the teduglutide group (27/43 [63%]) than the placebo group (13/43 [30%]; P = .002). At week 24, the mean reduction in parenteral support volume in the teduglutide group was 4.4 ± 3.8 L/wk (baseline 12.9 ± 7.8 L/wk) compared with 2.3 ± 2.7 L/wk (baseline 13.2 ± 7.4 L/wk) in the placebo group (P.001). The percentage of patients with a 1-day or more reduction in the weekly need for parenteral support was greater in the teduglutide group (21/39 [54%]) than in the placebo group (9/39 [23%]; P = .005). Teduglutide increased plasma concentrations of citrulline, a biomarker of mucosal mass. The distribution of treatment-emergent adverse events that led to study discontinuation was similar between patients given teduglutide (n = 2) and placebo (n = 3).Twenty-four weeks of teduglutide treatment was generally well tolerated in patients with SBS-IF. Treatment with teduglutide reduced volumes and numbers of days of parenteral support for patients with SBS-IF; ClinicalTrials.gov Number, NCT00798967.

Background & aims: Indications and timing for referral for intestinal transplantation (ITx) were investigated through a review of the literature on home parenteral nutrition (HPN) for benign intestinal failure and a benchmarking to the results of a prospective European survey which evaluated the appropriateness of the current indications for ITx. Methods: Manuscripts reporting outcomes of adults and children on HPN were retrieved through a PubMed search. Data from the European survey were compared with those on HPN reported in the literature, and with those on ITx reported by the USA registry and by the Pittsburgh center. Results: HPN is a safe treatment with a high probability of survival. The risk of death during HPN is increased by the absence of a specialist team, and appears greater during the early period of treatment. Survival probability is decreased in patients with: age >40 or

Ionized magnesium was measured potentiometrically using a clinical analyzer MICROLYTE 6 (KONE, Finland). Total magnesium was measured colorimetrically. Ionized magnesium (iMg) concentration changes with pH were made to observe the accuracy of the results if they were not recalculated to the actual pH of blood or recalculated with some uncertainty in parameters. The dependence of iMg and iCa on heparin (used as anticoagulant in plasma samples) was made. Less than 40 units per 1 mL of blood decreased the concentration of iMg and iCa less than 1.5%. The range of iMg and total Mg in serum and plasma of healthy and ill adults (short bowel syndrome, myocardial infarct) was investigated and compared. In both illnesses, the concentration of ionized and/or total magnesium is significantly different from the range of healthy people. The range of iMg and total Mg as well as the percentage of iMg against total Mg seem to be specific for a given illness.

The most frequent etiological factors of fungal infections in patients receiving total parenteral nutrition (TPN) belong to Candida genus of the yeastlike fungi. In the TPN patients the several infectious complications can develop: venous catheter infection, catheter candidemia (fungemia), fungal endocarditis or fungal ophtalmitis. The capability of hydrolytic (proteolytic, lipolytic) enzymes secretion as well as biofilm formation on artificial surfaces are the most important factors of fungal strains pathogenity. In the study from clinical materials of 37 patients receiving total parenteral nutrition 31 strains of Candida glabrata (56.4%), 13 strains of Candida albicans (23.6%), 3 Candida tropicalis strains, 2 Candida krusei strains, 2 Candida lusitaniae strains and 1 strain of Candida inconspicua were identified. The phenotypic analysis of isolated strains were performed using API YM (bioMerieux) tests for the enzymatic activity determination. Simultaneously the proteolytic and lipolytic activity analysis were performed. Candida albicans isolates secreted 10 out of 19 enzymes and Candida glabrata 7. The secretion of proteases was demonstrated in 12 C. albicans strains. All Candida glabrata isolates from examined and from control group secreted proteolitic enzymes. Candida glabrata is the dominant species in clinical materials of patients receiving total parenteral nutrition. The numerous isolation of C. glabrata from clinical materials of patients receiving total parenteral nutrition might be connected with the selection of azole resistant strains and also to ability of creatin biofilm on the biomaterial surfaces.

Background Intestinal failure is the outcome of a number of gastrointestinal diseases and characterized by significant reduction in functional gut mass. If not resolved patients often face long-term nutritional support. This study gathered information about how patients referred with intestinal failure are managed in specialised European centres. Methods A questionnaire was circulated in 7 European countries via representatives of the ESPEN-HAN working group to seek information about experience in treating patients with intestinal failure. We asked about clinical outcome, information about structure and organisation of the department, referral criteria, treatment procedures and guidelines. Results 17 centres in 6 European countries completed the questionnaire: UK, n = 6, France, n = 4, Spain, n = 3, Denmark, n = 2, Italy, n = 1, Poland, n = 1. The experience of the centres in treating patients was in the range 12–30 years. The total number of patients on HPN in all centres was 590. The number of patients referred to centres with intestinal failure during the period January to December 2000 was n = 882: UK, n = 375 (range 2–175), France, n = 308 (range 24–182), Italy and Spain, n = 43 (range 9–52), Denmark n = 51 (range 14–37), the centre in Poland included 53 patients. Comparing all centres the following distribution among patients (median % (range%)) with regard to the endpoints were reported: Oral nutrition 32% (23–50%), enteral/tube feeding 11% (4–23%), HPN 36% (15–57%), lost to follow up 10% (0–35%), dead 9% (5–18%). No patients had an intestinal transplant. Conclusion The study provides information about how patients with intestinal failure are managed across Europe and the data indicates that treatment practice varies between countries.

Summary Introduction & aim To gather information about how adult patients on home parenteral nutrition (HPN) are monitored after discharge from the hospital. Method A questionnaire about HPN monitoring practice was circulated to HPN centres in eight European countries through the representative of the ESPEN 1 HAN-working group 2 . Centres were asked about guidelines, home visits and how monitoring and handling of complications were managed. Results Fourty-two centres in eight European countries completed the questionnaire: UK n = 14 , France n = 9 , Belgium n = 4 , Italy n = 4 , Poland n = 4 , Denmark n = 4 , Spain n = 2 , Germany n = 1 . The HPN experience of the centres was in the range 2–30 years. Centres ranged in size from 0 to 125 HPN patients representing a total number of 934 of whom 54% had received HPN for more than 2 years. The primary disease was non-malignant in 90% whilst 10% had been diagnosed with active cancer. Of the centres 92% had a HPN team and 66% had written guidelines for monitoring HPN. Home visits after discharge for monitoring purposes were carried out by 31 of the centres involving the HPN team, general practitioner, community nurse or home care agency. Stable patients on HPN for more than 12 months were monitored at the discharging hospital (73%), at a local hospital (12%), by the General Practitioner (11%) or by a home care agency (4%). Of the centres, 90% reported that the main responsibility for monitoring was assigned to a specific person. The intervals between monitoring visits for the stable HPN patient was in the range 1–6 months, 52% of the centres reported intervals of 2–3 months. In case of complications 76% of centres reported that patients got in touch with the HPN team, 2% the local hospital, 5% the home care agency, and 17% other. Re-admission to hospital was usually to the HPN centre and only occasionally to a local hospital. Conclusion In Europe a specialised team at the discharging hospital monitors HPN patients and 66% of the centres had some kind of written guidelines.

A 61-year old man with fever, diarrhoea, weight loss has been admitted to the hospital. Nine years earlier an air bubble in the lower part of the left lung was recognised during the chest x-ray, four years later diagnostic studies have shown a megacolon situated in the chest that significantly pressed on the flesh of the left lung and shifted the mediastinum to the right side. At that time the patient did not agree for an operation treatment. He decided for surgery in May 2002. During the operation the presence of an enormous large intestine of the megacolon type has been determined which could be found there due to diaphragm loss. The megacolon and spleen were surgically removed and the injured diaphragm was sutured. After 2 years a clinical and functional examinations of the respiratory system were performed. There was an improvement of the exercise capacity, recession of restriction in functional examinations and an increase in body mass.

“Death by parenteral nutrition” was the title of the controversial editorial published in the June issue of Intensive Care Medicine by P.E. Marik and M. Pinsky [1]. One might believe that a real event was being described by the authors. Imagine our astonishment, which quickly turned to dismay, when we read the words: “…a poison or toxin is a substance that through its chemical action usually kills, injures or impairs an organism… and by this definition TPN meets all criteria of a poison/toxin, in the critically ill patient receiving parenteral nutrition.” We are surprised and perturbed that the authors have missed some important issues regarding the nutrition of patients in intensive care units (ICUs), exchanging sensationalism for sound scientific discussion.

Rationale: Animal models have showed that ubiquitinproteasome pathway (UPP) may be the effector of muscle loss during cancer cachexia. However, evidence from clinical studies is still needed to understand mechanisms involved in cancer induced muscle catabolism in patients. Methods: Patients (n = 17, 64±6 years) diagnosed with esophageal cancer were undergoing surgery with intent of resection of the primary tumor. As a control group, weight stable patients undergoing reflux surgery (n = 10, 60±7 years) were included. Vastus lateralis muscle biopsies were taken with a Bergstrom needle. Diaphragm biopsies were obtained by open surgery (cancer group) and by laparoscopic surgery (control group). Proteasome, caspase 3, calpains and lysosomal enzymatic activities were measured by using specific fluorogenic peptide substrates. Differences between the groups were tested with a Student’s t-test. Results: Cathepsin L activity was 115% higher in the vastus lateralis of cancer patients compared to the controls (5.3±0.4 vs 2.5±0.3 pmol/min/mg; p < 0.001). Cathepsin B activity in vastus lateralis was 85% higher in the cancer group compared to the control group (2.4±0.2 vs 1.3±0.2 pmol/min/mg; p < 0.001). This latter activity was correlated to the self-reported body weight loss of cancer patients (R2 = 0.41, p = 0.03). In diaphragm, activities of both cathepsins were 60% higher in cancer patients compared to the controls (p < 0.01). Proteasome, calpain and caspase3 activities did not differ between the two groups neither in vastus lateralis nor in diaphragm. Conclusion: The finding of weight-loss related activation of cathepsins in both skeletal and respiratory muscles in patients with esophageal cancer suggest that the lysosomal pathway might be involved in the development of cancer cachexia. In contrast to animal studies, in our study, UPP seems not to be the main or exclusive system implicated in muscle loss during cachexia.

Rationale: The purpose of this study is to report the frequency of central venous catheter (CVC) complications and to analyze the potential risk factors for complications requiring CVC removal in home parenteral nutrition (HPN) patients. Methods: A questionnaire developed by the ESPEN HAN WORKING GROUP was distributed to 12 European centers to investigate the complications occurring during the period between January 1995 and December 2000 when HPN patients used their first CVC. The questionnaire collected informations related to the Home Parenteral Nutrition technique and the underlying disease. Factors affecting the time of CVC removal were jointly investigated using Cox's multivariable regression models. Results: The study was performed on 447 patients for a total of 110,869 CVC-days. Complications occurred in about 1/4 of patients, approximately half were infections and about half required Central Venous Catheter removal. The Cox analysis showed that using the CVC 7 times/week and implanted ports were associated with a hazard ratio of 3 and 2.8, respectively. A reduced risk of removal (of about 40%) was associated with using CVC also for non-nutritional purposes ( P = 0.0016). Conclusions: Within the limits of this retrospective investigation, the type of CVC, the type of administration of HPN and the type of training are important factors associated with occurrence of complications or with CVC removal. However, in our opinion, proper care of the CVC, of preparation and administration of the nutritive admixture seem to be paramount for a safe management of HPN.

In the early days of parenteral nutrition (PN), a multiple (double or triple) bottle system (MB) was used, where amino acids, glucose and fat emulsionwere administered in parallel or in sequence from 0.5 to 1 l bottles. Minerals and vitamins were added to different bottles and infused at different times. It was common to have 6–8 bottle changes every day, and it was necessary to set up different irregular flow rates and make many different additions. Mistakes, hyperglycaemia and electrolyte disorders were common, requiring frequent controls of glycaemia and plasma electrolytes. Sometimes nutrient utilization was far from optimal. The only advantage of MB was (and still is) flexibility and ease of adjustment to rapidly changing patient needs (e.g. in ICU patients). It has been claimed, that using the MB system it is easy to overcome compatibility problems with no limitations on mineral and electrolyte dosage, because incompatible elements could be added to separate bottles. However, it is known that untested simultaneous administration of nutrients increases the risk of physicochemical incompatibilities. This can be further aggravated by drugs infused or injected via the same central

Rationale: Perioperative nutritional support via a surgically placed jejunostomy is commonly used in patients undergoing surgical resection of oesophago-gastric cancer. With the development of laparoscopic resectional techniques, is the use of jejunal feeding as safe as at open surgery? Methods: A prospective, comparative study of patients undergoing 2-stage oesophagectomy prior to and following the instigation of laparoscopic gastric mobilization and jejunostomy formation. End points assessed included major surgical complications, mechanical displacement and dislodgement and days of successful feeding. Results: 50 patients were assessed, 25 before and 25 after the change of practice (M:F ratio was 8:2, median age: 64 years). All had a successful insertion of jejunostomy and none had a significant surgical complication at time of insertion. Mechanical complications were similar between the 2 groups (8% in open surgery vs 12% in laparoscopic surgery) The mean number of days of nutritional support was also similar between the two sets of patients (medians with interquartile range) 39.6±42.35 days for open surgery and 19.6±13.21 days for laparoscopic insertion. Conclusion: Laparoscopically placed jejunostomies are as reliable and safe as those placed at open surgery for peri-operative nutritional support in patients undergoing oesophago-gastric cancer resection.