Protein trans-splicing by the naturally split intein of the gene dnaE from Nostoc punctiforme (Npu DnaE) was demonstrated here with non-native exteins in Escherichia coli. Npu DnaE possesses robust trans-splicing activity with an efficiency of >98%, which is superior to that of the DnaE intein from Synechocystis sp. strain PCC6803 (Ssp DnaE). Both the N-and C-terminal parts of the split Npu DnaE intein can be substituted with the corresponding fragment of Ssp DnaE without loss of trans-splicing activity. Protein splicing with the Npu DnaE N is also more tolerant of amino acid substitutions in the C-terminal extein sequence.

The purpose of this overview is to make the case for the establishment and publication of standards for home enteral nutrition (HEN) therapy in adult patients who require a long-term alternative to oral feeding. Overviews can provide a broad and often comprehensive summation of a topic area and, as such, have value for those coming to a subject for the first time. It will provide a broad summation, background and rationale, review specific considerations unique to HEN (tubes, products and supplies) and we describe a recent audit of seven HEN programs which highlights tube and process related challenges. Based on the overview of the literature and our experience with the audit we propose a way forward for best home enteral nutrition care.

Trace elements (TEs) are an essential component of parenteral nutrition (PN). Over the last few decades, there has been increased experience with PN, and with this knowledge more information about the management of trace elements has become available. There is increasing awareness of the effects of deficiencies and toxicities of certain trace elements. Despite this heightened awareness, much is still unknown in terms of trace element monitoring, the accuracy of different assays, and current TE contamination of solutions. The supplementation of TEs is a complex and important part of the PN prescription. Understanding the role of different disease states and the need for reduced or increased doses is essential. Given the heterogeneity of the PN patients, supplementation should be individualized.

Removal of Mn as an additive in HPN solutions resulted in resolution of MRI abnormalities in most patients. Over 5 years, all patients except for 1 maintained normal blood Mn levels. Therefore, Mn levels should be monitored and supplementation be individualized.

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A 57-year-old woman, with colonic Crohn disease (CD) diagnosed four years previously, presented to the emergency department with a six-week history of severe abdominal pain. She did not have diarrhea. She had inactive perianal fistulas. Laboratory tests at presentation showed an elevated C-reactive protein level of 103 mg/L, and low albumin of 24 g/L. Other bloodwork was unremarkable. Stool testing was negative for Clostridium difficile, and culture and sensitivity. Her medical history was significant for rheumatoid arthritis (RA). She had been receiving infliximab and methotrexate for RA and CD. A computed tomography scan revealed wall thickening in the ascending, transverse and descending colon. No lymphadenopathy was present. Pericolonic inflammatory changes were apparent. No obstruction was present. Colonoscopy at the time of admission, to confirm what appeared to be a CD flare, revealed a benign-appearing ulcerated stricture at 40 cm from the anal verge (Figure 1). The colonoscope could not pass the stricture. There was no active CD in the colon distal to the stricture. The stricture was biopsied. The patient was treated with intravenous solumedrol and, subsequently, prednisone for a presumed CD flare. Steroids led to resolution of her pain. Biopsies of the stricture unexpectedly revealed an anaplastic large cell lymphoma (ALCL) (Figure 2). Infliximab and methotrexate were discontinued. A bone marrow biopsy was negative for lymphoma and computed tomography enterography showed a normal small bowel. The patient successfully completed six cycles of CHOP (cyclophosphamide, hydroxy doxorubicin, vincristine, prednisone) chemotherapy. Repeat biopsies of the stricture postchemotherapy showed no lymphoma, but atypical cells were present (Figure 3). A tattoo was used to mark the location of the stricture. The stricture was balloon-dilated to allow visualization of the proximal colon. There was only a single, discrete patch of ulceration in the ascending colon. Biopsies here were consistent with CD. It was believed that her risk of lymphoma recurrence was high. She was referred for surgical intervention and underwent a left hemicolectomy.

Background Malnutrition is common in hospitalized patients and strategies to improve energy and protein intake have a positive impact on outcome. Despite early evidence suggesting the usefulness of peripheral parenteral nutrition (PPN), its adoption has been hampered by concerns regarding safety and efficacy. This study addresses this issue. Methods This prospective observational study was performed in medical and surgical inpatients in who were screened for nutrition risk and assessed using Subjective Global Assessment (SGA). Data captured included nutrition status, energy and protein requirements, intravenous access, indications for PPN, use of supplemental micronutrients, and disposition of patients on PPN. Results Ninety‐eight patients were recruited from two centers over 8 months. The average age was 61.5 years, the mean Charlson Comorbidity Index was 4.21 (±3.09), 52% were male, and 48% were admitted to medicine, whereas 52% were admitted to surgery. Thirty‐three percent of patients were SGA C, 44% were SGA B, and 19% were SGA A. Twenty‐seven percent of patients had cancer. The average length of hospital stay was 22 days. The main indications for PPN were gastrointestinal tract dysfunction (72%) and postsurgical status (16%). PPN provided an average of 1296 kcal (±191) and 46 g of protein (±7). Intravenous access complications in patients receiving PPN did not occur in excess of expected. Almost 40% of patients required transition to central PN. Conclusions PPN is a safe, effective way to deliver supplemental protein, energy, and micronutrients to malnourished patients and supports transition to other modes of nutrition care.

Background Obesity is a global pandemic with a steady increase in global BMI since 1975. Bariatric surgery is an effective treatment for patients with severe obesity in order to sustain long-term weight loss and reduce comorbidity burden and mortality associated with obesity. However, post-bariatric surgery patients face nutritional complications ranging from micronutrient deficiencies to intestinal failure requiring total parenteral nutrition (TPN). From our institution of home TPN patients, 6.4% of patients had bariatric surgery. Intestinal failure is a burdensome diagnosis for patients, and there is a paucity of literature characterizing patients post-bariatric surgery who develop intestinal failure. Aims We aim to identify the patient characteristics, surgical details, and nutritional traits that predisposed patients to developing intestinal failure requiring advanced nutritional support. Methods This is a retrospective chart review of 48 patient admitted to the Royal Alexandra Hospital post-bariatric surgery for nutritional support and followed by the TPN program dieticians and nurses. Results Our results show the mean BMI was 49.94 kg/m2 pre-bariatric surgery. Interestingly, the mean BMI at time of hospitalization for bariatric-surgery related complications was 33.210 kg/m2 which is classified as overweight but most of patients were severely malnourished with SGA C (43.8%), SGA B (29.17%), and 8.3% were SGA A. Patients requiring parenteral nutrition post-bariatric surgery are mostly female, developed barriers to oral intake, 15% engaged in medical tourism, 58.3% had an underlying mental health diagnosis, and only 18.8% were on a multivitamin even though it is standard of post-bariatric surgery care. The time between initial bariatric surgery to hospital admission was 11.2 years, and most required ≥1 revisional surgery. The mean age at bariatric surgery was 33.2-years old and the average age at initial hospitalization was 48.9-years old. Patients requiring ≥2 admissions had vertical band gastroplasty or sleeve gastrectomy (both 36.8%) while 21.1% had Roux-en-Y gastric bypass. Of these patients, 39.6% of patients required ≥2 hospital admissions and the mean total days spent in hospital was 57.15 days. While these complications are uncommon, these patients result in multiple prolonged hospitalizations and can be difficult to manage. Conclusions Overall, the results of our study will allow the multidisciplinary teams that care for post-bariatric surgery patients to identify patients at risk of intestinal failure and potentially intervene with early enrollment into home nutrition program. With increasing awareness, patients at higher risk can be closely monitored in order to prevent micronutrient deficiencies before they progress to intestinal failure and require lifetime parenteral nutrition. Funding Agencies None