This study supports the efficacy and safety of ELT in reducing CRBSI-related admissions in HPN patients and potentially helps reduce the burden of CRBSI-related healthcare costs. This novel technique shows great promise as a standard prophylaxis for CRBSI in HPN patients and must be incorporated in routine practice.
Fluid and electrolyte management is challenging for clinicians, as electrolytes shift in a variety of settings and disease states and are dependent on osmotic changes and fluid balance. The development of a plan for managing fluid and electrolyte abnormalities should start with correcting the underlying condition. In most cases, this is followed by an assessment of fluid balance with the goal of achieving euvolemia. After fluid status is understood and/or corrected, electrolyte imbalances are simplified. Many equations are available to aid clinicians in providing safe recommendations or at least to give a starting point for correcting the abnormalities. However, these equations do not take into consideration the vast differences between clinical scenarios, thus making electrolyte management more challenging. The supplementation plan, whether delivered intravenously or orally, must include an assessment of renal and gastrointestinal function, as most guidelines are established under the assumption of normal digestion, absorption and excretion. After the plan is developed, frequent monitoring is vital to regain homeostasis. A fluid and electrolyte management plan developed by a multidisciplinary team is advantageous in promoting continuity of care and producing safe outcomes.
The Cleveland Clinic institutional guidelines for the management of intestinal failure, including long-term or home parenteral nutrition and related complications, intestinal rehabilitation, and small bowel transplantation, were reviewed. PubMed was searched for relevant articles. The search was performed in November 2008; keywords used were home parenteral nutrition, short bowel syndrome, intestinal rehabilitation, and small-bowel transplantation. Randomized, prospective, observational, retrospective reviews and case report articles that contained relevant data for long-term parenteral nutrition, intestinal rehabilitation, and intestinal transplantation were selected. Researchers reviewed 67 selected articles that met our inclusion criteria. Our institution data registries for intestinal rehabilitation and home parenteral nutrition were also reviewed for relevant data. The survival of tens of thousands of children and adults with complicated gastrointestinal problems has been possible because of parenteral nutrition. In selected patients, a program of intestinal rehabilitation may avoid the need for long-term parenteral nutrition.
Intestinal failure is a complex disease state for which extensive therapy is often required. Parenteral nutrition is one of these therapies, but with its long-term use, life-threatening complications may develop. Intestinal rehabilitation to enhance intestinal absorption and function through diet and medication is another therapy that can be used in hopes of weaning parenteral nutrition and preventing malnutrition. For patients who develop complications from parenteral nutrition and fail intestinal rehabilitation interventions, intestinal transplantation may be the best option. In this review, therapies available for intestinal failure and the use of a multidisciplinary approach to the patient with intestinal failure will be reviewed.
T he ability to probe the base of a wound to periosteum or bone (the "probe-to-bone" test) is increasingly used to indicate the likelihood of underlying osteomyelitis. The original study (1) reported sensitivity, specificity, and positive (PPV) and negative (NPV) predictive values of 66, 85, 89, and 56%, respectively. However, this work has been criticized on the grounds of the high pretest probability of the disease (2), since the prevalence of osteomyelitis in the chosen sample (in-patients with clinically overt infection) was 66%. It follows that the usefulness of the test may be very different in less-selected populations. We have therefore determined the validity of the probe-to-bone test in a consecutive series of outpatients attending our own multidisciplinary service.A total of 81 patients (with a total 104 foot ulcers) attended the clinic over a 5-week period in May-June 2005. Ulcers were probed by one of two specialist podiatrists following debridement. The diagnosis of osteomyelitis was determined by one of two expert diabetologists, who were blind to the results of the probe to bone test. The diagnosis of osteomyelitis was based in each case on the presence of clinical signs of infection (inflammation with or without serous or purulent discharge) in association with radiologic evidence of bone destruction with interruption of the cortex (either at presentation or at any stage over the ensuing 8 weeks), supported when necessary by magnetic resonance imaging and microbiologic analysis of deep tissue samples. Those who were diagnosed with osteomyelitis included those in whom the diagnosis had already been made at the time of probing and those in whom the diagnosis was made later. Nineteen (23.5%) patients were diagnosed with osteomyelitis complicating foot ulcers, in two of whom bone infection complicated two separate nonadjacent ulcers. Three patients had two or more nonadjacent ulcers, of which only one was associated with osteomyelitis. A total of 14 patients had osteomyelitis complicating a single ulcer. A total of 21 ulcers (20.2% of 104) were associated with osteomyelitis. The probe-to-bone test was positive in 8 of these 21 ulcers and in 7 of 83 without associated bone infection (sensitivity 38%, specificity 91%). While the NPV was 85%, the PPV (the probability that a patient with a positive test would have osteomyelitis) was only 53%. It is possible that the calculation of both sensitivity and NPV might be in part explained by the fact that some cases of osteomyelitis may already have been responding to treatment at the time of probing, but this would not have affected the calculation of either the specificity or the PPV.These data emphasize that the predictive value of a positive probe-to bone test in the original report was influenced by the high prevalence of osteomyelitis in the population studied. The prevalence of osteomyelitis in the present population was still high at 23.5% patients (20.2% ulcers) but was only approximately one-third of that in the earlier study, and the PPV was corresp...
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