Nutrition in Clinical Practice最新文献

Objective: We report the results of a quality improvement initiative to reduce the time to full enteral feeds and number of central line and parenteral nutrition days in premature infants in a level IV neonatal intensive care unit (NICU) by 20%.

Study design: In 2020, a multidisciplinary team at our NICU initiated a quality improvement project to improve enteral feeding in infants with a birthweight <1800 g. The key drivers were early donor human milk consent, trophic feeds initiation, and modification of the enteral feeding guidelines. The interventions included prenatal donor human milk consents, mandatory staff education, and NICU newsletter reminders. Retrospective baseline data were collected May 1, 2020, to November 23, 2020, and prospective data were collected November 24, 2020, to September 30, 2022.

Results: Special cause variation was detected for time to achieve full enteral feeds, central line days, and parenteral nutrition days with 30%, 44%, and 42% improvements, respectively. There was no increase in feeding intolerance or necrotizing enterocolitis.

Conclusion: Small changes in feeding guideline processes improved enteral feedings in preterm infants without increase in morbidities. Our process measures are practical and easy to implement in most NICU settings.

Background: The administration of home parenteral nutrition improves quality of life for patients with intestinal failure, thus fostering their will to actively participate to social activities. Nevertheless, sports participation can be risky for patients with a central venous catheter (CVC). Despite literature thoroughly proving the positive impact of sports on motor-psychosocial development, no consistent evidence assessing its role on central-line complications is available. This study aimed to report the European centers' approach to children with intestinal failure on home parenteral nutrition and interested in playing sports, further assessing complications and how to prevent them.

Materials and methods: A questionnaire focusing on children with intestinal failure regarding physical activity was circulated to 20 centers. Questions assessed the centers' policy for CVC management, the sports-related recommendations for patients on home parenteral nutrition and complication rates.

Results: Sixteen (80%) centers filled in the questionnaire. Twelve centers reported not to have a standardized formal protocol for catheter care during sports. All centers encouraged patients to perform mild/moderate exercise, whereas high-contact sports were allowed by one center only. Specific dressings were suggested to protect the vascular access device, especially for water sports. Only one sports-related complication (rupture) was reported.

Conclusion: This survey emphasizes that sports should not be restricted in patients with intestinal failure and represents a blueprint for sports-related recommendations for these patients. Prospective studies assessing complication rates are advisable to ensure an improved access to sports for these patients.

Background: Malnutrition is common in hospitalized patients with cancer and adversely affects clinical outcomes. We evaluated the prevalence of malnutrition risk, dietitian-identified malnutrition (DIMN), and physician-diagnosed malnutrition (PDMN) at admission.

Methods: This retrospective study included adults diagnosed with a stage I-IV solid tumor malignancy and admitted to Atrium Health Carolinas Medical Center from January 2016 to May 2019. Malnutrition risk was determined by a score ≥2 on the Malnutrition Screening Tool (MST) administered by a registered nurse during the intake process. Registered dietitian nutritionist (RDN) assessments were reviewed for DIMN and grade (mild, moderate, or severe). PDMN included malnutrition International Classification of Diseases, Tenth Revision codes in the discharge summary. Univariate models were estimated; multivariate logistic regression models identified associations between clinicodemographic factors and malnutrition prevalence with stepwise selection.

Results: A total of 5143 patients were included. Median age was 63 (range 18-102) years, 48% were female, 70% were White, and 24% were Black. Upper gastrointestinal (21%), thoracic (18%), and genitourinary (18%) cancers were most common. A total of 28% had stage IV disease. MST scores were available for 4085 (79%); 1005 of 4085 (25%) were at malnutrition risk. Eleven percent (n = 557) had malnutrition coded by a physician or documented by an RDN; 4% (n = 223) of these were identified by both clinicians, 4% (n = 197) by RDNs only, and 3% (n = 137) by physicians only.

Conclusion: Malnutrition appears to be underdiagnosed by both RDNs and physicians. Underdiagnosis of malnutrition may have significant clinical, operational, and financial implications in cancer care.

Background: Peripheral parenteral nutrition (PPN) provides an alternative nutrition support strategy to centrally administered PN for specific patients requiring short-term PN. Previous studies have demonstrated limited use of PPN and variable complication rates. This study aimed to evaluate PPN complications and usage at this center.

Methods: This was a single-center retrospective observational study of all adult patients who received at least 1 day of PPN from June 2018 to December 2023. Demographic and clinical data were collected, including complications, indications for PN and reason for PPN, duration of therapy, reason for cessation of PPN, nutrition status, energy and protein provision, and central line insertion rates.

Results: 381 patients were included, the median age was 62 (interquartile range = 28-74) years, and 235 were men (61.7%). The most common indication for PN was ileus (n = 153, 40%) followed by gastrointestinal obstruction (n = 93, 24%). The median time receiving PPN was 3 (2-4) days. Patients received a median of 65% (55%-75%) of energy and 58% (50%-69%) of protein requirements with PPN. Malnutrition was diagnosed in 47.5% (n = 181) of this cohort. Total complication rates were 8.7% (n = 33), with cannula infiltration being the most common complication (6.6%, n = 25). 213 (56%) patients proceeded to central line insertion.

Conclusion: PPN proved to be a safe and effective therapy for short-term PN when managed by a nutrition support team. PPN has the potential to attenuate short-term nutrition deficits and prevent central venous access device insertion in selected patients, making it a valuable nutrition support therapy.

Background: A-mode ultrasound (US) is a potential method for directly measuring muscle thickness in patients with cancer, but its utility remains underexplored. We aimed to evaluate the feasibility of using A-mode US to assess muscle thickness, compare it with computed tomography (CT)-derived results, and assess its ability to diagnose sarcopenia.

Methods: A cross-sectional analysis was conducted with hospitalized patients with cancer. Muscle cross-sectional area (CSA) was derived from CT scans. Biceps muscle thickness (BMT) and thigh muscle thickness (TMT) by A-mode US were assessed. BMT + TMT were also combined as an additional phenotype. Muscle strength was assessed using handgrip strength (HGS) test. Sarcopenia was defined as low muscle mass (CT- and US-derived) + low HGS.

Results: We included 120 patients (53.3% women, 45% older adults, and 85.8% with disease stages III-IV). TMT alone and the combined approach (BMT + TMT) were weak and positively correlated and significantly associated with muscle CSA, explaining 35% of CSA variability (R² = 0.35). TMT individual and combined with BMT exhibited the highest accuracy for men (area under the curve >0.70). Sarcopenia diagnosed by BMT + TMT exhibited the highest frequency (34%) and moderate agreement with CT-derived sarcopenia (κ = 0.48).

Conclusion: A-mode US has the potential to be a feasible tool for diagnosing sarcopenia in clinical practice at the bedside for patients with cancer despite the need for further improvements in the tool's accuracy. Our main findings suggest that combining measurements of BMT and TMT may enhance its clinical significance in diagnosing sarcopenia.

Home enteral nutrition (HEN) provides nutrition through a tube to individuals at home who cannot meet their needs by mouth. Systematic reviews have explored the experiences of HEN subpopulations, such as those with head and neck cancers. Given HEN services care for adults with various underlying conditions, a synthesis of the experiences of all adults using HEN and their caregivers is warranted. The purpose of this study is to summarize the experiences of HEN adult users and their caregivers regardless of underlying condition. Medline, PsychINFO, EmBase and CINAHL were systematically searched in January 2024. Studies with qualitative results and adult participants and focused on HEN were included. Studies with participants in nursing facilities, results using word counts, or not in English were excluded. Study quality was assessed using the Johanna Briggs Institute (JBI) qualitative checklist. Study design and participants' details were extracted. Themes were collated using the JBI meta-aggregative method. Forty studies (n = 732) were included. Three synthesized findings were identified: positive experiences (very low ConQual score), negative experiences (low ConQual score), and facilitators and coping mechanisms (moderate ConQual score). Although more negative than positive experiences were reported, users and caregivers who developed coping mechanisms or accessed supports viewed HEN as a worthwhile experience. Those with few supports or coping mechanisms did not. Based on this review, it is proposed that before starting HEN, users and caregivers should be made aware of the available supports and coping mechanisms. As negative experiences arise, healthcare providers should help users and caregivers access supports to improve their experiences.

Background: This study aimed to understand the collective impact of trace elements, vitamins, cholesterol, and prealbumin on patient outcomes in the intensive care unit (ICU) using an advanced artificial intelligence (AI) model for mortality prediction.

Methods: Data from ICU patients (December 2016 to December 2021), including serum levels of trace elements, vitamins, cholesterol, and prealbumin, were retrospectively analyzed using AI models. Models employed included category boosting (CatBoost), extreme gradient boosting (XGBoost), light gradient boosting machine (LGBM), and multilayer perceptron (MLP). Performance was evaluated using area under the receiver operating characteristic curve (AUROC), accuracy, precision, recall, and F1-score. The performance was evaluated using 10-fold crossvalidation. The SHapley Additive exPlanations (SHAP) method provided interpretability.

Results: CatBoost emerged as the top-performing individual AI model with an AUROC of 0.756, closely followed by LGBM, MLP, and XGBoost. Furthermore, the ensemble model combining these four models achieved the highest AUROC of 0.776 and more balanced metrics, outperforming all models. SHAP analysis indicated significant influences of prealbumin, Acute Physiology and Chronic Health Evaluation II score, and age on predictions. Notably, the ratios of selenium to age and low-density lipoprotein to total cholesterol also had a notable impact on the models' output.

Conclusion: The study underscores the critical role of nutrition-related parameters in ICU patient outcomes. Advanced AI models, particularly in an ensemble approach, demonstrated improved predictive accuracy. SHAP analysis offered insights into specific factors influencing patient survival, highlighting the need for broader consideration of these biomarkers in critical care management.

Providing optimal nutrition support in the intensive care unit (ICU) is a challenging and dynamic process. Energy, protein, fluid, electrolyte, and micronutrient requirements all can be altered in patients with acute, chronic, and acute-on-chronic kidney disease. Given that renal dysfunction occurs in up to one-half of ICU patients, it is imperative that nutrition support providers understand how renal dysfunction, its metabolic consequences, and its treatments, including renal replacement therapy (RRT), affect patients' nutrition needs. Data on nutrient requirements in critically ill patients with renal dysfunction are sparse. This article provides an overview of renal dysfunction in the ICU and identifies and addresses the unique nutrition challenges present among these patients, including those receiving RRT, as supported by the available literature and guidelines.

Background: Despite the high risk of bacterial contamination, no studies have been found that evaluate the optimal hanging time of open-system enteral sets under room temperature and intensive care conditions. This study aims to determine the differences in microbial loads of solutions taken from open-system enteral feeding sets hanging for 24 h under room temperature and intensive care conditions.

Methods: This study is a descriptive type of research. The study sample consisted of a total of 40 samples, with 20 samples under room temperature (25.2-23.3°C) and 20 samples under intensive care conditions (21.1-24.2°C). A simple random sampling method was used for sample selection. The assessment of microbial quality was based on the US Food and Drug Administration online Bacteriological Analytical Manual.

Results: In this study, it was determined that 5% of the samples taken from intensive care and 15% of the samples taken at room temperature exceeded the accepted limit for aerobic mesophilic bacteria count. The count of catalase and coagulase-negative Staphylococcus spp was 5% in intensive care samples and 40% in room temperature samples. The total coliform count was not detected in intensive care samples but was 35% in room temperature samples. Escherichia coli was not detected in either group.

Conclusion: Differences in microbial loads were observed when commercial enteral solutions were administered using open-system enteral feeding sets under room and intensive care conditions for 24 h. Therefore, large-scale studies are needed to determine the safe use of open-system enteral feeding sets under room temperature conditions.

Background: The two-step Global Leadership Initiative on Malnutrition (GLIM) approach was recently introduced to malnutrition diagnosis in a hospital setting. This study compares the diagnostic performance of this approach that uses the Nutritional Risk Screening-2002 (NRS-2002) as a screening tool and the direct application of GLIM malnutrition diagnostic criteria in hospitalized patients.

Methods: This cross-sectional study involved 290 adult and older adult patients who were hospitalized. A trained nutritionist implemented the two-step GLIM approach, including NRS-2002 (in the first step) and GLIM criteria (in the second step) for each patient. Then, the accuracy, kappa index, area under the receiver operating characteristic curve (AUC ROC), sensitivity, and specificity of malnutrition diagnostic performance of the two-step GLIM approach and NRS-2002 were evaluated compared to the direct use of GLIM criteria.

Results: The NRS-2002 identified 145 (50.0%) patients as at risk of malnutrition. The prevalence of malnutrition using the two-step GLIM approach and GLIM malnutrition diagnosis criteria were 120 (41.4%) and 141 (48.6%), respectively. The kappa index showed substantial and almost perfect agreement for NRS-2002 (κ = 68%) and the two-step GLIM approach (κ = 85%) with GLIM malnutrition diagnostic criteria, respectively. Furthermore, the AUC ROC (0.926; 95% confidence interval (CI): 0.89-0.96) and accuracy (92.8%) of the two-step GLIM approach compared to the GLIM criteria indicated an acepptable ability to distinguish between malnourished and well-nourished patients.

Conclusion: The two-step GLIM approach using NRS-2002 as a screening tool (in step one) had acceptable malnutrition diagnostic performance compared to the direct application of GLIM criteria in hospitalized patients.