Nutrition in Clinical Practice最新文献

Background: Nutrition status significantly influences outcomes after solid organ transplantation, yet data on energy and protein intake in lung transplantation (LTx) patients in the intensive care unit (ICU) are scarce. The objective is to examine the medical nutrition therapy and clinical outcomes in mechanically ventilated post-LTx adults.

Methods: This retrospective study (2022-2023) included adults post-LTx receiving mechanical ventilation admitted to the ICU. Clinical and nutrition parameters were recorded for the first 14 days of ICU stay. The Wilcoxon rank sum test or Fisher exact test were used to compare variables followed by a multivariate analysis to determine predictors of ICU length of stay (LOS).

Results: One hundred patients were included in this study: 65 (65%) were male with a median age of 65 years and body mass index of 26.3 kg/m². Both ICU and total hospital LOS were prolonged in patients who received >1.2 g/kg/day of protein, but LOS was not affected by energy intake or nutrition status. There were no associations with mortality or infection rate. In a multivariate analysis, no individual main effect variable was significantly associated with ICU LOS. However, a significant interaction between protein intake and Acute Physiology and Chronic Health Evaluation Score (β = 0.0216; p = 0.0092) indicted that the effect of protein intake on ICU LOS is modified by illness severity.

Conclusion: In critically ill post-LTx patients, higher protein intake was associated with a longer ICU and hospital LOS. This relationship appears to be influenced by illness severity, emphasizing the importance of individualized nutrition strategies in this high-risk population.

Background: Patients with end-stage kidney disease (ESKD) are at risk of sarcopenia. To determine whether dietary protein intake (DPI) affects changes in body composition, changes in body composition of patients receiving peritoneal dialysis (PD) were reviewed.

Methods: A retrospective analysis of the association between DPI, estimated from the normalized protein nitrogen appearance rate (nPNA), and changes in body composition measured by bioimpedance in a cohort of established PD outpatients who had been treated with PD for >9 months, attending for routine peritoneal membrane assessments was undertaken. Patients with hospitalizations, peritonitis, and variable DPI between measurements were excluded.

Results: A total of 260 PD patients, mean age 61.6 ± 14.7 years, 58.9% male, 39.2% diabetic with a nPNA of 0.92 ± 0.25 g/kg/day were followed for a median of 13 (interquartile range, 12-15) months. Patients were divided into nPNA terciles, and whereas 56% in the highest nPNA group (nPNA >1 g/kg/day) gained lean body mass, >70% of patients in the two lower nPNA terciles lost lean body mass (P < 0.001). The annualized median change in lean body mass increased from the lowest to highest group (-3.1 to -1.0 to +0.6 kg/year; P < 0.01). On multivariable testing, the nPNA group remained independently associated with gains in lean body mass (relative risk, 2.1; P = 0.001).

Conclusion: The majority of patients with ESKD treated with PD with a nPNA of <1.0 g/kg/day lost lean body mass, whereas more than half with an nPNA of >1.0 g/kg/day had a gain. Thus, ensuring an adequate DPI is an important factor in preventing lean body mass loss in patients receiving PD.

Background: The purpose of our study was to describe the time to full oral enteral feeding for extremely low birth weight (ELBW) infants in the neonatal intensive care unit (NICU).

Methods: We conducted a retrospective chart review of ELBW infants born at a regional medical center between July 1, 2021, and December 31, 2022. Infants who died or were transferred before discharge from the NICU were excluded from the study. Fifty four ELBW infants met the inclusion criteria for the study. Survival analysis was conducted using Kaplan-Meier curves to estimate the time to full oral feeds over an observation period of up to 153 days.

Results: A total of 25% of all ELBW infants achieved full oral feeding by 94 days of life, and 33.3% achieved full oral feeding before discharge from the NICU. The median time to full oral feeding for ELBW infants born at 27 to 30 weeks gestational age was 82 days. After adjusting for gestational age and birthweight, infants who did not achieve full oral feeds were discharged 12 days later (95% confidence interval: 2-23 days; P = 0.02) than infants who achieved full oral feeds.

Conclusion: The majority of ELBW infants did not achieve full oral feeding before NICU discharge. Early discussion of an alternate home feeding plan may shorten the duration of NICU stay.

Background: Clinical nutrition (CN) is becoming increasingly complex because of the rising prevalence of chronic illness, cancer, and malnutrition-related conditions such as short bowel syndrome and refeeding syndrome. Despite its clinical significance, nutrition education among US physicians remains limited. Simultaneously, large language model (LLM)-based artificial intelligence assistants (AIAs) have emerged as tools to support complex clinical decision-making but remain largely untested in CN.

Methods: This retrospective study evaluated four LLM-based AIAs-ChatGPT (OpenAI), OpenEvidence (OpenEvidence Inc), Gemini (Google, Google DeepMind), and Copilot (Microsoft Corporation)-using five complex CN cases from our nutrition support service. Each AIA was queried with patient-specific CN questions. Responses were blinded and reviewed by five physician CN experts using an eight-item assessment tool evaluating clarity, relevance, evidence, and clinical utility.

Results: All AIAs produced clinically appropriate responses, with Gemini scoring highest in relevance (4.04) and clarity (4.16). Overall satisfaction scores ranged from 3.08 (Copilot) to 3.84 (Gemini). Citation quality and originality of insights varied and were generally limited, and no consistent differences in performance were observed across the five cases among the four AIAs.

Conclusion: LLM-based AIAs can reliably replicate expert reasoning in CN. Although not yet a source of novel clinical insights, the true potential of this approach may lie in its application among physicians without specialized expertise in CN, helping to bridge existing knowledge gaps in nutrition care. Presenting full clinical cases, as shown in this study, could support AIA-enabled e-consultation in the future, thereby addressing gaps in CN education.

Survivors of critical illness frequently do not achieve recommended nutrition targets because of multiple barriers. Consequently, malnutrition is prevalent during hospitalization, yet posthospital discharge nutrition interventions are often missing, leaving a gap during a crucial recovery phase. This scoping review aims to explore barriers to nutrition adequacy, consequences of inadequate nutrition, and interventions for adult survivors of critical illness following hospital discharge. Using Joanna Briggs Institute methodology in conjunction with the PRISMA-ScR checklist, searches were conducted in MEDLINE, Embase, CINAHL, Web of Science, and Cochrane databases (2010-2024) for studies on adult intensive care unit (ICU) survivors posthospital discharge, reporting nutrition barriers, consequences, and/or nutrition interventions. Factors identified from the data are analyzed and presented using a conceptual framework derived from the Biopsychosocial model and the Social Ecological Model. Forty-three studies (mostly observational) were included encompassing 32,165 participants. Commonly reported barriers included (% of studies) appetite loss (40%), dysphagia (26%), and psychological distress (40%), contributing to inadequate dietary intake (19%), malnutrition (42%), and weight loss (56%) persisting up to 12 months. Body composition changes, observed in 21% of studies, demonstrated increased fat mass, whereas lean mass was maintained or lost. Despite high nutrition risk, only 37% reported nutrition input. Nutrition interventions improved nutrition, physical, and psychological outcomes. This review emphasizes the complexity of nutrition recovery faced by ICU survivors, highlighting significant gaps in nutrition care following hospital discharge. Understanding nutrition challenges from survivors' perspective is essential before evaluating specific nutrition interventions addressing the diverse nutrition needs of individuals recovering from critical illness.

The preservation of lean mass (LM) and its restoration following catabolic loss represents a primary challenge for clinical nutrition in critically ill patients. A comprehensive review of recent literature confirms a clinical dilemma between unresponsiveness for feeding and harm of overfeeding and underfeeding. Time point-specific assessment and monitoring of body composition-via computed tomography, bioelectrical impedance analysis (BIA), and ultrasound-are recommended to become an integral part of daily care for all intensive care unit (ICU) patients. Currently, serial BIA for measuring fat-free mass appears to be the most feasible and promising method. Energy and protein supply throughout the phases of critical illness should be guided by sex-specific fat-free mass rather than total body weight, reinforcing the value of indirect calorimetry. Given the prevalence of post-intensive care syndrome, nutrition therapy and monitoring must continue into the post-ICU period. Combined strategies-rather than isolated interventions-provide the most plausible framework to support LM recovery during ICU care and throughout post-ICU rehabilitation. Future approaches, supported by machine learning, will warrant the combined use of biomarkers and clinical variables to identify anabolic resistance and determine "readiness for feeding." Further research is needed to elucidate the effects of micronutrient supplementation, ketogenic diets, and ω-3 fatty acids on muscle tissue, with a focus on mitochondrial function and anti-inflammation. The potential of orexigenic (eg, ghrelin) and anabolic (eg, nandrolone) hormones in the post-ICU phase warrants further investigation.

Background: The coronavirus disease 2019 (COVID-19) pandemic caused significant morbidity and mortality. Further study of modifiable factors influencing COVID-19 severity and outcomes continues to be necessary. Serum zinc levels may play a role in modulating COVID-19 virus replication and consequently influence clinical outcomes.

Methods: This was a prospective observational study of adult patients hospitalized with COVID-19 assessing the relationship between serum zinc levels and clinical outcomes. Serum zinc levels were measured within 7 days of admission. The primary outcome was the need for intubation at any time during inpatient stay. Secondary outcomes included hospital disposition and incidence of shock and acute kidney injury.

Results: Serum zinc levels could be obtained for 99 patients with COVID-19. The 25 requiring intubation during hospitalization had a statistically significantly lower median (IQR) zinc concentration (51.6 µg/dl [46.3-62.3 µg/dl]) than those who did not (64.4 µg/dl [55.2-76.0 µg/dl]; P < 0.01). Patients requiring more respiratory support on hospital day 1, having acute kidney injury on hospital day 8, or requiring pressors on hospital days 1 or 8 also had significantly lower zinc levels. In multivariable analysis including other clinical factors known to influence outcomes in COVID-19 disease, serum zinc level remained an independent predictor of the need for intubation (odds ratio 0.941, 95% CI 0.885-0.999; P = 0.048).

Conclusion: In multivariable analysis, lower serum zinc level was an independent predictor of inpatient intubation in COVID-19, but further investigation of zinc supplementation to prevent or reduce severity in COVID-19 infection is warranted before routine clinical use.

In clinical cancer settings, malnutrition can go undiagnosed and patients often receive nutrition care only after they have lost substantial weight or developed severe side effects. Neglecting to provide nutrition care to a patient in a timely manner can lead to increased difficulties in supporting them and to poorer clinical outcomes. The aim of this review was to identify the barriers to timely nutrition support for patients with cancer before and during medical treatment. PubMed and CINAHL platforms were used to search for relevant published literature in June 2022. The search was updated in January 2025. Advanced search was used using the terms "cancer," "malnutrition," "nutritional support," and their synonyms in combination with "under-recognition" and associated synonyms. The protocol was prospectively registered on OSF Open Science. A total of 4584 records were identified in the databases, and 41 abstracts were selected for full article screening. A total of 19 articles were included in the review. Evidence from the studies indicates that malnutrition identification and dietetic support are not always implemented in current practice. Identified barriers were grouped into four interconnected macro themes: educational barriers, communication barriers, resource barriers, and sociocultural barriers. This scoping review identifies four barriers to early nutrition support in oncological settings and discusses their implications and how they influence each other. Clinical governance should consider and look to address all barriers when trying to implement dietetic support or design pathways in a timely and efficient manner.

Background: Patients receiving home parenteral nutrition (HPN) face complex challenges and increasingly seek support online, including generative artificial intelligence (AI) platforms like ChatGPT. This survey study compared ChatGPT with clinician responses to common HPN-related questions.

Methods: Responses to 20 HPN-related questions spanning five content themes were generated by ChatGPT and provided by HPN expert clinicians. In a blinded online survey, practicing clinicians (study participants) rated each response on a five-point scale (1 = excellent; 5 = very poor) for accuracy, appropriateness, and empathy and selected their overall preferred response.

Results: Among 23 participants (73.9% registered dietitians; mean HPN experience: 14.0 years), ChatGPT's responses were rated more favorably for accuracy (median [IQR] = 1.80 [0.79] vs 2.15 [0.62], P = 0.003), appropriateness (1.80 [0.70] vs 2.15 [0.53], P = 0.013), and empathy (1.95 [0.66] vs 2.25 [0.65], P = 0.007). Participants preferred ChatGPT responses in 48.5% of cases, clinician responses in 33.9%, and had no clear preference in 17.6%. ChatGPT outperformed clinicians across content themes for "best practices, care, and safety of HPN use/infection risk" and scored more favorably for empathy in "symptoms" and for accuracy and appropriateness in "lifestyle stressors." Clinicians scored more favorably for appropriateness in "biochemical test concerns."

Conclusion: ChatGPT may support HPN care and patient education, particularly for broad medical and lifestyle topics. However, complex clinical issues require medical expertise. Further research is needed to guide the safe integration of AI into clinical practice and patient care.

Suboptimal nutrition provision has been observed during and after the intensive care unit (ICU) stay. Reasons for suboptimal nutrition provision are due to various barriers to intake found across hospitalization and after discharge home. The aim of this narrative review is to provide an overview of the nutrition challenges faced by patients after ICU discharge and in the home, as well as provide suggestions to promote recovery for survivors. Key areas to consider include the role of the patient, caregiver and clinician education, nutrition impact symptoms, the role of communication, and the use of multimodal interventions. Nutrition interventions may be of greatest benefit with longer-term optimization, identifying strategies to overcome barriers and the importance of transition periods as well as a clear follow-up plan.