Nutrition in Clinical Practice最新文献

The increasing use of home enteral nutrition (HEN) underscores the need for clinicians with the expertise to educate individuals, their families, and fellow healthcare professionals. Successful HEN education relies on interdisciplinary collaboration and timely communication led by clinicians knowledgeable in nutrition support who can provide guidance and planning necessary for effective implementation. Well-designed HEN plans align with individual and family goals, respect cultural values, and address unique learning needs to provide a foundation for meaningful education that enhances the individual's health-related quality of life. HEN education entails selecting an appropriate enteral access device, providing clear guidance for its care, and generating nutrition prescriptions and administration strategies that are both safe and aligned with the individual's lifestyle and nutrition requirements. Comprehensive HEN education also encompasses detailed documentation, ongoing monitoring, and timely adjustments to the care plan as needed. Techniques for educating clinicians, individuals, and families along with practical, patient-specific approaches are presented.

Background: Home parenteral nutrition (HPN) patients often have multiple comorbidities. A validated multimorbidity index (MMI) could help determine resource needs and risks with HPN. We evaluated MMI scoring to determine if it predicted HPN resource use and outcomes.

Methods: We performed a secondary analysis of 60 HPN patients from a previous study based on Cumulative Illness Rating Scale (CIRS) scoring. We examined three variables: PN formula changes, hospitalizations, and hospital length of stay (LOS). Density plots were produced to select a CIRS score cutoff value. Spearman correlations among the three variables of interest were computed. The data were then subjected to Wilcoxon rank sum tests and negative binomial regression models to determine if the measured variables differed significantly between the groups.

Results: In 60 HPN patients, CIRS scores ranged from 9 to 25 with a mean ± SD of 17.0 ± 3.85. Patients with CIRS scores ≥ 17 had higher rates of the three variables than those with CIRS scores < 17 (PN formula changes = 367 vs 297, hospitalizations = 19 vs 12, and total hospital LOS days = 122 vs 100). Although these raw data did not differ significantly, negative binomial regression analysis indicated that the interaction of total hospital LOS and PN formula changes was significantly higher in patients with a CIRS score ≥ 17 than a CIRS score < 17.

Conclusion: CIRS data from HPN patients showed a trend wherein higher multimorbidity scores were associated with PN changes and LOS. This approach requires further study and validation.

Background: Parenteral nutrition (PN) supports patients unable to absorb sufficient nutrients from their gastrointestinal tracts. Yet, information about the patterns and extent of PN's in-hospital use is lacking. Data on this topic should provide comparison points for nutrition support teams and hospital administrators examining PN use in their institutions.

Methods: A retrospective cohort study using 9 years of routinely collected administrative data from a healthcare system with tertiary care and community hospitals explored the extent, patterns, and trends of PN use in hospitals and individual clinical departments.

Results: PN was administered to 2984 patients during 4121 admissions to the tertiary facility for 68,047 days and to 298 patients on 367 admissions to the community hospital for 4925 days. Both hospitals' general surgery, surgical intensive care unit, and other surgical services accounted for half the patients receiving PN. The tertiary care hospital's adult and pediatric oncology/hematology/bone marrow transplantation services, services not provided in the community hospital, accounted for 29% of the hospital's patients receiving PN. Fifty-two percent of surgical patients accounted for 46% of PN-days, whereas the 29% of patients from the hematology/oncology/bone marrow transplantation services utilized 39% of PN-days, with longer durations of PN administration reflected in the latter group. Adult oncology admissions involving PN tripled (from 38 to 116 patients) between the first and last 3 years.

Conclusion: Different case mixes in the tertiary and community hospitals affected the extent and patterns of PN use. Dataset analysis provided an analytic framework for examining PN usage within and among hospitals.

Background: The Global Leadership Initiative on Malnutrition (GLIM) has released new criteria for diagnosing and grading malnutrition. However, their validation in patients with severe stroke has not been thoroughly documented. This study aims to investigate the application of GLIM criteria in nutrition assessment and mortality prediction among patients with severe stroke.

Methods: This prospective study included 281 patients with severe stroke from our hospital (July 2021 to July 2023) and a validation set of 121 patients (August 2023 to March 2024). Nutrition status was assessed using Subjective Global Assessment (SGA) and GLIM criteria. The association between nutrition status and 30-day mortality was analyzed using the Kaplan-Meier method and a Cox model. A dynamic nomogram incorporating GLIM and other prognostic variables was developed. The Concordance Index, receiver operating characteristic curve, and calibration curve were used to evaluate predictive accuracy.

Results: GLIM-defined malnutrition was found in 19.93% of the development set and 20.66% of the validation set. Using SGA as a reference tool to evaluate the diagnostic agreement of the GLIM criteria, the GLIM criteria demonstrated good agreement in identifying malnutrition, with a kappa value of 0.669. Patients with GLIM-defined moderate (hazard ratio [HR]: 2.526, P < 0.001) and severe malnutrition (HR: 5.626, P < 0.001) had significantly higher mortality risk than those identified by SGA. The nomogram accurately predicted 30-day mortality.

Conclusions: The GLIM criteria effectively assess malnutrition and predict 30-day mortality in patients with severe stroke. The developed dynamic nomogram provides accurate prognosis prediction.

Background: Plasma amino acid (AA) profiles in parenteral nutrition (PN)-dependent very preterm infants (VPIs) consistently show overprovision of essential AA (EAA) and arginine deficiency. This may have implications for growth and immune/inflammatory responses.

Aim: To compare plasma AA profiles on day 3 and day 10 in VPIs receiving standard PN (6.3 g/100 g AA arginine) and arginine-supplemented PN (18 g/100 g AA) in VPIs at <30 weeks' gestation.

Methods: VPIs were allocated (according to intervention PN availability) in a series of separate physiological studies to receive standard PN or arginine-supplemented PN. This approach led to a final PN AA formulation design containing 18 g/100 g AA. Clinical, nutrition intake, and biochemical data were collected. Point-of-care testing was used to measure ammonia levels. Plasma AA levels were measured on days 3, 10 and 30 using ion exchange chromatography.

Results: The highest mean daily arginine intake was on day 7: 521 mg/kg/day (142 mg/kg/day) at a dose of 18 g arginine/100 g parenteral AA. The median day 10 plasma arginine level was 85 (52-146) vs 41 (28-54) µmol/L for 18 g/100 g AA arginine vs control, respectively (P < 0.0001) The equivalent data for total EAA were 896 (750-1142) vs 1220 (1031-1428) µmol/L (P < 0.05) and blood ammonia levels were 46 (24-65) vs 51 (40-62) µmol/L (P = 0.28).

Conclusion: In VPIs, PN arginine supplementation of 18 g/100 g AA increases arginine concentrations and reduces provision of EAA as demonstrated in the plasma AA profile. Higher plasma arginine levels are not sustained once parenteral arginine is discontinued. Blood ammonia levels were not useful in identifying individual arginine deficiency.

Background: Pure fish oil-based fat emulsion (FO-ILE) dosed at 1 g/kg/day is FDA approved for the treatment of intestinal failure associated liver disease. However, this limited fat provision can lead to suboptimal weight gain and excessive caloric intake from dextrose, particularly in neonates. There is limited data on the use of FO-ILE at doses higher than 1 g/kg/day. This study describes our experience with pediatric patients receiving 1.5 g/kg/day of FO-ILE.

Methods: A retrospective chart review was performed on patients receiving parenteral nutrition aged 0-18 years and receiving FO-ILE at a dose of 1.5 g/kg/day for at least 14 days. Clinical outcomes of interest included weight gain, glucose infusion rates (GIRs) and adverse effects including cholestasis, postprocedure hemorrhage, hypertriglyceridemia and essential fatty acid (EFA) deficiency.

Results: Nine patients (range 2 months-12.9 years) receiving 1.5 g/kg/day of FO-ILE were included. Seven patients showed improved weight gain. Decrease of GIR was noted in four patients. One patient experienced worsening cholestasis with no clear etiology which prompted the decrease of FO-ILE to 1 g/kg/day with later resolution of cholestasis. Seven patients underwent invasive procedures, with one patient experiencing more than expected bleeding after circumcision not necessitating a decrease in dose. None of the patients developed hypertriglyceridemia. Eight patients had an EFA panel collected, all within normal limits.

Conclusion: Our findings suggest that higher doses of FO-ILE may be safe and beneficial in patients with suboptimal weight gain, and elevated GIR. Larger and long-term studies are required to validate these observations.

Objective: The cachexia index (CXI) demonstrates potential as both a diagnostic tool for cachexia and a prognostic tool for survival in cancer. However, CXI's predictive value has not been verified in cervical cancer. The purpose of this study is to investigate the prognostic value of the CXI in patients with cervical cancer treated with radiotherapy.

Methods: We retrospectively screened patients diagnosed with cervical cancer who underwent radiotherapy in a single institution between September 2013 to September 2015. The CXI was calculated as the skeletal mass index (SMI) × albumin/neutrophil-to-lymphocyte ratio. SMI was measured by computed tomography using the muscles of the third lumbar vertebra. Survival times were evaluated using the Kaplan-Meier method and Cox proportional hazards regression. A nomogram for predicting survival was developed.

Results: A total of 81 patients with cervical cancer were included. The cutoff value of the CXI was set at 59.7 using receiver operating characteristic (ROC) analyses. According to this cutoff value, 47 patients were assigned to the high-CXI group, and 34 were assigned to the low-CXI group. The Cox regression analysis showed that a low CXI was associated with decreased overall survival (hazard ratio [HR]: 3.15; 95% confidence interval [CI]: 1.24-8.00; P = 0.016). Patients in the low-CXI group also had shorter progression-free survival than those in the high-CXI group, but the difference was of borderline significance (HR: 2.26; 95% CI: 1.00-5.11; P = 0.05).

Conclusion: The pretreatment CXI is an independent prognostic factor in patients with FIGO II-III cervical cancer treated with radiotherapy.

Nutrition support among critically ill patients in the intensive care unit remains a cornerstone to standard-of-care strategies. Clinicians rely on a robust body of literature, societal guidelines and recommendations, evidence-based protocols, and more to aid in the appropriate delivery of nutrients to this patient population. Among critically ill patients, there is a growing population of patients with smoldering multiorgan dysfunction (MOD) known as persistent inflammation, immunosuppression, and catabolic syndrome (PICS-1). The growth of this patient population is likely related not only to increasing awareness of chronic critically ill patients but also has evolved as intensive care management has improved following the development of bundles, protocols, evidence-based practice, and multidisciplinary care teams. PICS-1 is being recognized more frequently as these patients have survived and can be salvaged from MOD. Unfortunately, there is no evidence regarding nutrition support for these patients (other than inferences from other bodies of literature). This review will serve to describe the origins, a brief epidemiologic discussion, and potential nutrition supplements that may impact the clinical outcomes of PICS-1.

Oral nutrition is the predominant mode of nutrition delivery on the post-Intensive Care Unit (ICU) ward; yet, it is associated with lower intake than via enteral or parenteral nutrition. There are limited data on barriers that influence oral intake in ICU survivors. Therefore, we conducted a scoping review to map and describe physiological nutrition-impacting symptoms following ICU discharge. Database searches of MEDLINE, Emcare, and CINAHL identified primary research in English that included adult patients eating orally throughout the post-ICU period. Data were extracted on study design, aim, population, post-ICU setting, and the physiological nutrition-impacting symptoms reported, including method of reporting and symptom prevalence. Twenty-nine studies comprising between 11 and 357 participants were included, most of which were prospective and observational in design. Post-ICU settings varied and were inclusive of acute care wards (n = 7, 23%), rehabilitation facilities (n = 5, 16%), and various timepoints following hospital discharge (n = 19, 61%). Key physiological nutrition-impacting symptoms reported were dysphagia (n = 25, 86%) and poor appetite (n = 10, 34%). Other common symptoms included early satiety, fatigue, and nausea. Variations occurred in both the method used to quantify symptoms and the prevalence of each symptom across isolated timepoints. The proportion of patients reporting at least one nutrition-impacting symptom at each time point was 16%-78% on the acute care ward, 29%-95% in rehabilitation facilities, and 10%-71% following hospital discharge. Further studies are required to determine which symptoms ICU survivors experience and their trajectory and impact on oral intake.

Background: Although pediatric temporary (e.g., nasogastric) feeding tubes are widely used for short-term nutrition support, family impacts remain poorly defined. Research from long-term (e.g., gastrostomy) feeding tubes does not generalize because management and burdens differ. This study aimed to explore the financial, time and family burdens of temporary feeding tubes, and their impact on children's quality of life.

Methods: A prospective mixed-methods longitudinal cohort study was conducted, following families over 4 months. Data were collected using diaries, interviews, Pediatric Quality of Life Inventory (PedsQL^TM) 4.0 Generic Core Scales, and a caregiver burden questionnaire. Analyses included descriptive statistics for financial and time burdens, a multiple linear regression model fitted to identify factors associated with health-related quality of life, and qualitative content analysis.

Results: Thirty-six parents participated. Parents reported spending an average of 3.1 h daily on tube-related care. Indirect costs (e.g., lost income) averaged USD$1494.15/month (SD = $339.11), and out-of-pocket nonmedical costs (e.g., hiring help) represented 44% of monthly family income. Employment disruptions were reported by n = 18 (61%) of parents. Key predictors of lower quality of life for children were toddler age group, prior home tube feeding experience, and regional/rural residence. Preterm birth status and involvement of 4-6 medical teams were associated with higher quality of life. Parents reported challenges managing mealtimes, outings, and holidays.

Conclusion: Temporary tube feeding imposes substantial financial burdens, time demands, and disruptions to family life, with impacts on children's quality of life. Supporting successful management for children requiring this intervention requires integrated family-centered care, including structured support, education, and psychosocial interventions.