Nutrition in Clinical Practice最新文献

Severe acute pancreatitis often presents as a complex critical illness associated with a high rate of infectious morbidity, multiple organ failure, and in-hospital mortality. Breakdown of gut barrier defenses, dysbiosis of intestinal microbiota, and exaggerated immune responses dictate that early enteral nutrition (EN) is preferred over parenteral nutrition (PN) as the primary route of nutrition therapy. EN, however, is not feasible in all cases because of intolerance, risk of complications, or a direct contraindication to enteral feeding. For these patients, PN can be provided in a manner that is safe, is metabolically appropriate, and follows the principles of modern critical care nutrition. Adherence to goal-directed fluid resuscitation, provision of trophic doses of PN to meet 20%-25% of protein and/or calorie requirements through the acute phases of illness, use of less-inflammatory intravenous lipid emulsions, and close monitoring of electrolytes, triglyceride levels, and signs of refeeding syndrome all serve to optimize the response to this route of nutrition support. For these reasons, prescribing PN remains an important strategy in the management of this difficult population of patients.

Background: The neutropenic diet has been a long-standing approach to preventing infection in patients with hematopoietic stem cell transplants (HSCTs), although data on its efficacy are inconclusive and its restrictive nature might contribute to harm by reducing dietary intake in this patient population who typically experiences poor oral intake. The aim was to determine if a liberalized diet (LD), in comparison with a neutropenic hospital diet (ND), would improve energy intake and lessen weight loss during neutropenia in patients with HSCTs.

Methods: A randomized controlled trial was conducted in a single-center HSCT/hematologic malignancy unit. The diet interventions were initiated when absolute neutrophil counts dropped to <500 cells/mm³; oral dietary intake was assessed during neutropenia until neutrophil recovery, which averaged 9.5 days.

Results: Meal intake compliance (consuming at least 50% of meals/day) was not different between groups (LD, 47%; ND, 43%; P = 0.66). Of the 191 patients assessed (LD, n = 92; ND, n = 99), mean (SD) energy, 678 (349) vs 724 (393) kcal/d (P = 0.46), and protein, 30.3 (18.5) vs 30.4 (18.1) g/day (P = 0.89) did not differ between groups nor did weight change, 0.3 (2.5) vs 1.2 (4.1) kg (P = 0.22) during neutropenia. None vs higher than or equal to grade 1 mucositis, allogeneic vs autologous stem cell transplantation, and fewer days on intervention favored higher energy and protein intakes.

Conclusion: Energy intake during neutropenia did not improve with a LD encouraging fresh fruits and vegetables. Thus, alternative approaches to improving dietary intake, such as energy-dense and nutrient-dense foods with sensory characteristics acceptable to patients experiencing significant mucositis, require exploration.

Background: Children with intestinal failure (IF) receiving prolonged parenteral nutrition (PN) are exposed to risk factors that predispose them to developing disordered eating behavior. This study aimed to assess the food interest patterns of PN-dependent children with IF and those who achieved enteral autonomy (EA).

Methods: A cross-sectional study was conducted in children aged 1-14 years with IF currently receiving PN for >60 days and in children who achieved EA. The American Speech-Language-Hearing Association-National Outcomes Measurement System (ASHA-NOMS) scale for oral feeding assessment and Children's Eating Behavior Questionnaire (CEBQ) for eating behavior were used. Children were divided into two groups, G1 (currently using PN) and G2 (achieved EA by discontinuation of PN), for the analysis of each subscale of the questionnaire. The PN dependency index (PNDI) was also assessed.

Results: Fifty-one children were evaluated, and the median (IQR) age was 47.0 (26.0-69.0) months. Thirty-five (68.6%) children were in G1, and 16 (31.4%) were in G2. Children in G2 had better mean scores than those in G1 on the satiety responsiveness, food responsiveness, and enjoyment of food subscales. These scores were significantly different among children with high/moderate PN dependence compared with those with mild dependence or those who achieved EA.

Conclusion: Compared with children who achieved EA, those with PN-dependent IF showed food avoidance patterns of less interest in and enjoyment of food. This pattern was more pronounced in those with moderate/high dependence on PN.

Home enteral nutrition (HEN) is a vital feeding practice for those who have chronic disorders that prevent them from eating normally. Although short-term feeding is predominantly done via nasogastric (NG) tubes and long-term feeding is done via percutaneous endoscopic gastrostomy (PEG) tube, we present a case that demonstrates that the long-term use of NG tubes may be possible. Our case involves an adult woman who has been fed via an NG tube for >3 years with no complications. She has had three replacement tubes inserted over these 3 years and has not required any healthcare visits related to tube dysfunction or complications. She continues to do well. A literature search determined that there are no reports of long-term use (greater than a year) of NG feeding tubes in outpatient adults, and thus the true rate of complications related to NG tubes is unknown. We review the reported complications associated with long-term PEG tubes. Although PEGs are typically regarded as safer in long-term feeding situations, this case demonstrates that NG tubes could prove effective under certain circumstances in which the insertion of a PEG may not be possible.

Background: Recent surveys suggest that registered dietitian nutritionists (RDNs) are increasingly supportive of blenderized tube feeding (BTF). However, its actual use in clinical practice continues to lag. This disconnect may be explained by a lack of comprehensive BTF policies. This study aimed to explore BTF policies in medical facilities in which RDNs are employed.

Methods: An electronic survey was disseminated to RDNs through enteral nutrition formula and supply company email databases. The survey collected participant demographics, medical facility type, barriers and contraindications for BTF use, and components of a comprehensive policy. Potential relationships between demographics and self-assessed BTF skill level were also explored.

Results: Of the 123 RDNs completing the survey, 87% supported BTF and 76.4% used it in clinical practice. Commercial BTF products (cBTFs) were allowed in 63.4% of facilities, but policy-related barriers hindered actual cBTF use. Home-prepared BTF policies were available in 54.5% of facilities, but only 7% of these policies were complete. Inpatient facilities were particularly lacking in any BTF policies compared with outpatient settings (χ² = 10.550, P = 0.005).

Conclusion: RDNs are increasingly supportive of BTF for their patients who want it. To provide optimal patient-centered care, comprehensive BTF policies are needed for successful implementation in healthcare facilities.

Background: In light of the complex and high-risk nature of parenteral nutrition (PN), reviewing PN processing steps is essential to minimize patient harm. The main steps include ordering, verification, compounding, and administration. Electronic health records (EHRs) have become increasingly utilized and can play a critical role in enhancing the safety of PN processin. Epic EHR is used throughout all PN processing steps within our health system. There is limited literature on health system quality improvement initiatives in PN processing.

Methods: We reviewed the steps of PN processing in our health region and applied a gap analysis to assess Epic's functionality in PN processing. This gap analysis aimed to identify opportunities to enhance PN safety.

Results: Epic applies 32 of 40 functions that enhance PN safety. We selected three functions to prioritize adding into future EHR iterations; these include (1) bidirectional automatic interfacing between the automated compounding device and EHR reflecting real-time updates on product availability/shortages, (2) automatically transmitting a pharmacist-modified PN order back to the prescriber for approval, and (3) adding additional clinical decision support tools, one of which is incorporating a 3-in-1 qualification calculator and the second is requiring prescriber justification for using compounded formulations over multichamber bags. Additional opportunities for improving safety in PN processing were identified and added to the gap analysis.

Conclusion: Using a gap analysis is a simple process to review a health system's EHR to identify opportunities to enhance patient care.

Background: Both blended tube feed (BTF) and commercial tube feed (CTF) can be administered through a gastrostomy tube (GT). There is very little evidence about using home BTF (HBTF). Nevertheless, families increasingly request this type of nutrition because they attribute some benefits to it. Our objective was to evaluate the efficacy and safety of using HBTF via GT as an alternative to CTF.

Methods: Single-center, retrospective, and observational study of patients under 18 years old who underwent GT between 2014 and 2020. We reviewed demographics, anthropometrics, clinical characteristics, and types of diet and gastrointestinal (GI) symptoms over 12 months after the placement of the GT.

Results: Forty patients (40% boys) were included. The median age at GT placement was 15 months (interquartile range 5-57.5). The most common underlying diagnosis was a neurological disorder (45%). In 75% of patients, Nissen fundoplication was performed. At the 12-month follow-up, 18 patients (45%) were receiving 100% HBTF, 14 (35%) were receiving a mixed diet (HBTF + CTF), four (10%) were receiving 100% CTF, and four (10%) were no longer using the GT. Those with a 100% HBTF diet showed a statistically significant higher weight at the 12-month follow-up than those who had received any percentage of CTF. No other statistically significant differences in anthropometric indices or GI symptoms were found between the two groups. Only three cases of mechanical complications were reported.

Conclusion: In our experience, using HBTF via the GT provides an alternative to CTF in pediatric patients who require enteral nutrition.

Background: The 2019 Enhanced Recovery After Cardiac Surgery (ERACS) guidelines presented perioperative recommendations to optimize treatment for patients undergoing cardiac surgery (CS). However, the guidelines have not established postoperative nutrition recommendations. Limited studies have analyzed oral intakes after CS, but to our knowledge, none have done so in an ERACS pathway. The main objective of this study was to evaluate the adequacy of postoperative oral intakes, including adherence to oral nutrition supplements (ONSs).

Methods: This was an observational prospective study. Postoperative oral intakes were analyzed from postoperative day (POD) 1 to 4, using direct observation of meal plates provided by the hospital. ONSs consumption was evaluated from POD2 to POD4. Adherence to other ERACS recommendations, including nutrition optimization before surgery, was recorded.

Results: Forty-three patients were included in this study. Nutrition optimization before CS was offered to three (7%) patients. Forty-one (95%) patients resumed oral intakes on POD1. Mean oral calorie and protein intakes from POD2 to POD4 were 1088 ± 437 kcal and 0.8 ± 0.3 g/kg, respectively; however, 17 (41%) patients had calorie and protein intakes ≥70% of their estimated requirements. On POD2, ONSs consumption contributed 35% ± 19% and 38% ± 20% of calorie and protein intake, respectively. There was a significant decrease in ONSs consumption starting on POD3.

Conclusion: Within an ERACS pathway and with the contribution of ONSs, 41% of patients achieved sufficient oral intakes within the first 4 days after CS. The optimization of ONSs adherence on postoperative oral intakes should be further studied.

Background: Malnutrition in pediatric oncology patients is a serious clinical condition. There is a need for standardized nutrition screening in pediatric oncology patients, as nutrition screening can offer a simple method to identify children with cancer at risk of malnutrition. This study aimed to determine the validity of a Turkish version of nutrition screening tool for childhood cancer (SCAN) in identifying the risk of malnutrition among children with cancer.

Materials and methods: A cross-sectional study was conducted with 78 children with cancer admitted to the pediatric hematology-oncology unit of a university hospital. In the first stage of this study, SCAN was translated into Turkish, and in the second stage, the validity of SCAN against pediatric Subjective Global Nutritional Assessment (SGNA) and Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition (AND/ASPEN) malnutrition criteria were evaluated.

Results: Patients had a median age of 8.0 years (range, 2-18 years; IQR, 5-14 years), 61.5% were male, and 60.3% were diagnosed with leukemia. According to SCAN, 53.8% had high risk of malnutrition. Validation of SCAN against pediatric SGNA showed that SCAN has a sensitivity of 97.5%, specificity of 94.5%, and accuracy of 96.1%.

Conclusion: The risk of malnutrition is common in children with cancer. The Turkish version of the SCAN is a simple, quick, and valid tool to determine the risk of malnutrition in children with cancer. Further research is needed to understand the impact of nutrition interventions on clinical outcomes in children at risk for malnutrition based on SCAN.

Mitochondrial dysfunction has been implicated in the pathogenesis of several neurodegenerative disorders, including progressive supranuclear palsy (PSP). PSP is a Parkinsonian syndrome characterized by a rapidly progressive state that manifests itself as tremors, bradykinesia, and supranuclear gaze palsy. Carnitine plays an essential role in mitochondrial function by transporting fatty acids across the mitochondrial membrane to be used in energy production. Mitochondrial dysfunction can bring about rapid neuronal depolarization and a calcium-mediated cellular apoptosis owing to a loss of oxidative metabolism, likely contributing to the PSP disease process. A White man aged 65 years with PSP presented with small bowel obstruction and severe malnutrition as a result of prior gastrointestinal surgeries for which a gastrostomy tube was placed. During his hospitalization, the patient was found to be deficient in both free and total carnitine. He was treated with levocarnitine supplementation and exhibited marked improvement in tremors, fatigue, and physical therapy activities. Posthospitalization follow-up showed sustained improvement in symptoms with continued levocarnitine supplementation. Treatment of PSP remains largely supportive in nature. No studies have investigated the role of carnitine supplementation in PSP. To our knowledge, this is the first case report to identify improvement in PSP symptoms after carnitine repletion and supportive care. Numerous animal studies have reported on carnitine supplementation in the context of mitochondrial dysfunction associated with neurodegenerative diseases, such as Parkinson disease and Alzheimer disease. Further investigation is necessary to elucidate the precise role of carnitine and other nutrition supplements in the pathophysiology of PSP.