Nutrition in Clinical Practice最新文献

Background: Muscle mass is a strong predictor of clinical outcomes. However, its continuous monitoring is not always feasible in critically ill patients. Surrogate methods, such as bioelectrical impedance analysis (BIA), may be affected by overhydration (OH). The aim of this study was to evaluate the agreement of BIA-derived fat-free mass (FFM) adjusted for hydration status in comparison with muscle mass assessed by computed tomography (CT) in critically ill patients with pneumonia due to COVID 19.

Methods: This secondary analysis includes patients with a CT scan of the third lumbar vertebra (L3) and a BIA performed within the first 24 to 48 h of hospital admission. FFM and hydration status were estimated using BIA (FFM_BIA), and then adjusted to OH (FFM_OH). Images from the skeletal muscle area obtained from L3 were used to calculate the FFM derived from CT (FFM_CT). The concordance between FFM derived from CT and BIA was analyzed using Bland-Altman and Student t test.

Results: Seventy-four patients were included. FFM_BIA overestimated compared with CT (54.6 ± 10.3 kg vs 47.4 ± 10.9 kg) with a mean difference of 7.2 kg (limits of agreement, -5.1 to 19.5; P < 0.01). Overestimation decreased by FFM_OH, with a mean difference of 3.5 kg (limits of agreement, -9.6 to 16.8; P = 0.06).

Conclusion: FFM_OH assessed by BIA shows a better agreement with FFM_CT in comparison with FFM_BIA.

Background: Children with spinal muscular atrophy (SMA) do not follow standard anthropometric growth trajectories; disease-specific curves were published in 2021. Our aim was to apply these in SMA children comparing their growth and body composition longitudinally, relative to the World Health Organization (WHO) standard.

Methods: This was a retrospective cohort of 19 SMA pediatric patients in a long-stay hospital with monthly anthropometric measurements from admission to discharge. We calculated body mass index) and length‑for‑age z scores (BMIz and LAzs) using WHO and SMA‑specific curves. Triceps skinfold and mid-upper arm circumference z scores (TSFz and MUACz) used WHO reference.

Results: Participants had a median age of 9 (IQR, 7-14) months, followed up for 19 months (IQR, 6.5-32). At admission, BMIz was -1.31 ± 0.66 by WHO and 0.77 ± 0.50 by SMA curves (P < 0.01). According to WHO, 11 (57.9%) were malnourished, 8 (42.1%), eutrophic, and 0 overweight, but with SMA curves the comparable values were 2 (10.5%), 9 (47.4%), and 8 (42.1%), respectively. MUACz was -0.3 ± 0.7 and TSFz 2.01 ± 0.84. TSFz correlated better with BMIz based on SMA (R² = 0.46) than with WHO curves (R² = 0.27). Over time, BMIz remained stable, HAz rose slightly by both curves, MUACz showed a declining trend, and TSFz increased 0.38 annually (R² = 0.34; 95% CI, 0.11-0.63; P = 0.006).

Conclusion: SMA‑specific growth curves assess better the nutrition status in children with SMA compared with WHO standards, aligning more closely with body composition. The cohort demonstrated increased fat accretion, normal length growth, and stable BMI over time.

Background: Diagnosing malnutrition in patients with pediatric cancer is challenging because tumor masses can interfere with anthropometric measurements. STRONGkids considers cancer a general risk factor, whereas Screening Tool for Childhood Cancer (SCAN) classifies patients as at risk or not, potentially missing those who need nutrition monitoring. This study describes development and validation of a new nutrition risk screening tool for childhood cancer in Brazil.

Methods: Nutrition Risk Screening for Childhood Cancer (NUTRICCAN) underwent online expert content validation. Twelve nutritionists applied it to oncology inpatients (0-19 years old) at the Pediatric Oncology Institute at Federal University of São Paulo from June to August 2024. Nutrition risk was assessed using NUTRICCAN, STRONGkids, and SCAN. Logistic regression identified screening variables associated with malnutrition (body mass index-for-age z score < -2, mid-upper arm circumference [MUAC] <5^th percentile, calf circumference below cutoff, or met any of the criteria for malnutrition). Receiver operating characteristic analysis determined cutoff scores, and sensitivity/specificity analyses allowed comparisons among instruments.

Results: Patients not receiving intensive care were almost three times more likely to have an inadequate MUAC (odds ratio [OR], 4.505; 95% confidence interval [CI], 1.446-14.033; P = 0.009). Low socioeconomic status or caregiver education increased the risk of malnutrition (OR, 2.845; 95% CI, 1.070-7.566; P = 0.036). Dietitians' subjective assessments were associated with a fourfold increased risk of malnutrition. NUTRICCAN was 70% accurate (area under the curve, 0.701; 95% CI, 0.617-0.785), outperforming the other tools.

Conclusion: NUTRICCAN better stratifies nutritional risk, considering clinical and socioeconomic factors, and may allow for more targeted interventions, especially in resource-limited settings.

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: Evidence-based guidelines (EBGs) in the nutrition management of advanced liver disease and enhanced recovery after surgery recommendations state that normal diet should recommence 12-24 h following liver transplantation. This study aimed to compare postoperative nutrition practices to guideline recommendations, explore clinician perceptions regarding feeding after transplant surgery, and implement and evaluate strategies to improve postoperative nutrition practices.

Methods: A pre-post multimethod implementation study was undertaken, guided by the knowledge-to-action framework. A retrospective chart audit of postoperative dietary practice and semistructured interviews with clinicians were undertaken. Implementation strategies were informed by the Consolidated Framework for Implementation Research-Expert Recommendations for Implementing Change matching tool and then evaluated.

Results: An evidence-practice gap was identified, with the median day to initiation of nutrition (free-fluid or full diet) on postoperative day (POD) 2 and only 25% of patients aligning with the EBGs. Clinician interviews identified belief in the importance of nutrition, with variation in surgical practice in relation to early nutrition, competing clinical priorities, and vulnerabilities in communication contributing to delays in returning to feeding. An endorsed postoperative nutrition protocol was implemented along with a suite of theory- and stakeholder-informed intervention strategies. Following implementation, the median time to initiate nutrition reduced to POD1 and alignment with EBGs improved to 60%.

Conclusion: This study used implementation frameworks and strategies to understand, implement, and improve early feeding practices in line with EBGs after liver transplant. Ongoing sustainability of practice change as well as the impact on clinical outcomes have yet to be determined.

Parenteral nutrition (PN) is a life-sustaining therapy for patients unable to meet nutrition needs via enteral routes, but its use presents significant ethical complexity. This narrative review provides clinicians with a practical, principle-based framework to navigate the ethical dilemmas inherent in PN across diverse clinical contexts. Grounded in the four pillars of medical ethics-autonomy, beneficence, nonmaleficence, and justice-the review explores decision-making challenges in vulnerable populations, long-term PN, and end-of-life care. Clinically relevant scenarios are examined, including initiation or withdrawal of PN in terminal illness, informed consent in cognitively impaired patients, and balancing parental wishes with a child's best interests in pediatric care. The ethical tension between prolonging life and enhancing quality of life is critically appraised, particularly in oncology and palliative settings. The review also addresses disparities in PN access and resource allocation, with actionable insights for clinicians practicing in low-resource settings. Key take-home strategies include using structured ethical frameworks such as the Four-Quadrant and Shared Decision-Making models, involving ethics committees in complex cases, and prioritizing transparent, compassionate communication. Clinicians are encouraged to consider both the clinical utility and psychosocial burden of PN, and to integrate multidisciplinary perspectives into care planning. Ultimately, this review underscores the need for ethically attuned, patient-centered PN decisions that align with individual goals, values, and context. It provides structured guidance to assist nutrition support teams in translating ethical principles into clinical practice, thereby ensuring that PN is administered judiciously, safely, and in accordance with the patient's best interests.

Background: Prolonged fasting before surgery remains common despite guidelines recommending liquid fasting for 2 h and solid fasting for 6 h preoperatively. Consuming carbohydrate-rich drinks until 2 h before surgery improves patient well-being and reduces postoperative complications and insulin resistance. Given the persistence of implementation barriers, including logistical challenges and insufficient patient education, this study aimed to implement drinking up to 2 h before elective orthopedic surgery.

Methods: The Grol and Wensing implementation approached was followed in a before-after study conducted at a Dutch academic orthopedic ward (April 2023 to May 2024), after approval by the Scientific Ethical Committee. Current practices and barriers were assessed, and tailored strategies were developed using implementation theory and taxonomies to develop implementation strategies for the identified factors, followed by integration and evaluation.

Results: Implementation included dissemination, patient-oriented, organizational, educational, and risk prevention strategies. A total of 39 patients participated in the initial analysis and 48 patients participated in the evaluation. Preoperative fasting from liquids significantly reduced from 8:20 h (IQR: 4:42-12:19 h) to 4:38 h (IQR: 2:58-6:12) by informing patients about the importance of drinking up to 2 h before surgery and to 2:45 h (IQR: 2:21-3:26) by facilitating drinking lemonade after admission when surgery would start in ≥2 h. Patients' comfort improved regarding thirst, whereas no effect was found for other symptoms. Adverse events, including postponement of surgeries and pulmonary aspirations, during surgery did not occur while accepting >1 h of fasting at the start of surgery.

Conclusions: Scalable implementation strategies for patient education on fasting and coordinated provision of lemonade reduced fasting duration among elective orthopedic patients.

Background: This project aimed to develop an evidence-based nursing care bundle after gastrostomy feeding tube insertion and implement it into clinical practice using the Knowledge to Action (KTA) framework.

Methods: This mixed-method design project was conducted in a university hospital between December 2021 and June 2022. The project was carried out in four phases: (1) development of an evidence-based care bundle, (2) education for care bundle training, (3) implementation of the care bundle, (4) evaluation of the care bundle. Nurses' compliance with bundles was measured using All-or-None measurement. The analysis of the qualitative interview conducted was performed using the content analysis method of Graneheim and Lundman.

Results: The developed Sezer gastrostomy care bundle consists of three parameters (peristomal area care, tube feeding, and medication administration through the feeding tube) and a total of 14 elements to be applied by nurses under these parameters. Compliance rates for peristomal area care, tube feeding, and medication administration through feeding tube parameters were 100%, 98.66%, and 98.66%, respectively. Two themes and six subthemes emerged: (1) reflection of using the Sezer gastrostomy care bundle on nursing care and (2) adoption of Sezer gastrostomy care bundle.

Conclusion: The gastrostomy care bundle was developed in accordance with the Institute of Healthcare Improvement's recommendations. The KTA framework provided an appropriate structure to transform evidence into practice, meticulously address barriers, evaluate outcomes, and ensure sustainability. The project found that nurses complied with all its parameters. Studies evaluating the effect of the gastrostomy care bundle on patient outcomes are recommended.

Implementation science (IS) offers a structured approach to bridging the gap between research and practice by facilitating the adoption of evidence-based interventions (EBIs). One established framework within IS is the Quality Enhancement Research Initiative (QUERI), developed by the US Department of Veterans Affairs. QUERI promotes the active dissemination of EBIs through a phased roadmap: preimplementation (data to knowledge), implementation (knowledge to performance), and sustainment (performance to data). This review article explores the QUERI framework in depth and its application in clinical nutrition settings. Two case studies illustrate how QUERI can enhance implementation efforts: (1) improving inpatient malnutrition screening and (2) integrating outpatient surgical prehabilitation programs. In the first case, QUERI guides the identification of low screening and diagnosis rates, stakeholder engagement, toolkit development, and ongoing evaluation to ensure sustainability. In the second, QUERI aids in developing and adapting evidence-based prehabilitation protocols while balancing fidelity and customization to local workflows. Both examples demonstrate the importance of structured planning, stakeholder involvement, and iterative evaluation in achieving sustained change. QUERI's emphasis on choosing a high-volume or high-risk problem, defining best practices, and documenting outcomes makes it a valuable tool for nutrition professionals aiming to improve outcomes through consistent application of EBIs. As clinical nutrition continues to evolve, implementation frameworks like QUERI offer a practical pathway for translating research into impactful, sustainable improvements in patient care.