Nutrition in Clinical Practice最新文献

Background: Registered dietitian nutritionists (RDNs) use clinical practice guidelines (CPGs) to inform evidence-based practice. Despite the availability of CPGs, guidelines are not always translated into practice. This challenge is central to implementation science (IS), which seeks to understand how evidence can be adopted and sustained.

Methods: The Gestational Diabetes Mellitus (GDM) Registry Study was a multiphase, multisite hybrid implementation study that explored guideline implementation using quality improvement (QI) methods grounded in the Model of Improvement and guided by Plan-Do-Study-Act (PDSA) cycles. Following a baseline period, RDNs completed training, conducted a gap analysis, and identified 2 CPG implementation aims. Sites completed iterative PDSA cycles. Deidentified nutrition care data were entered into the GDM Study Registry and manually audited to evaluate process outcomes. RDNs participated in a closing interview. Qualitative data were analyzed using a constructivist approach and reflexive thematic analysis, supported by artificial intelligence (AI)-assisted qualitative software.

Results: Six themes were identified, highlighting the value of assessing current practices and the flexibility of PDSA as an implementation strategy. Themes were mapped against the Normalization Process Theory and Consolidated Framework for Implementation Research and showed alignment between PDSA and implementation principles. The registry audit demonstrated improved process measures. The median normalization score across RDNs (9.00) and sites (9.42) was high, suggesting normalization.

Conclusion: PDSA facilitated the work of normalization and enabled practice changes. This study contributes to IS by demonstrating how QI strategies, such as PDSA can help RDNs translate evidence into everyday nutrition care.

Malnutrition among community-dwelling older adults (OAs) is prevalent, particularly in groups using healthcare services. Malnutrition burdens health, social, and aged-care systems in terms of expenses for hospital admissions and care in nursing homes and home care settings. Effective management requires early identification and multimodal interventions; however, studies report a significant gap between recommended nutrition interventions and current healthcare practices. Therefore, this study aimed to identify, present, and map existing evidence on barriers and facilitators in the implementation of nutrition interventions among OAs living in noninstitutional municipal healthcare settings. A scoping review following the Joanna Briggs Institute guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews checklist were conducted. The study included evidence from bibliographic databases and gray-evidence sources that identify barriers and/or facilitators from stakeholder perspectives that influence the implementation of nutrition interventions for malnutrition prevention or treatment among OAs (≥65 years) in noninstitutional municipal healthcare settings. Stakeholders were OAs, informal caregivers, or healthcare professionals (HCPs). Thirty-seven articles were included and 10 categories identified. Barriers were (1) lack of knowledge and awareness among HCPs, (2) lack of resources, (3) lack of collaboration and communication, (4) missing links between healthcare settings, and (5) poor insight among OAs and caregivers. Facilitators were (1) education and training of HCPs, (2) self-care, (3) person-centered care, (4) technology in nutrition care, and (5) social and psychological factors. Findings from this review indicate an imperative need for targeted implementation strategies for developing evidence-based nutrition home care practice.

Many nutrition interventions and innovations are supported by strong evidence; however, their adoption, implementation, and long-term sustainability in real-world healthcare settings too frequently remain a challenge. Implementation science offers methodologies to equip practitioners with tools to identify and address the contextual factors that influence implementation success in health settings (e.g., adoption, implementation, sustainability). Among the various frameworks and theories used in implementation science, the Consolidated Framework of Implementation Research (CFIR) is one of the most widely used. The CFIR synthesizes constructs from multiple behavioral and implementation theories into a comprehensive tool that can be used to systematically assess the barriers and facilitators that influence implementation outcomes. The framework enables practitioners and researchers to identify context-specific implementation determinants and to design tailored implementation strategies across diverse contexts and settings. Given its adaptability, the CFIR is highly relevant to the field of nutrition and dietetics to support sustained adoption and delivery of nutrition innovations (e.g., screening tools, educational programs, quality improvement initiatives); but it is relatively underutilized in nutrition practice. This article provides an overview of the CFIR and illustrates how it can be used to guide the implementation of nutrition innovations in clinical practice through two pragmatic case studies. We highlight the potential of the CFIR to be used as a guiding framework to advance the adoption, implementation, and sustainability of nutrition innovations and improve nutrition care and patient outcomes.

Introduction: A 1-day cross-sectional study at our hospital found that only 22% of patients with hip fractures at nutrition risk met their energy and protein requirements during hospitalization. This study aimed to test whether closer collaboration between a clinical dietitian and ward staff, guided by the Model for Improvement, could optimize nutrition care for hospitalized older patients with hip fractures at nutrition risk.

Method: A dietitian was embedded to facilitate staff-led enhancements in nutrition care at an orthopedic ward in from September to December 2024. Two Plan-Do-Study-Act cycles were implemented. Cycle 1 focused on nutrition documentation. Cycle 2 targeted nutrition intake. The primary outcome was the proportion of patients meeting individual energy and protein requirements (≥80%). Secondary process indicators were (1) ≥80% of patients screened using Nutrition Risk Screening 2002, and (2) ≥80% of at-risk patients with intake documented in the medical record. Preintervention data served as the baseline.

Results: The primary outcome was achieved, with 80% (8 of 10) of patients meeting both energy and protein requirements, a significant improvement from 22% (2 of 9) at baseline (P < 0.05). Documentation of nutrition risk increased from 10% (1 of 10) to 80% (8 of 10) (P < 0.01), and intake documentation improved from 30% (3 of 10) to 100% (10 of 10) (P < 0.01).

Conclusion: This quality improvement study demonstrates that applying the Model for Improvement to integrate a clinical dietitian into ward practice strengthened interdisciplinary nutrition care and led to measurable gains in screening, documentation, and nutrition intake among older patients with hip fractures at nutrition risk.

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: COVID-19 significantly affected traditional nutrition assessment methods, forcing experts to quickly adjust to new constraints. This study examined practices in clinical nutrition during the pandemic in Latin America based on professional background or experience.

Methods: A cross-sectional survey from July to November 2021 involved clinical nutrition experts from 18 Latin American countries. A 70-item questionnaire assessed anthropometric, biochemical, and dietetic indicators; screening and diagnostic tools; and methods for estimating nutrient requirements. For statistical analyses we used nonparametric tests and latent profile analyses.

Results: Among the 398 participants, the sample included dietitians/nutritionists (63%), physicians (25%), and nurses (12%). Biochemical indicators were used by 87%, dietetic indicators by 71%, and anthropometric measurements by 65%. Only one-third used GLIM criteria, whereas nearly 30% indicated that they did not use any screening tools. Variations in professional practices were observed regarding laboratory test requisitions and dietary assessment methodologies. Dietitians favored the use of recalls, whereas physicians generally ordered a greater number of biochemical tests. There was a significant variation in the estimation of protein and energy requirements, particularly outside of critical care environments. The influence of seniority on assessment practices was negligible.

Conclusion: Nutrition evaluation throughout the pandemic has demonstrated considerable variability with an individual's profession demonstrating a more substantial impact than their level of seniority. The limited utilization of standardized tools highlights continued fragmentation and emphasizes the necessity for interprofessional education and institutional policies to ensure consistent, evidence-based nutrition care.

Background: Blenderized tube feeding (BTF) use has increased in patient populations requiring enteral nutrition support, and healthcare providers need to be well-informed on the nuances of BTF-including administration. Patients and caregivers frequently prefer right-angle extension sets but are encouraged to use straight sets to avoid a potential clog at the right angle. The purpose of this study was to compare clog occurrences in straight and right-angle extension tubes between standard commercial formula (SCF) and all viscosity levels of BTF. The accuracy of formula volume delivered was also explored.

Methods: A home-prepared and a commercial product were manipulated such that all four viscosity levels were achieved and delivered by pump and syringe through right-angle and straight extension sets in mock tube feedings. A comparison SCF was also delivered via pump without adjusting the viscosity. All 1-h feedings were observed for any clogs at the right-angle or in the straight extension set.

Results: No clogs were observed at any viscosity level in pump delivery for right-angle or straight extension sets. One clog was observed in a single-observation syringe feeding. The volume delivered was more consistent at all viscosity levels through the right-angle sets, compared with straight set tubes delivering the 200-ml volume in 1 h.

Conclusion: Patient preference for right-angle extension sets may be honored for BTF delivered via new-generation feeding pumps.

Background: The effectiveness of thiamin supplementation in mitigating renal injury and mortality outcomes in patients with septic shock remains uncertain. This systematic review and meta-analysis aimed to determine the efficacy of thiamin in patients with septic shock.

Materials and methods: A systematic search was made of PubMed, Embase, Cochrane Library, and clinicaltrials.gov, without language restrictions. Randomized controlled trials (RCTs) on treatment of septic shock with thiamin, compared with placebo or blank, were reviewed. Studies were pooled to risk ratios (RRs) and weighted mean differences, with 95% confidence intervals (CIs). Six RCTs (enrolling 438 patients) met the inclusion criteria.

Results: Thiamin showed significant effects on in-hospital mortality (RR 0.80, 95% CI 0.65-0.99; P = 0.04) and renal replacement therapy (RR 0.48, 95% CI 0.31-0.74; P = 0.0009).

Conclusion: Thiamin was associated with a reduction in in-hospital mortality and the use of renal replacement therapy in patients with septic shock. Thiamin should be considered for patients with septic shock.

Background: Skeletal muscle is critical for functional status, quality of life, and treatment tolerance in pediatric patients with cancer. Traditional assessments of muscle mass involve radiation and are often unsuitable for frequent monitoring. Ultrasound (US) is noninvasive and radiation-free; however, its reliability in pediatric patients with cancer, who experience rapid changes in body composition, is not well established. This study aimed to determine the interrater reliability of US for measuring key muscle parameters.

Methods: A novice and an expert sonographer blindly measured muscle thickness (mT), cross-sectional area (CSA), and echo intensity (EI) for the quadriceps femoris (QF) and tibialis anterior (TA) muscles in an oncology group and a healthy group. Interclass correlation coefficients were calculated to assess interrater reliability.

Results: A total of 27 participants were included (n = 14 oncology and n = 13 healthy). All quadriceps measures had good reliability, with QF mT = 0.895 (95% CI, 0.77-0.952), rectus femoris (RF) mT = 0.881 (95% CI, 0.74-0.946), CSA = 0.801 (95% CI, 0.563-0.909), and EI = 0.839 (95% CI, 0.647-0.927). All TA measures had excellent reliability: mT = 0.968 (95% CI, 0.929-0.985), CSA = 0.925 (95% CI, 0.835-0.966), and EI = 0.909 (95% CI, 0.801-0.959). The oncology group's reliability remained high. Key results included RF mT = 0.906 (95% CI, 0.706-0.970), QF mT = 0.887 (95% CI, 0.646-0.964), TA mT = 0.972 (95% CI, 0.912-0.991), CSA = 0.947 (95% CI, 0.836-0.983), and EI = 0.943 (95% CI, 0.822-0.982).

Conclusion: Point-of-care US is a reliable method to measure muscle in pediatric oncology patients. Moreover, novice sonographers can be trained to perform these measurements reliably.

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.