Initiation Of Nutritional Therapy Research Articles

Nutritional x-ray of cardiac patients at the initiation of nutritional therapy: Are we nourishing already malnourished patients?

Nutritional x-ray of cardiac patients at the initiation of nutritional therapy: Are we nourishing already malnourished patients?

Multiplex Snapshot minisequencing for detection of common PAH gene mutations in Iranian patients with Phenylketonuria.

Phenylketonuria (PKU) is one of the most common inborn faults of amino acid metabolism in the world. It is caused by an autosomal recessive insufficiency of the hepatic enzyme phenylalanine hydroxylase (PAH) that catalysis the irreversible hydroxylation of phenylalanine to tyrosine. More than 950 different disease-causing mutations in the PAH gene have been identified. The most prominent complication of PKU if not diagnosed and treated is severe mental retardation. Early diagnosis and initiation of nutritional therapy are the most important measures in preventing this mental retardation. For this reason, we developed a simple and rapid molecular test for detection of the most frequent phenylalanine hydroxylase mutations. We have developed a PCR multiplex SNaPshot reaction that targets all 10 common mutations identified in PAH gene. Multiplex assays based on the SNaPshot minisequencing approach were developed to simultaneous genotype ten mutations at the PAH gene. We have optimized the detection of this mutations in one multiplex polymerase chain reaction (PCR) followed by ten single-nucleotide extension reactions. The different genotypes were determined based on the position and the fluorescent color of the peaks in a single electropherogram. DNA sequencing assay also were used to verify genotyping results obtained by SNaPshot minisequencing, all mutations were concordant. This method can be useful as secondary test in neonatal screening for hyperphenylalaninemia in neonates with a positive screening test and also be suitable for carrier screening. The assay can be easily applied for accurate, time and cost efficient genotyping of the selected SNPs in various populations.

Influence of nutritional assistance on mortality by COVID-19 in critically ill patients.

Background & aimsEvidence suggests the existence of an association between the institution of nutritional therapy and clinical outcomes in patients with critical COVID-19. Thus, the aim of this study was to evaluate the influence of nutritional assistance on COVID-19 mortality in patients admitted to intensive care units (ICU).MethodsThis is a subset of the cohort “Influence of nutritional therapy on clinical prognosis in patients with COVID-19: a multicenter retrospective cohort study”. Clinical and nutrition assistance information (type of assistance, evaluation of anthropometric status, and time of introduction of nutritional therapy) and presence of diabetes, hypertension and previous respiratory disease were collected from electronic medical records. To evaluate the association between the variables of interest and mortality, the hazard ratio was estimated.ResultsWe evaluated 153 critically ill patients ≥18 years old, affected by COVID-19, with a rate of mortality of 77.8%. Among non survivors 58.8% were female, 52.9% aged <65 years, 66.4% had arterial hypertension, 46.2% diabetes mellitus and 81.5% had an early onset of nutritional support. Initiation of nutritional therapy after 48 h (HR: 2.57; 95% CI: 1.57–4.20) and the presence of obesity (HR: 1.55; 95% CI: 1.04–2.31) were associated with higher mortality, even after adjustment for potential confounders.ConclusionsOur data suggests that the provision of early nutritional therapy should be prioritized, with greater attention directed to obese patients, and the nutritional assistance can contribute favorably to the clinical evolution and prognosis of critically ill patients with COVID-19.

Electrolyte disorders during the initiation of nutrition therapy in the ICU.

To summarize recent evidence on prevalence, risk factors, significance, treatment, and prevention of electrolyte disorders in critically ill with a specific focus on disorders during the initiation of nutrition. Electrolyte disturbances appear to occur often during critical illness, and most of them seem to be associated with impaired outcome. However, a recent systematic review indicated insufficient evidence to answer clinically relevant questions regarding hypophosphatemia. Similar questions (which thresholds of serum levels are clinically relevant; how serum levels should be corrected and how do different correction regimens/approaches influence outcome) are not clearly answered also for other electrolytes. The most crucial feature of electrolyte disturbances related to feeding is refeeding syndrome. Recent evidence supports that additionally to the correction of electrolyte levels, a temporary restriction of calories (reducing the magnitude of this metabolic feature, including electrolyte shifts) may help to improve outcome. Diverse electrolyte disorders often occur in critically ill patients. Hypophosphatemia, hypokalemia, and hypomagnesemia that are encountered after initiation of feeding identify refeeding syndrome. Along with correction of electrolytes, reduction of caloric intake may improve the outcome of the refeeding syndrome.

Refeeding syndrome is associated with increased mortality in malnourished medical inpatients: Secondary analysis of a randomized trial.

Background:Whether the occurrence of refeeding syndrome (RFS), a metabolic condition characterized by electrolyte shifts after initiation of nutritional therapy, has a negative impact on clinical outcomes remains ill-defined. We prospectively investigated a subgroup of patients included in a multicentre, nutritional trial (EFFORT) for the occurrence of RFS.Methods:In this secondary analysis of a randomized-controlled trial investigating the effects of nutritional support in malnourished medical inpatients, we prospectively screened patients for RFS and classified them as “RFS confirmed” and “RFS not confirmed” based on predefined criteria (i.e. electrolyte shifts, clinical symptoms, clinical context, and patient history). We assessed associations of RFS and mortality within 180 days (primary endpoint) and other secondary endpoints using multivariable regression analysis.Results:Among 967 included patients, RFS was confirmed in 141 (14.6%) patients. Compared to patients with no evidence for RFS, patients with confirmed RFS had significantly increased 180-days mortality rates (42/141 (29.8%) vs 181/826 (21.9%), adjusted odds ratio (OR) 1.53 (95% CI 1.02 to 2.29), P < .05). Patients with RFS also had an increased risk for ICU admission (6/141 (4.3%) vs 13/826 (1.6%), adjusted OR 2.71 (95% CI 1.01 to 7.27), P < .05) and longer mean length of hospital stays (10.5 ± 6.9 vs 9.0 ± 6.6 days, adjusted difference 1.57 days (95% CI 0.38–2.75), P = .01).Conclusion:A relevant proportion of medical inpatients with malnutrition develop features of RFS upon hospital admission, which is associated with long-term mortality and other adverse clinical outcomes. Further studies are needed to develop preventive strategies for RFS in this patient population.

The Refeeding Syndrome revisited: you can only diagnose what you know

Background/ObjectivesThe Refeeding Syndrome (RFS) is a serious complication in patients receiving nutrition support after a period of severe malnutrition. We frequently recognize and diagnose the RFS due to increased awareness. Thus, we observe that many physicians do not know the RFS and that it is rarely diagnosed. The aim of the study was to determine whether physicians in Germany know the RFS.Subjects/MethodsA questionnaire with a case vignette about an older person who developed the RFS after initiation of nutritional therapy was submitted to German physicians and fifth year medical students, who were participants of educational lectures.ResultsOf the 281 participants who answered the respective question, 40 participants (14%) correctly diagnosed the RFS of the case vignette and 21 participants (8%) gave nearly correct answers. Indeed, the majority of the participants did not diagnose the RFS.ConclusionsAlthough the RFS may lead to fatal complications, it is unknown to the majority of the queried physicians. Therefore, there is a call to implement the RFS in respective curricula and increase systematic education on this topic.

Refeeding syndrome : Pathophysiology, risk factors, prevention, and treatment

Refeeding syndrome is alife-threatening complication that may occur after initiation of nutritional therapy in malnourished patients, as well as after periods of fasting and hunger. Refeeding syndrome can be effectively prevented and treated if its risk factors and pathophysiology are known. The initial measurement of thiamine level and serum electrolytes, including phosphate and magnesium, their supplementation if necessary, and aslow increase in nutritional intake along with close monitoring of serum electrolytes play an important role. Since refeeding syndrome is not well known and the symptoms can be extremely heterogeneous, this complication is poorly recognized, especially against the background of severe disease and multimorbidity. This overview aims to summarize the current knowledge and increase awareness about refeeding syndrome.

Ocena stanu odżywienia pacjentów z nowotworami układów krwiotwórczego i chłonnego za pomocą skali PG-SGA

A dynamic course of hematologic neoplasms as well as intensive chemotherapy are related with development of malnutrition symptoms in a short time. For this reason, it is necessary to perform not only screening procedure but also detailed assessment of nutritional status. The purpose of this research was the assessment of nutritional status and nutritional intervention needs in patients with hematologic neoplasms by PG-SGA score. Most of people (45%) were assigned to category: well malnourished. Next, 43% people were moderately nourished and 11% were severely malnourished. Nutritional intervention was recommended to 83% people, among who 44% indicates a critical need for intervention. The PG-SGA score allows to fully assess actual nutritional status and estimate further changes, what may help to decide on initiation of nutritional therapy.

A Delphi consensus panel on nutritional therapy in chronic kidney disease.

The conservative management of chronic kidney disease (CKD) includes nutritional therapy (NT) with the aim to reduce the intake of proteins, phosphorus, organic acids, sodium, and potassium, while ensuring adequate caloric intake. While there is evidence that NT may help to prevent and control metabolic alterations in CKD, the criteria for implementing a low-protein regimen in CKD are still debated. There is no final consensus on the composition of the diet, nor indications for specific patient settings or different stages of CKD. Also when and how to start dietary manipulation of different nutrients in CKD is not well defined. A group of Italian nephrologists participated, under the auspices of the Italian Society of Nephrology, in a Delphi exercise to explore the consensus on some open questions regarding the nutritional treatment in CKD in Italy, generating a consensus opinion for 23 statements on: (1) general principles of NT; (2) indications for and initiation of NT; (3) role of protein-free products; (4) NT safety; (5) integrated management of NT. This Delphi exercise shows that there is broad consensus regarding NT in CKD across a wide range of management areas. These clinician-led consensus statements provide a framework for appropriate guidance on NT in patients with CKD, and are intended as a guide in decision-making whenever possible.

Evaluation of an Intravenous Potassium Dosing Algorithm for Hypokalemic Critically Ill Patients.

The intent of this study was to evaluate the safety and efficacy of an intravenous (IV) potassium (K) dosing algorithm for hypokalemic critically ill trauma patients. Adult patients, admitted to the trauma intensive care unit from June 2010 to October 2012 and who received IV K therapy according to a standardized dosing algorithm, were retrospectively evaluated. Patients who received IV K during resuscitation or following initiation of nutrition therapy, IV fluids containing >20 mEq/L of potassium, or medications known to alter K homeostasis or those with an arterial pH change >0.1, diarrhea, hypomagnesemia, renal impairment, or morbid obesity were excluded. In total, 715 patients were reviewed to obtain 100 evaluable patients. Serum K for patients with mild depletion (serum K, 3.5-3.9 mEq/L, n = 74) remained unchanged at 0.0 ± 0.3 mEq/L ( P = ns) following 46 ± 8 mEq. Serum K increased by 0.4 ± 0.3 mEq/L ( P = .001) following 78 ± 18 mEq during moderate depletion (serum K, 3-3.4 mEq/L). None of the patients experienced hyperkalemia (serum K, >5.2 mEq/L) postinfusion. The presence of traumatic brain injury (TBI) blunted the response to IV K for mild K depletion as only 26% had an increase in serum K compared with 55% of patients without TBI ( P = .025). The Nutrition Support Service-guided IV K dosing algorithm was safe for patients with mild and moderate hypokalemia and efficacious for those with moderate hypokalemia. Further study in patients with severe hypokalemia (serum K, <3 mEq/L) is warranted.

Efecto del soporte nutricional sobre la supervivencia en pacientes con esclerosis lateral amiotrófica

Introduction: Malnutrition affects morbidity and mor- tality of patients with ALS. The nutrition unit should evaluate these patients early and regularly providing the necessary steps in the evolution of the disease. Methods: A retrospective cohort study in which we analyzed 46 patients diagnosed with ALS, 21 of them received nutritional therapy. We studied age, mode of onset, date of entry into a nutritional protocol, placement of PEG and survival. We performed a test of Breslow comparing patients who were at nutritional protocol with those not receiving nutritional support, and those who received early nutritional therapy with those with delayed nutrition. Results: There was an increase in median survival for patients in nutritional therapy in bulbar ALS (452 vs 55 days) and in spinal ALS (1,798 vs 357 days) (p = 0.002). The median delay in the initiation of nutritional therapy in spinal ALS was 557 days while in bulbar ALS was 230 days. The survival in the spinal ALS of those who entered into nutritional protocol before the median survival was 325 days to 181 days (p = 0.09) while in bulbar ALS those who entered before had a median survival of 435 days to 177 days (p = 0.38). Conclusions: The entry of patients with ALS in a nutri- tional protocol increases survival. There is an advantage in the evolution of patients with early nutritional treat- ment.

Effect of nutritional support on survival in patients with amyotrophic lateral sclerosis

Malnutrition affects morbidity and mortality of patients with ALS. The nutrition unit should evaluate these patients early and regularly providing the necessary steps in the evolution of the disease. A retrospective cohort study in which we analyzed 46 patients diagnosed with ALS, 21 of them received nutritional therapy. We studied age, mode of onset, date of entry into a nutritional protocol, placement of PEG and survival. We performed a test of Breslow comparing patients who were at nutritional protocol with those not receiving nutritional support, and those who received early nutritional therapy with those with delayed nutrition. There was an increase in median survival for patients in nutritional therapy in bulbar ALS (452 vs 55 days) and in spinal ALS (1,798 vs 357 days) (p = 0.002). The median delay in the initiation of nutritional therapy in spinal ALS was 557 days while in bulbar ALS was 230 days. The survival in the spinal ALS of those who entered into nutritional protocol before the median survival was 325 days to 181 days (p = 0.09) while in bulbar ALS those who entered before had a median survival of 435 days to 177 days (p = 0.38). The entry of patients with ALS in a nutritional protocol increases survival. There is an advantage in the evolution of patients with early nutritional treatment.

Development of liver dysfunction under artificial nutrition: a reason to modify nutrition therapy in the intensive care unit?

Actual research suggests that artificial nutrition in critically ill patients can be associated with alterations in liver dysfunction biomarkers such as enzymes and serum bilirubin. In addition to known patient-dependent and nutrient-dependent factors, the time of initiation of nutrition therapy seems to influence the risk of altered biomarkers, whereas age and gender, weight, range of clinical scores, type of primary diagnosis, necessity for mechanical ventilation, and the composition of the lipid emulsion used within total parenteral nutrition had no significant effects. This commentary analyzes these new results in the light of known relationships between illness and artificial nutrition therapy.

Maternal Phenylketonuria: A New Cause for Concern

The start of newborn screening for phenylketonuria (PKU) during the early 1970s has given rise to an increasing number of women who have been identified and successfully treated for the disease in childhood and are now preparing to have children of their own. Early detection and initiation of nutritional therapy before conception is key to a successful pregnancy outcome. Nurses who understand the pathophysiology, dietary limitations, and management of PKU in pregnancy can provide the care necessary for optimal maternal and neonatal health.

Improving Timeliness of Nutrition Intervention Through a Collaborative Quality Improvement Program in a Pediatric Intensive Care Unit

The monitoring of the quality of patient care in today's health care environment may be best accomplished through collaborative continuous quality improvement (CQI) programs using the efforts of physicians, nurses, dietitians, and other health care professionals. The CQI Committee of the Pediatric Intensive Care Unit (PICU), a 10‐bed combined medical and surgical unit, developed a collaborative CQI audit to monitor whether critically ill PICU patients should receive nutrition therapy (oral, enteral, or parenteral) in a timely manner. Timely nutrition support was defined as initiation of nutrition therapy within 72 hours of admission for previously well‐nourished patients (category A) or within 48 hours of admission for patients with a history of chronic illness, malnutrition, or trauma (category B). Whether pediatric nutrition support team consultations on category B patients were completed within 72 hours of admission to the PICU also was monitored. An evaluation goal of 80% was set to meet the indicator criteria.

PLASMA INSULIN /IRI/, GLUCAGON /IRPG/ AND GROWTH HORMONE /STH/ IN INFANTS ON TOTAL PARENTERAL NUTRITION /TPN/ AND CONSTANT RATE ENTERAL NUTRITION /CREN/

Plasma glucose, FFA, IRI, IRPG, and STH levels were determined in the equilibrum period in average 20 days after initiation of nutritional therapy. 11 children on TPN and 9 on CREN were studied. Results: 1/The parameters studied remained stable during the investigation 2/ there were no significant differences between the parenteral and enteral introduction of nutritional substrates. Conclusion: These results suggest that the prolonged constant rate administration of the nutrients leads to a new hormonal equilibrium stable and characteristed by 1/The absence of increase in STH levels 2/the adaptation of biohormonal pancreatic secretion which provides a perfect homeostasis of carbohydrate metabolism, an inhibition of lipolysis as evidenced by the low FFA levels and the utilisation of aminoacids for anabolic needs.

Plasma Insulin /IRI/, Glucagon /IRPG/ and Growth Hormone /STH/ in Infants on Total Parenteral Nutrition /TPN/ and Constant Rate Enteral Nutrition /CREN/

Plasma glucose, FFA, IRI, IRPG, and STH levels were determined in the equilibrum period in average 20 days after initiation of nutritional therapy. 11 children on TPN and 9 on CREN were studied. Results: 1/The parameters studied remained stable during the investigation 2/ there were no significant differences between the parenteral and enteral introduction of nutritional substrates. Conclusion: These results suggest that the prolonged constant rate administration of the nutrients leads to a new hormonal equilibrium stable and characteristed by 1/The absence of increase in STH levels 2/the adaptation of biohormonal pancreatic secretion which provides a perfect homeostasis of carbohydrate metabolism, an inhibition of lipolysis as evidenced by the low FFA levels and the utilisation of aminoacids for anabolic needs.