Trial Of Nutritional Support Research Articles

Health economic value of postacute oral nutritional supplementation in older adult medical patients at risk for malnutrition: a US-based modelling approach

ObjectiveTo estimate the health economic value of postdischarge oral nutrition supplement (ONS) consumption among elderly adults who were malnourished during hospitalisation.DesignA cost-effectiveness model was developed from a US payer perspective based on a recent meta-analysis of randomised trials of nutritional support following hospital discharge and studies of US hospital mortality, readmission rates and costs.Participants and settingThe target population of this study was postacute care US patients aged ≥65 years who were identified as malnourished during hospitalisation.Intervention and outcome measuresA decision-tree model was used to evaluate the impact of postacute care daily consumption of ONS compared with no ONS. Outcomes were evaluated over a 1-year time interval. Clinical outcomes of interest included readmission and mortality rates. Economic value of ONS was quantified using three different metrics: cost per death averted, cost per readmission avoided and direct cost savings resulting from changes in postacute mortality and readmission rates. The economic value of ONS was also measured by gains in quality-adjusted life-years.ResultsCompared with patients not receiving ONS after hospital discharge, use of ONS during the postacute phase reduced mortality by 36.3% and readmissions by 11.0%. Reductions in readmissions resulted in annual savings of US$1113 per person. When extrapolating the results to the estimated 1 693 034 hospitalised elderly US adults at risk of malnutrition, the use of ONS after hospital discharge would prevent 67 747 deaths and 116 570 hospital readmissions per year. With the estimated cost of nutritional support at US$175 per patient per month corresponding to two servings ONS per day, the ONS cost per death and readmission avoided was estimated at US$4380 and US$2546, respectively.ConclusionsPostdischarge use of ONS among patients at risk for malnutrition is highly cost-effective with important reductions in mortality and readmission rates.

Nutritional Support with Omega-3 Fatty Acids in Burn Patients: A Systematic Review with Meta-Analysis of Randomized Controlled Trials

Background: In burn patients, the profound effect of nutritional support on improved wound healing and a reduced rate of hospitalization and mortality has been documented. Fish oil as a primary source of omega-3 fatty acids in nutritional support may attenuate the inflammatory response and enhance immune function; however, unclear effects on the improvement of clinical outcomes in burn patients remain. Methods: The systematic literature review was conducted by searching the electronic databases: Cochrane Library, PubMed, ScienceDirect, and Scopus to assess the randomized controlled trials of nutritional support with omega-3 fatty acids compared to control diets in patients that presented with burns from any causes. Results: Seven trials were included in this meta-analysis. We found no significant differences in length of stay (LOS) (p = 0.59), mortality (p = 0.86), ventilation days (p = 0.16), gastrointestinal complications—e.g., constipation and diarrhea (p = 0.73)—or infectious complications—e.g., pneumonia and sepsis (p = 0.22)—between the omega-3-fatty-acid-receiving group and the control/other diets group. Conclusions: We did not find a benefit of omega-3 support in reducing the various complications, mortality and LOS in burn patients. Further studies are necessary to find the effect of nutritional support with omega-3 fatty acids over low-fat diets in this population.

Chapter 16. Glucose and nutrition

Chapter 16. Glucose and nutrition

Evidence-based nutrition support in the intensive care unit: an update on reported trial quality

Meta-epidemiological reviews report that trials of nutritional support in critical illness rarely fulfil basic quality requirements, with overall quality rated as 'worse than poor'. This update reviews recently published trials to determine whether current evidence meets or exceeds basic quality requirements. Although recent trials were significantly more likely to report blinding, there is a concerning trend towards a decrease in overall trial quality. Many recent trials fail to report the use of 'any' of three key validity criteria: use of blinding, presentation of intention-to-treat analysis and the maintenance allocation concealment. Future researchers must improve the quality with which trials are conducted and reported. Submitting a clinical trial to an approved registry prior to enrolling patients provides transparency of conduct. Investigators must ensure that an intention-to-treat analysis is reported, especially when a subset efficacy analysis is presented, even if the intention-to-treat analysis requires imputing missing data values. Investigators also need to improve reporting details concerning allocation concealment and blinding. Finally, until investigators, editors and reviewers embrace these measures, we strongly recommend that readers should become familiar with the appropriate evidence-based medicine users' guides so that they can base clinical decisions on valid studies.

Possible mechanisms underlying the development of cachexia in COPD

About 25% of patients with chronic obstructive pulmonary disease (COPD) will develop cachexia (fat-free body mass index <17 kg.m(-2) (males) or <14 kg.m(-2) (females)). This is associated with approximately 50% reduction in median survival. The pathogenetic mechanism has been variously suggested to result from the following: 1) energy imbalance; 2) disuse atrophy; 3) tissue hypoxia from arterial hypoxaemia; 4) systemic inflammation; and 5) anabolic hormonal insufficiency. Genetic polymorphisms implicate inflammatory cytokines, especially interleukin (IL)-1beta, but IL-6 and tumour necrosis factor (TNF)-alpha do not show polymorphisms in these patients. Early reports of elevated TNF-alpha levels suggested a role for inflammation, but recent studies have not shown elevated levels of either IL-6 or TNF-alpha. Therapeutic trials of nutritional support, hormonal supplementation, anti-TNF-alpha immunotherapy, ghrelin and antioxidants have been conducted, but only a few have shown any benefits in muscle structure and function. Considerably more mechanistic knowledge is needed before therapeutic recommendations can be made. At this time, it is not possible to attribute cachexia in COPD unequivocally to inflammation or any other cause, and much more research is needed. To date, studies have been predominantly cross-sectional, with measurements made only after cachexia has developed. Future research should target prospective observation, studying patients as cachexia progresses, since once cachexia is established, inflammatory cytokine levels may not be abnormal.

Dietetic assistants improved postoperative clinical outcomes in older women with hip fracture

Source Citation Duncan DG, Beck SJ, Hood K, Johansen A. Using dietetic assistants to improve the outcome of hip fracture: a randomised controlled trial of nutritional support in an acute trauma war...

Using dietetic assistants to improve the outcome of hip fracture: a randomised controlled trial of nutritional support in an acute trauma ward

To examine how improved attention to nutritional status and dietary intake, achieved through the employment of dietetic assistants (DAs), will affect postoperative clinical outcome among elderly women with hip fracture. Open prospective randomised controlled trial, comparing conventional nursing care with the additional nutritional support provided by DA. Thirty-eight bedded acute trauma ward in a teaching hospital. All but 11 of 344 consecutive admissions with acute nonpathological hip fracture were approached. Three hundred and eighteen (93%) agreed to inclusion. Sixteen were ineligible as they were immediately transferred to another acute ward, were managed conservatively or died preoperatively. Postoperative mortality in the acute trauma unit. Postoperative mortality at 4 months after fracture, length of stay, energy intake and nutritional status. DA-supported participants were less likely to die in the acute ward (4.1 versus 10.1%, P = 0.048). This effect was still apparent at 4 month follow-up (13.1 versus 22.9%, P = 0.036). DA-supported subjects had significantly better mean daily energy intake (1,105 kcal versus 756 kcal/24 h, 95% CI 259-440 kcal/24 h, P<0.001), significantly smaller reduction in mid-arm circumference during their inpatient stay (0.39 cm, P = 0.002) and nonsignificantly favourable results for other anthropometric and laboratory measurements. Dietetic or nutrition assistants are being introduced in units across the UK. This, the largest ever study of nutritional support after hip fracture, shows that their employment significantly reduced patients' risk of dying in the acute trauma unit; an effect that persisted at 4 month follow-up.

Nutritional support and aging in preoperative nutrition.

In the past 20 years, an increased interest geriatric nutrition has induced researchers to document the distribution and magnitude of nutritional problems in the elderly population. It has been observed that the prevalence of malnutrition is greatly affected by the general health status and autonomy of the elderly. Among free-living healthy elderly persons, the prevalence of protein-caloric undernutrition is low. As health and functional capacities deteriorate with age, however, the prevalence increases dramatically to 30-65% of those in home care, nursing homes or in hospital. Formal nutritional assessment has typically been absent from most published programmes of geriatric evaluation and comprehensive geriatric assessment. This is frequently because of the lack of a specific validated tool to assess nutritional status in older persons and, at least partly, to explain this phenomenon. The Mini Nutritional Assessment was developed and validated on large representative samples of elderly persons to address these specific issues. Recent experimental studies have shown that advanced malnutrition is much more difficult to treat in the elderly than in younger adults. Trials of nutritional support using oral supplements or enteral tube feeding have shown improved outcome in those identified as malnourished on admission to hospital.

Clinical Trials of Nutritional Support in Cancer: Parenteral and Enteral Therapy

Cancer-related malnutrition is associated with poor prognosis. Although logic would dictate that nutritional support should improve malnutrition and thus outcome, when tested by controlled clinical trials, this has not borne out. With the exception of bone marrow transplantation, routine specialized nutritional support, particularly parenteral nutrition, has not demonstrated consistent therapeutic benefit with respect to any outcome measure and may be associated with harm to patients. The clinician must carefully select appropriate indications for specialized nutritional support in cancer patients.