Use Of Clinical Nutrition Research Articles

Protocol for a prospective cohort study on the use of clinical nutrition and assessment of long-term clinical and functional outcomes in critically ill adult patients

Limited data are available on the impact of clinical nutrition over the course of critical illness and post-discharge outcomes. The present study aims to characterize the use of nutrition support in patients admitted to European intensive care units (ICUs), and its impact on clinical outcomes. Here we present the procedures of data collection and evaluation. Around 100 medical, surgical, or trauma ICUs in 11 countries (Austria, Belgium, Czech Republic, Germany, France, Hungary, Italy, Poland, Spain, Sweden, United Kingdom) participate in the study. In defined months between November 2019 and April 2020, approximately 1250 patients are enrolled if staying in ICU for at least five consecutive days. Data from ICU day 1-4 are collected retrospectively, followed by a prospective observation period from day 5-90 after ICU admission. Data collection includes patient characteristics, nutrition parameters, complications, ICU and hospital length of stay, discharge status, and functional outcomes. For data analysis, the target is 1000 patients with complete data. Statistical analyses will be descriptive, with multivariate analyses adjusted for potential confounders to explore associations between nutritional balance and change in functional status, time-to-weaning from invasive mechanical ventilation, time to first clinical complication, and overall 15, 30 and 90-day survival. This non-interventional study was reviewed and approved by the ethics committee of the Medical University Vienna, Vienna, Austria (approval number 1678/2019), and the respective ethical committees from participating sites at country and/or local level, as required. Results will be shared with investigators on a country level, and a publication and results presentation at the 2021 ESPEN Congress is planned. ClinicalTrials.gov identifier NCT04143503.

Factors limiting nutritional support for patients in chronic critical illness

Patients in chronic critical illness after brain injury may experience various conditions that limit nutritional support. The aim of this work is to analyze the factors limiting or hindering the provision of nutritional support (in particular, enteral clinical nutrition) in patients in chronic critical illness after brain damage. Material and methods. This study is a prospective observational cohort study. In the course of the study, 47 patients (27 men and 20 women, mean age 52±18.4 years) in a chronic critical illness who were undergoing rehabilitation after brain damage and who had certain limitations in the provision of nutritional support were evaluated. The duration of the patients' stay in the intensive care unit was from 21 to 30 days. During hospitalization, adverse events and conditions were recorded in these patients, limiting the conduct of enteral clinical nutrition. Results. Among the undesirable phenomena and conditions limiting enteral nutrition, diarrheal syndrome most often developed - in 41.7% of patients (associated with the use of antibiotics in 25.0% of the examined). The second group in terms of frequency - the development of surgical pathology (of various etiology) - in 31.7% of patients, which attracted special attention, taking into account the neurological and/or neurosurgical nature of the underlying disease. At the same time, the appearance of a high residual volume of the stomach against the background of an increase in hydrocephalus developed only in 5.0% of cases. More attention should be paid to patients who are in the most severe physical condition, since they have a high probability of the occurrence of several factors at once that limit the use of clinical nutrition - this category of the studied sample included 19.1% of patients. Conclusion. Strict adherence to the technology of enteral nutrition can increase the efficiency of enteral nutrition in patients in chronic critical condition.

The Advantages of Clinical Nutrition Use in Oncologic Patients in Italy: Real World Insights.

This retrospective observational study aimed to provide insights on the use of clinical nutrition (CN) (enteral and parenteral feeding) and outcomes in an Italian real-world setting. The data source comes from administrative databases of 10 Italian Local Health Units. Patients diagnosed with malignant neoplasms from 1 January 2010 to 31 December 2015 were included. Metastasis presence was ascertained by discharge diagnosis in the hospitalization database. CN was identified by specific codes from pharmaceutical and hospitalization databases. Two cohorts were created—one for metastatic patients (N = 53,042), and one for non-metastatic patients (N = 4379) receiving CN. Two survival analyses were set for the cohort of metastatic patients—one included patients receiving CN and the second included malnourished patients. Our findings show that (1) administration of CN is associated with positive survival outcomes in metastatic patients with gastrointestinal, respiratory, and genitourinary cancer; (2) CN in malnourished metastatic patients with gastrointestinal and genitourinary cancer was associated with significant improvement in survival; (3) early administration of CN was associated with improvement in survival in non-metastatic patients with gastrointestinal cancer (HR 95%CI: 0.5 (0.4–0.6), p-value < 0.05). This study highlights the need to improve the assessment of nutritional status in oncologic patients and suggests a potential survival benefit of CN treatment in metastatic disease.

Unmet needs in clinical nutrition in oncology: a multinational analysis of real-world evidence.

Background:Knowledge about cancer-related malnutrition and the use of clinical nutrition (CN) in the real-world setting are lacking. We investigated diagnosis and treatment frequency of malnutrition in a multinational survey to identify unmet needs in cancer patients’ care.Methods:Retrospective analyses were conducted on data from three administrative healthcare datasets from France (n = 570,727), Germany (n = 4642) and Italy (n = 58,468). Data from France described frequency and timing of malnutrition diagnosis in hospitalized gastrointestinal cancer patients. The German data detailed home parenteral nutrition (HPN) use in cancer patients with stage III/IV cancers. The Italian data analysed three cohorts: metastatic with CN, metastatic without CN, and patients without metastatic disease.Results:In France, malnutrition diagnosis at first hospitalization occurred in 10% of patients, 13% were subsequently diagnosed, and 77% had no malnutrition diagnosis. In Germany, 16% of patients received HPN. Patients started HPN around 3 months before death. In Italy, 8.4% of metastatic cancer patients received CN; average time between metastasis diagnosis and first CN prescription was 6.6 months. Average time between first CN prescription and death was 3.5 months.Conclusions:These data indicate that in the real-world clinical practice, cancer-related malnutrition is under-recognized and undertreated. CN often appears to be prescribed as an end-of-life intervention or is not prescribed at all.Appropriate CN use remains challenging, and current practice may not allow optimal oncologic outcomes for patients at nutritional risk. Improving awareness of malnutrition and generating further evidence on clinical and economic benefits of CN are critical priorities in oncology.

1730P - Current use of clinical nutrition in oncology patients: Real world evidence from big data in Italy

1730P - Current use of clinical nutrition in oncology patients: Real world evidence from big data in Italy

Synthesis and Characterization of Mixed Short Chain Fatty Acid Triacylglycerols as a Potential Dietary Food Lipid Source

SCFA(Short Chain Fatty Acids) are readily absorbed in the gastrointestinal tract and play an important role in the maintenance of gut health. The deficiency of SCFA (particularly acetic, propionic and butyric) may affect the pathogenesis of a diverse range of diseases ranging from allergies to asthma to cancers. The potential of having three different SCFA on one molecule for direct ingestion and metabolism can be of significant importance to maintaining gut health. SCFA triglycerides have not been characterized for use in clinical nutrition therefore it is important to understand their specific structure and composition. We synthesized ten reaction products of various triacylglycerols containing different ratios of acetic, propionic and butyric SCFA by interesterification. The reaction products were characterized by Gas Chromatography (GC), GC/MS and H1 NMR. The weight % of the triesters found were compared to the amount predicted using the statistical randomized interesterification reaction model. We found that the difference in fatty acid size and the reduced steric demands of the SCFA did not give rise to positional specificity and found no observable deviations from the random interesterification model. By interesterification we have synthesized a molecule that contains SCFA essential to gut health. This molecule could potentially be used for direct ingestion possibly eliminating the need for other means of daily fiber intake.

Endotoxin neutralization activity (ENA) of bovine plasma and bovine Immunoglobulin (IgG)‐rich fractions as compared to human plasma

Translocation of endotoxin and other bacterial components from the gut is an important source of inflammation. A novel source of proteins with potential ENA is edible serum bovine immunoglobulin (SBI). SBI is &gt;;50% IgG and has GRAS (generally recognized as safe) status, permitting its use in clinical nutrition. This study compared the ENA of 4 test materials: human plasma (n=4); bovine plasma (n=4); purified human IgG (n=2); and SBI (n=7). Endotoxin B55:05 at 400 EU/ml was added to serial dilutions of the test materials and incubated. Post incubation samples and controls were assayed for LPS recovery. Response curves were generated and endotoxin neutralization capacities (ENC50) were calculated for each test material. A simple t‐test compared test materials ENA and ENC50. The expected curvilinear response for ENA of human plasma, bovine plasma and SBI samples was observed. Human IgG did not effectively neutralize endotoxin in this assay. The ENA of bovine plasma and SBI was not significantly different from human plasma (P&lt; 0.10). Calculated ENC50 (mg) of human plasma, bovine plasma and SBI was similar at 0.107±0.035, 0.089±0.053, and 0.129±0.044, respectively. The LAL assay can be used to assess ENA and ENC of both human and bovine plasma. SBI is a potential source of ENA with a similar level of ENC50 to human plasma. The use of SBI in clinical nutrition to preserve ENC merits research. This study was funded by Entera Health.

Análisis de la relevancia y factibilidad de indicadores de calidad en las unidades de nutrición

Introduction: The quality assessment in health activities requires the choice of indicators in line with the results we want to measure. Of all possible, we should prioritize those that allow us to obtain the most relevant information without overloading the regular work of our units. Objective: To determine the opinion of the members of SENPE regarding the relevance and feasibility of using a selection of quality indicators designed for use in clinical nutrition. Methods: E-mail survey sent to members of SENPE asking them their views on 12 quality indicators, evaluating each in terms of their relevance and feasibility of implementation in their environment. Results: 40 respondents answered from 40 centers in 12 different regions. In general, the indicators were considered more relevant than feasible. The indicators best rated were: “identification in artificial nutrition bags, “semi-recumbent position in patient with nasogastric tube feeding” and “basic clinical protocols”. Considering the type of indicator: “patient identification in the bags of artificial nutrition (structure),” a semi-incorporated “and” basic clinical protocols (process), and “fulfillment of the caloric goal” (result). Conclusion: The results of the survey can make a selection of indicators that could be considered for first-line

Professional Outcomes of Completing a Clinical Nutrition Fellowship

Cleveland Clinic has trained 17 physician nutrition specialists since the establishment of its clinical nutrition fellowship (CNF) in 1994. The paths taken by the graduates and whether they continue to practice clinical nutrition are largely unknown. To investigate the professional outcomes of completing a CNF, a survey of graduates was conducted. Fifty-seven percent of respondents (n = 8) applied to another fellowship prior to applying to a CNF. The 2 most common reasons for applying to a CNF were to increase knowledge of clinical nutrition and increase the chance of acquiring a gastroenterology fellowship. Eighty-five percent (n = 10) of graduates found the CNF to be valuable. Eighty-six percent (n = 12) went on to complete a gastroenterology fellowship, and 67% (n = 8) of graduates believed that completing a CNF increased their chances of gaining acceptance to a gastroenterology fellowship. Only 42% (n = 6) of the graduates currently hold professions that specifically dictate the use of clinical nutrition, but 61% (n = 8) reported using clinical nutrition in their daily or weekly practice. Fifty percent (n = 7) of graduates believed that completing a CNF made them more competitive job candidates, but only 21% (n = 3) said that their extra training is reflected in their current salary. It appears that CNFs are being used as a method of subsequently acquiring a gastroenterology or other medical fellowships. Although not working in defined clinical nutrition professions, >50% of graduates continue to apply their CNF skills after completing their training. A small percentage have found dedicated nutrition-based clinical professions.

Professional Outcomes of Completing a Clinical Nutrition Fellowship: Cleveland Clinicʼs 16-Year Experience

Purpose: Clinical Nutrition Fellowships (CNF) were established in the early 1990s with the intent increasing the number of physician nutrition specialists (PNS). Cleveland Clinic has trained 15 PNS since the start of its CNF in 1994. The paths taken by our graduates and whether they continue to practice clinical nutrition are largely unknown. Methods: A survey of our graduates was conducted to investigate the professional outcomes of completing a CNF. This was a descriptive, cohort, IRB approved study. Results: 15 electronic surveys were sent and 12 were returned for an 80% response rate. Our results show that 50% (6) of graduates applied to another fellowship prior to applying to a CNF. The two most common reasons for applying to a CNF were to increase their knowledge of clinical nutrition and to increase chances of acquiring a GI fellowship. 81% (9) of graduates found our CNF to be valuable. 92% (11) went on to complete a gastroenterology fellowship. 70% (7) of graduates believed that completing a CNF increased their chances of getting acceptance to a gastroenterology fellowship. Only 33% (4) of our graduates currently hold professions that specifically dictate the use of clinical nutrition, however, 33% (4) and 25% (3) reported the use of clinical nutrition in their daily and weekly practice, respectively. 50% (6) of graduates believed that completing a CNF made them more competitive job candidates but only 17% (2) said that their extra training is reflected on their current salary. 80% (8) of CNF graduates said that clinical nutrition training needs to be improved in GI fellowships. Conclusion: It appears that CNF are being used as a method of subsequently acquiring gastroenterology or other medical fellowships. Over 50% of graduates continue to apply their CNF skills after completing their training although not in defined clinical nutrition professions.Figure

Doctors and nurses on wards with greater access to clinical dietitians have better focus on clinical nutrition

According to the Council of Europe, clinical dietitians should assume a more central role in nutritional support. The aim of this study was to assess the opinions among doctors, nurses and clinical dietitians regarding the use of clinical dietitians' expertise in the hospital units and, further, to assess whether the presence of clinical dietitians in hospital departments influenced doctors and nurses focus on clinical nutrition. A questionnaire about the use of clinical nutrition was mailed to 6000 doctors and 6000 nurses working in hospital units where undernutrition is documented to be common, as well as to 678 clinical dietitians working in Scandinavian hospitals. The response rate of clinical dietitians, nurses and doctors were 53%, 46% and 29%, respectively. Nurses and doctors who saw clinical dietitians often found it less difficult to identify undernourished patients and found that insight into the importance of adequate nutrition was better than those who saw clinical dietitians seldom. Clinical nutrition had a higher priority in units with frequent visits by clinical dietitians. The present study shows that doctors and nurses on wards with greater access to clinical dietitians had better focus on clinical nutrition.

Clinical nutrition in Danish hospitals: a questionnaire-basednutrition among doctors and nurses

Specific nutrition standards are now developed by the Joint Commission on Accreditation ofHealthcare Organizations (JCAHO) in order to improve the nutritional status in hospitalized patients. We investigated the use of clinical nutrition in Danish hospitals and compared itwith the standards of JCAHO by doing a questionnaire-based investigation among doctors and nurses randomly selected in 40 hospitals including internal medicine, gastroenterology, oncology, orthopedic departments and intensive care units (ICU). Overall, 857 (43.4%) responded to the questionnaire (doctors: 395, nurses: 462). Seventy-seven percent stated that nutritional assessment ought to be performed on admission, but only 24% stated that it was a routine procedure. Forty percent found it difficult to identify risk-patients, and 52% needed specific screening tools. Twenty-two percent registered body weight in all patients, end 18% registered nutrient intake routinely. Eighty-four percent found that a nutrition plan should be described in the patient record, but 39% found it difficult to set up on individual plan, and 79% expressed a need for specific guidelines. Eighty-four percent would only accept a patient being on isotonic glucose and/or electrolyte infusion for < 5 days (42% for < 2 days), and 33% would only accept a weight loss of 5% before active nutrition was initiated. About 50% Would be restrictive in supplying enteral or parenteral nutrition to patients with impaired liver or kidney function. Twenty-seven percent did not use active nutritional therapy at all. Seventy-six percent found that nutritional assessment should be performed during hospital stays, but only 23% monitored the nutritional status. Sixty-eight percent stated that responsibility should be assigned to one or more persons, but this was the case in only 20%. The use of clinical nutrition in Danish hospitals did not fulfill the standards for nutrition supportaccording to the criteria established by JCAHO. Special efforts should be aimed at education, specific screening tools and introduction of guidelines in clinical nutrition.

Production and Characterization of Enzymatic Hydrolysate from Soy Protein Isolate

Soy protein isolate was enzymatically hydrolysed, for its potential use in clinical nutrition, using pancreatin as the hydrolytic agent. The hydrolysate, after separation of the insoluble fraction, showed differences in its amino acid composition with respect to soy protein isolate. There was a decrease in the content of the essential amino acids, Val, Leu and Phe, and an increase in Lys and Trp. The average peptide size was evaluated using gel exclusion chromatography on Sephadex G-25, total and free amino acid analysis, and NH2-group determination. The peptide size distribution of the hydrolysate was 0.24 peptides with 18 residues, 0.27 with 12 residues, 0.38 peptides with 2–5 residues and 0.12 free amino acid. This size distribution was similar to that of casein and soy protein hydrolysates which have been used successfully in clinical nutrition.

Intestinal absorption and lymphatic transport of eicosapentaenoic (EPA), docosahexaenoic (DHA), and decanoic acids: dependence on intramolecular triacylglycerol structure

We compared the absorption of eicosapentaenoic (EPA, 20:5n-3), docosahexaenoic (DHA, 22:6n-3), and decanoic acids in mesenteric lymph duct-cannulated rats following intragastric administration of two oils with different intramolecular triacylglycerol structures. One oil had a specific triacylglycerol structure with EPA and DHA located in the sn-2 position and decanoic acid in the sn-1 and sn-3 positions (specific M-n3-M) whereas the other oil had a random fatty acid distribution (random M-n3-M). The mol% (mol/100 mol total fatty acids) of fatty acids in the two oils was similar, with approximately 66 mol% of decanoic acid and 22 mol% of EPA and DHA. The lymphatic transport (microgram/min) of EPA and DHA as well as the mol% in the total lymph lipids were significantly (both P < 0.01) increased following intragastric administration of specific M-n3-M compared with random M-n3-M. The mol% of decanoic acid in the total lymph lipids was significantly (P < 0.01) higher after random M-n3-M compared with specific M-n3-M but the transport (microgram/min) of decanoic acid was not significantly different. We conclude that under our experimental conditions specific M-n3-M with EPA and DHA predominantly in the sn-2 position of the triacylglycerols was a more readily absorbed source of EPA and DHA and in this context should be investigated further for the potential use in clinical nutrition.

A national survey of attitudes and practices of primary-care physicians relating to nutrition: strategies for enhancing the use of clinical nutrition in medical practice

A nationwide mail survey was used to determine the degree to which primary-care physicians indicated that they practice the "core competencies" in clinical nutrition identified by Young et al (Am J Clin Nutr 1983;38:800-10). We also surveyed the nutrition-related attitudes of these physicians. Although the 3416 physicians who responded to the survey tended to report favorable attitudes toward using nutrition in their practice, these favorable attitudes were not consistent with their own reports of clinical performance. Neither the positive- or negative-attitude score correlated highly with the reported behavior-practice score. The clinical practices reported by those surveyed are well below the minimum level defined by the Young et al essential core competencies in clinical nutrition. The attitudes, practices, and demographic characteristics associated with the clinical performance variables suggest educational strategies for improving the competence of primary-care physicians and medical students in clinical nutrition.

Assessment of an automated chemiluminescence nitrogen analyzer for routine use in clinical nutrition.

An automated method of chemiluminescence analysis of nitrogen used routinely for 4 yr. Liquid samples (urine, enteral, and parenteral feeds) required simple dilution, whereas feces required a modified acid-digestion procedure, before analysis. For urine samples, the coefficient of variation was within batch from 0.9-3.6%, and between batch 4.3-7.6%. At a sample injection rate of 2 microliter/sec, the useful dynamic range, for urine diluted 1:200, was 0-14 g N/liter. Precision for fecal nitrogen analysis was 3.8-6.7% for samples of low to high nitrogen content. The correlation between this technique and an established Kjeldahl method for fecal analysis was studied (r = 0.96, slope = 1.30). The discrepancy between the methods was due to inefficient conversion of nitrogen to NH4+ during Kjeldahl digestion of feces, rather than systematic errors in chemiluminescence analysis. Reliability was as good as for other automated clinical analyzers and sample cost was ca. 0.22 pounds. It has proved possible to analyze approximately 80 samples in the working day. The efficiency of measuring 24-hr urine urea-nitrogen (UUN) and total urine nitrogen (TUN) in patients on general wards was measured. Results were obtained on 87% of TPN days, but large variations were noted in UUN/TUN from less than 30% to greater than 90% (average 75.7%) in patients receiving TPN, and from less than 55% to 100% (average 83.8%) in patients receiving enteral nutrition. In contrast, UUN/TUN was 87.0% and 84.0% in healthy subjects, fasted or receiving iv nutrition, respectively. We therefore expect that clinical nutritionists will find increasing applications for this method of nitrogen analysis.