Role of family medicine physicians in providing nutrition support to older patients admitted to orthopedics departments: a grounded theory approach.

BACKGROUND: Care of older adults requires comprehensive management and control of systemic diseases, which can be effectively managed by family physicians. Complicated medical conditions in older patients admitted to orthopedic departments (orthopedic patients) necessitate interprofessional collaboration. Nutrition is one of the essential components of management involved in improving the systemic condition of older patients. Nutrition support teams play an important role in nutrition management and can be supported by family physicians. However, the role of family physicians in nutrition support teams is not well documented. This study aimed to investigate the role of family physicians in supporting nutrition management in orthopedic patients. METHODS: This qualitative study was conducted between January and June 2023 using constructivist grounded theory methodology. Eight family medicine physicians, three orthopedic surgeons, two nurses, two pharmacists, four rehabilitation therapists, four nutritionists, and one laboratory technician working in Japanese rural hospitals participated in the research. Data collection was performed through ethnography and semi-structured interviews. The analysis was performed iteratively during the study. RESULTS: Using a grounded theory approach, four theories were developed regarding family physicians' role in providing nutrition support to orthopedic patients: hierarchical and relational limitation, delay of onset and detection of the need for geriatric care in orthopedic patients, providing effective family medicine in hospitals, and comprehensive management through the nutrition support team. CONCLUSIONS: The inclusion of family physicians in nutrition support teams can help with early detection of the rapid deterioration of orthopedic patients' conditions, and comprehensive management can be provided by nutrition support teams. In rural primary care settings, family physicians play a vital role in providing geriatric care in community hospitals in collaboration with specialists. Family medicine in hospitals should be investigated in other settings for better geriatric care and to drive mutual learning among healthcare professionals.

Successful nutritional support for a dysphagic patient with massive cirrhotic ascites and intrathoracic stomach using percutaneous endoscopic gastrostomy (PEG).

Although massive cirrhotic ascites is generally considered a contraindication for the placement of percutaneous endoscopic gastrostomy (PEG), such patients are usually poorly nourished. Preceding paracentesis of ascites is one method for controlling ascites and allowing the safe placement of PEG, but it often results in overuse of albumin. Preceding peritoneal-venous (P-V) shunting can avoid excessive use of albumin, but this introduces the risk of infectious contamination. We encountered an 88-y-old woman with massive cirrhotic ascites, a giant esophageal hernia with dislocation of the proximal stomach into the mediastinum, hypertrophy of the lateral segment of the liver, and malnutrition who had suffered from appetite loss and a swallowing disorder for 4 mo. She underwent PEG using a staged sequential introduction method using a Funada-style gastric wall fixation kit as follows: 1) full stretching and pushing out of the stomach from the mediastinum into the peritoneal cavity by deep insertion and a turning-over procedure of the endoscope, 2) full distention by air to adhere the gastric wall to the peritoneal wall without migration of the colon, 3) four-point square fixation under gastroenterological endoscopy without migration of the visceral organ, and 4) puncture of the needle introducer of the PEG tube in the center of the fixations under repeated gastroenterological endoscopy 3 d after the fixation. She underwent P-V shunting under local anesthesia on the 28th day after placement of PEG and enteral nutrition. Her case shows that we can achieve proper enteral nutritional support even for patients with massive cirrhotic ascites.