Treatment Challenges and Controversies in the Management of Critically Ill Diabetic Ketoacidosis (DKA) Patients in Intensive Care Units.

This review discusses the challenges and controversies in the treatment of diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). Key areas include the selection of intravenous (IV) fluids, insulin therapy, strategies for preventing and monitoring cerebral edema (CE) by managing hyperglycemia overcorrection, electrolyte replacement, timing of nutrition, use of IV sodium bicarbonate, and airway management in critically ill DKA patients. Isotonic normal saline remains the standard for initial fluid resuscitation, though balanced solutions have been shown to have faster DKA resolution. Current guidelines recommend using continuous IV insulin for DKA management after fluid status has been restored potassium levels have been achieved and subcutaneous (SQ) insulin is started only after the resolution of metabolic acidosis. In comparison, the British guidelines recommend using SQ insulin glargine along with continuous regular IV insulin, which has shown faster DKA resolution and shorter hospital stays compared to continuous IV insulin alone. Although rare, rapid overcorrection of hyperglycemia with fluids and insulin can lead to CE, seizures, and death. Clinicians should be aware of risk factors and preventive strategies for CE. DKA frequently involves multiple electrolyte abnormalities, such as hypokalemia, hypophosphatemia, and hypomagnesemia and regular monitoring is essential for DKA management. Early initiation of oral nutrition has been shown to reduce intensive care unit and overall hospital length of stay. For impending respiratory failure, Bilevel positive airway pressure is not recommended due to aspiration risks. Instead, intubation and mechanical ventilation, with monitoring and management of acid-base and fluid status, are recommended. The use of sodium bicarbonate is discouraged due to the potential for worsening ketosis, hypokalemia, and risk of CE. However, IV sodium bicarbonate can be considered if the serum pH falls below 6.9, or when serum pH is less than 7.2 and/or serum bicarbonate levels are below 10 mEq/L, pre-and post-intubation, to prevent metabolic acidosis and hemodynamic collapse that occurs from apnea during intubation. Managing DKA and HHS in critically ill patients includes using balanced IV fluid solutions to restore volume status, followed by continuous IV insulin, early use of SQ glargine insulin, electrolyte replacement, and monitoring, CE preventive strategies by avoiding hyperglycemia overcorrection, early nutritional support, and appropriate airway management.

Iodine Deficiency as a Risk Factor for Postpartum Depressive Disorder in Women.

Nutritional support is considered as one of the components of disease-modifying therapy for postpartum depressive disorder. Such nutrients include iodine, which is an important trace element in the development and functioning of the central nervous system. The brief review presents updated knowledge about the relationship of iodine deficiency with the development and severity of postpartum depressive disorders in women, based on the analysis and generalization of the results of domestic and international studies.

Advancements in nutritional diagnosis and support strategies during the perioperative period for patients with liver cancer.

Liver cancer represents a grave hepatic condition and constitutes a significant global health concern. Surgical resection remains the principal therapeutic modality for liver cancer. Nevertheless, perioperative malnutrition exerts a notable impact on patients with liver cancer, emerging as an independent risk factor for disease mortality and adverse outcomes. Hence, precise nutritional diagnosis and timely nutritional support hold the potential to enhance therapeutic efficacy and quality of life for liver cancer patients. This study represents a meticulous foray into the literature, extracting data from PubMed, Web of Science, and EMBASE databases, with a focus on the past 5 years. It scrutinizes the impact of malnutrition on patients undergoing liver cancer surgery, the etiological underpinnings of malnutrition within this patient cohort, the critical assessment of perioperative nutritional status, and the strategic approaches to nutritional support. Utilizing rigorous inclusion and exclusion criteria, the amassed scholarly works are meticulously synthesized, methodically organized, and categorically elaborated upon. Ultimately, the authors propose the incorporation of a multidisciplinary nutrition management team during the perioperative period, comprising nutritionists, pharmacists, physicians, nurses, psychologists, and rehabilitation therapists, among other specialized professionals. Together, they collaborate to devise and implement personalized nutritional support plans, monitor patients' nutritional status, and make necessary adjustments as required. Through comprehensive management and intervention, improvements in the nutritional status of liver cancer patients can be achieved, thereby enhancing surgical success rates and facilitating postoperative recovery. It is believed that this manuscript will offer valuable insights to advance the nutritional management during the perioperative phase of liver cancer, aiding in ameliorating patients' nutritional status and treatment outcomes.

Associations of serum 25-hydroxyvitamin D with hsCRP and other novel inflammatory biomarkers in children: a cross-sectional study.

OBJECTIVE: Previous studies have shown the anti-inflammatory effect of 25-hydroxyvitamin D (25(OH)D) and the crucial roles of high-sensitive C reactive protein (hsCRP) and novel inflammatory markers (red blood cell distribution width-platelet count ratio (RDWPCR), mean platelet volume-platelet count ratio (MPVPCR), neutrophil-lymphocyte ratio (NLR) and white blood cell-neutrophil ratios (WBCNR)) in several diseases, but scarce data explored the associations of 25(OH)D with hsCRP and novel inflammatory markers. This study aimed to investigate these associations in children. DESIGN: Cross-sectional study. SETTING: Children in China. PARTICIPANTS: 10141 children (mean age 14.6 months) were included. PRIMARY AND SECONDARY OUTCOME MEASURES: HsCRP, red blood cell distribution width, platelet count, mean platelet volume, neutrophil, lymphocyte and white blood cell were measured. RESULTS: Overall, serum 25(OH)D was inversely associated with hsCRP and novel inflammatory biomarkers. In multivariable analysis, serum 25(OH)D was inversely associated with hsCRP and novel inflammatory biomarkers (Q quartile (Q) 4 vs Q1: 1129.75 vs 2090.99 for hsCRP; 4246.94 vs 6829.89 for RDWPCR; 4863.57 vs 5545.66 for MPVPCR; 4345.76 vs 6507.46 for NLR; 2418.84 vs 2868.39 for WBCNR). Similar results also were observed in stratified analyses by sex (boys and girls). Moreover, serum 25(OH)D was inversely associated with elevated inflammation levels. After adjustment for other potential covariates, inverse associations between serum 25(OH)D and elevated inflammation levels were still observed. The corresponding ORs (95% CI) were 0.05 (0.04, 0.06) for hsCRP, 0.13 (0.11, 0.15) for RDWPCR, 0.74 (0.64, 0.85) for MPVPCR, 0.11 (0.09, 0.13) for NLR and 0.57 (0.49, 0.66) for WBCNR in the fourth quartile compared with the first quartile, respectively. CONCLUSIONS: Generally, the graded and inverse associations of serum 25(OH)D with hsCRP and four novel inflammatory markers (RDWPCR, MPVPCR, NLR and WBCNR) were observed. The present study provided further support for the anti-inflammatory effects of 25(OH)D.

The effect of preoperative supplementary parenteral nutrition on nutrition and inflammation in gastric cancer patients.

OBJECTIVES: Supplemental parenteral nutrition (SPN) is recommended to add when enteral nutrition alone is not sufficient. This research aims to evaluate the effect of preoperative SPN in patients with gastric cancer. METHODS: A total of 180 patients with gastric cancer were divided into three groups (60 patients per group) according to different nutritional support scheme. The primary endpoint was the changes in nutrition and inflammatory, while the secondary endpoint included the changes in prognosis. RESULTS: Compared with the control group, there were significant differences in nutrition and inflammation related indicators in the oral nutrition supplement (ONS) group and the SPN + ONS group (P < 0.05). Compared with the ONS group, the SPN + ONS group showed significant differences in the above indicators (P < 0.05). However, no significant changes were observed in the incidence of complications, the postoperative exhaust time, and the hospitalization time. CONCLUSIONS: Preoperative SPN had a positive effect on nutrition and inflammation of gastric cancer patients undergoing surgery, but had no significant effect on their prognosis.

Effectiveness of nutritional support for clinical outcomes in gastric cancer patients: A meta-analysis of randomized controlled trials.

Background: Gastric cancer (GC) is a leading cause of cancer-related morbidity and mortality globally. This meta-analysis was conducted to assess the impact of nutritional interventions on clinical outcomes in GC patients. Methods: Comprehensive search was conducted across four medical databases to identify randomized controlled trials (RCTs) that examined nutritional interventions in GC patients. The outcomes assessed included hospitalization duration, nutritional status, immune function, and complications. Results: A total of 11 studies were included. Enteral nutrition (EN) significantly reduce hospital stay duration compared to no nutritional intervention (SMD = -1.22, 95% CI [-1.72, -0.73], P < 0.001) and parenteral nutrition (PN) (SMD = -1.30, 95% CI [-1.78, -0.82], P < 0.001), but showed no significant difference compared to immunonutrition (IN). EN also improved nutritional status, indicated by higher albumin prealbumin levels, and improved immune function by elevating CD4+ levels (SMD = 1.09, 95% CI [0.61, 1.57], P < 0.001). However, IN showed superior effects on immunoglobulin levels (IgG and IgM). No significant differences were observed in complication rates among EN, IN, and PN interventions. Conclusion: Nutritional support, particularly EN and IN, can significantly improve hospitalization outcomes, nutritional status, and immune function. Customizing interventions according to patient requirements can optimize therapeutic outcomes, highlighting the need for further research in this area.

Prehabilitation to Enhance Vascular Surgery Outcomes: A Narrative Review.

Prehabilitation, an emerging strategy, prepares patients for elective surgery by encouraging healthy behaviors, including physical exercise and healthy nutrition, while providing psychological support, to improve postoperative outcomes and foster healthier lifestyles. Despite growing interest, there is little research on prehabilitation. Specifically, studies involving prehabilitation in vascular surgery are heterogeneous with small sample sizes. This review aimed to investigate the reported positive impact of prehabilitation on vascular surgery patients, discuss prehabilitation models, highlight prehabilitation program-associated challenges, and suggest appropriate interventions. Prehabilitation improves physical fitness, reduces postoperative complications, and enhances overall recovery. Multimodal prehabilitation programs can positively impact vascular surgery patients, with benefits including improved cardiovascular fitness, reduced postoperative complications, shorter postoperative hospital stays, enhanced overall recovery, and improved quality of life. The currently reported prehabilitation programs are heterogeneous, with limitations regarding patient adherence and lack of long-term outcomes, posing challenges to their widespread adoption. Overall, prehabilitation shows promise for improving vascular surgery outcomes and fostering long-term healthy behaviors. The systematic implementation of prehabilitation in vascular surgery care pathways, overcoming reported limitations, and integrating multimodal prehabilitation into routine preoperative care hold potential benefits. This review underscores the need for high-quality research to establish best practices in prehabilitation and integrate them into the standard of care for vascular surgery patients.

Effectiveness of High-Protein Energy-Dense Oral Supplements on Patients with Malnutrition Using Morphofunctional Assessment with AI-Assisted Muscle Ultrasonography: A Real-World One-Arm Study.

Background: User-friendly tools for assessing nutrition status and interventions in malnourished patients are crucial. This study evaluated the effectiveness of a personalised nutrition intervention using a novel oral nutritional supplement and AI-supported morphofunctional assessment to monitor clinical outcomes in patients with disease-related malnutrition (DRM). Methods: This prospective observational study involved patients receiving concentrated high-protein, high-calorie ONS (cHPHC-ONS), per usual clinical practice. Comprehensive assessments were performed at baseline (B0) and three months (M3) post-intervention. Results: 65 patients participated in the study. Significant decreases were observed in the percentage weight loss from B0 (-6.75 ± 7.5%) to M3 (0.5 ± 3.48%) (p < 0.01), in the prevalence of malnutrition (B0: 93.4%; M3: 78.9%; p < 0.01), severe malnutrition (B0: 60.7%; M3: 40.3%; p < 0.01), and sarcopenia (B0: 19.4%; M3: 15.5%; p < 0.04). Muscle area increased (p = 0.03), and there were changes in the echogenicity of the rectus femoris muscle (p = 0.03) from B0 to M3. In patients aged ≥60, an increase in muscle thickness (p = 0.04), pennation angle (p = 0.02), and handgrip strength (p = 0.04) was observed. There was a significant reduction in the prevalence of malnutrition (B0: 93.4%; M3: 78.9%; p < 0.01) and severe malnutrition (B0: 60.7%; M3: 40.3%; p < 0.01). Conclusions: In patients with DRM, a personalised intervention with cHPHC-ONS significantly reduces the prevalence of malnutrition, severe malnutrition, and sarcopenia and improves muscle mass and function.

Nutrition Supply and Growth Post Nutrition Support Team Activity in Neonatal Intensive Care Unit.

Purpose: For neonates admitted to the neonatal intensive care unit (NICU), appropriate nutritional assessment and intervention are important for adequate growth. In this study, we aimed to determine whether there were changes in the nutritional supply and growth status of premature infants hospitalized in the NICU after the introduction of the Nutrition support team (NST). Methods: This study retrospectively analyzed premature infants admitted to the NICU for over 14 days. The average daily calorie, protein, and fat supply at 1 and 2 weeks after birth were compared before and after NST, and growth was evaluated by changes in length, weight, and head circumference z-scores at birth and 28 days after birth. Results: A total of 79 neonates were included in the present study, with 32 in the pre-NST group and 47 in the post-NST group. The average daily energy supply during the first (p=0.001) and second (p=0.029) weeks postnatal was significantly higher in the post-NST group than in the pre-NST group. Lipid supply for the first week was significantly higher in the post-NST group than in the pre-NST group (p=0.010). The change in the z-score for length was significantly higher in the post-NST group than in the pre-NST group (p=0.049). Conclusion: Nutrient supply and length z-score change increased significantly at 28 days after birth in the post-NST group. These results suggest that calorie calculators and NST activity can promote adequate growth and development in neonates.

Multidisciplinary nutritional support team and mortality in critically ill patients with acute respiratory distress syndrome.

BACKGROUND: A careful approach is required when providing nutritional support to patients with acute respiratory distress syndrome (ARDS). This study investigated whether implementing a multidisciplinary nutritional support team (NST) is associated with improved survival outcomes in patients with ARDS. METHODS: In a nationwide population-based cohort study, all adult patients admitted to the intensive care unit (ICU) in South Korea with a primary diagnosis of ARDS from January 1, 2017, to December 31, 2021, were included. The NST comprised four professionals (physicians, full-time nurses, full-time pharmacists, and full-time clinical dietitians). Patients admitted to ICUs with and without the NST system were allocated to the NST and non-NST groups, respectively. RESULTS: The analysis comprised a total of 15,555 patients with ARDS. Among them, 6615 (42.5%) were in the NST group, and 8940 (57.5%) were in the non-NST group. After adjusting for covariates in the multivariable logistic regression, the NST group showed a 19% lower 30-day mortality than the non-NST group (odds ratio: 0.81, 95% confidence interval: 0.75-0.87, p < .001). Furthermore, after adjusting for covariates in multivariable Cox regression, the NST group showed a 12% lower 1-year all-cause mortality than the non-NST group (hazard ratio: 0.88, 95% confidence interval: 0.85-0.92, p < .001). CONCLUSIONS: NST implementation was associated with enhanced 30-day and 1-year survival rates in patients with ARDS. These findings indicate that nutritional support provided by the NST may influence the survival outcomes of patients with ARDS in the ICU.

Assessing Practices and Challenges in Providing Nutritional Support to Neonates and Children Pre- and Post-Surgery, and its Impact on Recovery and Outcomes.

Background: Providing adequate nutritional support to neonates and children undergoing surgery is crucial for their recovery and overall health outcomes. However, there are various challenges associated with this, including the unique nutritional requirements of this population and the potential complications that can arise pre- and post-surgery. Materials and Methods: This study aimed to assess the practices and challenges in providing nutritional support to neonates and children both pre- and post-surgery, and to analyze its impact on recovery and outcomes. A retrospective analysis was conducted on a cohort of 200 neonates and children who underwent surgery over a two-year period. Data regarding preoperative nutritional status, types of nutritional support provided, postoperative complications, and recovery outcomes were collected and analyzed. Results: The study found that 65% of neonates and children were malnourished preoperatively, with 45% experiencing delays in initiating enteral feeding post-surgery due to complications such as gastrointestinal intolerance and surgical complications. Among those who received parenteral nutrition, 30% developed catheter-related bloodstream infections. Overall, the mean length of hospital stay was prolonged by 7 days in malnourished patients compared to adequately nourished patients. Conclusion: Effective nutritional support in neonates and children undergoing surgery is essential for optimal recovery and outcomes. However, significant challenges exist, including preoperative malnutrition, delays in initiating enteral feeding, and complications associated with parenteral nutrition. Strategies to optimize nutritional status preoperatively, minimize postoperative complications, and enhance nutritional support are imperative to improve outcomes in this vulnerable population.

Significant Published Articles in 2023 for Pharmacy Nutrition Support Practice.

Purpose: The purpose of this article is to assist the pharmacist engaged in nutrition support therapy in staying current with pertinent literature. Methods: Several board-certified nutrition support pharmacists aggregated a list of articles relevant to pharmacy nutrition support published in 2023. The list was compiled into a spreadsheet whereby the authors were asked to assess whether the article was considered important. A culled list of publications was then identified whereby at least 5 out of the 8 author participants considered the article to be important for pharmacists practicing in nutrition support. Guideline and consensus papers, important to practice but not ranked, were also included. Results: A total of 133 articles were identified; 9 from the primary literature were voted by the group to be of high importance. Fourteen guidelines, position, recommendation, or consensus papers were also identified. The top-ranked articles from the primary literature were summarized and a narrative regarding its implications to pharmacy nutrition support practice were provided. Conclusion: We recommend that pharmacists engaged in nutrition support therapy be familiar with these articles as it pertains to their practice.

Closed laceration of the trachea, esophagus and guttural pouches in a mare caused by blunt trauma.

A mare was admitted for progressive swelling of the neck, lethargy and anorexia. Radiography revealed perilaryngeal, peritracheal, and periesophageal emphysema. Endoscopy revealed pharyngeal and tracheal roof collapse, and a small laceration on the trachea. Treatment with antimicrobials, fluids, and flunixin was initiated. To prevent exacerbation of the emphysema, temporary tracheostomy was performed. Clipping for the tracheostomy revealed a hoofprint mark on the ventral neck. Subsequent endoscopies revealed laceration of the esophagus and guttural pouch septum communicating with the visceral compartment of the neck. Four days after admission, an esophagostomy was performed to prevent leakage of ingesta into the neck and allow feeding. Complications occurred: Deep cervical infection requiring surgical drainage; Esophageal impaction with shavings on one occasion causing extensive mucosa erosions; Laminitis managed with restricted physical activity and corrective farriery. Tracheostomy tube removal, esophagostomy tube removal, and patient discharge occurred 10, 36 and 51 days after admission, respectively. The mare did well after discharge and returned to competing in children's showing classes. Blunt trauma to the neck can lacerate the trachea, esophagus and guttural pouches causing emphysema and deep cervical infection, which can be treated with antimicrobials, temporary tracheostomy, temporary esophagostomy, surgical drainage, and supportive care.

Nutritional therapy in intensive care unit inpatients at risk for refeeding syndrome: A systematic review.

The profiles of intensive care cnit (ICU) critically ill inpatients differ from those of other hospitalized patients, since organ dysfunction is a factor that increases the risk for Refeeding Syndrome (RS) development. It is important to understand the influence of feeding methods and caloric intake on mortality and RS incidence among critically ill adult inpatients. A systematic search, following PRISMA guidelines and protocol for systematic reviews, was conducted for interventional and experimental studies analyzing RS occurrence in adults admitted to ICUs. Pubmed, Scielo, Lilacs, Google Scholar, Scopus and Web of Science were the databases searched, and the Scottish Intercollegiate Guidelines Network (SIGN) tool was used to assess methodological quality of selected articles. Out of 945 abstracts screened, 32 articles were read in full and 20 were included for data extraction. Considerable heterogeneity was found between all studies reviewed. Enteral feeding was the most used method, and, in general, progression of caloric intake did not follow the American Society of Parenteral and Enteral Nutrition (ASPEN) or National Institute of Health and Care (NICE) recommendations for RS. In majority, data collection period of studies was less than 7 days; RS was observed in up to 52.5% of patients, and related mortality varied between 15.6 and 83.3%. Due to weak level of evidence and high heterogeneity found within reviewed studies, it is not possible to determine a robust recommendation as to what would be the best and safest feeding method and caloric progression protocol for patients at risk for developing RS.

Early selective enteral feeding in combination with active decompression of duodenum in treatment of moderate and severe acute pancreatitis - A proof-of-concept clinical study.

BACKGROUND: Acute pancreatitis (AP) is a significant clinical challenge with rising global incidence and substantial mortality rates, necessitating effective treatment strategies. Current guidelines recommend pain and fluid management and early enteral feeding to mitigate complications, yet optimal feeding route remains debated. METHODS: We conducted a prospective, randomized, controlled trial at nine centers from October 2020 to May 2023, enrolling 154 patients with moderate to severe AP. Patients were stratified into biliary and non-biliary categories and randomized 1:1 to receive either standard of care (SoC) or SoC plus PandiCath®, a novel catheter enabling selective enteral feeding and duodenal decompression. The primary clinical endpoint (PCE) was a composite of de novo multiple organ dysfunction syndrome (MODS), infectious complications, pancreatic and intestinal fistula formation, bleeding, abdominal compartment syndrome, obstructive jaundice, and AP-related mortality. RESULTS: In the primary modified intention-to-treat analysis, PandiCath® significantly reduced the PCE compared to SoC alone (P = 0.032). The Relative Risk (RR = 0.469, 95 % CI 0.228-0.964) and Number Needed to Treat (NNT = 6.384, 95 % CI 3.349-68.167) indicated its substantial clinical benefit, primarily driven by reduced rates of de novo MODS and infectious complications. These findings were further supported by the evaluation of other populations, including the standard intention-to-treat analysis. CONCLUSION: PandiCath®, facilitating targeted enteral feeding while isolating and decompressing the duodenum, demonstrates promise in improving outcomes for AP patients at risk of severe complications. Further studies are warranted to validate these findings and explore optimal timing and patient selection for this intervention.

Sex differences in clinical presentation, treatment response, and side effects of nutritional therapy among patients at nutritional risk: a secondary analysis of the randomized clinical trial EFFORT.

BACKGROUND: Considering sex-specific factors has become an increasingly recognized area for research and practice, in the field of clinical nutrition, there is insufficient evidence regarding differences in clinical presentation, treatment response, and side effects of nutritional therapy among female and male patients. METHODS: This secondary analysis investigated differences among female and male patients at risk for malnutrition regarding initial presentation, clinical outcomes, and treatment response in patients included in the Effect of Early Nutritional Support on Frailty, Functional Outcomes, and Recovery of Malnourished Medical Inpatients Trial (EFFORT), a randomized controlled trial comparing individualized nutritional support to usual care. RESULTS: Of 2028 patients included in the trial, 964 were females and 1064 were males. The nutritional history and clinical presentation of female patients was different: they consumed less food and had a greater loss of appetite than the male population. Male patients had higher risk for mortality at 180 d [27% compared with 19%; adjusted hazards ratio (HR): 1.35; 95% CI: 1.12, 1.63] and further adverse clinical outcomes. However, there was no difference in the effect of nutritional support on mortality among female and male patients (HR: 0.76; 95% CI: 0.45, 1.27, compared with HR: 0.81; 95% CI: 0.54, 1.21, respectively; P-interaction = 0.939). CONCLUSIONS: Results of this multicenter randomized trial suggest that multimorbid female inpatients have a different clinical presentation and are more prone to loss of appetite and reduced daily dietary intake than male inpatients. Importantly, the favorable response to nutritional interventions was similar in both sexes. This trial was registered at clinicaltrials.gov as NCT02517476.

Trends in Hospital Admissions for Patients with Amyotrophic Lateral Sclerosis: Insights from a Retrospective Cohort Study in a Province in Northern Italy.

ALS is characterized by a highly heterogeneous course, ranging from slow and uncomplicated to rapid progression with severe extra-motor manifestations. This study investigated ALS-related hospitalizations and their connection to clinical aspects, comorbidities, and prognosis. We performed a retrospective cohort study including patients residing in Modena, Italy, newly diagnosed between 2007 and 2017 and followed up until 31 December 2022. Data were obtained from the Emilia Romagna ALS registry, regional hospitals, and medical records. Among the 249 patients, there were 492 hospital admissions, excluding those for diagnostic purposes; 63% of the patients had at least one hospitalization post-diagnosis, with an average stay of 19.90 ± 23.68 days. Younger patients were more likely to be hospitalized multiple times and experienced longer stays (44.23 ± 51.71 days if <65 years; 26.46 ± 36.02 days if older, p < 0.001). Patients who were hospitalized at least once more frequently underwent gastrostomy (64.97%) or non-invasive (66.24%) and invasive (46.50%) ventilation compared to those never hospitalized (21.74%, 31.52%, 13.04%, respectively, p < 0.001 for all). Emergency procedures led to longer hospitalizations (62.84 ± 48.91 days for non-invasive ventilation in emergencies vs. 39.88 ± 46.46 days electively, p = 0.012). Tracheostomy-free survival was not affected by hospitalizations. In conclusion, younger ALS patients undergo frequent and prolonged hospitalizations, especially after emergency interventions, although these do not correlate with reduced survival.

The Association of the Essential Amino Acids Lysine, Methionine, and Threonine with Clinical Outcomes in Patients at Nutritional Risk: Secondary Analysis of a Randomized Clinical Trial.

Lysine, methionine, and threonine are essential amino acids with vital functions for muscle and connective tissue health, metabolic balance, and the immune system. During illness, the demand for these amino acids typically increases, which puts patients at risk for deficiencies with harmful clinical consequences. In a secondary analysis of the Effect of Early Nutritional Support on Frailty, Functional Outcomes, and Recovery of Malnourished Medical Inpatients Trial (EFFORT), which compared individualized nutritional support to usual care nutrition in patients at nutritional risk, we investigated the prognostic impact of the lysine, methionine, and threonine metabolism. We had complete clinical and amino acid data in 237 patients, 58 of whom reached the primary endpoint of death at 30 days. In a model adjusted for comorbidities, sex, nutritional risk, and trial intervention, low plasma methionine levels were associated with 30-day mortality (adjusted HR 1.98 [95% CI 1.16 to 3.36], p = 0.01) and with a decline in functional status (adjusted OR 2.06 [95% CI 1.06 to 4.01], p = 0.03). The results for lysine and threonine did not show statistically significant differences regarding clinical outcomes. These findings suggest that low levels of methionine may be critical during hospitalization among patients at nutritional risk. Further studies should investigate the effect of supplementation of methionine in this patient group to improve outcomes.

High-Protein Nutritional Supplements Improve Nutritional Status in Malnourished Patients with Systemic Sclerosis.

(1) Background: Impaired nutritional status in systemic sclerosis (SSc) is prevalent. (2) Objective: This study aimed to identify pre-cachexia and malnutrition in SSc patients and to estimate the effectiveness of a high-protein oral nutritional supplement (ONS) in improving their nutritional status. (3) Materials and methods: The SSc population comprised 56 patients and a control group of 49 healthy persons. After a baseline clinical evaluation, bioelectrical impedance analysis (BIA), and laboratory tests, SSc patients were divided into well-nourished, pre-cachectic, and malnourished categories. SSc patients with a nutritional disbalance received a high-protein ONS once daily for 3 months. Patients were reassessed at 3 and 12 months after inclusion in the study. (4) Results: SSc patients, in comparison to the control group, had a significantly lower seven-point SGA value [6(0) vs. 7(1), p < 0.001)], lean tissue mass [LTM, 35.1 (10.5) vs. 40.1 (10.10), p = 0.008], and lean tissue index [LTI, 13.5 (3) vs. 14.9 (4), p = 0.009]. Of the 56 SSc patients, 40 (71.4%) were well nourished, 5 (8.9%) had pre-cachexia, and 11 (19.7%) were malnourished. A high-protein ONS in the pre-cachexia group stabilized the SGA value, anthropometric measurements, and BIA after 3 and 12 months. In malnourished patients, it significantly improved the SGA value [5(0) vs. 6(0), p = 0.002], LTI [12.1 (2.1) vs. 12.7 (3.2), p = 0.021] and LTM [31.1 (7.7) vs. 35.1 (9.1), p = 0.021], and that effect remained stable at 12 months. (5) Conclusion: Malnutrition is a common complication of SSc that can be improved with nutritional intervention.

Nutritional support in hospitalised patients with diabetes and risk for malnutrition: a secondary analysis of an investigator-initiated, Swiss, randomised controlled multicentre trial.

OBJECTIVES: The main objective of this study was to investigate the effects of nutritional support on mortality in hospitalised patients with diabetes and nutritional risk participating in the Effect of early nutritional support on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial (EFFORT) trial. DESIGN: Secondary analysis of a Swiss-wide multicentre, randomised controlled trial. PARTICIPANTS: Patients with diabetes and risk for malnutrition. INTERVENTIONS: Individualised nutritional support versus usual care. PRIMARY OUTCOME MEASURE: 30-day all-cause mortality. RESULTS: Of the 2028 patients included in the original trial, 445 patients were diagnosed with diabetes and included in this analysis. In terms of efficacy of nutritional therapy, there was a 25% lower risk for mortality in patients with diabetes receiving nutritional support compared with controls (7% vs 10%, adjusted HR 0.75 (95% CI 0.39 to 1.43)), a finding that was not statistically significant but similar to the overall trial effects with no evidence of interaction (p=0.92). Regarding safety of nutritional therapy, there was no increase in diabetes-specific complications associated with nutritional support, particularly there was no increase in risk for hyperglycaemia (adjusted OR 0.97, 95% CI 0.56 to 1.67 p=0.90). CONCLUSION: Patients with diabetes and malnutrition in the hospital setting have a particularly high risk for adverse outcomes and mortality. Individualised nutritional support reduced mortality in this secondary analysis of a randomized trial, but this effect was not significant calling for further large-scale trials in this vhighly ulnerable patient population. TRIAL REGISTRATION NUMBER: NCT02517476.