Intensive care unit-acquired weakness - preventive, and therapeutic aspects; future directions and special focus on lung transplantation.

In this editorial, comments are made on an interesting article in the recent issue of the World Journal of Clinical Cases by Wang and Long. The authors describe the use of neural network model to identify risk factors for the development of intensive care unit (ICU)-acquired weakness. This condition has now become common with an increasing number of patients treated in ICUs and continues to be a source of morbidity and mortality. Despite identification of certain risk factors and corrective measures thereof, lacunae still exist in our understanding of this clinical entity. Numerous possible pathogenetic mechanisms at a molecular level have been described and these continue to be increasing. The amount of retrievable data for analysis from the ICU patients for study can be huge and enormous. Machine learning techniques to identify patterns in vast amounts of data are well known and may well provide pointers to bridge the knowledge gap in this condition. This editorial discusses the current knowledge of the condition including pathogenesis, diagnosis, risk factors, preventive measures, and therapy. Furthermore, it looks specifically at ICU acquired weakness in recipients of lung transplantation, because - unlike other solid organ transplants- muscular strength plays a vital role in the preservation and survival of the transplanted lung. Lungs differ from other solid organ transplants in that the proper function of the allograft is dependent on muscle function. Muscular weakness especially diaphragmatic weakness may lead to prolonged ventilation which has deleterious effects on the transplanted lung - ranging from ventilator associated pneumonia to bronchial anastomotic complications due to prolonged positive pressure on the anastomosis.

Food Addiction Screening, Diagnosis and Treatment: A Protocol for Residential Treatment of Eating Disorders, Substance Use Disorders and Trauma-Related Psychiatric Comorbidity.

Food addiction, or ultra-processed food addiction (UPFA), has emerged as a reliable and validated clinical entity that is especially common in individuals seeking treatment for eating disorders (EDs), substance use disorders (SUDs) and co-occurring psychiatric disorders (including mood, anxiety and trauma-related disorders). The clinical science of UPFA has relied on the development and proven reliability of the Yale Food Addiction Scale (YFAS), or subsequent versions, e.g., the modified YFAS 2.0 (mYFAS2.0), as well as neurobiological advances in understanding hedonic eating. Despite its emergence as a valid and reliable clinical entity with important clinical implications, the best treatment approaches remain elusive. To address this gap, we have developed and described a standardized assessment and treatment protocol for patients being treated in a residential program serving patients with psychiatric multi-morbidity. Patients who meet mYFAS2.0 criteria are offered one of three possible approaches: (1) treatment as usual (TAU), using standard ED treatment dietary approaches; (2) harm reduction (HR), offering support in decreasing consumption of all UPFs or particular identified UPFs; and (3) abstinence-based (AB), offering support in abstaining completely from UPFs or particular UPFs. Changes in mYFAS2.0 scores and other clinical measures of common psychiatric comorbidities are compared between admission and discharge.

Nasogastric Tube Feeding in Anorexia Nervosa: A Propensity Score-Matched Analysis on Clinical Efficacy and Treatment Satisfaction.

The choice of a refeeding strategy is essential in the inpatient treatment of Anorexia Nervosa (AN). Oral nutrition is usually the first choice, but enteral nutrition through the use of a Nasogastric Tube (NGT) often becomes necessary in hospitalized patients. The literature provides mixed results on the efficacy of this method in weight gain, and there is a scarcity of studies researching its psychological correlates. This study aims to analyze the effectiveness of oral versus enteral refeeding strategies in inpatients with AN, focusing on Body Mass Index (BMI) increase and treatment satisfaction, alongside assessing personality traits. We analyzed data from 241 inpatients, comparing a group of treated vs. non-treated individuals, balancing confounding factors using propensity score matching, and applied regression analysis to matched groups. The findings indicate that enteral therapy significantly enhances BMI without impacting treatment satisfaction, accounting for the therapeutic alliance. Personality traits showed no significant differences between patients undergoing oral or enteral refeeding. The study highlights the clinical efficacy of enteral feeding in weight gain, supporting its use in severe AN cases when oral refeeding is inadequate without adversely affecting patient satisfaction or being influenced by personality traits.

Dismantling the myth of "all foods fit" in eating disorder treatment.

We call for a reevaluation of the long-standing dogmatic nutritional principle that "all foods fit" for all cases of eating disorders (EDs) and its corollary, "there are no bad foods" (for anyone ever) during ED treatment. Based on accumulated scientific research, we challenge these ideologies as outdated, confusing, and potentially harmful to many patients. We review the evidence that indicates the folly of these assumptions and show there are a variety of exceptions to these rules, including (1) food allergies, sensitivities, and intolerances, (2) religious and spiritual preferences or doctrines, and (3) the ubiquitous emergence and widespread availability of ultra-processed foods leading to the potential development of addiction-like eating and a higher prevalence of various medical and psychiatric comorbidities, as well as higher mortality. This evidence supports a nutritional psychiatry approach that should be integrated into (rather than dissociated from) ED treatment research and practice.

Dose-dependent effects of enteral nutrition on the faecal microbiota and short chain fatty acids.

INTRODUCTION: Enteral nutrition (EN) involves replacing all or part of a person's habitual diet with a nutritional formula. The impact of varying doses of EN on the gut microbiome remains understudied. METHODS: Healthy adults replaced all (100% EN) or part (85% EN, 50% EN and 20% EN) of their energy requirements with EN for 7 days. Faecal samples were collected before and on day 7 of interventions. Faecal pH, short chain fatty acids (SCFAs), branched-chain fatty acids (BCFAs) and 16S rRNA sequencing were performed. Dietary assessment was performed with 7-day food diaries. RESULTS: Sixty-one participants (31 females; median (IQR) age: 24.7 (23.0-27.8) years) were recruited. A dose-dependent impact of EN on faecal microbiota, SCFAs, BCFAs) and pH was observed, with changes detectable at EN intakes of at least 50% of energy requirements. 100% and 85% EN reduced the abundance of fibre-fermenting taxa such as Agathobacter, Faecalibaterium, Succinivibrio and Acidaminococcus. In parallel, potentially harmful organisms like Eubacterium, Actinomyces, and Klebsiella increased. In the 50% EN group, adherence to a diet high in fish, vegetables, potatoes, non-alcoholic beverages, and fat spreads, and low in cereal products, milk, and meat negatively correlated with changes in microbiota structure (r = -0.75, P = 0.025). This signal was not observed when using compositional tools for microbiota analysis. CONCLUSIONS: EN detrimentally influences the faecal microbiota and diet-related bacterial metabolites in a dose-dependent manner, particularly at doses of at least 50%. The findings of this study have implications for the dietary management and counselling of patients receiving high volume EN.

Short-term outcomes of the study of refeeding to optimize inpatient gains for patients with atypical anorexia nervosa.

OBJECTIVE: The StRONG trial demonstrated the safety and efficacy of higher calorie refeeding (HCR) in hospitalized adolescents and young adults with malnutrition secondary to restrictive eating disorders. Here we compare refeeding outcomes in patients with atypical anorexia nervosa (atypical AN) versus anorexia nervosa (AN) and examine the impact of caloric dose. METHOD: Patients were enrolled upon admission and randomized to meal-based HCR, beginning 2000 kcal/day and advancing 200 kcal/day, or lower calorie refeeding (LCR), beginning 1400 kcal/day and advancing 200 kcal every other day. Atypical AN was defined as %median BMI (mBMI) > 85. Independent t-tests compared groups; multivariable linear and logistic regressions examined caloric dose (kcal/kg body weight). RESULTS: Among n = 111, mean ± SD age was 16.5 ± 2.5 yrs; 43% had atypical AN. Compared to AN, atypical AN had slower heart rate restoration (8.7 ± 4.0 days vs. 6.5 ± 3.9 days, p = .008, Cohen's d = -.56), less weight gain (3.1 ± 5.9%mBMI vs. 5.4 ± 2.9%mBMI, p < .001, Cohen's d = .51) and greater hypomagnesemia (29% vs. 11%, p = .03, OR = 3.29). These suboptimal outcomes were predicted by insufficient caloric dose (32.4 ± 6.9 kcal/kg in atypical AN vs. 43.4 ± 9.8 kcal/kg in AN, p < .001, Cohen's d = 1.27). For every 10 kcal/kg increase, heart rate was restored 1.7 days (1.0, 2.5) faster (p < .001), weight gain was 1.6%mBMI (.8, 2.4) greater (p < .001), and hypomagnesemia odds were 70% (12, 128) lower (p = .02). DISCUSSION: Although HCR is more efficacious than LCR for refeeding in AN, it contributes to underfeeding in atypical AN by providing an insufficient caloric dose relative to the greater body weight in this diagnostic group. PUBLIC SIGNIFICANCE: The StRONG trial previously demonstrated the efficacy and safety of higher calorie refeeding in patients with malnutrition due to restrictive eating disorders. Here we show that higher calorie refeeding contributes to underfeeding in patients with atypical anorexia nervosa, including poor weight gain and longer time to restore medical stability. These findings indicate these patients need more calories to support nutritional rehabilitation in hospital.

The incidence of refeeding syndrome and the nutrition management of severely malnourished inpatients with eating disorders: An observational study.

OBJECTIVE: Nutritional rehabilitation and weight restoration are often critical for the treatment of eating disorders (ED), yet are restricted by the potential risk of refeeding syndrome (RFS). The primary objective was to determine the incidence of RFS. Secondary objectives were to explore predictive factors of RFS and describe its impact on treatment goals for patients with ED. METHOD: This retrospective observational study reviewed the nutrition management for patients admitted to a quaternary hospital for ED treatment from 2018 to 2020. Data were collected during the first 4 weeks of admission and included anthropometry, energy prescription, incidence and severity of RFS, and electrolyte and micronutrient prescription. Outcomes included incidence of RFS, energy prescription and advancement, and weight change. RESULTS: Of 423 ED admissions, 217 patients (median [interquartile range, IQR] age 25 [21-30.5] years; 210 [97%] female) met inclusion criteria. Median (IQR) body mass index (BMI) on admission was 15.5 (14.1-17.3) kg/m2 . The mean (standard deviation) length of admission was 35 (7.3) days. Median (IQR) initial energy prescription was 1500 (930-1500) kcal/day. Seventy-three (33%) patients developed RFS; 34 (16%) mild, 27 (12%) moderate, and 12 (5%) severe. There was no association between RFS severity and admission BMI, energy prescription, or prescription of prophylactic electrolytes or micronutrients. Lower admission weight was associated with RFS (odds ratio 0.96, 95% confidence interval [0.93-1.00], p = .035). Less than half of the participants met the weight gain target (>1 kg per week) in the first 3 weeks of admission. DISCUSSION: The incidence of severe RFS was low in this cohort and was associated with lower admission weight. PUBLIC SIGNIFICANCE: This study is one of the largest studies to utilize consensus-defined criteria to diagnose RFS among adult patients admitted for treatment of an ED. This population is still considered to be at risk of RFS and will require close monitoring. The results add to the growing body of research that restriction of energy prescription to prevent RFS may not require the level of conservatism traditionally practiced.

Classes of medications prescribed to malnourished children and their relationship with time to recovery.

OBJECTIVE: There is conflicting evidence around prescription practices in the management of malnutrition; the study objective was to explore medication classifications prescribed and their relationship between time-to-recovery and specific demographic characteristics among children with malnutrition in Guatemala. DESIGN: Descriptive correlational study of data obtained in a retrospective record review. SAMPLE: Children aged 0-5 years with malnutrition treated in a Guatemalan Nutrition Rehabilitation Center between 2019 and 2020 (N = 155). MEASURES: Variables assessed were medication classification of prescribed medications, age, gender, time-to-recovery, malnutrition severity, and COVID cohort. RESULTS: The most frequently used medication classifications were vitamins (95%), respiratory (75%), antipyretic (68%), antibiotic (61%), and gastrointestinal agents (54%). Antibiotic, respiratory, corticosteroid, antipyretic, and gastrointestinal agents were prescribed significantly more in cases with a time-to-recovery of 6 weeks or greater. CONCLUSIONS: Medication classifications prescribed most often were related to common comorbidities of malnutrition and illnesses affecting children in Guatemala, such as respiratory and diarrheal diseases. The medication used in cases with a time-to-recovery of ≥6 weeks suggest these cases may have had more comorbidities, which could explain the longer recovery times. Caution is suggested in routine prophylactic antibiotic use in public health settings, given the lack of association with improved recovery times, the potential for antibiotic drug resistance, and the negative effects on renal function among children.

Functioning of a Nutritional Rehabilitation Center against acceptable levels of care.

Background: Establishment of Nutritional Rehabilitation Centers (NRCs) is an initiative under National Rural Health Mission to provide institutional care for children with severe acute malnutrition (SAM). The aim of the study was to assess the effectiveness of nutritional interventional measures in improving the nutritional status of children admitted to an NRC. Methods: A retrospective health facility-based descriptive study was conducted in the NRC, Rural Health Training Center, All India Institute of Medical Sciences, Raipur. Results: A total of 765 children were enrolled in the NRC between March 2015 and November 2019, and majority (87.97%) were admitted as per weight for height/length (<-3SD) criteria. The total number of SAM children with complications were 428 (55.94%). Of the 724 total discharges, 498 (68.78%) were cured, 197 (27.2%) were nonresponders and 28 (3.87%) were defaulters. Conclusion: The findings suggest factors affecting nutritional rehabilitation that are complex and require a more integrated management in the health system and community. Regular review, supportive supervision and identification of nutrient-dense food from locally available low-cost ingredients is the need of the hour.

Cross-sectional assessment of body composition and detection of malnutrition risk in participants with low body mass index and eating disorders using 3D optical surface scans.

BACKGROUND: New recommendations for the assessment of malnutrition and sarcopenia include body composition, specifically reduced muscle mass. Three-dimensional optical imaging (3DO) is a validated, accessible, and affordable alternative to dual X-ray absorptiometry (DXA). OBJECTIVE: Identify strengths and weaknesses of 3DO for identification of malnutrition in participants with low body mass index (BMI) and eating disorders. DESIGN: Participants were enrolled in the cross-sectional Shape Up! Adults and Kids studies of body shape, metabolic risk, and functional assessment and had BMI of <20 kg/m2 in adults or <85% of median BMI (mBMI) in children and adolescents. A subset was referred for eating disorders evaluation. Anthropometrics, scans, strength testing, and questionnaires were completed in clinical research centers. Lin's Concordance Correlation Coefficient (CCC) assessed agreement between 3DO and DXA; multivariate linear regression analysis examined associations between weight history and body composition. RESULTS: Among 95 participants, mean ± SD BMI was 18.3 ± 1.4 kg/m2 in adult women (N = 56), 19.0 ± 0.6 in men (N = 14), and 84.2% ± 4.1% mBMI in children (N = 25). Concordance was excellent for fat-free mass (FFM, CCC = 0.97) and strong for appendicular lean mass (ALM, CCC = 0.86) and fat mass (FM, CCC = 0.87). By DXA, 80% of adults met the low FFM index criterion for malnutrition, and 44% met low ALM for sarcopenia; 52% of children and adolescents were <-2 z-score for FM. 3DO identified 95% of these cases. In the subset, greater weight loss predicted lower FFM, FM, and ALM by both methods; a greater percentage of weight regained predicted a higher percentage of body fat. CONCLUSIONS: 3DO can accurately estimate body composition in participants with low BMI and identify criteria for malnutrition and sarcopenia. In a subset, 3DO detected changes in body composition expected with weight loss and regain secondary to eating disorders. These findings support the utility of 3DO for body composition assessment in patients with low BMI, including those with eating disorders. This trial was registered at clinicaltrials.gov as NCT03637855.

A Systematic Review to Manage Avoidant/Restrictive Food Intake Disorders in Pediatric Gastroenterological Practice.

Avoidant/Restrictive food intake disorder (ARFID) is a feeding disorder characterized by persistent difficulty eating, such as limited choices of preferred foods, avoidance or restriction of certain foods or food groups, and negative emotions related to eating or meals. Although ARFID mainly affects children, it can also occur in adolescents and adults. ARFID can have serious physical and mental health consequences, including stunted growth, nutritional deficiencies, anxiety, and other psychiatric comorbidities. Despite its increasing importance, ARFID is relatively underrecognized and undertreated in clinical practice. Treatment consists of a multidisciplinary approach involving pediatric gastroenterologists, nutritionists, neuropsychiatrists, and psychologists. However, there are several gaps in the therapeutic approach for this condition, mainly due to the lack of interventional trials and the methodological variability of existing studies. Few studies have explored the nutritional management of ARFID, and no standardized guidelines exist to date. We performed a systematic literature review to describe the different nutritional interventions for children and adolescents diagnosed with ARFID and to assess their efficacy and tolerability. We identified seven retrospective cohort studies where patients with various eating and feeding disorders, including ARFID, underwent nutritional rehabilitation in hospital settings. In all studies, similar outcomes emerged in terms of efficacy and tolerability. According to our findings, the oral route should be the preferred way to start the refeeding protocol, and the enteral route should be generally considered a last resort for non-compliant patients or in cases of clinical instability. The initial caloric intake may be adapted to the initial nutritional status, but more aggressive refeeding regimens appear to be well tolerated and not associated with an increased risk of clinical refeeding syndrome (RS). In severely malnourished patients, however, phosphorus or magnesium supplementation may be considered to prevent the risk of electrolyte imbalance, or RS.

Pulmonary Tuberculosis in Severely Malnourished Children Admitted to Nutrition Rehabilitation Centers: A Multicenter Study.

OBJECTIVES: To identify prevalence of pulmonary tuberculosis (TB) in severely malnourished children admitted to nutritional rehabilitation centers. METHODS: A multicenter cross-sectional study involving 41 nutrition rehabilitation centres (NRCs) across India was carried out to document prevalence of pulmonary tuberculosis in acute severe malnourished children admitted in NRCs. After training of the NRC staff to follow algorithm provided by national tuberculosis elimination program, children admitted to NRCs were screened for pulmonary tuberculosis. RESULTS: A total of 4356 children were enrolled across all the sites. Gastric aspirate for Cartridge based nucleic acid amplification test (CBNAAT), tuberculin skin test (TST) and X-ray film of chest were done in more than 99% of enrolled subjects. A total of 189 children (4.3%) had pulmonary tuberculosis. Eighty-seven (1.99%) were microbiologically confirmed by positive CBNAAT. On multivariate analysis, only significant association was with history of contact with TB patient in family. CONCLUSIONS: The present results suggest that a significant proportion (>4%) of children admitted in NRCs suffer from pulmonary tuberculosis. It is feasible to improve diagnosis of tuberculosis as a whole and microbiologically confirmed TB.

Nutritional rehabilitation of malnourished children: are nutritional supplements a must?

OBJECTIVE: Malnutrition threatens children worldwide. The objective of the current study was to highlight the role of nutritional screening, evaluate the effectiveness of nutritional intervention program, and whether nutritional supplements have surplus benefit. PATIENTS AND METHODS: Screening Tool for the Assessment of Malnutrition in Pediatrics (STAMP) was used to screen 3640 clinically stable 2-5 years old children recruited from the outpatient clinics, Children's Hospital, Ain Shams University. A total of 100 patients at high risk of malnutrition were enrolled. Full nutritional assessment was done and according to the distribution of the calories in the daily meal plan, the patients were randomly divided into two groups each comprised 50 patients. Group A received tailored nutritional dietary rehabilitation plan including dietary supplements, while Group B received only dietary advice. Anthropometric measurements, laboratory tests, as well as STAMP scoring were reassessed after the nutritional rehabilitation programs. RESULTS: Nutritional screening revealed that 5.14% were at high risk of malnutrition. Both studied groups showed significant improvement in caloric intake and all anthropometric measurements upon nutritional rehabilitation, except for the height z scores. Patients who received nutritional supplements showed significantly better changes regarding weight, BMI, caloric intake, and hemoglobin. Regarding STAMP categories during follow up, Group A had only 6% of the patients still in the high-risk category and 76% were at low risk compared to 14% high risk and only 54% were at low risk in Group B. CONCLUSIONS: Nutritional screening in pediatric outpatient facilities can lead to implementing prompt nutritional rehabilitation, which can reflect on the patients' overall health. Tailored nutritional plan can accomplish good response in terms of improvement of caloric intake, anthropometric measurements and laboratory parameters. Adding a nutritional supplement to the dietary plan during nutritional rehabilitation isn't a must but it ensures superior goal achievement.

Outcome of Malnourished Children Admitted in the Nutritional Rehabilitation Home.

BACKGROUND: Globally, the burden of malnutrition, especially undernutrition, as well as the consequences of malnutrition is of the rise which is especially of significant concern for underdeveloped countries. Countries like Nepal are also facing a similar problem of malnutrition. In Madhesh province, among the under 5 children the incidence of chronic malnutrition is 29.3%. Our aim is to assess the malnourishment in the children of Madhesh province in Nepal. METHODS: This cross-sectional quantitative study was carried out among 409 malnourished children who were admitted from July 17, 2018 to July 16, 2022 at NRH in Gajendra Narayan Singh Hospital. Collected data were fed into Microsoft-excel and analyzed using SPSS software, version-2016. As data were normally distributed, frequency, percentage, mean and standard deviation were calculated for descriptive analysis. To find out the association of categorical variables, the Chi-square test or Fisher's Exact test was used where appropriate. P-value <0.05 was significant. RESULTS: Out of 409 malnourished cases, 145 cases were SAM (SD<-3) and 264 cases were MAM (-2 to -3SD) at the time of admission. The mean increment in the weight was 1.14±0.44  kg.  The average length of stay was 19.82±8.73 days. There is a significant difference (p<0.001) in the length of stay among the SAM and MAM cases of our study and a difference in the increment of weight in comparison to mean weight gain (1.14±0.44  kg) with respect to the length of stay of the malnourished child who stayed for more than 28 days and less. CONCLUSIONS: There is significant weight gain in malnourished children after management at the Nutritional Rehabilitation Center.

The effectiveness of facility-based management of children with Severe acute malnutrition and their determinants in Jharkhand, India: A retrospective study.

Background: Children with Severe acute malnutrition (SAM) experience a high risk of disease and developmental delays contributing to large scale morbidity and mortality particularly in the developing world with existing progress inadequate to attain the Sustainable Development Goal for improved nutrition, and the cessation of all forms of undernourishment by 2030.The study objective was to assess the functioning and effectiveness of facility-based management of children with SAM in terms of their recovery (anthropometric indicators), adherence to discharge, and follow-up guidelines. Methods: This secondary data analysis obtained data from the physical patient registers of two malnutrition treatment centres (MTCs) located in the Jamtara district of Jharkhand. Information of 245 children admitted to these MTCs from April 2019-April 2020 was obtained consecutively including anthropometric outcome (weight, length, and Mean Upper Arm Circumference) measurements during the period of their admission. The primary outcome was the proportion of children who attained the recommended discharge criterion of greater than 15% weight gain at the time of discharge. Results: The mean (SD) age of the children with SAM was 1.52 (0.73) years including 55.1% females and 44.9% males. There were 38% of children had a MUAC below 11.5 cm, and 62% had a Z score for weight for height below -3SD. The mean (SD) length of admission stay at the MTCs was 17.16 (5.76) days. A statistically significant improvement in the mean weight and MUAC at discharge was found although the effect size was small (0.98 kg). Only 105 (44.3%) (n=237) children with SAM achieved recovery as per the discharge criterion requirement of ≥15% weight gain since the time of admission. The mean (SD) duration of stay of the children who recovered was 20.43 (5.64) days, being significantly higher compared to the children who failed to recover as per the weight guidelines 14.59 (4.4) days (p < 0.001). Conclusion: MTCs were effective in the management of children with SAM although the recovery rate through weight gain criterion was poor due to premature discharge and lack of follow-up suggestive of a high-burden of adverse social determinants and inadequate health system sensitization and preparedness.

Diet, Digestion, and the Dietitian: A Survey of Clinicians' Knowledge, Attitudes and Practices to Advance the Treatment of Gastrointestinal Disturbances in Individuals with Anorexia Nervosa.

Despite advances in treatment of anorexia nervosa (AN), current therapeutic approaches do not fully consider gastrointestinal disturbances (GID), often present in AN. Addressing GID, both symptoms and disorders, is likely to improve treatment adherence and outcomes in people with AN. GID are complex and are linked to a range of factors related to eating disorder symptomology and can be impacted by nutritional treatment. It is not known which dietetic practices are currently used to address GID in AN. Therefore, this survey aimed to explore the perceived knowledge, attitudes, and practices (KAP) of Australian dietitians treating AN and co-occurring GID. Seventy dietitians participated by completing an online survey. Knowledge scores were calculated based on correct responses to knowledge items (total: 12 points); and two groups were generated: higher knowledge (≥10 points, n = 31) and lower knowledge (≤9 points, n = 39). A greater proportion of dietitians with higher knowledge recognized the role of GID in pathogenesis of AN (p = 0.002) and its impact on quality of life (p = 0.013) and screened for GID (p ≤ 0.001), compared with those with lower knowledge. These results suggest that attitudes and practices toward patients presenting with AN and GID differ depending on level of knowledge. This may have important implications for treatment outcomes for individuals with AN and GID.

Influence of a quality improvement intervention on rehabilitation outcomes of children (6-24 months) with acute malnutrition: a retrospective study in rural Angola.

BACKGROUND: Defaulting is the most frequent cause of Community Management of Acute Malnutrition (CMAM) program failure. Lack of community sensitization, financial/opportunity costs and low quality of care have been recognized as the main driving factors for default in malnutrition programs. The present study aimed to evaluate if a logistic reorganization (generic outpatient department, OPD vs dedicated clinic, NRU) and a change in management (dedicated vs non dedicated staff) of the follow-up of children between 6 and 24 months of age with acute malnutrition, can reduce the default, relapse and readmission rate and increase the recovery rate. METHODS: Retrospective observational study on the impact of quality improvement interventions on rehabilitation outcomes of children (6-24 months) with acute malnutrition, admitted at the Catholic Mission Hospital of Chiulo (Angola) from January 2018 to February 2020. Main outcome measures were recovery rate, the default rate, the relapse rate, and the readmission rate. RESULTS: The intervention was associated with a decrease in the default rate from 89 to 76% (p = 0.02). Recovery rate was 69% in OPD and 88% in NRU (p = 0.25). Relapse rate was nil. CONCLUSIONS: The present study supports the hypothesis that an improvement in quality of care can positively influence the rehabilitation outcomes of malnourished children. Further studies are needed to identify children at risk of low adherence to follow-up visits to increase the effectiveness of rehabilitation programs.

Performance Appraisal of Nutritional Rehabilitation Centers in Central India: A Retrospective Facility-Based Descriptive Study.

Background: Nutritional rehabilitation centers (NRCs) were established with the objective of providing institutional care to malnourished children and building the capacity of the primary caregivers of these children. Objectives and Methodology: The objective of this study was to assess the effect of nutritional interventional measures undertaken at NRCs in improving the nutritional status of admitted children; a retrospective facility-based descriptive study was conducted using the monthly performance reports (March 2015 to November 2019) of all NRCs in Dhamtari district, Chhattisgarh. Results: Of the 3171 children registered in the NRCs, the majority were 1-3 years of age (59.22%), female children (55.50%), and from Other Backward Class caste category (56.79%). The district records a cure rate of 56.12%, death rate of 0.03%, and defaulter rate of 4.71%, with an average length of stay being 16.5 days. NRCs of Dhamtari district had less than acceptable level of recovery/cure rate though death rate and defaulter rate were within acceptable standards. Conclusion: Lower cure rate along with lower defaulter rate and death rate with more than recommended length of stay reflects the below-average performance of the NRCs in the district.

Monitoring and treating hypoglycemia during meal-based rapid nutritional rehabilitation in patients with extreme anorexia nervosa.

PURPOSE: Hypoglycemia, a complication of prolonged starvation, can be life-threatening and is presumed to contribute to the high mortality of anorexia nervosa. Furthermore, early refeeding in severe anorexia nervosa can precipitate paradoxical post-prandial hypoglycemia. Few studies have analyzed the course of hypoglycemia during nutritional rehabilitation in patients with extremely low-weight anorexia nervosa. No standard practice guidelines exist and recommended strategies for managing hypoglycemia (i.e., nasogastric feeds, high-fat diets) have limitations. METHODS: This cohort study assessed prevalence and correlates of hypoglycemia in 34 individuals with very low body mass index (BMI < 14.5 kg/m2) anorexia nervosa treated in an intensive eating disorders program with an exclusively meal-based rapid weight gain nutritional protocol. Hypoglycemia was monitored with frequent point of care (POC) glucose testing and treated with oral snacks and continuous slow intravenous 5% dextrose in 0.45% saline (IV D5 1/2 NS) infusion. RESULTS: POC hypoglycemia was detected in 50% of patients with highest prevalence noted on the day of admission. Hypoglycemia resolved during the first week of hospitalization in most cases and was generally asymptomatic. Seven patients (20.6%) experienced at least one episode of severe hypoglycemia with POC glucose < 50 mg/dl. Lower admission BMI was associated with higher likelihood of developing hypoglycemia and longer duration of hypoglycemia. CONCLUSION: Meal-based management of hypoglycemia supplemented by continuous IV D5 1/2 NS appears a viable alternative to alternate strategies such as enteral tube feeding. We discuss recommendations for hypoglycemia monitoring during nutritional rehabilitation and directions for future research. LEVEL OF EVIDENCE: Level III, retrospective cohort study.