Research Priorities in Prehabilitation for Patients Undergoing Cancer Surgery: An International Delphi Study.

BACKGROUND: Recently, the number of prehabilitation trials has increased significantly. The identification of key research priorities is vital in guiding future research directions. Thus, the aim of this collaborative study was to define key research priorities in prehabilitation for patients undergoing cancer surgery. METHODS: The Delphi methodology was implemented over three rounds of surveys distributed to prehabilitation experts from across multiple specialties, tumour streams and countries via a secure online platform. In the first round, participants were asked to provide baseline demographics and to identify five top prehabilitation research priorities. In successive rounds, participants were asked to rank research priorities on a 5-point Likert scale. Consensus was considered if > 70% of participants indicated agreement on each research priority. RESULTS: A total of 165 prehabilitation experts participated, including medical doctors, physiotherapists, dieticians, nurses, and academics across four continents. The first round identified 446 research priorities, collated within 75 unique research questions. Over two successive rounds, a list of 10 research priorities reached international consensus of importance. These included the efficacy of prehabilitation on varied postoperative outcomes, benefit to specific patient groups, ideal programme composition, cost efficacy, enhancing compliance and adherence, effect during neoadjuvant therapies, and modes of delivery. CONCLUSIONS: This collaborative international study identified the top 10 research priorities in prehabilitation for patients undergoing cancer surgery. The identified priorities inform research strategies, provide future directions for prehabilitation research, support resource allocation and enhance the prehabilitation evidence base in cancer patients undergoing surgery.

Dehydration in geriatrics: consequences and practical guidelines.

PURPOSE OF REVIEW: Geriatric dehydration is a widespread and under recognized problem. The purpose of this review was to examine the latest evidence regarding geriatric dehydration and provide practical guidance for health professionals. RECENT FINDINGS: This review covers evidence from the past 2 years and shows that geriatric dehydration is not benign and is associated with significant personal distress, as well as negative economic and health system consequences. New guidance on nutrition and hydration in the elderly recommend against the use of skin turgor, dry mouth, urine colour or specific gravity to determine hydration status in the elderly. Instead, serum osmolality is considered the gold standard. SUMMARY: Strategies to prevent and manage geriatric dehydration should differ depending on aetiology (low intake, volume depletion or both). Widespread dissemination and implementation of innovative strategies that target improved access to fluids, and systems change to enable rapid and accurate identification and treatment are required.

When you are living and dying at the same time: A qualitative exploration of living with gastrointestinal motility disorders.

BACKGROUND: An expanding base of evidence indicates that chronic gastrointestinal disorders not only impact physical wellbeing, but also affect many psychosocial aspects of life. However, less is known about gastrointestinal motility disorders. The present study aimed to explore how individuals experience gastrointestinal motility disorders and their impact on daily living. METHODS: Eleven people with a gastrointestinal motility disorder participated in semi-structured interviews face-to-face or via telephone. The interviews explored how participants came to be diagnosed, their experiences with health professionals, as well as the impact of dysmotility on enjoyment of food, socialising, eating out and quality of life (QoL). Interviews were tape-recorded, transcribed and analysed using an inductive thematic analysis approach. RESULTS: Analysis revealed an overarching theme of frustration that stemmed from three subthemes: (1) feeling misunderstood, judged and dismissed by health professionals leading to delayed diagnosis, misdiagnosis and multiple diagnoses; (2) severity and unpredictability of undesirable gastrointestinal symptoms; and (3) reduced QoL because of physical and social limitations, impairing their ability to have normal life experiences, including education, work and social activities. CONCLUSIONS: Dysmotility is a complex illness that impacts almost all aspects of a person's life. In addition to managing reported physical symptoms, the social and psychological burden associated with dysmotility needs to be addressed to improve outcomes and QoL.

The impact of targeted interventions aimed to improve quality of life in patients receiving home parenteral nutrition: A systematic literature review.

BACKGROUND: Home parenteral nutrition (HPN) is a specialised therapy offered to people suffering from intestinal failure. Underlying disease, HPN complications and limitations of HPN can significantly impact a person's quality-of-life (QOL). The aim of this review was to evaluate the evidence on existing non-surgical/non-pharmacological interventions aimed at improving QOL, clinical, patient-reported and economic outcomes for patients receiving parenteral nutrition therapy at home across adult and paediatric settings. METHODS: Online databases Medline (Ovid), Embase and Cinahl were searched to identify studies published between 1937 and 31 March 2022. Identified studies were appraised using the Cochrane Collaboration risk of bias tool and Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessment. RESULTS: Nine studies were included in this review. Interventions were focused on education (n = 4), telemedicine (n = 2), preparation of infusion mixtures (n = 1), mindfulness-based cognitive therapy (n = 1) and a multi-modal approach (n = 1). Only one study measured QOL before and after the intervention using a validated QOL tool. All studies were assessed at either some, high or critical risk of bias, resulting in low or very low-quality evidence for the interventions evaluated. CONCLUSIONS: The findings from this review highlight the lack of high-quality non-surgical/non-pharmacological studies seeking to improve QOL for people on HPN. Because the majority of people receiving HPN are not eligible for surgical or pharmaceutical treatments, higher quality research using clinical trial design, and research focused on improving QOL is needed to inform healthcare managers about the effectiveness (and value) of alternative service delivery models for this vulnerable patient group.

Dietary interventions on the prevention and management of diabetes in post-kidney transplantation - A systematic review.

Post-transplant diabetes mellitus is associated with long-term immunosuppression and weight gain, and is related to an increased risk of cardiovascular disease, accelerated loss of graft and increased mortality. There is an absence of strong evidence-based dietary guidelines for the prevention and management of post-transplant diabetes mellitus in kidney transplant recipients. The aim of this study was to systematically review all dietary evidence for kidney transplant recipients on clinical outcomes relating to diabetes, patient-reported outcomes and economic outcomes. A comprehensive literature search was conducted in August 2020 using the databases Medline, Embase, CENTRAL and CINAHL. Studies were critically appraised using Cochrane risk of bias tools and GRADE. A total of 12 studies and 1928 participants were included. Four papers focused on diet and exercise, one paper on diet only, two papers on magnesium supplementation, one paper on magnesium and fibre intake, two papers on Mediterranean diet, one paper on marine n-3 fatty acid supplementation and one paper on fruit and vegetable intake. There were no significant effects on outcomes relating to dietary counselling, magnesium supplementation, magnesium and fibre intake or marine n-3 fatty acid supplementation. Low-quality evidence supports the Mediterranean diet in reducing the risk of post-transplant diabetes mellitus and fasting plasma glucose levels. Low-quality evidence suggests vegetable intake being associated with a lower risk of post-transplant diabetes mellitus. This review demonstrates limited evidence for dietary interventions in the prevention and management of diabetes in post-kidney transplantation. The findings suggest that further high-quality research with robust study designs is required.

Preoperative nutritional status impacts clinical outcome and hospital length of stay in pelvic exenteration patients - a retrospective study.

BACKGROUND: Preoperative malnutrition is common in surgical oncology patients and can have negative effects on postoperative outcomes. Pelvic exenteration is major surgery associated with high morbidity rates. Associations between preoperative malnutrition, determined using the patient-generated subjective global assessment, and postoperative outcomes in this patient cohort has not yet been investigated. AIM: To determine if preoperative nutritional status is associated with postoperative surgical and quality of life (QoL) outcomes after pelvic exenteration surgery. METHODS: A retrospective cohort study was conducted at a quaternary hospital investigating 123 patients who had pelvic exenteration surgery from January 2017 to August 2019. Preoperative nutritional status and postoperative surgical and QoL outcomes were collected and analysed to determine any associations. RESULTS: Overall, 49.6% of patients were female with a median age of 59 years. Forty patients (32.5%) were malnourished and 83 (67.5%) were well nourished before surgery. Well-nourished patients had a shorter length of hospital stay (p = 0.034) and at 6 months post-surgery, presented with a significantly better physical and mental QoL score (p = 0.038 and p = 0.001 respectively). The regression analyses showed that intensive care unit (ICU) readmission rates were 7.19 times more likely to occur in malnourished patients (p = 0.022). CONCLUSIONS: Preoperative malnutrition is associated with increased length of stay, ICU readmissions and poorer QoL following pelvic exenteration. Nutrition screening, assessment and optimisation of management are essential in this patient cohort to improve patient outcomes. Future studies are needed to measure the effect of interventions and identify the most beneficial model of care for this complex patient group.

Nutritional status and quality of life in interstitial lung disease: a prospective cohort study.

BACKGROUND: Malnutrition and altered body composition are well-documented in chronic pulmonary diseases; however, investigation of nutritional status in interstitial lung disease (ILD) is limited. This study aimed to describe the nutritional status of ILD patients within three diagnostic groups and explore the relationship between nutritional status and quality of life (QoL). METHODS: Consecutive patients attending an ILD clinic within a tertiary referral hospital in Sydney, Australia were studied. Weight, body-mass-index, anthropometrics, handgrip strength (HGS), subjective global assessment and QoL questionnaires (EQ-5D-5L and King's-Brief Interstitial-Lung-Disease 'K-BILD') were collected. Associations between nutritional status and QoL were analysed. RESULTS: Ninety participants were recruited and categorised: (1) Idiopathic Pulmonary Fibrosis (IPF) (2) Connective-Tissue Disease associated-ILD (CTD-ILD) or (3) Other (non-IPF/non-CTD ILD). Median age was 66.5 (18) years. Four-percent of patients were underweight and 50% were overweight or obese. Median HGS was 71%-(25.3) of predicted and was correlated to all measures of QoL including EQ-5D health-state index (r = 0.376, p < 0.0001), patient-reported EQ-5D-5L Visual Analogue Score (r = 0.367, p < 0.0001) and K-BILD total score (r = 0.346, p = 0.001). Twenty-three percent of the variance in K-BILD total score (F = 12.888, p < 0.0001) was explained by HGS (ß = 0.273, p = 0.006) and forced vital capacity % predicted (ß = 0.331, p = 0.001). CONCLUSIONS: Although a small number of ILD patients were malnourished, a large proportion of the cohort were overweight or obese. Handgrip strength was compromised and correlated to QoL. Future research with a larger cohort is required to explore the role of HGS as a predictor of QoL.

A framework to support quality of care for patients with chronic intestinal failure requiring home parenteral nutrition.

BACKGROUND AND AIM: Chronic intestinal failure requiring home parenteral nutrition (HPN) is a disabling condition that is best facilitated by a multidisciplinary approach to care. Variation in care has been identified as a key barrier to achieving quality of care for patients on HPN and requires appropriate strategies to help standardize management. METHOD: The Australasian Society for Parenteral and Enteral Nutrition (AuSPEN) assembled a multidisciplinary working group of 15 clinicians to develop a quality framework to assist with the standardization of HPN care in Australia. Obstacles to quality care specific to Australia were identified by consensus. Drafts of the framework documents were based on the available literature and refined by two Delphi rounds with the clinician work group, followed by a further two involving HPN consumers. The Oxford Centre for Evidence-Based Medicine Levels of Evidence was used to assess the strength of evidence underpinning each concept within the framework documents. RESULTS: Quality indicators, standards of care, and position statements have been developed to progress the delivery of quality care to HPN patients. CONCLUSION: The quality framework proposed by AuSPEN is intended to provide a practical structure for clinical and organizational aspects of HPN service delivery to reduce variation in care and improve quality of care and represents the initial step towards development of a national model of care for HPN patients in Australia. While developed for implementation in Australia, the evidence-based framework also has relevance to the international HPN community.

Nutritional management of patients with oesophageal cancer throughout the treatment trajectory: benchmarking against best practice.

PURPOSE: Oesophageal cancer (OC) impacts nutritional status and outcomes. This study aims to benchmark the current nutrition management of patients with OC against best practice recommendations, identify critical points in the treatment trajectory where nutritional status is compromised, service gaps and opportunities for improvement. METHODS: A retrospective audit collected demographic, medical and nutritional data from medical records of patients who received curative treatment for OC at a tertiary referral hospital in Sydney, Australia. RESULTS: Thirty-seven patient records were audited over the time period. Twenty-nine patients underwent nutrition screening on admission to the service. Eighteen out of 25 patients receiving neoadjuvant radiation therapy, all patients during surgical admission, and only 19 patients at postsurgical discharge were seen by a dietitian. All patients received tube feeding post-operatively; however, initiation within 24 h only occurred for 14 patients. Weight significantly declined over the course of treatment (p < 0.001), whilst malnutrition during surgical admission (p = 0.004) and postsurgical discharge (p = 0.038) were both associated with significantly higher unplanned readmissions. CONCLUSIONS: Best practice recommendations were met for aspects of the immediate post-operative period; however, service gaps remain during pre-operative and post-discharge care. Findings from this study indicate that nutritional care is inconsistent across different treatment stages, and malnutrition impacts negatively on unplanned readmission. Research is needed to address evidence-practice gaps, assess appropriateness of recommendations and provide evidence for models of care during multimodality treatments and across different services.

Oral nutrition interventions in patients undergoing gastrointestinal surgery for cancer: A systematic literature review.

PURPOSE: Weight loss and poor food intake have been shown to affect several outcomes in patients undergoing surgery for gastrointestinal cancer. This review aims to examine the effect of pre-, post- or perioperative nutrition interventions focused on increasing oral energy or protein intake in patients undergoing surgery for gastrointestinal cancer. Interventions using standard oral nutrition supplements and/or dietary counselling were included. The primary outcome was weight change, and secondary outcomes were energy and protein intake. A secondary aim was to examine this effect in malnourished patients. METHODS: Embase, Medline, CINAHL and CENTRAL were searched from inception to September 2019 for relevant randomised controlled trials. Study quality was assessed using the revised Cochrane Collaboration risk of bias tool for randomised trials. The quality of evidence for each outcome was assessed using GRADE. RESULTS: Fourteen articles met the inclusion criteria. Studies assessed patients undergoing surgery for gastric, colorectal, oesophageal and pancreatic cancers. The interventions studied included oral nutrition supplements and/or dietary counselling. Five studies reported preoperative interventions; five studies reported post-operative interventions; six studies reported post-discharge interventions; and two studies reported perioperative interventions. Overall, low or very low quality evidence was found to support the use of oral nutrition supplements to positively influence weight and increase energy and protein intake in the preoperative period and immediate post-operative period. Very low quality evidence was found to support the use of oral nutrition interventions to influence weight, energy or protein intake in the post-discharge period. Very limited evidence with high risk of bias was found to support positive effects of nutrition intervention in malnourished patients. CONCLUSIONS: This review demonstrates limited evidence for the use of oral nutrition supplements to increase intake and positively influence weight in patients undergoing surgery for gastrointestinal cancer. Overall, results were heterogeneous leading to inconsistent results. Further research into optimal nutrition support interventions and timing of interventions is required.

Assessing nutritional status in a cohort of liver cirrhosis outpatients: A prospective cross-sectional study.

BACKGROUND: Malnutrition impairs prognosis in patients with liver cirrhosis (LC). There is limited research exploring the prevalence of malnutrition in patients with LC in an Australian population and in outpatient settings. AIMS: One aim of this study was to investigate the prevalence of malnutrition in patients with LC in an outpatient liver clinic at a tertiary metropolitan hospital in Sydney, Australia, and explore other factors that may be associated with malnutrition. The second aim was to compare different versions of Subjective Global Assessment (SGA). METHODS: This cross-sectional study evaluated the nutritional status of 42 prospectively recruited participants by SGA, SGA modified for liver disease (SGA-LD) and patient-generated SGA (PG-SGA). Anthropometric measures and handgrip strength (HGS) were also measured for comparison. Clinical and demographic data were compared with nutritional status. RESULTS: SGA, SGA-LD and PG-SGA yielded the same prevalence of malnutrition of 40% with very good agreement (kappa value = 1.00). Malnourished patients had a lower median HGS% of normal than those who were well-nourished. Malnourished patients also had anthropometric measurements trending towards the lower percentiles of a healthy population. Nutritional status was significantly associated with ethnicity (p = 0.02) and PG-SGA score (p < 0.0001). CONCLUSION: The present study showed that nearly half of our study population were malnourished (40%). Thus, nutrition intervention in terms of nutrition support could improve patient outcomes. It appears that the standard SGA is suitable to assess nutritional status in patients in the early stages of LC compared to more time-consuming SGA versions.

Preoperative Nutrition Status and Postoperative Outcomes in Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy.

BACKGROUND: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is a complex surgery to treat peritoneal surface malignancy (PSM). PSM and gastrointestinal (GI) resection from CRS can lead to significant GI symptoms and malnutrition. There is limited research into the nutrition status of this patient group and the impact of malnutrition on morbidity. OBJECTIVE: This study aims to determine if preoperative malnutrition, assessed using the Subjective Global Assessment (SGA), is associated with postoperative morbidity and increased length of stay (LOS) in patients undergoing CRS/HIPEC for PSM. METHODS: This study prospectively assessed the nutritional status of patients undergoing CRS/HIPEC using a validated nutrition assessment tool. Preoperative clinical symptoms, Peritoneal Cancer Index (PCI), intraoperative blood transfusions, operative time, GI resections, postoperative morbidity, and LOS, as well as pre- and postoperative nutritional interventions, were recorded. The impact of preoperative nutritional status was assessed in relation to postoperative complications and hospital LOS. RESULTS: The study included 102 participants; 34 patients (33%) were classified as malnourished (SGA = B or C). Preoperative weight loss (15% vs. 74%; p ≤ 0.001) and the presence of clinical symptoms (18% vs. 47%; p = 0.002) were significantly higher in malnourished patients. While PCI, intraoperative blood transfusions, and GI resections were independent predictors of morbidity, malnutrition was significantly associated with infectious complications and LOS. For each grade of worsening malnutrition, LOS increased by an average of 7.65 days. CONCLUSIONS: Preoperative malnutrition is prevalent in patients undergoing CRS/HIPEC and postoperative morbidity is common. Malnutrition is linked to LOS and plays a role in postoperative outcomes such as infection. Clear pre- and postoperative nutrition pathways are needed to optimize nutrition support and postoperative recovery.

Exploring reasons behind patient compliance with nutrition supplements before pelvic exenteration surgery.

PURPOSE: Compliance with oral nutrition support (ONS) is poorly reported in the literature. Many factors influence compliance, which could mask the true benefits of preoperative ONS. Surgical oncology patients, including pelvic exenteration patients, are often requested by healthcare workers to consume nutrition supplements before surgery. Exploration of barriers and enablers to compliance with nutrition supplements is needed to improve patient compliance and understand the real impact of preoperative ONS. METHOD: A qualitative study using semi-structured interviews was performed to investigate enablers and barriers to preoperative nutrition supplement compliance. Twenty participants who had been asked to consume 15 nutrition supplements, either immunonutrition or standard polymeric supplements, were interviewed. Inductive thematic analysis was used to determine major themes associated with compliance. RESULTS: Twelve out of 20 participants were not compliant with recommended dosing. Well-nourished participants were more compliant than malnourished participants. Major themes associated with compliance were flavour, volume, texture, impact on dietary intake and motivation to consume supplements. Flavour differed between the two groups, negatively impacting compliance in the immunonutrition group. Volume, texture and impact on dietary intake also negatively impacted compliance whereas motivation positively impacted compliance. CONCLUSION: To overcome barriers and enforce enablers with nutrition supplement compliance, it is essential healthcare workers implement individualised interventions, taking into account nutritional status. A range of flavours, minimal volume and low viscosity supplements should be provided to address individual preference and minimise poor compliance. Better-targeted education and regular motivation are needed to improve compliance.

Bridging the gap between research and practice for nutrition support after pelvic exenteration surgery.

BACKGROUND AND OBJECTIVES: Current best practice for postoperative feeding in surgical patients is well established, however implementation of evidence-based practice comes with many challenges. A common barrier is surgeon adherence to guidelines and the reasons behind this are not well understood. Pelvic exenteration surgery is a complex surgery and postoperative feeding methods in this patient cohort vary significantly from patient to patient. The aim of this study was to identify barriers and enablers for surgeons to implement evidence based feeding methods after pelvic exenteration surgery and provide practical strategies for non-surgeon healthcare workers to improve compliance. METHODS AND STUDY DESIGN: A qualitative study was conducted by performing semi-structured interviews with 12 Consultant Surgeons at hospitals in Australia and New Zealand with dedicated pelvic exenteration services. Deductive and inductive thematic analysis was performed in line with the Theoretical Domains Framework and Behaviour Change Wheel model to identify relevant domains, themes and intervention functions. RESULTS: Culture was identified as an overarching theme that influenced postoperative feeding practices, surgeon behaviours and sub-themes. Identified sub-themes included motivation, relationships and expectations, environment and 'moving forward'. Motivations to use different types of feeding routes postoperatively varied across hospitals. Relationships, surgeons' expectations and the environment all influenced the way in which patients were fed postoperatively. Practical strategies were identified to assist non-surgeon healthcare workers achieve positive change moving forward with postoperative feeding. CONCLUSIONS: Practical strategies to promote enablers and reduce barriers are required to bring about positive change and align practice with the evidence.

Development of consensus on models of care in adults with intestinal failure using a modified Delphi approach.

BACKGROUND AND AIM: The aims of this study were to establish consensus on service delivery models for management of Type III intestinal failure (IF) and home parenteral nutrition (HPN) within the Australian health-care system and to identify barriers and enablers in moving towards this ideal model. METHODS: A modified Delphi methodology was utilized to survey experts working in Type III IF HPN. The panel comprised physicians, dietitians, nurses, and pharmacists from 18 of the 20 adult Type III IF HPN centres across Australia. The study consisted of two rounds of email administered questionnaires developed around four key areas of health service delivery: access to services, clinical care, service guidance, and models of care. Open-ended responses were evaluated via an inductive thematic approach to identify areas of consensus. Experts reviewed the final report to consolidate consensus and validity. RESULTS: There was >80% consensus that an ideal team should consist of a physician, nurse, dietitian, pharmacist, and access to psychological support. Consensus supported the need for updated guidelines (75%) and a hub and spoke model of care (82%). However, further consultation is required in order to establish consensus around the use of HPN in the palliative oncology setting (69%). CONCLUSIONS: This consensus provides a framework within which health professionals, managers, policy-makers, and consumer groups can move towards optimal management for Type III IF HPN patients. Advocacy and a review of service delivery across Australia are now required to facilitate the ideal model of care identified.

A prospective audit of preprocedural fasting practices on a transplant ward: when fasting becomes starving.

AIMS AND OBJECTIVES: To investigate the prevalence and duration of preprocedural medically ordered fasting during a period of hospitalisation in an Australian population of patients with hepatic cirrhosis or following liver transplantation and to identify potential solutions to reduce fasting times. BACKGROUND: Protein-energy malnutrition is a common finding in patients with hepatic cirrhosis and can impact significantly on survival and quality of life. Protein and energy requirements in patients with cirrhosis are higher than those of healthy individuals. A significant feature of cirrhosis is the induction of starvation metabolism following seven to eight hours of food deprivation. Many investigative and interventional procedures for patients with cirrhosis necessitate a period of fasting to comply with anaesthesia guidelines. DESIGN: An observational study of the fasting episodes for 34 hospitalised patients with hepatic cirrhosis or following liver transplantation. METHODS: Nutritional status was estimated using subjective global assessment and handgrip strength. The prevalence and duration of fasting practices for diagnostic or investigational procedures were estimated using electronic records and patient notes. RESULTS: Thirty-three patients (97%) were malnourished. Twenty-two patients (65%) were fasted during the observation period. There were 43 occasions of fasting with a median fasting time of 13·5 hours. On 40 occasions fasting times exceeded the maximum six-hour guideline recommended prior to the administration of anaesthesia by the majority of Anaesthesiology Societies. The majority of procedures (77%) requiring fasting occurred after midday. Eating breakfast on the day of the procedure reduced fasting time by 45%. CONCLUSIONS: Medically ordered preprocedural fasting times almost always exceed existing guidelines in this nutritionally compromised group. RELEVANCE TO CLINICAL PRACTICE: Adherence to fasting guidelines and eating breakfast before the procedure can reduce fasting times significantly and avoid the potential induction of starvation metabolism in this nutritionally at risk group.

A qualitative study into the impact of fasting within a large tertiary hospital in Australia--the patients' perspective.

AIMS AND OBJECTIVES: This qualitative study aims to explore the physical and emotional impact of fasting from the patients' perspective. BACKGROUND: Fasting patients in hospital is common practice and generally viewed as necessary for symptom management or for safety of healthcare provision. Negative impacts of repeated or prolonged fasting on nutritional status have been well researched, but little is documented as to how fasting impacts an individual patient's psyche. DESIGN: Qualitative descriptive design within a tertiary hospital in Sydney, Australia. METHODS: Twelve patients having had prolonged periods of continuous or intermittent fasting were invited to participate in a semi-structured interview between January-September 2012. Questions for interview explored each patient's experience of fasting, including physical and emotional impacts, interpretation of communication regarding fasting and the process of recommencing on fluids or foods. An inductive thematic analysis approach was used. RESULTS: Analyses showed six main themes: physical impacts; emotional impacts; food as structure; nil by mouth as jargon; fear of food re-introduction; and dissatisfaction regarding unnecessary fasting. Overwhelmingly, thirst was reported as the worst physical effect of fasting. In the first few days of fasting, patients became emotionally fixated on food. This quickly dissipated leading to a lack of appetite and fear of starting to eat again. CONCLUSIONS: Discomfort experienced by patients coupled with lack of appetite resulting from prolonged fasting and difficulty with food re-introduction strengthens the argument for reducing fasting times in hospital. When patients are fasted, proper hydration and establishing alternate routes of medication administration should be a priority. RELEVANCE TO CLINICAL PRACTICE: It is well recognised that fasting for prolonged periods is detrimental to health outcomes, but this study also shows the distress that fasting can cause. Inadequate hospital systems and out-dated practices need to be replaced with evidence-based, patient-centred governance, addressing the physical, emotional and psychosocial impact of fasting.

Funding and resource availability for home parenteral nutrition in Australia: A national cross-sectional survey.

BACKGROUND: Home parenteral nutrition (HPN) is a life-saving therapy required for the management of type III intestinal failure, one of the rarest organ failures. It requires a multidisciplinary approach to manage the complexity of the underlying medical, surgical, and nutrition issues, but the current levels of healthcare funding in Australia are unknown. This study aimed to quantify the caseload, staffing, and capacity of existing HPN centers nationally. METHODS: This was a cross-sectional survey inviting centers known to provide HPN care. The survey was designed to capture metrics related to the national framework for the delivery of HPN. These centered on staffing levels, patient load, capacity to audit key outcomes, and service challenges. RESULTS: A total of 24 (89%) of 27 invited centers responded to the survey. There were 17 (71%) adult centers and 7 (29%) pediatric centers. Adult centers managed a median of 12 (interquartile range [IQR]: 6-25) patients vs 16 (IQR: 9-17) in pediatric centers. Several centers did not have dedicated funding for core team members. The total funded clinician time each week per patient was 7 min (IQR: 0-12 min) in adult centers and 14 min (IQR: 10-21 min) in pediatric centers. Fewer than half of centers reported having sufficient resources to regularly audit key metrics. CONCLUSION: The availability of dedicated expertise to manage the highly complex needs of people living with type III intestinal failure is lacking in Australia. Current funding of HPN services falls well short of being sufficient to meet the requirements outlined in the national quality framework.

The impact of malnutrition on cognition in older adults: A systematic review.

BACKGROUND: There is a lack of evidence to support the hypothesis that malnutrition may promote cognitive decline. This study aimed to explore the available literature on this topic. METHODS: A systematic review was undertaken of studies investigating the effect of nutritional status on cognitive function in adults of any age, using Medline, Embase, PsycINFO and Global Health via OvidSP from earliest available dates to January 2024. Studies were excluded if they were conducted in animal or paediatric populations, or if they did not include measurements of baseline nutritional status or follow-up assessment of cognitive function. Selected studies were assessed for quality, and data extracted. A meta-analysis was not conducted due to the heterogeneity of the data. RESULTS: A total of nine studies (three randomised and six observational) was retrieved, including total 8697 subjects who were all in older age groups. Study quality was generally poor. Seven of the nine studies supported the hypothesis that baseline nutritional status is predictive of change in cognitive function at later assessment, but all studies failed to control for significant confounders and six of the nine had large amounts of missing data at follow-up, so that it remains unclear whether nutrition is independently associated with later cognitive function. CONCLUSION: Malnutrition may be associated with subsequent development of cognitive dysfunction in older adults. Higher quality studies in a wider range of age groups are needed to investigate whether nutritional status has an independent impact on cognitive function, and whether this is related to specific nutrient deficiencies.