Effectiveness of ORSL® Variants as an Adjuvant along with Standard-of-care Treatment in the Restoration of Oral Fluid, Electrolytes, and Energy in Patients with Fever and/or General Weakness in Indian Patients in an Outpatient Setting.

BACKGROUND: Dehydration due to reduced intake or increased losses including insensible losses in patients with acute nondiarrheal diseases may lead to fluid, electrolytes, and energy (FEE) deficits. The impact of oral FEE supplementation adjuvant to standard of care (SOC) treatment on recovery in patients with acute nondiarrheal diseases is yet to be evaluated. AIM: To determine the effectiveness of ORSL® variants (ORSL® Apple Drink and ORSL® PLUS Orange Drink), fruit juice-based electrolyte drinks as an adjuvant along with SOC in the restoration of oral FEE in patients with acute nondiarrheal disease with fever and/or general weakness who attended an outpatient department (OPD). MATERIALS AND METHODS: This was a prospective, interventional, open-label, multicenter, real-world, study conducted at eight sites across India. Patients with fever and/or general weakness due to an acute nondiarrheal illness were given either ORSL® Apple Drink or ORSL® PLUS Orange Drink as an adjuvant along with SOC treatment per physician's discretion. The primary endpoint of the study was to assess improvement from baseline in energy or hydration levels after ORSL® variants consumption at 6, 24, and 48 hours measured by a new aided recovery scale (ARS). Secondary endpoints were to assess the improvement in energy and hydration levels at 20, 40, and 60 minutes, as well as energy levels and hydration levels at 20, 40, and 60 minutes, 6, 24, and 48 hours after the consumption of ORSL® Apple Drink or ORSL® PLUS Orange Drink. The patient's consumption of ORSL® variants and treatment experience, physician's experience of recommending ORSL® variants, and product safety were evaluated. RESULTS: In total, 612 patients were enrolled with mean age 38.3 years, of whom 62.9% were male. The mean baseline level of energy and hydration was 1.59 (range 1.0-2.0) on ARS. Statistically significant (p < 0.0001) improvements were observed in energy or hydration 6 hours after first consumption of ORSL formulations. Furthermore, improvement was observed from 40 minutes, and in levels of energy, hydration, and both energy and hydration from 60 minutes. Patients and physicians reported a positive experience with ORSL® variants. CONCLUSION: ORSL® Apple Drink and ORSL® PLUS Orange Drink are clinically proven to provide hydration and/or energy to patients with fever and/or general weakness.

Association of Physicians of India Expert Recommendations on Oral Fluid, Electrolytes, and Energy Management during Transition Care and Discharge for Hospitalized Patients with Nondiarrheal Illnesses.

Acute nondiarrheal illnesses (NDIs) involve overt or subclinical dehydration, requiring rehydration and electrolyte repletion. Dehydration is frequently under-recognized and under-managed, both in outpatient departments (OPDs) and inpatient departments (IPDs). Postadmission dehydration is associated with longer hospital stays and higher inhospital mortality rates. Recognizing and understanding dehydration in hospitalized patients is necessary due to the adverse outcomes associated with this condition. In this article, we aimed to develop practical consensus recommendations on the role of oral fluid, electrolyte, and energy (FEE) management in hospitalized patients with FEE deficits in NDI. The modified Delphi consensus methodology was utilized to reach a consensus. A scientific committee comprising eight experts from India formed the panel. Relevant clinical questions within three major domains were formulated for presentation and discussion: (1) burden and factors contributing to dehydration in hospitalized patients; (2) assessment of fluid and electrolyte losses and increased energy requirements in hospitalized patients; and (3) management of FEE deficits in hospitalized patients [at admission, during intravenous (IV) therapy, IV to oral de-escalation, and discharge]. The consensus level was classified into agreement (mean score ≥4), no consensus (mean score <4), and exclusion (mean score <4 after the third round of discussion). The questions that lacked agreement were discussed during the virtual meeting. The experts agreed that the most common factors contributing to dehydration in patients with NDI hospitalized in IPDs include decreased oral fluid intake, increased fluid loss due to the illness, insensible fluid loss, and a lack of awareness among doctors about dehydration, which can result in poor fluid intake. Time constraints, discontinuity of care, lack of awareness of the principles of fluid balance, lack of formal procedures for enforcing hydration schemes, and lack of adequate training are most often barriers to the assessment of hydration status in hospital settings. Experts used hydration biomarkers, such as changes in body weight, serum, or plasma osmolality; fluid intake; and fluid balance charts; along with urine output, frequency, quantity, and color, to determine hydration status in hospital settings. Experts agreed that appropriate FEE supplementation in the form of ready-to-drink (RTD) fluids can restore FEE deficits and shorten the length of hospital stays in hospitalized patients at admission, during de-escalation from IV to oral therapy, and at discharge. RTD electrolyte solutions with known concentrations of electrolytes and energy are good choices to avoid taste fatigue and replenish FEE in hospitalized patients during transition care and at discharge.

Oral Fluid, Electrolytes, and Energy Management in Various Adult and Geriatric Illnesses beyond Diarrhea: An Indian Expert Panel Delphi Consensus Recommendation.

BACKGROUND: Dehydration is a highly prevalent clinical challenge in adults which can go undetected. Although dehydration is commonly associated with an increased risk of hospitalization and mortality, only a few international guidelines provide recommendations regarding oral fluids, electrolytes, and energy (FEE) management in adults/geriatrics with dehydration due to nondiarrheal causes. Currently, there is a lack of comprehensive recommendations on the role of oral FEE in nondiarrheal dehydration in adult and geriatric Indian patients. MATERIALS AND METHODS: A modified Delphi approach was designed using an online questionnaire-based survey followed by a virtual meeting, and another round of online surveys was used to develop this consensus recommendation. In round one, 130 statements, including 21 open-ended questions, were circulated among ten national experts who were asked to either strongly agree, agree, disagree, or strongly disagree with statements and provide responses to open-ended questions. The consensus was predefined at 75% agreement (pooling "strongly agree" and "agree" responses). Presentation of relevant literature was done during a virtual discussion, and some statements (the ones that did not achieve predefined agreement) were actively discussed and deliberately debated to arrive at conclusive statements. Those statements that did not reach consensus were revised and recirculated during round two. RESULTS: Consensus was achieved for 130/130 statements covering various domains such as assessment of dehydration, dehydration in geriatrics, energy requirement, impact of oral FEE on patient outcome, and fluid recommendations in acute and chronic nondiarrheal illness. However, one statement was not added as a recommendation in the final consensus (129/130) as further literature review did not find any supporting data. Oral FEE should be recommended as part of core treatment from day 1 of acute nondiarrheal illness and started at the earliest feasibility in chronic illnesses for improved patient outcomes. Appropriately formulated fluids with known electrolyte and energy content, quality standards, and improved palatability may further impact patient compliance and could be a good option. CONCLUSION: These consensus recommendations provide guidance for oral FEE recommendations in Indian adult/geriatric patients with various nondiarrheal illnesses.

Practice Guidelines for Enteral Nutrition Management in Dysglycemic Critically Ill Patients: A Relook for Indian Scenario.

BACKGROUND AND AIM: Intensive-care practices and settings differ for India in comparison to other countries. While guidelines are available to direct the use of enteral nutrition (EN), there are no recommendations specific to nutritional management of EN in dysglycemic patients, specific to patients in Indian critical care settings. Advisory board meetings were arranged to develop the practice guidelines specific to the Indian context, for the use of EN in dysglycemic critically ill patients and to overcome challenges in this field. MATERIALS AND METHODS: Two advisory board meetings were organized to review various existing guidelines, meta-analyses, randomized controlled trials (RCTs), controlled trials and review articles, for their contextual relevance and strength. Three rounds of Delphi voting were done to arrive at consensus on certain recommendations. A systematic grading of practice guidelines by the advisory board was done based on strength of the consensus voting and reviewed supporting evidences. RESULTS: Based on the literature review, the recommendations for developing the practice guidelines were made as per the grading criteria agreed upon by the advisory board. The recommendations were to address challenges regarding prediction and assessment of dysglycemia (DG), acceptable glycemic targets in such settings, general nutritional aspects pertaining to DG nutrition, and nutrition in various superspecialty cases in critical care settings, where DG is commonly encountered. CONCLUSION: This paper summarizes the optimum EN practices for managing DG in critically ill patients. The practical solutions to overcome the challenges in this field are presented as practice guidelines at the end of each section. These guidelines are expected to provide guidance for EN management in dysglycemic critically ill patients. These guidelines also outline the model glycemic control task force and its roles in nutrition care as well as an intensive care unit DG nutrition protocol. HOW TO CITE THIS ARTICLE: Mehta Y, Mithal A, Kulkarni A, Reddy BR, Sharma J, Dixit S, et al. Practice Guidelines for Enteral Nutrition Management in Dysglycemic Critically Ill Patients: A Relook for Indian Scenario. Indian J Crit Care Med 2019;23(12):594-603.

Comparative clinical and radiographic evaluation of mineralized cancellous bone allograft (puros®) and autogenous bone in the treatment of human periodontal intraosseous defects: 6-months follow-up study.

AIMS: Several materials have been introduced as bone grafts, i.e., autografts, allograft, xenografts, and alloplastic grafts, and studies have shown them to produce greater clinical bone defect fill than open flap debridement alone. The aim of this clinical and radiological 6-month study was to compare and evaluate the clinical outcome of deep intraosseous defects following reconstructive surgery with the use of mineralized cancellous bone allograft (Puros®) or autogenous bone. MATERIALS AND METHODS: Ten patients with 12 sites exhibiting signs of moderate generalized chronic periodontitis were enrolled in the study. The investigations were confined to two and three-walled intra bony defects with a preoperative probing depth of ≥5 mm. Six of these defects were treated with Puros® (group A) the remaining six were treated with autogenous bone graft (group B). Allocation to the two groups was randomized. The clinical parameters, plaque index (PI), gingival index (GI), probing pocket depth (PPD), clinical attachment level (CAL), and bone fill, were recorded at different time intervals at the baseline, 1 month, 3 months, and 6 months. Intraoral radiographs were taken using standardized paralleling cone technique at baseline, 1, 3, and 6 months. Statistical analysis was done by using the one-way analysis of variance (ANOVA) followed by Tukey highly significant difference. RESULTS: Both groups resulted in decrease in probing depth (group A, 3.0 mm; group B, 2.83 mm) and gain in clinical attachment level (group A, 3.33 mm; group B, 3.0 mm) over a period of 6 months, which was statistically insignificant. CONCLUSION: Within the limitations of the present study, it can be concluded that both mineralized cancellous bone allograft (Puros®) or autogenous bone result in significant clinical improvements.

Enteral Nutrition: Whom, Why, When, What and Where to Feed?

Oral and enteral nutrition affects both the anatomical and physiological integrity of the gastrointestinal tract. It downregulates systemic immune response, reduces overall oxidative stress and limits systemic inflammatory responses. It reduces bacterial translocation, limits pathogenic bacteria in the intestines and enables the production of short-chain fatty acids in the colon. Therefore, it is the most physiologic way of providing nutritional support in all patients. The enteral formulas are available as polymeric, semi-elemental and elemental diets. The beneficial effects on the gastrointestinal tract and systemic organs of 'early' enteral nutrition depend on the timing, dose, location and different modalities of enteral delivery. Being familiar with the basic tenets of providing enteral nutrition - the 'Who, Why, When, Where and What' - will result in safe nutritional interventions and achieve a positive clinical outcome.

Noncaloric Benefits of Carbohydrates.

Noncaloric benefits of carbohydrates are due to the presence of dietary fibers, which are a heterogeneous group of natural food sources and form an important component of a healthy diet. They differ in physiochemical properties such as solubility, fermentability and viscosity. They have a wide range of physiological effects resulting in gastrointestinal and systemic benefits. These include appetite, satiety, bowel transit time and function, production of short-chain fatty acids and certain vitamins, and effects on gut microbiota, immunity and inflammation, as well as mineral absorption. They also help to control the glycemic status and serum lipid levels, resulting in reduced incidence rates of atherosclerosis, hypertension, stroke and cardiovascular diseases.

Evidence-based recommendations for addressing malnutrition in health care: an updated strategy from the feedM.E. Global Study Group.

The prevalence of malnutrition ranges up to 50% among patients in hospitals worldwide, and disease-related malnutrition is all too common in long-term and other health care settings as well. Regrettably, the numbers have not improved over the past decade. The consequences of malnutrition are serious, including increased complications (pressure ulcers, infections, falls), longer hospital stays, more frequent readmissions, increased costs of care, and higher risk of mortality. Yet disease-related malnutrition still goes unrecognized and undertreated. To help improve nutrition care around the world, the feedM.E. (Medical Education) Global Study Group, including members from Asia, Europe, the Middle East, and North and South America, defines a Nutrition Care Pathway that is simple and can be tailored for use in varied health care settings. The Pathway recommends screen, intervene, and supervene: screen patients' nutrition status on admission or initiation of care, intervene promptly when needed, and supervene or follow-up routinely with adjustment and reinforcement of nutrition care plans. This article is a call-to-action for health caregivers worldwide to increase attention to nutrition care.