Documented nutritional therapy in relation to nutritional guidelines post burn injury - a retrospective observational study.

BACKGROUND & AIMS: Intensive nutritional therapy is an essential component of burn care. Regarding post-minor burn injuries, the literature is lacking. The aim of this study was to evaluate documented nutritional therapy in relation to international guidelines after both minor and major burn injuries. The secondary aim of this study was to evaluate the adequacy of energy and protein intake compared to individual nutritional goals post-burn injury. METHODS: A retrospective observational single-centre study including patients admitted between 2017 and 2019 at a burn centre in Sweden was performed. The patients included in the study were ≥18 years old and in need of hospital care for ≥72 h post-burn injury. Information about patients' demographics, nutritional therapy, and clinical characteristics of burn injury was collected. The patients were divided according to total body surface area burnt (TBSA %) into minor burn injuries (TBSA <20%) and major burn injuries (TBSA ≥20%). Descriptive statistics were used to analyse data. Adherence to guidelines was established by comparing 24 nutritional therapy recommendations to documented treatment. If documented nutritional treatment were in accordance with guidelines, adherence was considered high (≥80%), moderate (60-79.9%) or low (<59.9%). RESULTS: One hundred thirty-four patients were included, 90 patients with minor burn injuries and 44 patients with major burn injuries. Documented adherence to the nutritional guideline was overall low. After minor burn injury, 8% (2/24) of nutritional therapy recommendations had a high adherence (fat intake <35% of total energy intake and enteral nutrition as prioritized feeding route), 17% (4/24) a moderate adherence, and 75% (18/24) a low adherence. In patients treated after a major burn injury, there were two recommendations with documented high adherence (Vitamin C and Zinc); 25% (6/24) had moderate adherence, and 67% (16/24) had low adherence. In addition, quite a large amount of missing data was found. Adequacy of documented nutritional intake, compared to the individual documented goal, was 78% (±23%) for energy and 66% (±22%) for protein after minor burn injury. After major burn injury, the adequacy was 89% (±21%) for energy and 78% (±19%) for protein, respectively. CONCLUSIONS: This study revealed low adherence to nutritional guidelines in patients treated for minor and major burn injuries. Compared to major burn injuries, lower documented adequacy for both energy and proteins was found in minor burn injuries. Given the disparity between guidelines and documented nutritional therapy, and the lack of specific guidelines for minor burn injuries, there could be a considerable risk of inadequate nutritional therapy post-burn injury.

Macronutrient composition and its effect on body composition changes during weight loss therapy in patients with non-alcoholic fatty liver disease: Secondary analysis of a randomized controlled trial.

OBJECTIVES: Dietary composition may affect body composition during weight loss therapy. We tested the hypothesis of whether dietary macronutrient composition influences the reduction of total abdominal adipose tissue, subcutaneous adipose tissue (SAT), or visceral adipose tissue (VAT) during weight loss. METHODS: Dietary macronutrient composition and body composition were analyzed as a secondary outcome of a randomized controlled trial of 62 participants with non-alcoholic fatty liver disease. Patients were randomly assigned to a calorie-restricted intermittent fasting (5:2), calorie-restricted low-carbohydrate high-fat (LCHF), or healthy lifestyle advice (standard-of-care) diet in a 12-wk intervention phase. Dietary intake was assessed by self-reported 3-d food diaries and by characterization of total plasma fatty acid profile. Percentage of energy intake (E%) from different macronutrients was calculated. Body composition was assessed by magnetic resonance imaging and anthropometric measurements. RESULTS: The macronutrient composition differed significantly between the 5:2 (fat 36 E% and carbohydrates 43 E%) and the LCHF (fat 69 E% and carbohydrates 9 E%) groups (P < 0.001). Weight loss was similar in the 5:2 and LCHF groups (-7.2 [SD = 3.4] kg versus 8.0 [SD = 4.8] kg; P = 0.44) and significantly larger than for standard of care (-2.5 kg [SD = 2.3]; P < 0.001). The volume of total abdominal fat, adjusted for height, decreased on average by 4.7% (standard of care), 14.3% (5:2), and 17.7% (LCHF), with no significant differences between the 5:2 and LHCF groups (P = 0.32). VAT and SAT, adjusted for height, decreased on average by 17.1% and 12.7% for 5:2, respectively, and by 21.2% and 17.9% for LCHF, with no significant group differences (VAT [P = 0.16] and SAT [P = 0.10]). VAT was mobilized to a greater extent than SAT in all diets. CONCLUSIONS: The 5:2 and LCHF diets had similar effects on changes in intraabdominal fat mass and anthropometrics during weight loss. This might indicate that overall weight loss is more important than diet composition to achieve changes in total abdominal adipose tissue, VAT, or SAT. The results of the present study suggest that there is a need for further studies on the effect of diet composition on body composition changes during weight loss therapy.

Protein intake early after liver transplantation and postoperative outcome: An observational study comparing two nutritional protocols.

OBJECTIVES: Patients undergoing liver transplantation (LT) are at risk for eating difficulties. Adequate nutritional support is important to promote enhanced recovery and to reduce postoperative complications. The aim of this study was to evaluate two nutritional protocols and their effect on total protein intake during the first 7 d after LT. METHODS: Adult patients were monitored daily for energy and protein intake during the first week after LT. Patients with ≥3 d of monitoring were included in the study. Two patient groups were studied: protocol A (pA) based on enteral nutrition (EN) provided from postoperative days 1 through 4 (historical control); and protocol B (pB), which was based on high volume of EN and high-protein oral nutritional supplements (ONS). Outcome measures were hospital length of stay and grade of complications according to Clavien-Dindo within the first 3 mo after transplantation. RESULTS: Seventy patients were included in the study (pA n=34, pB n= 36). The median age was 59 y and 70% were men. During postoperative week 1, patients with pB had a higher daily protein intake (95 g versus 77 g, P < 0.01) and met a higher proportion of estimated protein requirements (80% versus 70%, P < 0.05). There were no differences in severe postoperative outcomes between the two groups. CONCLUSIONS: A nutritional protocol with a higher rate of EN and high-protein ONS resulted in a higher protein intake early after LT. However, there was no difference in severe postoperative outcomes between the two nutritional protocols.

Complications of Gastrostomy Tubes in Patients With Head and Neck Cancer.

OBJECTIVES: Head and neck cancers (HNCs) include various malignant tumors of the upper aerodigestive tract. Due to their anatomical location, HNCs can cause obstruction, odynophagia, or trismus, leading to dysphagia. In addition, this patient group may be vulnerable to treatment side effects both by surgery and oncological treatment, exposing the patients to an even higher risk of malnutrition. The risk of malnourishment is often resolved by applying a feeding gastrostomy tube. The present study aims to identify complication rates after percutaneous endoscopic gastrostomy (PEG) and open gastrostomy (OG) in patients treated for HNC in a high-volume center. STUDY DESIGN: Retrospective cohort study. METHODS: A retrospective cohort study of all patients treated for a new diagnosis of HNC at the Department of Otorhinolaryngology and Head and Neck Surgery at Karolinska University Hospital between January 1, 2000 and December 31, 2018 in whom gastrostomy was performed. RESULTS: Regarding tumor location, 165 (56.7%) were in the pharynx, 68 (23.4%) in the oral cavity, 57 (19.6%) in the larynx, and 1 (0.3%) in the nasal cavity. PEG was performed in 240 (82.5%) and OG in 51 (17.5%) patients. The overall complication rate was 28.2%: 64 (26.7%) among PEG patients and 18 (35.3%) among OG patients. The incidence of major complications was 3.1%. CONCLUSIONS: Our study confirms that enteral feeding via gastrostomy is a safe method, regardless of the technique used (PEG or OG), with a low rate of major complications and no mortality linked to the procedure. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:1778-1784, 2022.

Treatment of NAFLD with intermittent calorie restriction or low-carb high-fat diet - a randomised controlled trial.

BACKGROUND & AIMS: The first-line treatment for non-alcoholic fatty liver disease (NAFLD) is weight reduction. Several diets have been proposed, with various effects specifically on liver steatosis. This trial compared the effects of intermittent calorie restriction (the 5:2 diet) and a low-carb high-fat diet (LCHF) on reduction of hepatic steatosis. METHODS: We conducted an open-label randomised controlled trial that included 74 patients with NAFLD randomised in a 1:1:1 ratio to 12 weeks' treatment with either a LCHF or 5:2 diet, or general lifestyle advice from a hepatologist (standard of care; SoC). The primary outcome was reduction of hepatic steatosis as measured by magnetic resonance spectroscopy. Secondary outcomes included transient elastography, insulin resistance, blood lipids, and anthropometrics. RESULTS: The LCHF and 5:2 diets were both superior to SoC treatment in reducing steatosis (absolute reduction: LCHF: -7.2% [95% CI = -9.3 to -5.1], 5:2: -6.1% [95% CI = -8.1 to -4.2], SoC: -3.6% [95% CI = -5.8 to -1.5]) and body weight (LCHF: -7.3 kg [95% CI = -9.6 to -5.0]; 5:2: -7.4 kg [95% CI = -8.7 to -6.0]; SoC: -2.5 kg [95% CI =-3.5 to -1.5]. There was no difference between 5:2 and LCHF (p = 0.41 for steatosis and 0.78 for weight). Liver stiffness improved in the 5:2 and SoC but not in the LCHF group. The 5:2 diet was associated with reduced LDL levels and was tolerated to a higher degree than LCHF. CONCLUSIONS: The LCHF and 5:2 diets were more effective in reducing steatosis and body weight in patients with NAFLD than SoC, suggesting dietary advice can be tailored to meet individual preferences. LAY SUMMARY: For a person with obesity who suffers from fatty liver, weight loss through diet can be an effective treatment to improve the condition of the liver. Many popular diets that are recommended for weight reduction, such as high-fat diets and diets based on intermittent fasting, have not had their effects on the liver directly evaluated. This study shows that both a low-carb high-fat and the 5:2 diet are effective in treating fatty liver caused by obesity. CLINICAL TRIALS REGISTRATION: This study is registered at Clinicaltrials.gov (NCT03118310).

Energy expenditure early after liver transplantation: Better measured than predicted.

OBJECTIVE: There is no consensus on how to estimate energy requirements after liver transplantation (LT). The aim of this study was to compare measured resting energy expenditure (REE) with predictive equations and fixed factors, and evaluate whether clinical variables were associated with REE. METHODS: During the period of 2011 through 2018, REE measured with indirect calorimetry and predicted by the Harris and Benedict (HB) equation was compared in patients during the first 30 postoperative days after LT. The fixed factors 25 kcal/kg, 30 kcal/kg, or 35 kcal/kg were used to calculate energy requirements. The accuracy of HB and fixed factors were evaluated with a Bland-Altman analysis and Lin's concordance correlation coefficient. The associations of pre- and postoperative clinical variables with REE were evaluated in a multivariate regression analysis. RESULTS: A total of 143 patients were evaluated and had indirect calorimetry performed on postoperative day 6 (interquartile range: 3) in median. The mean measured REE was 1950 ± 461 kcal (range, 720-3309 kcal) or 24.5 ± 6.1 kcal/kg body weight. Large limits of agreements were observed in the Bland-Altman analyses for both HB and fixed factors. HB was closer than fixed factors with a positive concordance (concordance correlation: 0.350; 95% confidence interval, 0.248-0.445) and Pearsons r2 = 0.261. Measured REE was significantly associated (P < 0.05) with age, sex, Model for End-Stage Liver Disease score before LT, surgery time, and graft cold ischemia time according to the multiple regression analysis. CONCLUSIONS: The low accuracy of HB and fixed factors suggests risks of both under- and overfeeding of individual patients if energy requirement is only based on calculation. REE measurement is recommended after LT to secure accurate and safe nutritional therapy.

Nutrition impact symptoms are related to malnutrition and quality of life - A cross-sectional study of patients with chronic liver disease.

BACKGROUND AND AIMS: Patients with chronic liver disease often experience symptoms that affect their ability to eat. These symptoms can contribute to weight loss and malnutrition. We aimed to examine the prevalence of nutrition impact symptoms (NIS) in patients with chronic liver disease, and to investigate the relationships between NIS, malnutrition and health-related quality of life. METHODS: In a cross-sectional study on adult patients with chronic liver disease under evaluation for liver transplantation, we studied NIS with two questionnaires: the Eating Symptoms Questionnaire and the Disease-Related Appetite Questionnaire. Malnutrition was primarily assessed with the Global Leadership Initiative on Malnutrition (GLIM) criteria. Health-related quality of life (HRQOL) was assessed with the Chronic Liver Disease Questionnaire. RESULTS: Among the 133 included patients, 90% reported one or more NIS and 51% reported four or more NIS. The most common symptoms were dry mouth (61%), abdominal pain (58%), diarrhoea (45%) and nausea (41%). Malnutrition was present in 32% according to GLIM criteria. Malnourished patients reported more NIS (p = 0.004) and had lower HRQOL (p < 0.001). Certain NIS, such as pain, poor appetite, changes in taste and early satiety, were predictors for malnutrition. CONCLUSIONS: NIS are common in patients with chronic liver disease and are associated with malnutrition and worse HRQOL. NIS should therefore be systematically assessed in patients with chronic liver disease. Whether identification and proper management of NIS can prevent malnutrition and improve quality of life deserves further exploration.

Assessment of muscle mass depletion in chronic liver disease: Dual-energy x-ray absorptiometry compared with computed tomography.

OBJECTIVES: The aim of this study was to perform intermethod comparisons between the following three measures of muscle mass depletion in patients eligible for liver transplantation: 1) fat-free mass index (FFMI) measured by dual-energy x-ray absorptiometry (DXA), 2) appendicular skeletal muscle mass index (ASMI) measured by DXA, and 3) skeletal muscle index (SMI) measured at the third lumbar level by computed tomography (CT). METHODS: The medical records of patients who received liver transplants between 2009 and 2012 at Karolinska University Hospital were retrospectively reviewed. Adult patients with a chronic liver disease who had both DXA and CT scans performed within a 30-d period during their pretransplant workup were included. RESULTS: Appendicular skeletal muscle mass index measured by DXA (ASMIDXA) and skeletal mass index measured by computed tomography (SMICT) provide similar results when assessing the presence of muscle mass depletion in patients with chronic liver diseases and FFMIDXA can be falsely high in patients with ascites. Both ASMIDXA and SMICT thus appear to be useful methods in the pretransplant evaluation of muscle mass depletion both for patients with and without ascites. CONCLUSIONS: ASMI measured with DXA is a useful alternative method to SMI measured with CT when a CT scan is not clinically indicated or available.

Body composition evaluation with computed tomography: Contrast media and slice thickness cause methodological errors.

OBJECTIVE: Although computed tomography (CT) is frequently used to determine body composition, the effects of using different CT protocols is not well known. The aim of this study was to determine whether contrast media phase, radiation dose, and slice thickness in CT affect body composition segmentation. METHODS: Clinically indicated perfusion CTs of the upper abdomen in 20 patients (seven women) between 40 and 87 y of age with high suspicion of hepatocellular carcinoma were analyzed retrospectively. Axial images from the L3 level with varying imaging delay were reconstructed after contrast media injection (18 images per patient), slice thickness (5 images, 2-10 mm), and radiation dose (4 images with one-third to four-thirds of standard dose). Muscle and fat areas were segmented semiautomatically by drawing regions of interests and using established cutoff thresholds. Skeletal muscle index (SMI), steatotic muscle area, and adipose tissue index, as well as muscle attenuation and fat attenuation, were evaluated. RESULTS: Average SMI increased by up to 2.8% after contrast media injection. Steatotic muscle area decreased by ≤13.8%, and adipose tissue index decreased by ≤6.5%. Muscle attenuation increased after contrast media injection, whereas fat attenuation decreased (all P < 0.001). SMI decreased by 1.9% on average when increasing slice thickness from 2 to 10 mm. Steatotic muscle area increased by ≤3.3%, and adipose tissue index increased by ≤1.5% (all P < 0.05). Muscle attenuation did not change significantly with reconstruction thickness. Radiation dose had no effect on estimated area of spinal muscle, fatty spinal muscle, or visceral fat. CONCLUSIONS: Contrast media have a strong effect on the evaluation of body composition, whereas the influence of slice thickness is less pronounced. Radiation dose can be reduced by ≥66% without significantly affecting segmentation.

Influence of tube potential on CT body composition analysis.

OBJECTIVES: Our purpose was to investigate whether tube potential in contrast-enhanced computed tomography (CT) affects body composition analysis. METHODS: Images from dual-source, dual-energy CT from the abdomen with intravenous contrast media administration were used. A total of 17 patients (11 women, mean age 52) with a mean body mass index of 20.8 kg/cm2 were included. Simultaneously acquired images with a tube voltage of 80 kV and 140 kV were compared. Body composition was analyzed on a single slice at the L3 level. Parameters evaluated included muscle and fat attenuation (Hounsfield units [HU]), skeletal muscle index (cm2/m2), muscle area (cm2), and steatotic muscle area (cm2). Significant differences between 80 kV and 140 kV series were compared using the paired Student's t test. RESULTS: Tube potential affected muscle attenuation with an average difference of 17% between 80 kV and 140 kV series (48 HU versus 41 HU, P < 0.01), fat attenuation (-84 HU versus -69 HU, P < 0.01), skeletal muscle index of 5.2% (40.1 cm2/m2 versus 42.2 cm2/m2, P < 0.01), muscle area of 5.1% (117 cm2 versus 123 cm2, P < 0.01), and steatotic muscle area of 12.9% (31 cm2 versus 35 cm2, P < 0.01). CONCLUSION: Tube potential significantly affects body segmentation in contrast-enhanced CT.