How to interpret and apply the results of indirect calorimetry studies: a case-based tutorial.

Evidence is growing that the individual adjustment of energy targets guided by indirect calorimetry (IC) can improve outcome. With the development of a new generation of devices that are easier to use and rapid, it appears important to share knowledge and expertise that may be used to individualize nutrition care. Despite the focus of this tutorial being on one contemporary device, the principles of IC apply across existing devices and can assist tailoring the nutrition prescription and in assessing response to nutrition therapy. The present tutorial addresses its clinical application in intubated mechanically ventilated and spontaneously breathing adult patients (canopy), i.e. it covers the range from critical illness to outpatients. The cases that are presented show how the measured energy expenditure (mEE), and the respiratory quotient (RQ), i.e. the ratio of expired CO2 to consumed O2, should be applied in different cases, to adapt and individualize nutrition prescription, as it is a good marker of over- or underfeeding at the different stages of disease. The RQ also informs about the patient's body's capacity to use different substrates: the variations of RQ indicating the metabolic changes revealing insufficient or excessive feeding. The different cases reflect the use of a new generation device as a metabolic monitor that should be combined with other clinical observations and laboratory biomarkers. The tutorial also points to some shortcomings of the method, proposing alternatives.

Nutrition, endocannabinoids, and the use of cannabis: An overview for the nutrition clinician.

The endocannabinoid system (ECs) is composed of multiple signaling compounds and receptors within the central and peripheral nervous system along with various organs, including the gut, liver, and skeletal muscle. The ECs has been implicated in metabolism, gut motility, and eating behaviors. The ECs is altered in disease states such as obesity. Recent studies have clarified the role of the gut microbiome and nutrition on the ECs. Exogenous cannabinoid (CB) use, either organic or synthetic, stimulates the ECs through CB1 and CB2 receptors. However, the role of CBs is unclear in regard to nutrition optimization or to treat disease states. This review briefly summarizes the effect of the ECs and exogenous CBs on metabolism and nutrition. With the increased legalization of cannabis, there is a corresponding increased use in the United States. Therefore, nutrition clinicians need to be aware of both the benefits and harm of cannabis use on overall nutrition status, as well as the gaps in knowledge for future research and guideline development.

Fecal Microbiota Transplantation for Severe or Fulminant Clostridioides difficile Infection: Systematic Review and Meta-analysis.

BACKGROUND: Severe or fulminant Clostridioides difficile infection (SFCDI) is associated with significant morbidity and mortality. Emerging evidence suggests fecal microbiota transplant (FMT) may be a promising therapy for SFCDI. AIM: This systematic review determines the safety and efficacy of FMT in medically refractory SFCDI. METHODS: A systematic search of the literature was conducted using PubMed (1965 to 2020), Web of Science (1900 to 20), EMBASE (1974 to 2020), and Cochrane Review (1945 to 2020). Quality appraisal by NIH Study Quality Assessment tools, and data extraction were performed by two teams of independent researchers. The primary outcome was resolution of SFCDI 4 weeks after the final FMT. Pooled resolution rates were calculated using generalized linear mixed models estimates. RESULTS: Two hundred and forty patients from 10 studies (8 case series, 1 case-control and 1 randomized study) were included with 209 individual patient-level data. FMT resulted in resolution of SFCDI within 4 weeks in 211/240 individuals for a pooled estimate of 88% (95% confidence interval [CI]: 0.83 to 0.91). The mean number of FMT required was 1.6 for severe and 2.0 for fulminant CDI resolution. The pooled proportional estimates for patients requiring CDI-directed antimicrobials after FMT was 50% (95% CI: 0.06 to 0.94) for severe CDI and 67.0% (95% CI: 0.30 to 0.91) for fulminant CDI. Serious adverse event rates were low. CONCLUSION: FMT appears effective in treating SFCDI patients with low adverse events, but requires multiple treatments with a significant proportion of patients requiring additional anti-CDI antibiotics to achieve resolution. The optimal route of FMT delivery remains unknown. The presence of pseudomembranous colitis may guide additional FMT or anti-CDI antibiotic treatment.

Implementation of a Whole Food Plant Based Diet in a Food as Prevention Program in a Resource Constrained Environment.

Background: The efficacy of a Whole Food Plant-based (WFPB) diet has been shown in randomized controlled trials in diabetes, cardiovascular disease and obesity. However, it's effectiveness in routine clinical settings is less well documented. This study describes the implementation and outcomes of a "Food as Prevention" program run by a single clinician. Methods: Participants were referred to a "Food as Prevention" program run by a single gastroenterologist at an academic teaching center. The program included 5 physician-led discussion and small group educational sessions. Data collected included demographics, weight and biochemical measurements before and after completion of the program. Statistical analysis included paired t-test and Pearson correlation coefficients were used to assess differences before and after WFPB implementation. Results: A total of 17 participants (age 59 years; 59% female) with an average weight of 90.0 kg attended a median of 3 group sessions. Majority of patients had hyperlipidemia (71%) followed by hypertension (47%) and coronary artery disease (35%), fatty liver disease (35%) and diabetes mellitus (29%). Adoption of a WFPB diet led to significant decreases in weight (4.3 kg; p < 0.01), total cholesterol (0.72 mmol/L; p = 0.046), and triglycerides (0.53 mmol/L; p = 0.005) with an increase in high-density lipoprotein (HDL) (0.10 mmol/L; p = 0.01).Conclusions Implementation of the WFPB diet in this novel pilot program led to weight loss and improvement in biochemical markers of disease. Future studies are needed to implement this model on a larger scale.

The complexities of approaching nutrition in inflammatory bowel disease: current recommendations and future directions.

Inflammatory bowel diseases (IBDs), including Crohn's disease and ulcerative colitis predispose patients to malnutrition due to a combination of increased basal metabolic rate, decreased oral intake, and increased nutritional losses and malabsorption. Malnutrition is common, affecting up to 75% of patients with Crohn's disease and 62% of patients with ulcerative colitis, and is associated with worse disease prognosis, higher complication rates, decreased quality of life, and increased mortality risk. It is imperative to screen patients with IBD for malnutrition to assess those at increased risk and treat accordingly to prevent progression and complications. This literature review provides an overall approach to optimizing nutrition in IBD, focusing on the assessment for the diagnosis of malnutrition, management of macro- and micronutrient deficiencies, and identification of areas for future study.

Challenges in parenteral nutrition in adult ultrashort gut: A case of cachexia.

Patients with ultrashort gut have inadequate nutrient absorption. Parenteral nutrition (PN) is required to meet nutrition requirements caused by chronic intestinal failure (IF). We present a case of cachexia and IF caused by ultrashort gut following an extensive small-bowel resection caused by volvulus that was complicated by small-bowel ischemia. Targeting energy prescriptions to optimize PN using indirect calorimetry in this population with ultrashort gut has not been reported in adults. This case serves to outline the challenges in optimizing PN, including factors such as anabolic status, to meet nutrition requirements in patients with ultrashort gut and cachexia.

A Multi-Factorial Observational Study on Sequential Fecal Microbiota Transplant in Patients with Medically Refractory Clostridioides difficile Infection.

Fecal microbiota transplantation (FMT) is highly effective in recurrent Clostridioides difficile infection (CDI); increasing evidence supports FMT in severe or fulminant Clostridioides difficile infection (SFCDI). However, the multifactorial mechanisms that underpin the efficacy of FMT are not fully understood. Systems biology approaches using high-throughput technologies may help with mechanistic dissection of host-microbial interactions. Here, we have undertaken a deep phenomics study on four adults receiving sequential FMT for SFCDI, in which we performed a longitudinal, integrative analysis of multiple host factors and intestinal microbiome changes. Stool samples were profiled for changes in gut microbiota and metabolites and blood samples for alterations in targeted epigenomic, metabonomic, glycomic, immune proteomic, immunophenotyping, immune functional assays, and T-cell receptor (TCR) repertoires, respectively. We characterised temporal trajectories in gut microbial and host immunometabolic data sets in three responders and one non-responder to sequential FMT. A total of 562 features were used for analysis, of which 78 features were identified, which differed between the responders and the non-responder. The observed dynamic phenotypic changes may potentially suggest immunosenescent signals in the non-responder and may help to underpin the mechanisms accompanying successful FMT, although our study is limited by a small sample size and significant heterogeneity in patient baseline characteristics. Our multi-omics integrative longitudinal analytical approach extends the knowledge regarding mechanisms of efficacy of FMT and highlights preliminary novel signatures, which should be validated in larger studies.

Patient-centered approaches to targeting incomplete bowel preparations for inpatient colonoscopies.

BACKGROUND: A high-quality colonoscopy bowel prep is vital to completing the procedure. Adequate inpatient bowel preparation has been consistently difficult to achieve because of multiple factors. Incomplete bowel prep can lead to repeated colonoscopies, poor patient experience, increased costs, and prolonged hospitalization. This study aimed to develop patient-centered interventions to optimize bowel prep for inpatients undergoing colonoscopy. METHODS: The Model for Improvement and Donabedian frameworks guided this project. An interdisciplinary team compiled quality improvement tools that identified areas for improvement. Interventions development included a nursing tip sheet for troubleshooting symptoms, a standardized order label and a patient educational placemat. Plan-Do-Study-Act (PDSA) cycles were carried out to test and analyze the effects of the interventions. The project aim was a 30% reduction in incomplete inpatient colonoscopies from poor bowel prep. Process measures included the number of colonoscopy split prep order labels, and placemats used. The balancing measure was the number of repeat colonoscopies. RESULTS: Prior to the intervention, 44% (44/99) of inpatient colonoscopies had poor bowel prep resulting in 10 repeat procedures (10%). Post intervention, 60% (28/47) of the colonoscopies used the standardized label, 66% of physician orders used 2-L split prep, and 80% of patients were provided with the educational placemat. Of the 47 colonoscopies audited post intervention, there was a significant decrease in poor prep (27.7% [13/47], P=0.038) for colonoscopies. The percentage of repeated colonoscopies decreased to 4% (2/47). CONCLUSION: Developing simple and easy-to-use patient-centered interventions can effectively improve colonoscopy preparation for hospitalized patients.

Illness progression in chronic fatigue syndrome: a shifting immune baseline.

BACKGROUND: Validation of biomarkers for myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) across data sets has proven disappointing. As immune signature may be affected by many factors, our objective was to explore the shift in discriminatory cytokines across ME/CFS subjects separated by duration of illness. METHODS: Cytokine expression collected at rest across multiple studies for female ME/CFS subjects (i) 18 years or younger, ill for 2 years or less (n = 18), (ii) 18-50 years of age, ill for 7 years (n = 22), and (iii) age 50 years or older (n = 28), ill for 11 years on average. Control subjects were matched for age and body mass index (BMI). Data describing the levels of 16 cytokines using a chemiluminescent assay was used to support the identification of separate linear classification models for each subgroup. In order to isolate the effects of duration of illness alone, cytokines that changed significantly with age in the healthy control subjects were excluded a priori. RESULTS: Optimal selection of cytokines in each group resulted in subsets of IL-1α, 6, 8, 15 and TNFα. Common to any 2 of 3 groups were IL-1α, 6 and 8. Setting these 3 markers as a triple screen and adjusting their contribution according to illness duration sub-groups produced ME/CFS classification accuracies of 75-88 %. The contribution of IL-1α, higher in recently ill adolescent ME/CFS subjects was progressively less important with duration. While high levels of IL-8 screened positive for ME/CFS in the recently afflicted, the opposite was true for subjects ill for more than 2 years. Similarly, while low levels of IL-6 suggested early ME/CFS, the reverse was true in subjects over 18 years of age ill for more than 2 years. CONCLUSIONS: These preliminary results suggest that IL-1α, 6 and 8 adjusted for illness duration may serve as robust biomarkers, independent of age, in screening for ME/CFS.