Incident hyperglycemia, parenteral nutrition administration and adverse outcomes in patients with myeloma admitted for initial auto-SCT.

Parenteral nutrition (PN) exacerbates hyperglycemia, which is associated with increased morbidity and mortality in various cancer populations. By using a retrospective design, we examined incident hyperglycemia in PN and non-PN recipients and the associations with clinical events and 5-year survival in a cohort treated for myeloma with melphalan and auto-SCT (n=112). Clinical comparisons were made at admission, and 'before' and 'after' initiating PN to discern differences and temporality. Actual infusion times were used for PN patients; time frames based on mean PN infusion days were created for the non-PN recipients. Oral intake was lower 'before' in PN vs non-PN patients (P<0.001); however, no differences in mucositis, emesis, infections or transfusions were detected 'before.' Incident hyperglycemia (≥7.0 mmol/L) was significant 'after' PN initiation, and PN recipients experienced delays in WBC (P<0.05) and platelet engraftment (P=0.009), and required significantly greater RBC (P=0.0014) and platelet (P=0.001) support 'after' than non-PN patients. Neutropenic fever and longer hospital stay were more frequent among PN vs non-PN recipients (P<0.001). Differences in 5-year mortality were not apparent. The findings fail to support clinical benefits of PN administration during auto-SCT for myeloma. Further study is needed to discern if hyperglycemia or feeding per se was deleterious in this patient population.

Nutrition assessment: the reproducibility of subjective global assessment in patients requiring mechanical ventilation.

BACKGROUND/OBJECTIVES: The detection of malnutrition in the intensive care unit (ICU) is critical to appropriately address its contribution on outcomes. The primary objective of this investigation was to determine if nutritional status could be reliably classified using subjective global assessment (SGA) in mechanically ventilated (MV) patients. SUBJECTS/METHODS: Fifty-seven patients requiring MV >48 h in a university-affiliated medical ICU were evaluated in this cross-sectional study over a 3-month period. Nutritional status was categorized independently by two registered dietitians using SGA. Frequencies, means (+ s.d.), χ (2) and t-tests were used to describe the population characteristics; agreement between raters was evaluated using the κ statistic. RESULTS: On admission, the average patient was 50.4 (±14.2) years of age, overweight (body mass index: 29.0±9.2kg/m(2)), had an acute physiology and chronic health evaluation II score of 24 (±10) and respiratory failure. Fifty percent (n=29) of patients were categorized as malnourished. Agreement between raters was 95% before consensus, reflecting near perfect agreement (κ=0.90) and excellent reliability. Patients categorized as malnourished were more often admitted to the hospital floor before the ICU (n=32; 56%), reported decreased dietary intake (69 vs 46%, P=0.02) and exhibited signs of muscle wasting (45 vs 7%, P<0.001, respectively) and fat loss (52 vs 7%, P<0.001, respectively) on physical exam when compared with normally nourished individuals. CONCLUSIONS: SGA can serve as a reliable nutrition assessment technique for detecting malnutrition in patients requiring MV. Its routine use should be incorporated into future studies and clinical practice.

Enteral compared with parenteral nutrition: a meta-analysis.

BACKGROUND: The difference in outcomes in patients is unclear when 2 types of enteral nutrition, ie, tube feeding and conventional oral diets with intravenous dextrose (standard care), are compared with parenteral nutrition. OBJECTIVE: We reviewed systematically and aggregated statistically the results of prospective randomized clinical trials (PRCTs) to examine the relations among the nutrition interventions, complications, and mortality rates. DESIGN: We conducted a MEDLINE search for PRCTs comparing the effects of enteral and parenteral nutrition in adults. Two different people abstracted data for the method and outcomes separately. We used fixed-effects meta-analysis technique to combine the relative risks (RRs) of the outcomes of infection, nutrition support complications, other complications, and mortality. RESULTS: Twenty-seven studies in 1828 patients met the study criteria. Aggregated results showed a significantly lower RR of infection with tube feeding (0.64; 95% CI: 0.54, 0.76) and standard care (0.77; 95% CI: 0.65, 0.91). A priori hypotheses showed a lower RR of infection with tube feeding than with parenteral nutrition, regardless of nutritional status, presence of cancer, year of study publication, or quality of the study method. In studies in which participants had high rates of protein-energy malnutrition, there was a significantly higher risk of mortality (3.0; 95% CI: 10.9, 8.56) and a trend toward a higher risk of infection with standard care than with parenteral nutrition (1.17; 95% CI: 0.88, 1.56). CONCLUSIONS: Tube feeding and standard care are associated with a lower risk of infection than is parenteral nutrition; however, mortality is higher and the risk of infection tends to be higher with standard care than with parenteral nutrition in malnourished populations.

Impact of declines in nutritional status on outcomes in adult patients hospitalized for more than 7 days.

OBJECTIVE: To assess the association between changes in nutritional status in hospitalized patients and the occurrence of infections, complications, length of stay in hospital, and hospital charges. DESIGN: A prospective observational study with a retrospective component was conducted over a 7-month interval at a university hospital. SUBJECTS: A total of 404 adults (> or = 18 years old) admitted to the inpatient service for more than 7 days who were not pregnant or lactating and not a psychiatric patient were included. MAIN OUTCOME MEASURES: Major outcome variables included changes in nutritional status as assessed by subjective global assessment (SGA) at hospital admission and discharge, length of stay, hospital charges, complications, and infections. STATISTICAL ANALYSIS PERFORMED: Analysis of variance with a Tukey adjustment for multiple comparisons was used to examine the impact of changes in nutritional status between nutrition change categories for continuous variables (charges and length of stay). Discrete variables were assessed using chi 2 analysis. Logistic regression was used to calculate odds ratios with 95% confidence intervals for the development of complications and infections when compared with the reference group. RESULTS: Compared with the reference group (normally nourished at admission and discharge), patients who declined nutritionally, regardless of nutritional status at admission, had significantly higher hospital charges ($28,631 +/- 1,835 vs $45,762 +/- 4,021). Odds of complications were significantly greater for patients who declined nutritionally, regardless of nutritional status at admission, compared with the reference group. APPLICATIONS/CONCLUSIONS: Declines in patients' nutritional status while they are hospitalized, regardless of their nutritional status at admission, were associated with significantly higher hospital charges and a higher likelihood of complications. Practicing clinicians should make reducing declines in patients' nutritional status a priority regardless of patients' nutritional status at admission.