Nutrition Support Therapy.

Nutrition support therapy is the delivery of formulated enteral or parenteral nutrients to restore nutritional status. Family physicians can provide nutrition support therapy to patients at risk of malnutrition when it would improve quality of life. The evidence for when to use nutrition support therapy is inconsistent and based mostly on low-quality studies. Family physicians should work with registered dietitian nutritionists to complete a comprehensive nutritional assessment for patients with acute or chronic conditions that put them at risk of malnutrition. When nutrition support therapy is required, enteral nutrition is preferred for a patient with a functioning gastrointestinal tract, even in patients who are critically ill. Parenteral nutrition has an increased risk of complications and should be administered only when enteral nutrition is contraindicated. Family physicians can use the Mifflin-St Jeor equation to calculate the resting metabolic rate, and they should consult with a registered dietitian nutritionist to determine total energy needs and select a nutritional formula. Patients receiving nutrition support therapy should be monitored for complications, including refeeding syndrome. Nutrition support therapy does not improve quality of life in patients with dementia. Clinicians should engage in shared decision-making with patients and caregivers about nutrition support in palliative and end-of-life care.

Nutritional Support Indications in Gastroesophageal Cancer Patients: From Perioperative to Palliative Systemic Therapy. A Comprehensive Review of the Last Decade.

Gastric cancer treatments are rapidly evolving, leading to significant survival benefit. Recent evidence provided by clinical trials strongly encouraged the use of perioperative chemotherapy as standard treatment for the localized disease, whereas in the advanced disease setting, molecular characterization has improved patients' selection for tailored therapeutic approaches, including molecular targeted therapy and immunotherapy. The role of nutritional therapy is widely recognized, with oncologic treatment's tolerance and response being better in well-nourished patients. In this review, literature data on strategies or nutritional interventions will be critically examined, with particular regard to different treatment phases (perioperative, metastatic, and palliative settings), with the aim to draw practical indications for an adequate nutritional support of gastric cancer patients and provide an insight on future directions in nutritional strategies. We extensively analyzed the last 10 years of literature, in order to provide evidence that may fit current clinical practice both in terms of nutritional interventions and oncological treatment. Overall, 137 works were selected: 34 Randomized Clinical Trials (RCTs), 12 meta-analysis, 9 reviews, and the most relevant prospective, retrospective and cross-sectional studies in this setting. Eleven ongoing trials have been selected from clinicaltrial.gov as representative of current research. One limitation of our work lies in the heterogeneity of the described studies, in terms of sample size, study procedures, and both nutritional and clinical outcomes. Indeed, to date, there are no specific evidence-based guidelines in this fields, therefore we proposed a clinical algorithm with the aim to indicate an appropriate nutritional strategy for gastric cancer patients.

How the Covid-19 epidemic is challenging our practice in clinical nutrition-feedback from the field.

The viral epidemic caused by the new Coronavirus SARS-CoV-2 is responsible for the new Coronavirus disease-2019 (Covid-19). Fifteen percent of the Covid-19 patients will require hospital stay, and 10% of them will need urgent respiratory and hemodynamic support in the intensive care unit (ICU). Covid-19 is an infectious disease characterized by inflammatory syndrome, itself leading to reduced food intake and increased muscle catabolism. Therefore Covid-19 patients are at high risk of being malnourished, making the prevention of malnutrition and the nutritional management key aspects of care. Urgent, brutal and massive arrivals of patients needing urgent respiratory care and artificial ventilation lead to the necessity to reorganize hospital care, wards and staff. In that context, nutritional screening and care may not be considered a priority. Moreover, at the start of the epidemic, due to mask and other protecting material shortage, the risk of healthcare givers contamination have led to not using enteral nutrition, although indicated, because nasogastric tube insertion is an aerosol-generating procedure. Clinical nutrition practice based on the international guidelines should therefore adapt and the use of degraded procedures could unfortunately be the only way. Based on the experience from the first weeks of the epidemic in France, we emphasize ten challenges for clinical nutrition practice. The objective is to bring objective answers to the most frequently met issues to help the clinical nutrition caregivers to promote nutritional care in the hospitalized Covid-19 patient. We propose a flow chart for optimizing the nutrition management of the Covid-19 patients in the non-ICU wards.

[Current status and future vision of nutrition support team at the neurological hospital].

The effect of malnutrition on intractable neurological diseases, including neurodegenerative diseases, is variable. Nutritional status is dependent on various factors such as disease characteristics; various symptoms including dysphagia, respiratory dysfunction, motor weakness, muscle rigidity, involuntary movement, and ataxia; and changes in energy metabolism caused by diseases and its stage. Nutritional therapy for patients with intractable neurological diseases requires the provision of tailor-made supports for individual patients based on sharing of knowledge and experience in multidisciplinary members. Evidence on nutritional management in the field of neurology is limited compared to that in the fields of surgery and internal medicine. This article thus aimed to describe the activities of the nutrition support team (NST) at our hospital that is specialized in intractable neurological diseases and the knowledge obtained through the activities.

Adherence to Guidelines on Nutritional Support by Medical Residents in an Intensive Care Unit in China: A Prospective Observational Study.

BACKGROUND The use of evidence-based clinical practice guidelines improves the quality of patient medical care. Although the implementation of clinical guidelines can be a challenge, nutritional support is important for critically ill patients. This prospective observational study aimed to investigate the attention to and implementation of guidelines for nutritional support in an Intensive Care Unit (ICU) in China and to identify factors that determine attention to these guidelines. MATERIAL AND METHODS The study included 16 medical residents who were interviewed while working in an emergency Intensive Care Unit (ICU) during one month. A structured interview questionnaire on attention to patient nutritional guidelines was used. Interviews were conducted daily after an early ICU ward round, and residents were asked questions regarding each patient. RESULTS The response rate from medical residents was 99.6% (455/457). The rate of attention to and implementation of nutritional support guidelines was 57.1% (260/455) and 73.1% (334/457), respectively. Multivariate logistic regression analysis showed that weekdays and weekends (OR, 0.59; 95% CI, 0.38-0.91), medical groups (OR, 0.67; 95% CI, 0.46-0.98), and the numbers of patients admitted (OR, 0.91; 95% CI, 0.85-0.97) were independently associated with attention to nutritional support guidelines by the residents. CONCLUSIONS Nutritional guidelines for patients in the ICU were not fully paid attention to by medical residents or implemented. The reasons included high work demands and lack of standardized training. Further studies are needed to determine whether measures to reduce workload and improve medical training can improve adherence to nutritional support guidelines in the ICU.

Metabolic interventions in Autism Spectrum Disorder.

Metabolic interventions including special diets and supplements are commonly used in Autism Spectrum Disorder (ASD). Yet little is known about how these interventions, typically initiated by caregivers, may affect metabolic function or the core symptoms of ASD. This review examines possible direct and indirect roles for metabolism in the core symptoms of ASD as well as evidence for metabolic dysfunction and nutritional deficiencies. We also discuss some of the most popular diets and supplements used in our patient population and suggest strategies for discussing the utility of these interventions with patients, families, and caregivers.

Malnutrition in head and neck cancer patients: Impacts and indications of a prophylactic percutaneous endoscopic gastrostomy.

INTRODUCTION: Head and neck cancer (HNC) patients often experience malnutrition before and during treatment. Prophylactic gastrostomy has emerged as an efficient tool for ensuring adequate nutrition. However, there is no suitable algorithm able to identify patients at high risk of malnutrition. The aim of this study was to describe the nutritional management, to assess the impact of prophylactic gastrostomy, and to identify predictors of malnutrition. METHODS: This retrospective study included 152 patients treated with surgery, radiotherapy, or chemotherapy for HNC. The patients were classified according to their gastrostomy status (prophylactic or non-prophylactic). Nutritional, tumoral and treatment characteristics were reported. Clinical and nutritional outcomes were measured 6 weeks after the beginning of treatment. In order to describe the nutritional management and the impact of prophylactic gastrostomy on patients, univariate analysis was generated using chi-square test and Mann-Whitney test or Student's t-test. Logistic regression was performed to identify factors associated with malnutrition. RESULTS: Forty-one patients received prophylactic gastrostomy whereas 111 patients had no nutritional support. Prophylactic gastrostomy placement was associated with a lower initial body mass index, with severe malnutrition, and with initial oral intake disorder. Patients who did not experienced prophylactic gastrostomy had much worse outcomes such as hospital readmissions (P=0.042), relative weight loss at 6 weeks (P<0.0001), dysphagia, severe malnutrition, and poor state of health (P=0.001). Our complication rates (4.9%) were lower than the usual range (5.9-9.3%) and no life-threatening complication was reported. Positive N status, oral intake disorder, concomitant radiochemotherapy, nasopharyngeal, and hypopharyngeal tumor site were significant predictive factors for malnutrition. CONCLUSIONS: Prophylactic percutaneous endoscopic gastrostomy showed advantages in terms of hospital readmissions, relative weight loss at 6 weeks, dysphagia, severe malnutrition, and poor state of health. Tumoral, nutritional and treatment characteristics seem to be predictors for malnutrition. Hence, physicians should integrate these factors in their nutrition algorithm approach.

Survey of nutritional practices in total gastrectomy and oesophagectomy procedures.

AIM: Total gastrectomy and Ivor Lewis oesophagectomy procedures are the mainstay of upper gastrointestinal cancer management. Maintenance of adequate nutritional intake is essential for positive patient outcomes. Although numerous nutritional support options exist, clear evidence-based guidelines on the optimal means and duration of nutritional support are lacking. The aim of this study is to establish preliminary data on the current perioperative nutritional practices of upper gastrointestinal surgeons performing these procedures across Australia and New Zealand. It is hoped this will help provide the platform for future research towards establishing evidence-based guidelines in upper gastrointestinal surgery. METHODS: A questionnaire exploring the nutritional practices and considerations of surgeons was developed and emailed to the members of the Australia & New Zealand Gastric & Oesophageal Surgery Association. RESULTS: A total of 27.4% of Australia & New Zealand Gastric & Oesophageal Surgery Association members completed the questionnaire. Surgeons reported inserting a jejunostomy feeding tube intraoperatively in Ivor Lewis oesophagectomy procedures 80-100% of the time, compared to only 20-39% of the time in total gastrectomy procedures. For both procedures, surgeons often refer their patients to a dietitian preoperatively, and always postoperatively. Preoperative immune-enhancing nutrition is rarely administered. Patient age and BMI are deemed to be of low importance when determining the means of nutritional support. CONCLUSIONS: This study has demonstrated the current nutritional practices employed in Australia and New Zealand for patients undergoing major upper gastrointestinal surgery. Questions remain regarding the noted differences between procedures as well as the optimal means and duration of perioperative nutritional support.

Changes in nutritional routines at discharge in Scandinavia during a 10-year period: A follow-up survey.

BACKGROUND AND AIMS: Time to treat malnutrition during hospital admission is limited due to short hospital stays. Therefore, nutritional care often needs to be continued after discharge from hospital. However, health care professionals' attitudes and discharge routines may not always support continuity of good nutritional practice. The aim of this study was to investigate changes in nutritional discharge routines and related attitudes in Scandinavia (Denmark, Norway, Sweden) over a 10-year period. METHODS: A survey among doctors and nurses in Scandinavian hospitals was conducted in 2012/2014 and results were compared with an identical survey from 2004. Differences between countries were also studied. RESULTS: Response rate in 2012/2014 survey was 25% with 2733 questionnaires returned. There was a statistically significant difference between the countries regarding proportions of respondents reporting routinely measuring patients' weight at discharge (Denmark 14% vs. Norway 4% vs. Sweden 22%, p < 0.0005). However, these proportions had increased since the 2004 survey in all countries. In Denmark and Sweden, evaluation of nutritional status at discharge was more often stated to be a standard procedure in 2012/2014 compared to 2004 (10% vs. 18%, p < 0.0005; 8% vs. 15%, p < 0.0005, respectively). A statistically significant increase was found in the proportion of Danish and Swedish participants responding that the nutritional regimens initiated during hospital stay are always included in discharge summaries (35% vs 41%, p < 0.004; 51% vs. 63%, p < 0.0005, respectively). CONCLUSIONS: The results suggest a positive development in the nutritional discharge routines. Nevertheless, there appears to be room for improvement. Differences in the nutritional practices still exist between the Scandinavian countries.

Nutritional Support Using Enteral and Parenteral Methods.

The purpose of this Clinical Practice Guideline is to provide an approach for optimal nutritional support in the postinjury period for those injured in combat. Indications and contraindications for enteral and parenteral nutrition are addressed. Timing of nutritional support, nutritional goals, energy requirements, and ideal formula selection for various types of traumatic injuries are addressed. Challenges encountered providing nutrional support for the traumatically injured in the deployed environment are also discussed.

Changing paradigms in metabolic support and nutrition therapy during critical illness.

PURPOSE OF REVIEW: To summarize the most recent advances in acute metabolic care and critical care nutrition. RECENT FINDINGS: Recent research has demonstrated unknown consequences of high protein and amino acid administration in the early phase of ICU stay associated with dysregulated glucagon release leading to hepatic amino acid breakdown and suggested adverse effects on autophagy and long-term outcome. Progress has been made to measure body composition in the ICU. Refeeding hypophosphatemia and refeeding syndrome are common during critical illness, phosphate monitoring is essential after the start of nutrition therapy, and caloric restriction is recommendable in these patients.In recent studies, enteral nutrition is no longer superior to parenteral nutrition and signals of harm using the enteral route in shock have been suggested. However, during extracorporeal life support, enteral nutrition seems well tolerated. Intermittent or bolus enteral feeding seems an exciting concept concerning its potential anabolic effects. Studies on vitamin C, thiamine, and corticosteroid combinations suggest potential to improve outcome. SUMMARY: These new findings will probably change the practice of metabolic and nutrition therapy in critical illness and challenge paradigms advocated for long.

Overview of Intensive Care Unit-Related Physical and Functional Impairments and Rehabilitation-Related Devices.

Rehabilitation after critical illness requires a multidisciplinary effort. Nutrition support of critically ill patients aims to correct the imbalance between protein synthesis and protein degradation to maximize strengthening and muscle mass, whereas physical and occupational therapists focus on optimizing strength and mobility through functional activity to help intensive care (ICU) patients return to their precritical illness level of function and improve quality of life. Early mobility has become the new standard of care for ICU patients. Therapists utilize various devices and technologies to increase the feasibility of early mobility and enhance the rehabilitation process to ensure that patients reach their rehabilitation goals. Tools such as electrical stimulation, cycle ergometers, dynamic tilt tables, and resistive bands aid in strengthening. Therapists use safe patient-handling equipment and ambulation aids to address gait impairments. Adaptive toileting, dressing, bathing, and feeding tools facilitate greater independence with activities of daily living. Augmentative and alternative communication devices promote well-being and communication of basic needs. Splints prevent joint contracture and maintain functional range of motion. Overall, many rehabilitation devices are safe and feasible for use in an ICU setting and serve to maximize strength and functional independence. The purpose of this narrative review is to discuss the benefits and limitations of available rehabilitation devices in the context of critical illness rehabilitation goals.

Nutrition in the ICU: new trends versus old-fashioned standard enteral feeding?

PURPOSE OF REVIEW: The narrative review aims to summarize the relevant studies from the last 2 years and provide contextual information to understand findings. RECENT FINDINGS: Recent ICU studies have provided insight in the pathophysiology and time course of catabolism, anabolic resistance, and metabolic and endocrine derangements interacting with the provision of calories and proteins.Early provision of high protein intake and caloric overfeeding may confer harm. Refeeding syndrome warrants caloric restriction and to identify patients at risk phosphate monitoring is mandatory.Infectious complications of parenteral nutrition are associated with overfeeding. In recent studies enteral nutrition is no longer superior over parenteral nutrition.Previously reported benefits of glutamine, selenium, and fish oil seem to have vanished in recent studies; however, studies on vitamin C, thiamine, and corticosteroid combinations show promising results. SUMMARY: Studies from the last 2 years will have marked impact on future nutritional support strategies and practice guidelines for critical care nutrition as they challenge several old-fashioned concepts.