A look inside the gut as a clue to nutritional status.

PURPOSE OF REVIEW: Malabsorption and malnutrition are common gastrointestinal manifestations clinicians face, requiring diagnostic workup for effective diagnosis and management of the underlying cause. This review discusses recent advances in diagnostic approaches to malabsorption and maldigestion of macronutrients - lipids, proteins, and carbohydrates. We highlight underrecognized causes, available testing modalities, and ongoing diagnostic unmet needs. RECENT FINDINGS: Innovations in the diagnostic landscape are enhancing our understanding of malabsorption syndromes. Stool collection and handling is uncomfortable and commonly avoided. The objective quantification of stool lipids, bile acids, and gut enzymes is therefore underused in the diagnosis and management of common disorders such as exocrine pancreatic insufficiency, bile acid diarrhea, protein-losing enteropathy, and more. We review the recent advancements in spot quantification of stool fat and bile acid content, endoscopic imaging techniques such as endocytoscopy, confocal laser endomicroscopy, and optical coherence tomography and the future place in clinical practice. SUMMARY: Malabsorption and maldigestion represent significant challenges in clinical nutrition and gastroenterology. Through the integration of advanced diagnostic techniques, clinicians will be better equipped to tailor therapy and monitor treatment response, ultimately improving patient health outcomes. This review underscores the critical role of innovative diagnostic tools in accurately detecting and effectively managing gastrointestinal disorders linked to nutritional status.

A scoping review of parenteral requirements (macronutrients, fluid, electrolytes and micronutrients) in adults with chronic intestinal failure receiving home parenteral nutrition.

INTRODUCTION: Home parenteral nutrition (HPN) prescriptions should be individualised in adults with chronic intestinal failure (IF). The aims of the review were to explore HPN requirements and available guidelines and to determine whether adults (≥ 18 years) receive recommended parenteral nutrient doses. METHODS: Online databases searches identified empirical evidence (excluding case-reports), reviews and guidelines (Published 2006-2024 in English language). Additional reference lists were hand-searched. Older studies, cited in national guidelines were highlighted to map evidence source. Two reviewers screened 1660 articles independently, with 98 full articles assessed and 78 articles included (of which 35 were clinical studies). Citation tracking identified 12 older studies. RESULTS: A lack of evidence was found assessing parenteral macronutrient (amounts and ratios to meet energy needs), fluid and electrolyte requirements. For micronutrients, 20 case series reported serum levels as biomarkers of adequacy (36 individual micronutrient levels reported). Studies reported levels below (27 out of 33) and above (24 out of 26) reference ranges for single micronutrients, with associated factors explored in 11 studies. Guidelines stated recommended parenteral dosages. Twenty-four studies reported variable proportions of participants receiving HPN dosages outside of guideline recommendations. When associated factors were assessed, two studies showed nutrient variation with type of HPN administered (multichamber or individually compounded bags). Five studies considered pathophysiological IF classification, with patients with short bowel more likely to require individualised HPN and more fluid and sodium. CONCLUSIONS: This review highlights substantial evidence gaps in our understanding of the parenteral nutritional requirements of adult receiving HPN. The conclusions drawn were limited by temporal bias, small samples sizes, and poor reporting of confounders and dose. Optimal HPN nutrient dose still need to be determined to aid clinical decision-making and further research should explore characteristics influencing HPN prescribing to refine dosing recommendations.

Sodium depletion and secondary hyperaldosteronism in outpatients with an ileostomy: a cross-sectional study.

OBJECTIVE: Patients with an ileostomy may experience postoperative electrolyte derangement and dehydration but are presumed to stabilise thereafter. We aimed to investigate the prevalence of sodium depletion in stable outpatients with an ileostomy and applied established methods to estimate their fluid status. METHODS: We invited 178 patients with an ileostomy through a region-wide Quality-of-Life-survey to undergo outpatient evaluation of their sodium and fluid status. The patients delivered urine and blood samples, had bioelectrical impedance analysis performed and answered a questionnaire regarding dietary habits. RESULTS: Out of 178 invitees, 49 patients with an ileostomy were included; 22 patients (45%, 95% CI, 31-59%) had unmeasurably low urinary sodium excretion (<20 mmol/L), indicative of chronic sodium depletion, and 26% (95% CI, 16-41%) had plasma aldosterone levels above the reference value. Patients with unmeasurably low urinary sodium excretion had low estimated glomerular filtration rates (median 76, IQR 63-89, mL/min/1.73m2) and low venous blood plasma CO2 (median 24, IQR 21-26, mmol/L), indicative of chronic renal impairment and metabolic acidosis. Bioelectrical impedance analysis, plasma osmolality, creatinine and sodium values were not informative in determining sodium status in this population. CONCLUSION: A high proportion of patients with an ileostomy may be chronically sodium depleted, indicated by absent urinary sodium excretion, secondary hyperaldosteronism and chronic renal impairment, despite normal standard biochemical tests. Sodium depletion may adversely affect longstanding renal function. Future studies should investigate methods to estimate and monitor fluid status and aim to develop treatments to improve sodium depletion and dehydration in patients with an ileostomy.IMPACT AND PRACTICE RELEVANCE STATEMENTSodium depletion in otherwise healthy persons with an ileostomy was identified in a few publications from the 1980s. The magnitude of the problem has not been demonstrated before. The present study quantifies the degree of sodium depletion and secondary hyperaldosteronism in this group, and the results may help guide clinicians to optimise treatment. Sodium depletion is easily assessed with a urine sample, and sequelae may possibly be avoided if sodium depletion is detected early and treated. This could ultimately help increase the quality of life in patients with an ileostomy.

Impact of negative pressure wound therapy on enteroatmospheric fistulation in the septic open abdomen.

AIM: The effect of negative pressure wound therapy (NPWT) on the pathogenesis and outcome of enteroatmospheric fistulation (EAF) in the septic open abdomen (OA) is unclear. This study compares the development and outcome of EAF following NPWT with that occurring in the absence of NPWT. METHODS: Consecutive patients admitted with EAF following abdominal sepsis at a National Reference Centre for intestinal failure between 01 January 2005 and 31 December 2015 were included in this study. Patients were divided into two groups based on those that had been treated with NPWT and those that had not (non-NPWT) and characteristics of their fistulas compared. Clinical outcomes concerning nutritional autonomy at 4 years and time to fistula development, size of abdominal wall defect and complete fistula closure were compared between groups. RESULTS: A total of 160 patients were admitted with EAF following a septic abdomen (31-NPWT and 129-non-NPWT). Median (range) time taken to fistulation after OA was longer with NPWT (18 [5-113] vs. 8 [2-60] days, p = 0.004); these patients developed a greater number of fistulas (3 [2-21] vs. 2 [1-10], p = 0.01), involving a greater length of small bowel (42.5 [15-100] cm vs. 30 [3.5-170] cm, p = 0.04) than those who did not receive NPWT. Following reconstructive surgery, nutritional autonomy was similar in both groups (77% vs. 72%) and a comparable number of patients were also fistula-free (100% vs. 97%). CONCLUSIONS: Negative pressure wound therapy appears to be associated with more complex and delayed intestinal fistulation, involving a greater length of small intestine in the septic OA. This did not, however, appear to adversely affect the overall outcome of intestinal and abdominal wall reconstruction in this study.

Small bowel feeding: do you pay the price for bypassing the stomach?

PURPOSE OF REVIEW: Hydration and nutritional support is a vital part of medical care, thus a clear understanding of the optimal approach is vital for medical professionals. This is a particularly pertinent issue for patients admitted to a critical care setting. This article aims to define the advantages and disadvantages of gastric and postpyloric feeding in the critical care setting, thus aiding decision-making for clinicians. RECENT FINDINGS: Within the article, the main themes covered are those relating to enteral feeding tube placement, the impact of enteral feeding route on ventilator-associated pneumonia, optimization of enteral tube feeding in critical care and the impact that a chosen route may have upon gastrointestinal function. SUMMARY: The value of enteral feeding in critical illness is proven beyond doubt and the simplest approach has long been 'if the gut works, use it'. If gastric feeding is not able to be established or is not tolerated then jejunal feeding should be considered as a preferable alternative to parenteral nutrition. Improving access to service or techniques for postpyloric tube placement would assist in optimizing nutritional support in the critical care setting.

Patient-Reported Outcomes and Health-Related Quality of Life in People Living With Ileostomies: A Population-Based, Cross-Sectional Study.

BACKGROUND: The impact of a stoma on long-term health-related quality of life in people living with ileostomies is not clear. OBJECTIVE: This study aimed to describe important patient-reported outcomes and health-related quality of life in people with ileostomies. DESIGN: This is a population-based, cross-sectional study. Patients were invited to answer questionnaires estimating stoma-specific and generic health-related quality of life (EQ-5D-5L and the Major Depression Inventory). Danish norms were retrieved from reference literature. SETTINGS: This study was conducted at the major stoma clinic at Aarhus University Hospital, Denmark. PATIENTS: We invited all patients with ileostomies who were in contact with the clinic between 2012 and 2017. MAIN OUTCOME MEASURES: The primary outcomes measured were patient-reported outcomes specific to people with ileostomies. RESULTS: Of 621 identified patients (50% women), 412 (67%) responded to the survey. Among the responders, 178 (43%) reported that they still had an ileostomy at the time of the survey and were included in the analysis. Fatigue was frequent; 68% (95% CI 60%-75%) reported being tired and 26% (95% CI 20%-33%) answered that they were "always tired," whereas 43% (95% CI 36%-51%) lacked energy, 62% (95% CI 54%-69%) reported poor sleep, and 59% (95% CI 52%-66%) needed to rest during the day. Fifty-six percent (95% CI 48%-63%) needed to know the immediate location of the nearest toilet, and 58% (95% CI 51%-66%) felt sexually unattractive because of their ileostomy. Health-related quality of life measured with generic questions indicated 0.124 points lower health-related quality of life than the Danish norm ( p < 0.001), and 18% (95% CI 13%-25%) scored above the threshold for depression, which is 2.6 times higher than the background population (7%, 95% CI 6%-9%; p < 0.001). LIMITATIONS: This study was limited by potential selection bias, and all participants did not answer all items. CONCLUSIONS: Fatigue and low health-related quality of life is common in people living with ileostomies. Addressing fatigue and stoma-specific challenges in patients with an ileostomy is warranted. See Video Abstract at http://links.lww.com/DCR/B803 . DESENLACES INFORMADOS POR PACIENTES Y CALIDAD DE VIDA RELACIONADA CON LA SALUD EN PERSONAS QUE VIVEN CON ILEOSTOMAS UN ESTUDIO TRANSVERSAL POBLACIONAL: ANTECEDENTES:El impacto de un estoma en la calidad de vida relacionada con la salud a largo plazo en personas que viven con ileostomías no está claro.OBJETIVO:Describir desenlaces importantes informados por pacientes y la calidad de vida relacionada con la salud en personas con ileostomías.DISEÑO:Estudio transversal poblacional. Se invitó a los pacientes a responder cuestionarios que estiman la calidad de vida relacionada con la salud general y específica del estoma (EQ-5D-5L y el Inventario de depresión mayor). Las normas danesas se recopilaron de la literatura de referencia.AJUSTES:El estudio se llevó a cabo en la clínica principal de estomas del Hospital Universitario de Aarhus, Dinamarca.PACIENTES:Invitamos a todos los pacientes con ileostomías que estuvieron en contacto con la clínica entre 2012 y 2017.PRINCIPALES MEDIDAS DE RESULTADO:Resultados informados por el paciente específicos para personas con ileostomías.RESULTADOS:De 621 pacientes identificados (50% mujeres), 412 (66%) respondieron la encuesta. Entre los que respondieron, 178 (43%) informaron que todavía tenían una ileostomía en el momento de la encuesta y fueron incluidos en el análisis. La fatiga era frecuente; el 68% (intervalo de confianza del 95%: 60-75%) informó estar cansado y el 26% (20-33%) respondió "siempre cansado", mientras que el 43% (36-51%) carecía de energía, el 62% (54-69%)) refirieron dormir mal y el 59% (52-6%) necesitaba descansar durante el día. El cincuenta y seis por ciento (48-63%) necesitaba saber la ubicación inmediata del baño más cercano y el 58% (51-66%) se sentía sexualmente poco atractivo debido a su ileostomía. La calidad de vida relacionada con la salud medida con preguntas genéricas indicó una calidad de vida relacionada con la salud 0,124 puntos más baja que la norma danesa ( p < 0,001), y el 18% (13-25%) puntuó con depresión, que es 2.6 veces más alta que la población de base (7%, 6-9%, p < 0,001).LIMITACIONES:Posible sesgo de selección, y no todos los participantes respondieron a todos los ítems.CONCLUSIONES:La fatiga y la baja calidad de vida relacionada con la salud es común en las personas que viven con ileostomías. Se justifica abordar la fatiga y los desafíos específicos del estoma en pacientes con una ileostomía. Consulte Video Resumen en http://links.lww.com/DCR/B803 . (Traducción-Juan Carlos Reyes ).

An evaluation of plasma vitamin C concentrations in individuals requiring home parenteral nutrition.

BACKGROUND: Ascorbic acid (VitC) is an essential coenzyme to maintain health, but there are minimal data on the adequacy of VitC supply in patients requiring home parenteral nutrition (HPN). METHODS: A prospective pilot study was carried out measuring plasma VitC, serum vitamins A, D and E, and the minerals zinc, copper, selenium and magnesium in 28 adult HPN-dependent (≥6 months) patients. RESULTS: Fifty-seven percent of patients had insufficient VitC status. There was a strong, positive correlation between HPN provision of VitC and plasma VitC concentrations (rs = 0.663, p = 0.00) with an 83% insufficiency rate below a provision of 800 mg week-1 . There was no association seen between plasma VitC and number of HPN days week-1 (p = 0.539), number of months on HPN (p = 0.773) or dependency on HPN (86% ± 31% of energy requirements met via HPN (77% ± 23%, p = 0.39). CONCLUSIONS: VitC insufficiency is prevalent in HPN-dependent patients. Our data highlight the need for regular monitoring of VitC in those living with type III intestinal failure.

A European survey on the practice of nutritional interventions in head-neck cancer patients undergoing curative treatment with radio(chemo)therapy.

PURPOSE: As the practice of nutritional support in patients with head and neck cancer (HNC) during curative radio(chemo)therapy is quite heterogeneous, we carried out a survey among European specialists. METHODS: A 19-item questionnaire was drawn up and disseminated via the web by European scientific societies involved in HNC and nutrition. RESULTS: Among 220 responses, the first choice was always for the enteral route; naso-enteral tube feeding was preferred to gastrostomy in the short term, while the opposite for period longer than 1 month. Indications were not solely related to the patient's nutritional status, but also to the potential burden of the therapy. CONCLUSION: European HNC specialists contextualize the use of the nutritional support in a comprehensive plan of therapy. There is still uncertainty relating to the role of naso-enteral feeding versus gastrostomy feeding in patients requiring < 1 month nutritional support, an issue that should be further investigated.

Chronic intestinal failure: an overview and future perspectives.

Intestinal failure (IF) is the inability of the gut to absorb necessary water, macronutrients, micronutrients, and electrolytes sufficient to sustain life and requiring intravenous supplementation or replacement. IF Types 1 and 2 are the initial phase of this condition and usually last for weeks to a few months. Type 3 IF (also known as chronic IF [CIF]) is a chronic and stable condition, usually irreversible, whose main treatment is home parenteral nutrition. CIF is a relatively rare condition, and its prevalence and different causes vary throughout the world. Due to its complexity, CIF requires a multidisciplinary team with experience in this field to achieve successful outcomes. This editorial aims to provide an overview of CIF in adults, emphasizing the challenges faced by clinicians when managing this rare entity, as well as outlining the role of the gastroenterologist.

Nutritional considerations in severe primary chronic small intestinal dysmotility.

PURPOSE OF REVIEW: To provide an update on the recent evidence underpinning the approach to nutritional care in patients with severe primary chronic small bowel dysmotility. RECENT FINDINGS: Patients with severe chronic small intestinal dysmotility suffer nutritional and nonnutritional morbidity, both as a result of their underlying polysymptomatic, poorly understood condition and the interventions required. A proportion require artificial nutrition support; however, this is associated with impaired quality of life and associated complications. The approach to nutritional support must therefore engage a multidisciplinary team (MDT) to ensure that decisions to escalate beyond oral nutrition reflect individualised risk-benefit discussions while adopting a holistic approach to symptom management. Since nutritional outcomes are worse in those with the chronic intestinal pseudo-obstruction (CIPO) phenotype, differentiation into CIPO and non-CIPO subgroups, using a pragmatic diagnostic approach rather than invasive/poorly tolerated investigations, can be an important step in achieving nutritional care tailored to the individual. SUMMARY: Malnutrition in patients with severe chronic small intestinal dysmotility is multifactorial. Early engagement of a broad team that includes dietitians, psychologists and pain management experts is crucial to achieving the most beneficial and least harmful patient-centred nutritional care outcomes.

The management of adult patients with severe chronic small intestinal dysmotility.

Adult patients with severe chronic small intestinal dysmotility are not uncommon and can be difficult to manage. This guideline gives an outline of how to make the diagnosis. It discusses factors which contribute to or cause a picture of severe chronic intestinal dysmotility (eg, obstruction, functional gastrointestinal disorders, drugs, psychosocial issues and malnutrition). It gives management guidelines for patients with an enteric myopathy or neuropathy including the use of enteral and parenteral nutrition.

Advances in chronic intestinal failure management and therapies.

PURPOSE OF REVIEW: To summarize changes and recent advances in therapies for chronic intestinal failure (CIF). RECENT FINDINGS: In the last few years, the management of CIF has significantly improved through better prevention and treatment of catheter-related bloodstream infections (CRBSIs) and intestinal failure-associated liver disease (IFALD), as well as improved enteral autonomy by using small bowel growth factors in selected patients. This may have been reflected by a recent reduction in small bowel transplantations. SUMMARY: Although CIF management has become more established and effective, the long-term implications of parenteral nutrition still place substantial burden on patients such that further work is required to improve patients' quality of life as well as continued efforts to reduce complications relating to CIF management.

Measurement of Muscle Mass and Sarcopenia Using Anthropometry, Bioelectrical Impedance, and Computed Tomography in Surgical Patients with Colorectal Malignancy: Comparison of Agreement Between Methods.

Background: Low skeletal muscle index (SMI) and sarcopenia adversely affect clinical outcomes in oncology patients. Study aims were to assess the agreement of bioelectrical impedance analysis (BIA), mid-arm muscle circumference (MAMC), and computed tomography (CT) at the third lumbar vertebra (L3), for the measurement of muscle mass and identification of sarcopenia, in patients with colorectal cancer (CRC).Method: A comparison study of low SMI and sarcopenia determined by BIA and MAMC, compared to CT. Sensitivity, specificity and area under the curve (AUC) were calculated.Results: CT scans were obtained for 100 participants. Low SMI was identified in 29%, 57%, and 20% of participants using CT at L3, BIA, and MAMC, respectively. For low muscle mass BIA showed 60% of participants were correctly classified (AUC 0.619, sensitivity 80%, specificity 52%, kappa 0.241, P = 0.009) and for MAMC, 73% of participants were correctly classified (AUC 0.625, sensitivity 38%, specificity 88%, kappa 0.286, P = 0.005). There were 14%, 31%, and 10% of participants identified as having sarcopenia from CT, BIA, and MAMC, respectively.Conclusions: Both BIA and MAMC show a poor level of agreement for measuring muscle mass compared to CT scans using L3 in patients with CRC.

Intestinal failure-associated liver disease in adult patients.

PURPOSE OF REVIEW: The aim of this review is to give up-to-date information on intestinal failure-associated liver disease (IFALD) and how its investigation and management has evolved. Despite advances in treatment for patients with intestinal failure, IFALD remains a significant cause of mortality. RECENT FINDINGS: Liver biopsy remains as the gold standard for the diagnosis of IFALD, but its invasive nature has prompted assessment of noninvasive techniques. Risk factors for IFALD are both nonnutritional (e.g. sepsis) and nutritional. Strict protocols for the prevention of central venous catheter infections in patients with intestinal failure are well established, as is the optimization of the constituents of parenteral nutrition. Further research comparing the available lipid emulsions has become available. Novel approaches at maximizing intestinal absorption are discussed including glucagon-like peptide-2 analogues, as well as surgical approaches. SUMMARY: Although there are data on the novel investigative and therapeutic strategies for managing IFALD, further study is required to identify a suitable noninvasive technique for earlier diagnosis and then monitoring of IFALD. Further data are also required on the impact of novel therapies aimed at improving absorption and reducing parenteral nutrition load on IFALD occurrence and progression.

Monitoring long-term parenteral nutrition.

PURPOSE OF REVIEW: This review discusses the monitoring aimed at achieving good long-term outcomes in people dependent on home parenteral nutrition (HPN). RECENT FINDINGS: There have been recent studies highlighting the importance of treating low bone mineral density in HPN-dependent patients, methods of screening for liver disease, assessment of quality of life (QoL) and the need for early assessment for intestinal transplantation and growth factor therapy. SUMMARY: High-quality HPN services require expert multidisciplinary teams with a focus on strict aseptic catheter care protocols alongside regular monitoring and management of clinical, laboratory and patient-related factors. Areas that should be considered in the routine monitoring of HPN include regular laboratory measurements, QoL, assessment for intestinal failure-associated liver disease, treatment of metabolic bone disease and consideration of evolving treatments, alongside management of any underlying condition leading to intestinal failure.

Perioperative nutrition for the treatment of bladder cancer by radical cystectomy.

BACKGROUND: Radical cystectomy (RC) is the primary surgical treatment for muscle-invasive urothelial carcinoma of the bladder. This major operation is typically associated with an extended hospital stay, a prolonged recovery period and potentially major complications. Nutritional interventions are beneficial in some people with other types of cancer and may be of value in this setting too. OBJECTIVES: To assess the effects of perioperative nutrition in people undergoing radical cystectomy for the treatment of bladder cancer. SEARCH METHODS: We performed a comprehensive search using multiple databases (Evidence Based Medicine Reviews, MEDLINE, Embase, AMED, CINAHL), trials registries, other sources of grey literature, and conference proceedings published up to 22 February 2019, with no restrictions on the language or status of publication. SELECTION CRITERIA: We included parallel-group randomised controlled trials (RCTs) of adults undergoing RC for bladder cancer. The intervention was any perioperative nutrition support. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion, extracted data, and assessed risk of bias and the quality of evidence using GRADE. Primary outcomes were postoperative complications at 90 days and length of hospital stay. The secondary outcome was mortality up to 90 days after surgery. When 90-day outcome data were not available, we reported 30-day data. MAIN RESULTS: The search identified eight trials including 500 participants. Six trials were conducted in the USA and two in Europe.1. Parenteral nutrition (PN) versus oral nutrition: based on one study with 157 participants, PN may increase postoperative complications within 30 days (risk ratio (RR) 1.40, 95% confidence interval (CI) 1.07 to 1.82; low-quality evidence). We downgraded the quality of evidence for serious study limitations (unclear risk of selection, performance and selective reporting bias) and serious imprecision. This corresponds to 198 more complications per 1000 participants (95% CI 35 more to 405 more). Length of hospital stay may be similar (mean difference (MD) 0.5 days higher, CI not reported; low-quality evidence).2. Immuno-enhancing nutrition versus standard nutrition: based on one study including 29 participants, immuno-enhancing nutrition may reduce 90-day postoperative complications (RR 0.31, 95% CI 0.08 to 1.23; low-quality evidence). These findings correspond to 322 fewer complications per 1000 participants (95% CI 429 fewer to 107 more). Length of hospital stay may be similar (MD 0.20 days, 95% CI 1.69 lower to 2.09 higher; low-quality evidence). We downgraded the quality of evidence of both outcomes for very serious imprecision.3. Preoperative oral nutritional support versus normal diet: based on one study including 28 participants, we are very uncertain if preoperative oral supplements reduces postoperative complications. We downgraded quality for serious study limitations (unclear risk of selection, performance, attrition and selective reporting bias) and very serious imprecision. The study did not report on length of hospital stay.4. Early postoperative feeding versus standard postoperative management: based on one study with 102 participants, early postoperative feeding may increase postoperative complications (very low-quality evidence) but we are very uncertain of this finding. We downgraded the quality of evidence for serious study limitations (unclear risk of selection and performance bias) and very serious imprecision. Length of hospital stay may be similar (MD 0.95 days less, CI not reported; low-quality evidence). We downgraded the quality of evidence for serious study limitations (unclear risk of selection and performance bias) and serious imprecision.5. Amino acid with dextrose versus dextrose: based on two studies with 104 participants, we are very uncertain whether amino acids reduce postoperative complications (very low-quality evidence). We are also very uncertain whether length of hospital stay is similar (very low-quality evidence). We downgraded the quality of evidence for both outcomes for serious study limitations (unclear and high risk of selection bias; unclear risk of performance, detection and selective reporting bias), serious indirectness related to the patient population and very serious imprecision.6. Branch chain amino acids versus dextrose only: based on one study including 19 participants, we are very uncertain whether complication rates are similar (very low-quality evidence). We downgraded the quality of evidence for serious study limitations (unclear risk of selection, performance, detection, attrition and selective reporting bias), serious indirectness related to the patient population and very serious imprecision. The study did not report on length of hospital stay.7. Perioperative oral nutritional supplements versus oral multivitamin and mineral supplement: based on one study with 61 participants, oral supplements compared to a multivitamin and mineral supplement may slightly decrease postoperative complications (low-quality evidence). These findings correspond to 135 fewer occurrences per 1000 participants (95% CI 256 fewer to 65 more). Length of hospital stay may be similar (low-quality evidence). We downgraded the quality of evidence of both outcomes for study limitations and imprecision. AUTHORS' CONCLUSIONS: Based on few, small and dated studies, with serious methodological limitations, we found limited evidence for a benefit of perioperative nutrition interventions. We rated the quality of evidence as low or very low, which underscores the urgent need for high-quality research studies to better inform nutritional support interventions for people undergoing surgery for bladder cancer.

Dietary interventions for adult cancer survivors.

BACKGROUND: International dietary recommendations include guidance on healthy eating and weight management for people who have survived cancer; however dietary interventions are not provided routinely for people living beyond cancer. OBJECTIVES: To assess the effects of dietary interventions for adult cancer survivors on morbidity and mortality, changes in dietary behaviour, body composition, health-related quality of life, and clinical measurements. SEARCH METHODS: We ran searches on 18 September 2019 and searched the Cochrane Central Register of Controlled trials (CENTRAL), in the Cochrane Library; MEDLINE via Ovid; Embase via Ovid; the Allied and Complementary Medicine Database (AMED); the Cumulative Index to Nursing and Allied Health Literature (CINAHL); and the Database of Abstracts of Reviews of Effects (DARE). We searched other resources including reference lists of retrieved articles, other reviews on the topic, the International Trials Registry for ongoing trials, metaRegister, Physicians Data Query, and appropriate websites for ongoing trials. We searched conference abstracts and WorldCat for dissertations. SELECTION CRITERIA: We included randomised controlled trials (RCTs) that recruited people following a cancer diagnosis. The intervention was any dietary advice provided by any method including group sessions, telephone instruction, written materials, or a web-based approach. We included comparisons that could be usual care or written information, and outcomes measured included overall survival, morbidities, secondary malignancies, dietary changes, anthropometry, quality of life (QoL), and biochemistry. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodological procedures. Two people independently assessed titles and full-text articles, extracted data, and assessed risk of bias. For analysis, we used a random-effects statistical model for all meta-analyses, and the GRADE approach to rate the certainty of evidence, considering limitations, indirectness, inconsistencies, imprecision, and bias. MAIN RESULTS: We included 25 RCTs involving 7259 participants including 977 (13.5%) men and 6282 (86.5%) women. Mean age reported ranged from 52.6 to 71 years, and range of age of included participants was 23 to 85 years. The trials reported 27 comparisons and included participants who had survived breast cancer (17 trials), colorectal cancer (2 trials), gynaecological cancer (1 trial), and cancer at mixed sites (5 trials). For overall survival, dietary intervention and control groups showed little or no difference in risk of mortality (hazard ratio (HR) 0.98, 95% confidence interval (CI) 0.77 to 1.23; 1 study; 3107 participants; low-certainty evidence). For secondary malignancies, dietary interventions versus control trials reported little or no difference (risk ratio (RR) 0.99, 95% CI 0.84 to 1.15; 1 study; 3107 participants; low-certainty evidence). Co-morbidities were not measured in any included trials. Subsequent outcomes reported after 12 months found that dietary interventions versus control probably make little or no difference in energy intake at 12 months (mean difference (MD) -59.13 kcal, 95% CI -159.05 to 37.79; 5 studies; 3283 participants; moderate-certainty evidence). Dietary interventions versus control probably led to slight increases in fruit and vegetable servings (MD 0.41 servings, 95% CI 0.10 to 0.71; 5 studies; 834 participants; moderate-certainty evidence); mixed results for fibre intake overall (MD 5.12 g, 95% CI 0.66 to 10.9; 2 studies; 3127 participants; very low-certainty evidence); and likely improvement in Diet Quality Index (MD 3.46, 95% CI 1.54 to 5.38; 747 participants; moderate-certainty evidence). For anthropometry, dietary intervention versus control probably led to a slightly decreased body mass index (BMI) (MD -0.79 kg/m², 95% CI -1.50 to -0.07; 4 studies; 777 participants; moderate-certainty evidence). Dietary interventions versus control probably had little or no effect on waist-to-hip ratio (MD -0.01, 95% CI -0.04 to 0.02; 2 studies; 106 participants; low-certainty evidence). For QoL, there were mixed results; several different quality assessment tools were used and evidence was of low to very low-certainty. No adverse events were reported in any of the included studies. AUTHORS' CONCLUSIONS: Evidence demonstrated little effects of dietary interventions on overall mortality and secondary cancers. For comorbidities, no evidence was identified. For nutritional outcomes, there was probably little or no effect on energy intake, although probably a slight increase in fruit and vegetable intake and Diet Quality Index. Results were mixed for fibre. For anthropometry, there was probably a slight decrease in body mass index (BMI) but probably little or no effect on waist-to-hip ratio. For QoL, results were highly varied. Additional high-quality research is needed to examine the effects of dietary interventions for different cancer sites, and to evaluate important outcomes including comorbidities and body composition. Evidence on new technologies used to deliver dietary interventions was limited.

Palliative home parenteral nutrition in patients with ovarian cancer and malignant bowel obstruction: experiences of women and family caregivers.

BACKGROUND: Malnutrition is a problem in advanced cancer, particularly ovarian cancer where malignant bowel obstruction (MBO) is a frequent complication. Parenteral nutrition is the only way these patients can received adequate nutrition and is a principal indication for palliative home parenteral nutrition (HPN). Giving HPN is contentious as it may increase the burden on patients. This study investigates patients' and family caregivers' experiences of HPN, alongside nutritional status and survival in patients with ovarian cancer and MBO. METHODS: This mixed methods study collected data on participant characteristics, clinical details and body composition using computed tomography (CT) combined with longitudinal in-depth interviews underpinned by phenomenological principles. The cohort comprised 38 women with ovarian cancer and inoperable MBO admitted (10/2016 to 12/ 2017) to a tertiary referral hospital. Longitudinal interviews (n = 57) were carried out with 20 women considered for HPN and 13 of their family caregivers. RESULTS: Of the 38 women, 32 received parenteral nutrition (PN) in hospital and 17 were discharged on HPN. Nutritional status was poor with 31 of 33 women who had a CT scan having low muscle mass, although 10 were obese. Median overall survival from admission with MBO for all 38 women was 70 days (range 8-506) and for those 17 on HPN was 156 days (range 46-506). Women experienced HPN as one facet of their illness, but viewed it as a "lifeline" that allowed them to live outside hospital. Nevertheless, HPN treatment came with losses including erosion of normality through an impact on activities of daily living and dealing with the bureaucracy surrounding the process. Family caregivers coped but were often left in an emotionally vulnerable state. CONCLUSIONS: Women and family caregivers reported that the inconvenience and disruption caused by HPN was worth the extended time they had at home.

An Observational Cohort Study Investigating Risk of Malnutrition Using the Malnutrition Universal Screening Tool in Patients with Stroke.

BACKGROUND: Malnutrition in patients hospitalized with a stroke have been assessed using different nutritional screening methods but there is a paucity of data linking risk of malnutrition to clinical outcomes using a validated tool. AIMS: To identify the prevalence of malnutrition risk in patients after a stroke and assess the predictive value of the Malnutrition Universal Screening Tool (MUST) on clinical outcomes. PATIENTS AND METHODS: Using data from electronic records and the Sentinel Stroke National Audit Programme (January 2013 and March 2016), patients aged more than 18 years with confirmed stroke admitted to a tertiary care stroke unit were assessed for risk of malnutrition. The association between malnutrition risk and clinical outcomes was investigated and adjusted for confounding variables. RESULTS: Of 1101 patients, 66% were screened at admission. Most patients (n = 571, 78.5%) were identified as being at low risk, 4.1% (n = 30) at medium risk, and 17.4% (n = 126) at high risk of malnutrition. Compared with low risk, patients with medium or high risk of malnutrition were more likely to have a longer hospital stay (IRR 1.30, 95% confidence interval [CI] 1.07, 1.58), and had greater risk of mortality (10.9% versus 3.5%, 95% CI .03, .13). CONCLUSIONS: Prevalence of malnutrition assessed by MUST in patients after a stroke was relatively low, but nearly a third of patients were not screened. Patients classified as being at medium or high risk of malnutrition were more likely to experience negative outcomes. Early identification of this population may improve outcome if appropriate care is provided.

Interventions to reduce acute and late adverse gastrointestinal effects of pelvic radiotherapy for primary pelvic cancers.

BACKGROUND: An increasing number of people survive cancer but a significant proportion have gastrointestinal side effects as a result of radiotherapy (RT), which impairs their quality of life (QoL). OBJECTIVES: To determine which prophylactic interventions reduce the incidence, severity or both of adverse gastrointestinal effects among adults receiving radiotherapy to treat primary pelvic cancers. SEARCH METHODS: We conducted searches of CENTRAL, MEDLINE, and Embase in September 2016 and updated them on 2 November 2017. We also searched clinical trial registries. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of interventions to prevent adverse gastrointestinal effects of pelvic radiotherapy among adults receiving radiotherapy to treat primary pelvic cancers, including radiotherapy techniques, other aspects of radiotherapy delivery, pharmacological interventions and non-pharmacological interventions. Studies needed a sample size of 20 or more participants and needed to evaluate gastrointestinal toxicity outcomes. We excluded studies that evaluated dosimetric parameters only. We also excluded trials of interventions to treat acute gastrointestinal symptoms, trials of altered fractionation and dose escalation schedules, and trials of pre- versus postoperative radiotherapy regimens, to restrict the vast scope of the review. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methodology. We used the random-effects statistical model for all meta-analyses, and the GRADE system to rate the certainty of the evidence. MAIN RESULTS: We included 92 RCTs involving more than 10,000 men and women undergoing pelvic radiotherapy. Trials involved 44 different interventions, including radiotherapy techniques (11 trials, 4 interventions/comparisons), other aspects of radiotherapy delivery (14 trials, 10 interventions), pharmacological interventions (38 trials, 16 interventions), and non-pharmacological interventions (29 trials, 13 interventions). Most studies (79/92) had design limitations. Thirteen studies had a low risk of bias, 50 studies had an unclear risk of bias and 29 studies had a high risk of bias. Main findings include the following:Radiotherapy techniques: Intensity-modulated radiotherapy (IMRT) versus 3D conformal RT (3DCRT) may reduce acute (risk ratio (RR) 0.48, 95% confidence interval (CI) 0.26 to 0.88; participants = 444; studies = 4; I2 = 77%; low-certainty evidence) and late gastrointestinal (GI) toxicity grade 2+ (RR 0.37, 95% CI 0.21 to 0.65; participants = 332; studies = 2; I2 = 0%; low-certainty evidence). Conformal RT (3DCRT or IMRT) versus conventional RT reduces acute GI toxicity grade 2+ (RR 0.57, 95% CI 0.40 to 0.82; participants = 307; studies = 2; I2 = 0%; high-certainty evidence) and probably leads to less late GI toxicity grade 2+ (RR 0.49, 95% CI 0.22 to 1.09; participants = 517; studies = 3; I2 = 44%; moderate-certainty evidence). When brachytherapy (BT) is used instead of external beam radiotherapy (EBRT) in early endometrial cancer, evidence indicates that it reduces acute GI toxicity (grade 2+) (RR 0.02, 95% CI 0.00 to 0.18; participants = 423; studies = 1; high-certainty evidence).Other aspects of radiotherapy delivery: There is probably little or no difference in acute GI toxicity grade 2+ with reduced radiation dose volume (RR 1.21, 95% CI 0.81 to 1.81; participants = 211; studies = 1; moderate-certainty evidence) and maybe no difference in late GI toxicity grade 2+ (RR 1.02, 95% CI 0.15 to 6.97; participants = 107; studies = 1; low-certainty evidence). Evening delivery of RT may reduce acute GI toxicity (diarrhoea) grade 2+ during RT compared with morning delivery of RT (RR 0.51, 95% CI 0.34 to 0.76; participants = 294; studies = 2; I2 = 0%; low-certainty evidence). There may be no difference in acute (RR 2.22, 95% CI 0.62 to 7.93, participants = 110; studies = 1) and late GI toxicity grade 2+ (RR 0.44, 95% CI 0.12 to 1.65; participants = 81; studies = 1) between a bladder volume preparation of 1080 mls and that of 540 mls (low-certainty evidence). Low-certainty evidence on balloon and hydrogel spacers suggests that these interventions for prostate cancer RT may make little or no difference to GI outcomes.Pharmacological interventions: Evidence for any beneficial effects of aminosalicylates, sucralfate, amifostine, corticosteroid enemas, bile acid sequestrants, famotidine and selenium is of a low or very low certainty. However, evidence on certain aminosalicylates (mesalazine, olsalazine), misoprostol suppositories, oral magnesium oxide and octreotide injections suggests that these agents may worsen GI symptoms, such as diarrhoea or rectal bleeding.Non-pharmacological interventions: Low-certainty evidence suggests that protein supplements (RR 0.23, 95% CI 0.07 to 0.74; participants = 74; studies = 1), dietary counselling (RR 0.04, 95% CI 0.00 to 0.60; participants = 74; studies = 1) and probiotics (RR 0.43, 95% CI 0.22 to 0.82; participants = 923; studies = 5; I2 = 91%) may reduce acute RT-related diarrhoea (grade 2+). Dietary counselling may also reduce diarrhoeal symptoms in the long term (at five years, RR 0.05, 95% CI 0.00 to 0.78; participants = 61; studies = 1). Low-certainty evidence from one study (108 participants) suggests that a high-fibre diet may have a beneficial effect on GI symptoms (mean difference (MD) 6.10, 95% CI 1.71 to 10.49) and quality of life (MD 20.50, 95% CI 9.97 to 31.03) at one year. High-certainty evidence indicates that glutamine supplements do not prevent RT-induced diarrhoea. Evidence on various other non-pharmacological interventions, such as green tea tablets, is lacking.Quality of life was rarely and inconsistently reported across included studies, and the available data were seldom adequate for meta-analysis. AUTHORS' CONCLUSIONS: Conformal radiotherapy techniques are an improvement on older radiotherapy techniques. IMRT may be better than 3DCRT in terms of GI toxicity, but the evidence to support this is uncertain. There is no high-quality evidence to support the use of any other prophylactic intervention evaluated. However, evidence on some potential interventions shows that they probably have no role to play in reducing RT-related GI toxicity. More RCTs are needed for interventions with limited evidence suggesting potential benefits.