Search

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.

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.

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.

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.

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., (Copyright © 2019 Elsevier Inc. All rights reserved.)

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.

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., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

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., (© 2018 Dietitians Association of Australia.)

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., (Copyright © 2018 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.)

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.

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.

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., (© 2018 American Society for Parenteral and Enteral Nutrition.)

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.

Since 2015, Society of Critical Care Medicine/American Society for Parenteral and Enteral Nutrition and Canadian critical care nutrition support guidelines have both been updated. Despite a similar evidentiary basis, there remain key differences between guideline recommendations. These differences in recommendations may pose confusion for the clinician and may encumber widespread applicability. The aim of this review was to enhance practitioner confidence in applying critical care nutrition support guidelines to patient care in their settings by outlining the similarities and differences between the American and Canadian methods for guideline development and describing the key differences and reasons behind the differences.

Oncology patients often experience the classic signs of malnutrition-weight loss as well as fat and muscle wasting, which have been associated with poor tolerance to treatment and increased morbidity and mortality. Nutrition status may be an important factor in determining tolerance to treatment and outcomes associated with it. Thus, identification of those with preexisting malnutrition or who are at risk for developing malnutrition is crucial not only at time of cancer diagnosis but also throughout the treatment course so that nutrition interventions may be implemented to prevent development or worsening of malnutrition in this high-risk population. These patients often have extremely complicated hospital courses due to the aggressive nature of the disease and treatment, leading to intensive care unit admission and periods of critical illness. Critical illness is associated with catabolism, extreme stress on the body, and a state of systemic inflammation. During critical illness, it is important to provide adequate nutrition to prevent further break down of lean muscle mass and oxidative cellular injury and to regulate favorable immune responses. The purpose of this review is to discuss the importance of nutrition screening and assessment for the critically ill patient with cancer; to appropriately identify those at risk for, or who have developed, malnutrition; and to provide appropriate interventions to optimize nutrition status. This review also discusses the complications and difficulties associated with feeding this patient population and offers nutrition support recommendations.

With slowly increasing survival rates in pancreatic cancer and international consensus guidelines recommending surgical resection of premalignant lesions, survival post-pancreatic resection is increasing. With longer survival time, the significant comorbidities of such major surgery have far-reaching effects on the nutrition status of the survivor of pancreatic cancer. This review describes the many nutrition-related side effects of pancreatic surgery, including the development of pancreatic enzyme insufficiency, micronutrient deficiencies, diabetes, fatty liver, and metabolic bone disease. Beyond causing additional medical problems, each of these can have significant effects on quality of life and functional status. The potential mechanisms, diagnosis criteria, and potential treatments of these conditions are described. Overall, little literature exists to fully describe the effects of these comorbidities, and even less is able to guide effective treatments for this population. Clinicians caring for these patients should begin incorporating goals for promotion of long-term health and reduction of these known and reported comorbidities in patients who have undergone pancreatic surgery. Treatment plans in this population remain understudied, and clinicians may need to consider recommendations for similar disease states when developing interventions for these patients.

The digestive system provides nourishment to the whole body. Disorders in this system would result in many associated illnesses as the body is deprived of essential nutrients. Gastrointestinal diseases, in particular, gastric ulceration, inflammatory bowel diseases and colorectal cancer have become more prevalent in all population age groups. While this can be attributed to diet and lifestyle changes, the measures to combat these illnesses with conventional drugs is losing popularity owing to the harsh side effects, drug resistance and lack of patient compliance. The focus of this review is to endorse promising nutraceutical dietary components such as phytosterols, polyphenols, anthocyanins and polyunsaturated fatty acids and their synergistic value, in combination with conventional management of key gastrointestinal diseases. As most of these nutraceuticals are labile compounds, the need for protection and delivery using a carrier system is stressed and the methods for targeting to specific parts of the gastrointestinal tract are discussed. A section has also been devoted to perspectives on co-encapsulation methods of drugs and nutraceuticals using different particle systems. Multilayered carrier systems like double layered and core shell particles have been proposed as an exemplary system to co-encapsulate both drugs and nutrients while keeping them segregated., (Copyright © 2016 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Background: Many patients are admitted to hospital and are already malnourished. Gaps in practice have identified that care processes for these patients can be improved. Hospital staff, including management, needs to work towards optimizing nutrition care in hospitals to improve the prevention, detection and treatment of malnutrition. The objective of this study was to understand how staff members perceived and described the necessary ingredients to support change efforts required to improve nutrition care in their hospital., Methods: A qualitative study was conducted using purposive sampling techniques to recruit participants for focus groups (FG) (n = 11) and key informant interviews (n = 40) with a variety of hospital staff and management. Discussions based on a semi-structured schedule were conducted at five diverse hospitals from four provinces in Canada as part of the More-2-Eat implementation project. One researcher conducted 2-day site visits over a two-month period to complete all interviews and FGs. Interviews were transcribed verbatim while key points and quotes were taken from FGs. Transcripts were coded line-by-line with initial thematic analysis completed by the primary author. Other authors (n = 3) confirmed the themes by reviewing a subset of transcripts and the draft themes. Themes were then refined and further detailed. Member checking of site summaries was completed with site champions., Results: Participants (n = 133) included nurses, physicians, food service workers, dietitians, and hospital management, among others. Discussion regarding ways to improve nutrition care in each specific site facilitated the thought process during FG and interviews. Five main themes were identified: building a reason to change; involving relevant people in the change process; embedding change into current practice; accounting for climate; and building strong relationships within the hospital team., Conclusions: Hospital staff need a reason to change their nutrition care practices and a significant change driver is perceived and experienced benefit to the patient. Participants described key ingredients to support successful change and specifically engaging the interdisciplinary team to effect sustainable improvements in nutrition care., Trial Registration: Retrospectively registered ClinicalTrials.gov Identifier: NCT02800304 , June 7, 2016.

Background: Due to the demographic ageing process and the increasing number of pre-frail and frail individuals, new lifestyle interventions to enhance the quality of life (QoL) in community-dwelling older adults are necessary. Therefore, we performed a randomised controlled trial (RCT) to compare effects of a lay-led home-based physical and nutritional intervention programme with social support alone on different QoL domains in community-dwelling pre-frail and frail older adults., Methods: In this analysis within a RCT (12 weeks), lay volunteers visited one-on-one pre-frail or frail older adults at home twice a week. Participants in the physical training and nutritional intervention (PTN) group performed six strength exercises and discussed main nutritional issues during each visit. The social support (SOSU) group received home visits twice a week for social exchanges. The QoL was assessed with the WHOQOL-BREF and the WHOQOL-OLD instruments. Analyses of covariance (ANCOVA) were used to examine differences between groups with baseline values as the covariate. Changes within groups were assessed with paired t-tests., Results: Eighty participants (n = 39 in the PTN group and n = 41 in the SOSU group) were included. No significant differences were found between the two groups except in past, present and future activities domain [β = 3.66 (95% confidence interval 0.13 to 7.18)] in favour of the PTN group. However, there was some evidence of greater within group improvements in the PTN group particularly in overall QoL, social relations and social participation. In the SOSU group, no significant effect was observed in any QoL domain., Conclusion: A combination of a home-based physical and nutritional intervention was not more effective compared to social support alone, on QoL in community-dwelling pre-frail and frail older adults. However, the small but significant improvement within the PTN group suggests that a home-based physical and nutritional intervention delivered by volunteers may influence the QoL in a positive way., Trial Registration: The study protocol was registered on 6 November 2013 at ClinicalTrials.gov (identifier: NCT01991639 ).

Alcoholic hepatitis (AH) manifests as a clinical syndrome characterized by recent jaundice and liver function deterioration in an actively drinking patient. The principal cause of AH is alcoholic steatohepatitis (ASH) defined histologically by the coexistence of steatosis, hepatocyte ballooning and satellitosis. While nonsevere AH usually responds to alcohol abstinence, severe AH, identified by Maddrey scoring ≥ 32, has a bad prognosis and is traditionally treated by a 28-day course of prednisone therapy. A recent trial, which showed no improvement of long-term survival but significant reduced mortality after 28 days of corticoid therapy compared to placebo, opens a debate on its efficacy. N-acetyl-cysteine supplementation combined with steroid therapy is also able to reduce the 28-day mortality compared to steroid alone. While guidelines recommend high-calorie intake and protein supplementation in decompensated liver diseases, intensive enteral nutrition together with corticoid treatment does not reduce mortality compared to corticoid alone in a recent study with ASH patients. Stimulation of liver regeneration through interleukin-22, granulocyte colony-stimulating factor or farnesoid X receptor agonists, inhibition of apoptosis, early liver transplantation and modulation of gut microbiota through antibiotic or faecal transplantation approaches constitute new therapeutic perspectives that are investigated in current clinical trials. Inhibition of oxidative stress, modulation of gut fungal populations and stimulation of progenitor cell proliferation and pro-regenerative inflammatory pathways constitute prospects for future human trials. For long-term survival, strategies for persistent alcohol abstinence remain the key of success, opening another large research field., (© 2017 Stichting European Society for Clinical Investigation Journal Foundation.)

Nutrition support is a necessary therapy for critically ill cardiac surgery patients. However, conclusive evidence for this population, consisting of well-conducted clinical trials is lacking. To clarify optimal strategies to improve outcomes, an international multidisciplinary group of 25 experts from different clinical specialties from Germany, Canada, Greece, USA and Russia discussed potential approaches to identify patients who may benefit from nutrition support, when best to initiate nutrition support, and the potential use of pharmaco-nutrition to modulate the inflammatory response to cardiopulmonary bypass. Despite conspicuous knowledge and evidence gaps, a rational nutritional support therapy is presented to benefit patients undergoing cardiac surgery.

Background Feeding dysfunction occurs commonly in infants with single ventricle heart disease and impacts growth and long-term outcomes. Little evidence exists to guide safe feeding in this population. This study surveyed centers participating in the National Pediatric Cardiology Quality Improvement Collaborative to assess prevailing feeding practices amongthose caring for single ventricle neonates. Methods Web-based survey of 56 pediatric cardiac surgical centers was conducted. Questions addressed peri-operative feeding approaches and responses were presented and analyzed descriptively. Results Of 56 centers, 46 (82%) completed a survey. Preoperative feeding was common in single ventricle infants (30/46; 65%), routes varied. Centers who did not feed infants preoperatively cited the risk of necrotizing enterocolitis (16/16; 100%), presence of umbilical artery catheter (12/16; 75%), and prostaglandin infusion (9/16; 56%) as main concerns. 67% of centers reported no specific vital sign thresholds for withholding enteral feedings. In the postoperative period, most centers used an "internal guideline" (21/46; 46%) or an "informal practice" (15/46; 33%) to determine feeding readiness. Approaches to findings were significantly different among centers. About 40% of centers did not send patients home with feeding tubes, and there was no clear consensus between preferred feeding tube modality at discharge. Conclusion Considerable variation exists in feeding practices for infants with single ventricle congenital heart disease among 46 centers participating in a quality improvement collaborative. Although most centers generally feed infants preoperatively, feeding practices remain center-specific. Variability continues in the immediate post-operative and interstage periods. Further opportunities exist for investigation, standardization and development of best-practice feeding guidelines., (© 2016 Wiley Periodicals, Inc.)

Evidence based medicine has preferably been based on prospective randomized controlled trials (PRCT's) and subsequent meta-analyses in many fields including nutrition and metabolism. These meta-analyses often yield convincing, contradictory or no proof of effectiveness. Consequently recommendations and guidelines of varying validity and quality have been published, often failing to convince the medical, insurance and government worlds to support nutritional care. Causes for lack of adequate proof of effectiveness are manifold. Many studies and meta-analyses lacked pathophysiological depth in design and interpretation. Study populations were not homogenous and endpoints not always clearly defined. Patients were included not at nutritional risk, unlikely to benefit from nutritional intervention. Others received nutrients in excess of requirements or tolerance due to organ failure. To include all available studies in a meta-analysis, study quality and homogeneity were only assessed on the basis of formal study design and outcome rather than on patient characteristics. Consequently, some studies showed benefit but included patients suffering harm, other studies were negative but contained patients that benefited. Recommendations did not always emphasize these shortcomings, confusing the medical and nutritional community and creating the impression that nutritional support is not beneficial. Strong reliance on meta-analyses and guidelines shifts the focus of education from studying clinical and nutritional physiology to memorizing guidelines. To prevent or improve malnutrition more physiological knowledge should be acquired to personalize nutritional practices and to more correctly value and evaluate the evidence. This also applies to the design and interpretation of PRCT's and meta-analyses., (Copyright © 2015 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Purpose of Review: The mortality and morbidity associated with severe acute malnutrition (SAM) remain high. A summary of recent studies that are of interest to clinicians treating children with SAM is provided., Recent Findings: Three important themes emerged in 2015: the use of anthropometry in the diagnosis of SAM and its correlation with body composition; the composition of ready-to-use therapeutic feeds (RUTF); and an improved understanding of the pathophysiology of SAM., Summary: Standard anthropometry does not accurately predict body composition and mid-upper arm circumference more accurately reflects fat mass in children. As single measure, mid-upper arm circumference identifies those children who are most likely to die from SAM and is not influenced by dehydration. However, a significant proportion of SAM children requiring treatment will not be detected. Present RUTF formulations are deficient in long chain polyunsaturated fatty acids. Current evidence suggests that preformed docosahexaenoic acid should be added and/or the content of linoleic acid reduced in RUTF. In contrast to an animal model, stabile children with SAM have the same cardiac index as children without SAM. The situation in haemodynamically unstable children is unknown, continued conservative use of intravenous fluids seems advisable. A reduction in variability of the faecal DNA virome may account for increased susceptibility to malnutrition in vulnerable children.

Purpose of Review: Nutrition impacts outcome in critically ill children. Based on evolving neuro-endocrine, immunologic and metabolic alterations, three different phases can be proposed during the course of illness. The different phases each demand for tailored macronutrient intakes in critically ill children., Recent Findings: Early enteral nutrition is associated with decreased morbidity and mortality, but several misconceptions concerning the provision of enteral nutrition prevent adequate intake. Parenteral nutrition in critically ill children is associated with potential disadvantages, as nosocomial infections, but evidence on the effect on clinical outcome is lacking. Nutrient restriction early during critical illness might be beneficial for short and long-term outcomes by decreasing the incidence of side-effects and possibly by amplifying the acute catabolic stress response and stimulating autophagy and muscle integrity. Higher caloric and protein intake via the enteral route are associated with higher 60-day survival, asking for a more aggressive feeding approach in subsequent phases., Summary: Understanding the stress response to critical illness and its phases is essential for nutritional recommendations in critically ill children. Although parenteral nutrient restriction during the acute phase might be beneficial, inclining requirements ask for a more aggressive approach during the stable and recovery phase to enable recovery, growth and catch-up growth.

Multiple organ failure (MOF) is an evolving pathologic phenotype that plagues intensive care units globally. This manuscript aims to depict the evolution of single organ failure through multiple organ failure, ending in the newest phenotype called persistent inflammation, immunosuppression, catabolism syndrome (PICS). Among the other MOF phenotypes discussed are systemic inflammatory response syndrome (SIRS) and compensatory anti-inflammatory response syndrome. Along with a review of the four phenotypes of MOF there is a review of the current literature on nutritional supplementation. Discussed in these sections are possible etiologies for the various progression of MOF, total enteral nutrition (TPN) versus early enteral nutrition (EEN), early versus late parenteral nutrition, glycemic control, and new enteral formulas. Finally, as the newest phenotype, PICS, has evolved we try to make inferences from similar pathologic states to recommend nutritional support that has proven beneficial.

This review addresses recent relevant advances to clinical nutrition regarding gastrointestinal disease surgery. Medline Ovid, EMBASE and Central were searched systematically in April 2014. Inclusion criteria were randomized controlled trials, non-randomized controlled trials and observational studies evaluating nutritional support in gastrointestinal surgery published within 5 years. The review included 56 relevant studies. Themes were: nutrition screening and risk factors predict outcome; preoperative nutritional support; shortening fasting periods and including carbohydrate solutions; early nutrition after surgery; immune modulating nutrition; synbiotics, growth hormone, omega-3 and oral, enteral and parenteral nutrition in combination. Screening for nutritional risk is profound, with special focus on dietary intake in the past week. Age and severity of disease need to be included in the screening system. Patients at severe nutritional risk benefit from nutritional therapy before surgery. New standards are developing quickly and clinical guidelines on surgery should include updated knowledge within clinical nutrition.

Background: The present study describes the development of evidence-based practice guidelines for the nutritional management of adult patients with head and neck cancer using a wiki platform to enable wide international stakeholder consultation and maintain currency., Methods: A dietitian steering committee and a multidisciplinary steering committee were established for consultation. Traditional methods of evidence-based guideline development were utilised to perform the literature review, assess the evidence and produce a draft document. This was transferred to a wiki platform for stakeholder consultation and international endorsement processes in Australia, New Zealand and the UK. Data were collected on website traffic utilising Google Analytics., Results: In addition to broad stakeholder consultation through the steering committees, an additional twenty comments were received via the wiki by twelve individuals covering six different professions from three different countries, compared to four comments by e-mail. The guidelines were subsequently endorsed by the dietetic associations of Australia, New Zealand and the UK. During a 4-month period monitoring the use of the guidelines, there were 2303 page views to the landing page from 33 countries. The average number of pages accessed per visit was five and the duration of time spent on the website was approximately 6 min., Conclusions: Using a wiki platform for guideline development and dissemination is a successful method for producing high-quality resources that can undergo wide international stakeholder review and include open public consultation. This can replace conventional methods whereby guidelines can quickly become outdated., (© 2013 The Authors Journal of Human Nutrition and Dietetics © 2013 The British Dietetic Association Ltd.)

The purpose of this review is 2-fold. First, it speculates on future scientific work that will have the greatest effect on clinical practice of nutrition care. Second, it discusses the current and future state of the healthcare system, paying special attention to demographic trends and the future of healthcare reform as it will affect nutrition practice.

The use of nutritional support in cancer patients has evolved since its introduction in the clinical practice 40 years ago. Both parenteral and enteral nutrition are now increasingly integrated within the main oncologic strategy with the aim of making surgery, chemotherapy and radiation therapy more safe and effective. This requires a better awareness of the inherent risk of starvation and undernutrition by the surgeons, medical oncologists and radiologists, the ability to implement a policy of nutritional screening of cancer patients and to propose them the nutritional support in a single bundle together with the oncologic drugs. Four different areas of nutritional intervention are now recognized which parallel the evolutionary trajectory of patients with tumour: the perioperative nutrition in surgical patients, the permissive nutrition in patients receiving chemotherapy and/or radiation therapy and the home parenteral nutrition which may be total (in aphagic-obstructed-incurable patients) or supplemental (in advanced weight-losing anorectic patients). Since cancer is a common disease and the continuous progress in medical therapy is changing its natural history, with more and more patients entering in a chronic and finally incurable phase where nutrition is determinant for survival, we can expect an increased demand for nutritional support in the next future., (2011 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Introduction: The debate over use of artificial nutrition and hydration (ANH) in terminal illness, including advanced dementia, remains contentious despite extensive ethical and empirical investigation., Methods: For this narrative review we undertook a focused, selective review of literature reflecting ethical analysis, empirical assessment of outcomes, legal responses, and thinking within the Roman Catholic religious tradition., Results: The history of the debate over the past 60 years results from a complex interplay of ethical concerns, a growing empirical database, legal changes, public opinion, and financial as well as institutional concerns. Discussions of ANH today are often conducted without any understanding of this historical context., Discussion: Patients' interests could be better protected through remedial action at both the individual and the policy levels.

Two of the most challenging issues in the clinical management of the obese patient are assessing energy requirements and whether hypocaloric (permissive) underfeeding should be employed. Multiple predictive equations have been used in the literature to estimate resting metabolic rate, although no consensus has emerged regarding which prediction equation is most accurate and precise in the obese population. Hypocaloric, or permissive underfeeding, specifically refers to the intentional administration of calories that are less than predicted energy expenditure. Thus far, very few studies performed have been performed to assess the efficacy of hypocaloric feeding in the obese hospitalized patient. It is concluded that the optimal caloric intake of obese patients in the intensive care unit remains unclear given the limitation of the existing data.

Nutrition in the intensive care setting is a vital part of patient care, and may even be referred to as "nutritional therapy". Current nutritional practices have progressed a lot over the past few years, and draw from a large body of accumulating evidence. Yet, as with other trends in critical care, there are a lot of variations in the way nutrition is approached between institutions, as well as between individual physicians. This review attempts to look at some of these differences and provide recommendations based upon the available literature.

Purpose of Review: To highlight recent developments in the field of perioperative nutritional support by reviewing clinically pertinent English language articles from October 2008 to December 2010, that examined the effects of malnutrition on surgical outcomes, optimizing metabolic function and nutritional status preoperatively and postoperatively., Recent Findings: Recognition of patients with or at risk of malnutrition remains poor despite the availability of numerous clinical aids and clear evidence of the adverse effects of poor nutritional status on postoperative clinical outcomes. Unfortunately, poor design and significant heterogeneity remain amongst many studies of nutritional interventions in surgical patients. Patients undergoing elective surgery should be managed within a multimodal pathway that includes evidence-based interventions to optimize nutritional status perioperatively. The aforementioned should include screening patients to identify those at high nutritional risk, perioperative immuno-nutrition, minimizing 'metabolic stress' and insulin resistance by preoperative conditioning with carbohydrate-based drinks, glutamine supplementation, minimal access surgery and enhanced recovery protocols. Finally gut-specific nutrients and prokinetics should be utilized to improve enteral feed tolerance thereby permitting early enteral feeding., Summary: An evidence-based multimodal pathway that includes interventions to optimize nutritional status may improve outcomes following elective surgery.

Nutrition support in the critically ill patient has shifted from adjunctive toward fundamental therapy with the publication of high-grade evidence. Early enteral nutrition (EN) is recommended because it is associated with decreased infectious complications and use of EN is associated with decreased mortality and infections compared with parenteral nutrition (PN). EN is not without risks, such as diarrhea or aspiration, but use of prokinetic agents, head of bed elevation, and use of feeding protocols can maximize benefits and minimize risks. Although recently high-grade evidence on nutrition support in the critically ill population has been published, many controversies still exist. In obese patients, use of hypocaloric feedings with increased protein has been demonstrated to promote weight loss and improved glucose management. In nonobese patients, small studies have demonstrated that providing more than 70% or less than 30% of goal caloric intake may be associated with worse outcomes, but more studies are needed. Additional research is also needed to conclude whether withholding intravenous fat emulsions for the first 7 to 10 days of PN reduces infectious complications. Finally, more high-quality studies are needed to define the role of immune-enhancing nutrients such as arginine, glutamine, omega-3 fatty acids, zinc, and selenium.

Micronutrients are defined as those compounds necessary for the adequate physiological status of the organism and that may be administered through the daily diet either enteral or parenteral. The term micronutrient encompasses the vitamins and oligoelements, also termed trace elements. Vitamins cannot be synthesized by the organism and are categorized in two groups: water-soluble vitamins (the vitamin B group, C, folic acid, and biotin) and lipid-soluble vitamins (A, D, E, and K). Oligoelements are found in small amounts in the human body, and copper, cobalt, chrome, iron, iodine, manganese, molybdenum, nickel, selenium, and zinc are considered to be essential. The important role of micronutrients in critically-ill patients has been demonstrated, and their influence on the immune system, cancer, burnt, septic, and poly-traumatized patients has extensively been put in evidence. It is important to establish the micronutrients demands for each individual in order to achieve an adequate intake. However, there is little evidence on the necessary intake to achieve proper physiological functioning under different pathologies; therefore, studies bringing light to this situation are needed. The aim of this review is to update the current state of knowledge on micronutrients supplementation in the adult population with pathologies such as cancer, coronary and cardiovascular disease, bowel inflammatory disease, short-bowel syndrome, cystic fibrosis, liver disease, renal failure, respiratory failure, the surgical patient, big-burnt patient, pancreatitis, poly-traumatized patients, sepsis and HIV. After the bibliographical search, we describe the current state of knowledge regarding micronutrients intake in artificial nutrition under the above-mentioned pathologies.

Board certification and credentialing in nutrition for physicians are problematic issues. Many board examinations are offered, but have few candidates and poor recognition. This discussion focuses on the feasibility of establishing a single board examination body. Some key considerations were identified to improve credentialing and examination in nutrition for physicians. Increasing the number of nutrition physicians and improving recognition of their credentials should ultimately translate to better patient health and safety. Consolidation of board examinations may be in the best interest of physician nutritionists.

Academic interest in nutritional support teams (NSTs) has increased rapidly in Japan since 1999, when they were first planned by the Japanese Society for Parenteral and Enteral Nutrition (JSPEN). The JSPEN promoted their use extensively after 2006 when extra medical fees were approved for medical management by NSTs under the national health insurance system. The purpose of NSTs is to provide the best nutritional support to patients who are malnourished or at high risk of developing malnutrition, without causing conflict among different medical staff. NSTs offer appropriate medical support and help prevent the deterioration of patients' health. The teams are comprised of specialized medical staff with nutritional expertise who work at the bedside and are committed to establishing good medical practice. The main targets of NSTs are patients who undergo surgery or are being treated in a geriatric or internal medicine unit, including those with lifestyle-related diseases. Therefore, most targets of NSTs are patients with common conditions. A package medical system based on the diagnostic-procedure combination was established, and regional medical centers were integrated to ensure high-quality medical care throughout Japan. Under this system, NSTs are expected to resolve individual patients' dietary issues. In addition, improvement of medical care quality and the training of reliable medical staff are necessary to provide nutritional management in the clinical setting. It will be necessary to the revise the assessment of NSTs as proposed by a committee of the Japanese Nutritional Support Promotion Group or to carry out surveillance to evaluate the outcomes of NST activity.