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Rationale Malnutrition is highly prevalent in hospitalized patients, but seldom recognized and treated. Malnutrition poses several adverse events, such as increased infection rates, length of hospital stay, and mortality, as well as costs. Early nutrition interventions have been shown to decrease the associated malnutrition burdens, leading to relevant savings. Thus, this study aims to evaluate the cost-effectiveness of nutrition therapy, including oral supplements to at-risk or malnourished adult inpatients admitted to the Brazilian Public System (SUS) hospitals. Method A cost-effectiveness model, encompassing a one-year period regarding total costs, length of hospital stay, readmissions, and mortality related to malnutrition, was developed, having the provision of early nutrition therapy as the intervention variable. The number of avoided hospitalization days prevented hospital readmissions and deaths defined the effectiveness of the model. All the costs were estimated based on the SUS database. Results Early nutrition therapy provided to all at-risk or malnourished patients would represent cost-effectiveness of US$92.24, US$544.59, US$1,848.12, and US$3,698.92, per day of hospitalization avoided, for additional patients having access to hospitalization, for preventing readmission, and death, respectively. The highest impact on savings was represented by the mean reduction in the length of hospital stay. Conclusion Early oral nutrition intervention to at risk of malnutrition or malnourished patients resulted in overall reduced hospital costs. These findings provide a rationale to tackle the implementation of educational programs focusing on the care of inpatients with malnutrition or its risk. This article is protected by copyright. All rights reserved.

Background Impaired gastric emptying (GE) is associated with morbidity in surgical critically ill children. The relationship between inflammation, gut barrier integrity (lipopolysaccharide binding protein [LBP]; zonulin), and GE has not been described in this cohort. Methods Children ≥2 years of age and requiring critical care after surgery were enrolled. Preoperative and postoperative levels of serum cytokines, LBP, and zonulin, and GE by the acetaminophen absorption test, were measured, allowing patients to serve as their own controls. Postoperative delayed GE was defined as a decrease in GE by ≥20% compared with preoperative GE. The following were examined : comparison between postoperative andpreoperative values, correlations between fold change (postoperative/preoperative) in study variables, and fold change in study variables between patients with and without postoperative delayed GE. Results Twenty patients, median age 14 years (12.25, 18), 12 female, were included. Eight of 20 patients had postoperative delayed GE. Postoperative interleukin‐6 (IL‐6), IL‐8, IL‐10, and LBP were increased, and zonulin was decreased (P‐values < .05). Fold change in IL‐10 and zonulin were inversely correlated (ρ −0.618, P = .004). Patients with postoperative delayed GE had greater fold increase in IL‐10 (P = .0159) and fold decrease in zonulin (P = .0160). Five of 7 (71%) patients with both fold increase in IL‐10 and decrease in zonulin had delayed GE. Conclusion Postoperative changes in IL‐10 and zonulin were associated with delayed GE in surgical critically ill children, which might suggest a mechanism to for delayed GE in postoperative inflammation and gut barrier dysregulation after surgery.

Background In China, the trend of the prevalence of nutrition risk and malnutrition among the patients in hospitals has changed dramatically in the past few years. The aim of this study was to compare the prevalence of nutrition risk, undernutrition, and the application of nutrition support among hospitalized general surgery patients over a 7‐year period from 2010 to 2017. Methods A total of 810 consecutive inpatients who met the inclusion criteria upon admission and provided informed consent were recruited from March to December 2017. Nutrition risk was screened using the Nutritional Risk Screening 2002 tool. All the data collected in 2017 were compared with the data collected in 2010. Results The prevalence of undernutrition among the surgical patients in 2017 (12.8%) was lower than that in 2011 (15.5%) (P < .05), whereas the prevalence of nutrition risk in 2017 (42.6%) was higher than that in 2011 (30.4%) (P < .01). The application of nutrition support, including parenteral nutrition and enteral nutrition, among the patients in 2017 was higher than that in 2010 (P < .05). In 2017, 70.7% of the patients who were at nutrition risk received nutrition support, whereas only 48.9% of patients at nutrition risk did in 2010 (P < .05). Moreover, 26.9% of patients without nutrition risk received nutrition support in 2017 compared with 18.0% of patients in 2010. Conclusions The nutrition statuses among surgical inpatients changed from 2010 to 2017. The prevalence of undernutrition was reduced, whereas the prevalence of nutrition risk increased. The application of nutrition support increased significantly, whereas inappropriate application of nutrition support still existed in our hospital. More attention should be paid to the nutrition‐related issues of general surgery inpatients in the future.

Background Increased resting energy expenditure (REE) has been hypothesized to be a potential cause of weight loss in individuals with Crohn's disease (CD). This study aimed to develop and validate new predictive equations for estimating REE in adults with CD. Methods Adults, ages 18–65 years, with CD were recruited. Anthropometry, indirect calorimetry, and bioimpedance analysis were performed in all patients. Disease activity was assessed by Crohn's Disease Activity Index. The new predictive equations were generated using different regression models. Prediction accuracy of the new equations was assessed and compared with the most commonly used equations. Results A total of 270 CD patients (159 males, 111 females) were included and randomly assigned to the calibration (n = 180) and validation groups (n = 90). REE was directly correlated with weight and bioimpedance index, whereas the relation with both age and disease activity was inverse. The new equations were suitable for estimating REE at population level (bias: −0.2 and −0.3, respectively). Individual accuracy was good in both models (≥80%, respectively), especially in females; and similar results were shown by some of the selected equations. But, when accuracy was set within ±5%, the new equations gave the highest prediction. Conclusion The new, disease‐specific, equations for predicting REE in individuals with CD give a good prediction accuracy as far as those proposed in the literature for the general population. However, the new ones performed better at the individual level. Further studies are needed to verify the reliability and usefulness of these new equations.

Background Delayed gastric emptying is the leading cause of enteral feeding intolerance (EFI) in critical illness. This phase 2a study compared TAK‐954, a selective agonist of 5‐hydroxytryptamine type 4 receptors, with metoclopramide in critically ill patients with EFI (NCT01953081). Methods A blinded, double‐dummy trial was conducted in mechanically ventilated patients with EFI (>200 mL gastric residual volume within 24 hours before randomization). Patients were randomized to receive either 0.5 mg intravenous TAK‐954 over 1 hour then 0.9% saline injection 4 times/d (sham metoclopramide) or the active comparator 10 mg intravenous metoclopramide 4 times/d and a 1‐hour 0.9% saline infusion. After initial dosing, participants received a radiolabeled meal of liquid nutrient (Ensure; 106 kcal), and gastric emptying was measured (scintigraphy). Adverse events (AEs) were recorded from the time of consent through to day 5; serious AEs were collected to day 30. Results Thirteen patients (TAK‐954, n = 7; metoclopramide, n = 6) participated. Five patients in the TAK‐954 group and 4 in the metoclopramide group experienced AEs (2 and 3, respectively, were serious). All AEs except 1 (diarrhea in the metoclopramide group) were considered unrelated to study drug. Following treatment, a greater proportion of patients receiving TAK‐954 had normal gastric retention (

Background No consensus exists on the optimal method to estimate resting energy expenditure (REE) in critically ill children following cardiopulmonary bypass (CPB). This study assesses the accuracy of REE estimation equations in children with congenital heart disease following CPB and tests the feasibility of using allometric scaling as an alternative energy prediction equation. Methods A retrospective analysis of a pediatric cohort following CPB (n = 107; median age 5.2 months, median weight 5.65 kg) who underwent serial measures (median 5 measurements) of REE using indirect calorimetry for 72 hours following CPB. We estimated REE using common estimation methods (Dietary Reference Intake, Harris Benedict, Schofield, World Health Organization [WHO]) as well as novel allometric equations. We compared estimated with measured REE to determine accuracy of each equation using overall discrepancy, calculated as a time‐weighted average of the absolute deviation. Results All equations incorrectly estimated REE at all time points following CPB, with overestimation error predominating. WHO had the lowest discrepancy at 10.7 ± 8.4 kcal/kg/d. The allometric equation was inferior, with an overall discrepancy of 16.9 ± 10.4. There is a strong nonlinear relationship between body surface area and measured REE in this cohort, which is a key source of estimation error using linear equations. Conclusion In a cohort of pediatric patients with congenital heart disease following CPB, no currently utilized clinical estimation equation reliably estimated REE. Allometric scaling proved inferior in estimating REE in children following CPB. Indirect calorimetry remains the ideal method of determining REE after CPB until nonlinear methods can be derived due to overestimation using linear equations.

Background The optimal nutritional support for critically ill septic patients remains unknown. This study evaluates the associations of macronutrient intake during the first week of intensive care unit (ICU) admission and long‐term clinical outcomes in septic and non‐septic patients. Methods Prolonged mechanically ventilated patients were retrospectively studied. The association of protein (low: 1.2 g/kg/d) and energy intake (110% was associated with decreased mortality in septic patients (HR: 0.400, 95% CI: 0.222‐0.721, P=0.002), whereas in non‐septic patients, late medium energy intake (80%–110%) was associated with better survival (HR: 0.379, 95% CI: 0.175‐0.820, P=0.014), both compared with low energy intake. Conclusion Divergent associations of macronutrient intake were found; early high protein intake in non‐septic patients, but not in septic patients, was found to be associated with higher 6‐month mortality.

Background In line with recent guidance from the American Society for Parenteral and Enteral Nutrition (ASPEN) and the European Society for Clinical Nutrition and Metabolism (ESPEN) to minimize healthcare team exposure by clustering care and relying on other providers or telehealth to collect relevant nutrition assessments, our nutrition support team has adopted a modified workflow using information technology to provide parenteral nutrition (PN) remotely in a safe and timely manner. We aim to compare our prescribing adequacy and PN‐related complications before and during the coronavirus disease 2019 (COVID‐19) outbreak using the modified workflow in non–critically ill patients. Methods This study reviewed a prospectively recruited cohort of adults receiving PN in the general wards or high‐dependency units from December 5, 2019, to April 15, 2020. Demographic data, nutrition assessment, PN prescriptions, blood results, electronic notes, capillary blood glucose monitoring, and catheter‐related bloodstream infection rates were reviewed for patients who received PN. Results We found that patients who started PN during COVID‐19 were more malnourished with lower body mass index and higher proportion of Subjective Global Assessment B/C scores (52 [92.9%] vs 36 [73.5%], P < .005). The proportion of patients who achieved target energy amounts within 5 days was similar in both groups. Protein prescription was >1 g/kg/day in both groups, though there was a trend of higher protein prescription during COVID‐19. Complications were similar in both groups. Conclusion Our study demonstrates that minimal contact with effective multidisciplinary communication using the modified workflow can allow for safe and timely PN administration.

Background A rapid infusion rate for intravenous lipid emulsion (ILE) can cause adverse effects; therefore, safe and efficient infusion rates are desired. This study aimed to develop a triglyceride (TG) kinetic model after soybean oil-based ILE (SO-ILE) administration and individualize the infusion rate via a population pharmacokinetic approach. Methods Eighty-three inpatients were enrolled in this prospective observational study. A TG kinetic model was applied to the observations based on population pharmacokinetics using a non-linear mixed-effect model. The patients' characteristics and laboratory parameters were evaluated to identify predictors of TG kinetics, and the maximum acceptable infusion rate was defined as that for which the maximum TG concentration did not exceed 400 mg/dL in 90% of patients. Results No adverse events associated with SO-ILE administration were observed. The developed TG kinetic model explained the observed TG concentrations and identified the baseline TG concentration and body weight as predictors of TG kinetics. The estimated maximum acceptable infusion rates greatly varied among individuals, ranging from 0.025 to 0.3 g/kg/h. Conclusion The present study suggested the necessity and demonstrated the feasibility of individualizing the infusion rates of SO-ILE using a population pharmacokinetic approach. This article is protected by copyright. All rights reserved.

BACKGROUND Gaps in hospital-based nutrition care practices and opportunities to improve care of patients at risk of malnutrition or malnourished have been demonstrated by several US hospitals implementing quality improvement (QI) projects. This study examined the impact of nutrition care process improvements focused on better documentation of identification and diagnosis of malnutrition in 5 hospital services and differences between nutritionally targeted vs nontargeted services. METHODS Data on malnutrition risk screening, nutrition assessment, malnutrition diagnosis, and nutrition care plan delivery were collected from 32,723 hospital encounters for patients admitted to the intensive care unit, pulmonology, oncology, urology, and general medicine services (targeted) as well as the rest of the nontargeted hospital services between 2017 and 2019. RESULTS Higher rates of morbidity in targeted service patients compared with those in the patient population admitted in the nontargeted services were observed, including higher rates of malnutrition risk (37.43% vs 19.16%, P < .001), higher rates of moderate and severe malnutrition first identified by a registered dietitian nutritionist (20.27% vs 9.67%, P < .001), and malnutrition diagnosis confirmed by an admitting physician (16.72% vs 6.74%, P < .001). CONCLUSIONS The findings suggest sustained improvements in confirmed rates of malnutrition identification and diagnosis are achievable. Targeting malnutrition QI efforts to hospital services with higher patient morbidity is an effective method for improving malnutrition diagnosis, in particular in hospitals with limited resources, which in turn can result in improved nutrition care delivery.

Introduction Clinical reports show a positive correlation between phytosterol concentrations and severity of cholestatic liver disease markers in infants during long-term administration of parenteral lipid emulsions. Establishing a causal link between phytosterols and cholestasis has been complicated by confounding factors of lipid emulsion load, fatty acid composition, and vitamin E in many of these studies. Aim The goal of this study is to determine whether altering the phytosterol concentration within a common soybean oil-based emulsion will alter the onset and severity of cholestasis in parenterally fed preterm piglets. Methods Preterm piglets were administered for 21 days either enteral nutrition (ENT) or parenteral nutrition prepared from a soybean oil-based emulsion containing either 24.0% (depleted, DEP), 100% (Intralipid, normal phytosterol concentration NP), and 144% (enriched, ENR) total phytosterol concentration. Results At the end of the study, plasma and liver phytosterol concentrations were highest in the ENR group followed by NP, then DEP and ENT. Serum direct bilirubin, serum bile acids, and gamma glutamyl transferase was higher in the ENR and NP groups compared either DEP or ENT groups. All PN lipid groups showed evidence of mild hepatic steatosis, but no change in hepatic expression of proinflammatory cytokines or farnesoid X receptor target genes. Conclusion The increase in serum direct bilirubin was lower in the depleted group vs. the lipid emulsions with normal or enriched phytosterols. Our results provide additional evidence that phytosterols are linked to an increase in serum markers of cholestasis in preterm PN-fed pigs. This article is protected by copyright. All rights reserved.

OBJECTIVE Peptide -based (PB) enteral tube feeding (ETF) formulas have been shown to reduce gastrointestinal (GI) intolerance in patients receiving enteral nutrition. However, limited data exist in relation to their use in the postacute/home care setting. We sought to assess the real-world GI tolerance, healthcare utilization, and resource use costs of 100% whey-protein PB ETF in adults in a postacute care setting and describe their demographic, clinical, and treatment characteristics. METHOD Using medical claims data from the United States, we analyzed GI intolerance events occurring in adults receiving 100% whey-protein PB ETF (Peptamen® adult formulas) for one year before and after initiation of ETF. Resource use costs were subsequently estimated using a multivariate general linearized model and adjusted for age, gender, and Charlson Comorbidity Index score. RESULTS The proportion of adults experiencing no GI intolerance events increased from 41% (418/1022) to 59% (601/1022) in the one-year period after initiation of 100% whey PB ETF (P < .001). The proportion of patients with at least one hospital inpatient visit also decreased from 100% (1022/1022) to 72% (737/1022) over the same period, and the mean number of inpatient visits per patient decreased from 15.6 to 13.0. Cost modeling revealed that outpatient visits accounted for 42% ($1174/$2820) of total estimated healthcare resource costs in the first 30 days after 100% whey PB ETF initiation, with only 9% ($255/$2820) due to emergency room visits. CONCLUSION These 100% whey-protein PB ETF formulas are a valuable nutrition treatment option for patients with or at risk of malnutrition who show intolerance to standard ETF formulas and may reduce hospital inpatient visits and associated costs.

BACKGROUND: Teduglutide reduces or eliminates parenteral support (PS) dependency in patients with short bowel syndrome (SBS). Recent post hoc analyses demonstrated that effects are correlated with baseline PS volume. We assessed the SBS-related quality-of-life (QoL) impact of teduglutide, particularly whether improvements are greater among subgroups achieving more PS volume reduction.METHODS: Using phase 3 trial data of teduglutide in patients with SBS (NCT00798967), change in Short Bowel Syndrome-Quality of Life (SBS-QoL) scores from baseline were compared between teduglutide vs placebo in the overall population and subgroups classified by baseline PS volume requirement, disease etiology, and bowel anatomy. Generalized estimating equation models were fitted to assess impact of teduglutide on SBS-related QoL using data from all visits, adjusted for baseline characteristics.RESULTS: Of 86 patients, 43 each were randomized to teduglutide or placebo (mean age: 51 vs 50 years, respectively). In adjusted analyses, teduglutide had a nonsignificant reduction (improvement) of -8.6 points (95% CI: 2.6 to -19.8) in SBS-QoL sum score from baseline to Week-24 vs placebo. The impact of teduglutide varied by subgroup. Patients treated with teduglutide experienced significantly greater reductions in SBS-QoL sum score at Week-24 vs placebo in 2 subgroups, ie, the third (highest) tertile baseline PS volume (-27.3, 95% CI: -50.8 to -3.7) and inflammatory bowel disease (IBD; -29.6, 95% CI: -46.3 to -12.9). Results were similar for SBS-QoL subscale and item scores.CONCLUSIONS: The impact of teduglutide treatment on SBS-related QoL vs placebo varied among subgroups and was significant and most pronounced among patients with highest baseline PS volume requirement or IBD.

Hypoalbuminemia is associated with inflammation. Despite being addressed repeatedly in the literature, there is still confusion regarding its pathogenesis and clinical significance. Inflammation increases capillary permeability and escape of serum albumin, leading to expansion of interstitial space and increasing the distribution volume of albumin. The half‐life of albumin has been shown to shorten, decreasing total albumin mass. These 2 factors lead to hypoalbuminemia despite increased fractional synthesis rates in plasma. Hypoalbuminemia, therefore, results from and reflects the inflammatory state, which interferes with adequate responses to events like surgery or chemotherapy, and is associated with poor quality of life and reduced longevity. Increasing or decreasing serum albumin levels are adequate indicators, respectively, of improvement or deterioration of the clinical state. In the interstitium, albumin acts as the main extracellular scavenger, antioxidative agent, and as supplier of amino acids for cell and matrix synthesis. Albumin infusion has not been shown to diminish fluid requirements, infection rates, and mortality in the intensive care unit, which may imply that there is no body deficit or that the quality of albumin “from the shelf” is unsuitable to play scavenging and antioxidative roles. Management of hypoalbuminaemia should be based on correcting the causes of ongoing inflammation rather than infusion of albumin. After the age of 30 years, muscle mass and function slowly decrease, but this loss is accelerated by comorbidity and associated with decreasing serum albumin levels. Nutrition support cannot fully prevent, but slows down, this chain of events, especially when combined with physical exercise.

Background: Enteral nutrition (EN) increases hyperglycemia due to high carbohydrate concentrations while providing insufficient protein. The study tested whether an EN formula with very high‐protein‐ and low‐carbohydrate‐facilitated glucose control delivered higher protein concentrations within a hypocaloric protocol. Methods: This was a multicenter, randomized, open‐label clinical trial with parallel design in overweight/obese mechanically ventilated critically ill patients prescribed 1.5 g protein/kg ideal body weight/day. Patients received either an experimental very high‐protein (37%) and low‐carbohydrate (29%) or control high‐protein (25%) and conventional‐carbohydrate (45%) EN formula. Results: A prespecified interim analysis was performed after enrollment of 105 patients (52 experimental, 53 control). Protein and energy delivery for controls and experimental groups on days 1–5 were 1.2 ± 0.4 and 1.1 ± 0.3 g/kg ideal body weight/day (P = .83), and 18.2 ± 6.0 and 12.5 ± 3.7 kcals/kg ideal body weight/day (P < .0001), respectively. The combined rate of glucose events outside the range of >110 and ≤150 mg/dL were not different (P = .54, primary endpoint); thereby the trial was terminated. The mean blood glucose for the control and the experimental groups were 138 (−SD 108, +SD 177) and 126 (−SD 99, +SD 160) mg/dL (P = .004), respectively. Mean rate of glucose events >150 mg/dL decreased (Δ = −13%, P = .015), whereas that of 80–110 mg/dL increased (Δ = 14%, P = .0007). Insulin administration decreased 10.9% (95% CI, −22% to 0.1%; P = .048) in the experimental group relative to the controls. Glycemic events ≤80 mg/dL and rescue dextrose use were not different (P = .23 and P = .53). Conclusions: A very high‐protein and low‐carbohydrate EN formula in a hypocaloric protocol reduces hyperglycemic events and insulin requirements while increasing glycemic events between 80–110 mg/dL.

BACKGROUND: The variability of parenteral nutrition (PN) utilization for pediatric inpatients is currently unknown. The purpose of this study is to determine the variability in PN utilization in U.S. children’s hospitals and the association of PN utilization with inpatient healthcare utilization. METHODS: We performed a retrospective cohort study of children who received PN during an inpatient encounter in U.S. children’s hospitals. Hospitals were divided into tertiles based on their rates of PN utilization into low (51.8/1,000 encounters) categories. Multivariable regression models were developed to assess the associations between hospital PN utilization and time to PN initiation, PN duration, and encounter length of stay after adjustment for salient patient characteristics. RESULTS: The cohort included 82,142 patients receiving PN, and rates of hospital PN utilization ranged from 5.9 to 76.7 encounters receiving PN per 1,000 inpatient encounters. After multivariable adjustment, patients treated at high utilization hospitals had a significantly shorter time to initiation of PN compared to low utilization hospitals (incident rate ratio [95% Confidence Interval]: 0.78 [0.69–0.89], p

The COVID‐19 pandemic has reached worldwide and until a vaccine is found it will continue to cause significant morbidity and mortality. The clinical presentation of COVID‐19 ranges from that of being asymptomatic to developing a fatal illness characterized by multiple organ involvement. Approximately 20% of the patients will require hospitalization; one quarter of hospitalized patients will develop severe COVID‐19 requiring admission to the intensive care unit, most frequently, with acute respiratory failure.An ongoing effort is being made at identifying the patients that will develop severe COVID‐19. Grossly, patients present with three different nutritional risk phenotypes: 1) the frail older patient, 2) the patient with severe ongoing chronic illness, and 3) the patient with severe and morbid obesity. These three phenotypes represent different nutritional risks, and diverse nutrition interventions. This article explores the different potential approaches to nutrition intervention in patients with COVID‐19 evaluating, in this process, the challenges faced for the implementation of guidelines written by different societies. This article is protected by copyright. All rights reserved

BACKGROUND: Infants with gastroschisis require operations and lengthy hospitalizations due to intestinal dysmotility. Dysbiosis may contribute to these problems. Little is known on the microbiome of gastroschisis infants. METHODS: The purpose of this study was to investigate the fecal microbiome in gastroschisis infants. Microbiome profiling was performed by sequencing the V4 region of the 16S rRNA gene. The microbiome of gastroschisis infants was compared to the microbiome of healthy controls, and the effects of mode of birth delivery, gestational age, antibiotic duration, and nutrition type on microbial composition and diversity were investigated. RESULTS: The microbiome of gastroschisis infants (n=13) was less diverse (Chao1, p < 0.001), lacked Bifidobacterium (p = 0.001) and had increased Staphylococcus (p = 0.007) compared to controls (n=83). Mode of delivery (R(2) = 0.04, p = 0.001), antibiotics duration greater than or equal to seven days (R(2) = 0.03, p = 0.003), age at sample collection (R(2) = 0.03, p = 0.009), and gestational age (R(2) = 0.02, p = 0.035) explained a small portion of microbiome variation. In gastroschisis infants, Escherichia-Shigella was the predominate genus, and those delivered via cesarean section had different microbial communities, predominantly Staphylococcus and Streptococcus, from those delivered vaginally. While antibiotic duration contributed to the variation in microbiome composition, there were no significant differences in taxa distribution or alpha diversity by antibiotic duration or nutrition type. CONCLUSION: The microbiome of gastroschisis infants is dysbiotic, and mode of birth delivery, antibiotic duration, and gestational age appear to contribute to microbial variation.

Background Converting nutrition support to energy results in free radical production from the electron chain transport, possibly increasing oxidative stress. Highly prevalent single nucleotide polymorphisms (SNP) exist for the genes encoding antioxidant enzymes responsible for the detoxification of reactive oxygen species. Objective Our objective was to explore the interaction between nutrition support and genetic polymorphisms for two anti-oxidant proteins (rs4880 SNP for manganese superoxide dismutase and rs1050450 SNP for glutathione peroxidase 1) on oxidative stress and secondarily on ICU mortality. Design We performed a post-hoc analysis on 34 mechanically ventilated sepsis patients from a the FeDOX trial. Participants were dichotomized into those who carried both the rs4880 and the rs1050450 at-risk alleles (Risk Group) versus all others (Non-Risk Group). We explored the interaction between genotype and the percent time spent in the upper median of calorie exposure on oxidative stress and ICU mortality. Results Adjusting for confounders, the slope of log F2-isoprostane levels across percentage of days spent in the upper median of daily kcal/kg was 0.01 higher in the Risk Group compared to the Non-Risk Group (p = 0.01). Every every 1 percent increase in days spent in the upper median of daily Kcals/kg was associated with an adjusted 10.3 percent increased odds of ICU mortality amongst participants in the Risk Group (OR = 1.103, p = 0.06) but was highly insignificant in the Non-Risk group (OR = 0.991, p = 0.79). Conclusions Nutrition support may lead to increased oxidative stress and worse clinical outcomes in a large percent of ICU patients with an at-risk genotype. This article is protected by copyright. All rights reserved.

Background To assess the appropriate energy expenditure requirement for liver transplant (LT) recipients in South Korea, 4 commonly used predictive equations were compared with indirect calorimetry (IC). Methods A prospective observational study was conducted in the surgical intensive care unit (ICU) of an academic tertiary hospital between December 2017 and September 2018. The study population comprised LT recipients expected to remain in the ICU >48 hours postoperatively. Resting energy expenditure (REE) was measured 48 hours after ICU admission using open-circuit IC. Theoretical REE was estimated using 4 predictive equations (simple weight-based equation [25 kcal/kg/day], Harris-Benedict, Ireton-Jones [ventilated], and Penn State 1988). Derived and measured REE values were compared using an intraclass correlation coefficient (ICC) and Bland-Altman plots. Results Of 50 patients screened, 46 were enrolled, were measured, and completed the study. The Penn State equation showed 65.0% agreement with IC (ICC, 0.65); the simple weight-based (25 kcal/kg/day), Harris-Benedict, and Ireton-Jones equations showed 62.0%, 56.0% and 39.0% agreement, respectively. Bland-Altman analysis showed that all 4 predictive equations had fixed bias, although the simple weight-based equation (25 kcal/kg/day) showed the least. Conclusion Although predicted REE calculated using the Penn State method agreed with the measured REE, all 4 equations showed fixed bias and appeared to be inaccurate for predicting REE in LT recipients. Precise measurement using IC may be necessary when treating LT recipients to avoid underestimating or overestimating their metabolic needs.

Background Malnutrition in hospitalized patients can adversely affect health outcomes and increase the cost of care. Real-world strategies are needed for prompt identification and treatment of patients at risk of malnutrition. Objectives The aim of this quality improvement (QI) study was to measure the impact of a nutrition-focused program on the malnutrition care processes of participating hospitals. Secondary objectives were to determine whether improvements in these nutrition-related processes reduced hospital readmissions and length of stay (LOS) in patients ≥65 years. Methods A group of 27 US hospitals ("The Collaborative") implemented the Malnutrition Quality Improvement Initiative (MQii), as guided by a Malnutrition QI Toolkit and 4 electronic clinical quality measures (eCQMs), including (1) nutrition screening; (2) nutrition assessment following detection of malnutrition risk; (3) nutrition care plan for patients identified as malnourished after completed nutrition assessment; and (4) documentation of malnutrition diagnoses. Multivariate analyses identified the variables best correlated with patient outcomes. Results Improvements were observed for all 4 eCQMs. The greatest improvements were achieved as a result of timely nutrition assessment (P = .06) and malnutrition diagnosis (P = .02). Patients ≥65 years with a malnutrition diagnosis and nutrition care plan had a 24% lower likelihood of 30-day readmission but a longer mean LOS than did those without a care plan. Conclusions In this study, the implementation of MQii practices significantly improved the identification of malnutrition. The prompt identification and treatment of patients at malnutrition risk can improve patient care and health, as well as reduce costly readmissions.

Background Prospective randomized controlled trials (PRCTs) that found harm in patients receiving higher levels of energy exposure have been largely ignored, in part because of the lack of a known mechanism of harm. Objective The current 7‐day pilot study is a PRCT and post hoc analysis designed to explore the relationship between energy exposure and oxidative stress (as plasma total F2‐isoprostanes) in mechanically ventilated intensive care unit patients with systemic inflammatory response syndrome. Methods Thirty‐five participants were randomized to receive either 100% or 40% of their estimated energy needs. Our intent‐to‐treat model found no differences in F2‐isoprostanes between groups. A post hoc analysis revealed that on days when participants were in the highest tertile of daily kcal/kg, the real‐time energy flow rate within 2 hours of the blood draw was predictive of increased oxidative stress. On these days, participants in the second or third vs the first tertile of real‐time energy flow rate experienced a 41.8% (P = .006) or 26.5% (P = .001) increase in F2‐isoprostane levels, respectively. This was confirmed through a within‐group subanalysis restricted to participants with measurements on both sides of the median of real‐time energy flow rate that found a 28.2% F2‐isoprostane increase on days in the upper vs lower median of flow rate (P = .002). Conclusion The benefits of feeding may be more nuanced than previously suspected. Our findings imply a potential mechanism of harm in meeting the current recommendations for nutrition support in the critically ill that warrants further investigation.

BACKGROUND Diet therapies may be recommended for pediatric functional gastrointestinal disorders (FGIDs). However, little is known about the frequency with which diet therapy is recommended in FGIDs. Our aims were to determine and contrast the frequency and types of diet recommendations provided to children with FGIDs by pediatric gastroenterologists (PGIs) versus primary care pediatricians (PCPs). METHODS A retrospective chart review was performed using data from a large, metropolitan children's academic healthcare system to identify subjects meeting Rome IV criteria for functional abdominal pain, functional dyspepsia, irritable-bowel syndrome (IBS), and/or abdominal migraine over a period of 23 months. RESULTS Of 1929 patient charts reviewed, 268 were included for further analyses. Of these, 186 patients (69%) were seen by a PGI and 82 (31%) by a PCP. The most common diagnosis was IBS (49% for PGIs and 71% for PCPs). Diet recommendations were provided to 115 (43%) patients (PGI group: 86 [75%] vs PCP group: 29 [25%]; P < .1). The most frequent recommendations were high fiber (PGI: 15%; PCP: 14%) and low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) diet (PGI: 12%; PCP: 4%). Of those provided with diet recommendations, only 20% (n = 23) received an educational consult by a dietitian. Provision of diet recommendations was not affected by years in practice. CONCLUSION Despite increasing awareness of the role of diet in the treatment of childhood FGIDs, a minority of patients receive diet recommendations in tertiary care or primary care settings. When diet recommendations were given, there was great variability in the guidance provided.

BACKGROUND Nutrition support plays a pivotal role in improving the clinical outcomes of the patients admitted to the intensive care unit (ICU). However, there are controversies regarding the optimal amount of energy for the reduction of morbidity and mortality in neurosurgical patients at the ICU. METHODS This randomized clinical trial was conducted on 560 patients who were admitted to trauma, stroke, and neurosurgery ICUs, and 68 patients were enrolled based on the inclusion criteria. In total, data of 58 patients were analyzed. In the full-energy group, enteral feeding started at 75% of their daily energy expenditure and gradually increased to 90%-100%. In the hypocaloric group, enteral feeding started with 30% of the daily energy expenditure and reached 75% within 7 days of the intervention. RESULTS No significant differences were observed in the baseline characteristics of the patients in the hypocaloric and full-energy groups. The incidence of severe gastrointestinal intolerance was relatively high in the full-energy group (P

This systematic review and meta‐analysis investigated ω‐3 fatty‐acid enriched parenteral nutrition (PN) vs standard (non‐ω‐3 fatty‐acid enriched) PN in adult hospitalized patients (PROSPERO 2018 CRD42018110179). We included 49 randomized controlled trials (RCTs) with intervention and control groups given ω‐3 fatty acids and standard lipid emulsions, respectively, as part of PN covering ≥70% energy provision. The relative risk (RR) of infection (primary outcome; 24 RCTs) was 40% lower with ω‐3 fatty‐acid enriched PN than standard PN (RR 0.60, 95% confidence interval [CI] 0.49‐0.72; P < 0.00001). Patients given ω‐3 fatty‐acid enriched PN had reduced mean length of intensive care unit (ICU) stay (10 RCTs; 1.95 days, 95% CI 0.42‐3.49; P = 0.01) and reduced length of hospital stay (26 RCTs; 2.14 days, 95% CI 1.36‐2.93; P < 0.00001). Risk of sepsis (9 RCTs) was reduced by 56% in those given ω‐3 fatty‐acid enriched PN (RR 0.44, 95% CI 0.28‐0.70; P = 0.0004). Mortality rate (co‐primary outcome; 20 RCTs) showed a nonsignificant 16% reduction (RR 0.84, 95% CI 0.65‐1.07; P = 0.15) for the ω‐3 fatty‐acid enriched group. In summary, ω‐3 fatty‐acid enriched PN is beneficial, reducing risk of infection and sepsis by 40% and 56%, respectively, and length of both ICU and hospital stay by about 2 days. Provision of ω‐3‐enriched lipid emulsions should be preferred over standard lipid emulsions in patients with an indication for PN.

Background Sepsis is characterized by life-threatening organ dysfunction caused by a dysregulated host response to infection and affects over 1 million Americans annually. Loss of glycemic control in sepsis is associated with increased morbidity and mortality, and novel approaches are needed to promote euglycemia and improve outcomes in sepsis. Recent studies from our laboratory demonstrate that early low-level enteral dextrose infusion in septic mice attenuates the systemic inflammatory response and improves glycemic control by inducing intestine-derived incretin hormone secretion. Aim The aim of the Study of Early Enteral Dextrose in Sepsis (SEEDS) is to test the effect of a 24-hour enteral dextrose infusion in critically ill septic patients as a therapeutic agent to decrease systemic inflammation and promote euglycemia. Methods SEEDS is a single-center, double-blind, randomized, controlled trial that will enroll 60 septic patients admitted to the intensive care units at the University of Pittsburgh Medical Center Health System in Pittsburgh. Participants will be randomized 1:1 to receive enteral dextrose (n = 30) or water (placebo, n = 30) infusion for 24 hours. The primary outcome is the circulating interleukin-6 level measured after the 24-hour infusion compared between dextrose and placebo groups. Secondary outcomes include postinfusion circulating insulin, incretin, and other proinflammatory cytokine levels, as well as incidence of hyperglycemia and hypoglycemia during the infusion period. Discussion This trial will characterize the effects of early enteral dextrose on endogenous endocrine pathways and the systemic inflammatory response in sepsis. The results of this trial will inform future larger interventional studies of early enteral nutrients in critically ill patients with sepsis.

BACKGROUND Intravenous fish oil (FO) treats pediatric intestinal failure-associated liver disease (IFALD). There are concerns that a lipid emulsion composed of ω-3 fatty acids will cause an essential fatty acid deficiency (EFAD). This study's objective was to quantify the risk for abnormal fatty acid concentrations in children treated with FO. METHODS Inclusion criteria for this prospective study were children with intestinal failure. Intravenous soybean oil (SO) was replaced with FO for no longer than 6 months. Serum fatty acids were analyzed using linear and logistic models, and compared with age-based norms to determine the percentage of subjects with low and high concentrations. RESULTS Subjects (n = 17) started receiving FO at a median of 3.6 months (interquartile range 2.4-9.6 months). Over time, α-linolenic, linoleic, arachidonic, and Mead acid decreased, whereas docosahexaenoic and eicosapentaenoic acid increased (P

Item does not contain fulltext Chronic intestinal failure (CIF) patients are at risk for developing intestinal failure-associated liver disease (IFALD), which can progress to end-stage liver disease. Liver biopsy is the current reference standard to diagnose and monitor IFALD. However, due to its associated complications, biopsy is an unattractive tool in this respect. Our aim was to assess the evidence regarding non-invasive assessment of IFALD in the adult population and provide ideas to take this field further. We searched the PubMed, EMBASE and Web of Science databases in accordance with the PRISMA guideline. We included studies in the adult/mixed intestinal failure population, performing non-invasive diagnostic assessment of IFALD and using liver biopsy, 1H-MRS or MRI-PDFF as reference. Quality of the included studies was assessed using the QUADAS-2 tool. Four studies were included, assessing two serum (vitamin B12, FGF21) and two imaging tests (Fibroscan, CAUS). Three used liver biopsy as reference, all according to a different histological scoring system. One used 1H-MRS as reference. Vitamin B12 did not correlate with liver injury, Fibroscan did not correlate with fibrosis, but with cholestasis. FGF21 correlated with steatosis grade. Several CAUS parameters correlated with the degree of steatosis assessed by 1H-MRS. In conclusion, three tests show promise to non-invasively assess IFALD, but the limited data do not justify conclusions on the diagnostic value of the tested biomarkers. Hence, additional studies are needed. Identification of and validation for grading and staging of clinically relevant histomorphological parameters of IFALD is also crucial and a conceptual study set up is provided.

BACKGROUND The subjective global assessment (SGA) is a powerful tool for nutrition status assessment. Our aim was to compare vitamin C serum levels among patients classified as A, B, or C in the SGA. METHODS One hundred-and-fifty adults in the wards of the University Hospital participated in this study. Besides SGA, all cases were submitted to anthropometry, bioelectrical impedance analysis (BIA), and 24-hour dietary recall. Laboratory data included blood hemoglobin, serum ferritin, serum albumin, transferrin, C-reactive protein (CRP), and vitamin C. Acute phase response was defined by serum CRP > 0.5 mg/dL; low serum vitamin C was defined by serum levels < 0.4 mg/dL. Analysis of variance and χ2 tests were used to compare groups; P

This document represents the American Society for Parenteral and Enteral Nutrition (ASPEN) clinical guidelines to describe best practices in the selection and care of central venous access devices (CVADs) for the infusion of home parenteral nutrition (HPN) admixtures in adult patients. The guidelines targeted adults >18 years of age in which the intervention or exposure had to include HPN that was administered via a CVAD. Case studies, non-English studies, or studies of CVAD no longer available in the United States were excluded. In total, 564 abstract citations, 350 from Medline and 214 from PubMed/non-MEDLINE databases, were scanned for relevance. Of the 564 citations, 13 studies addressed at least 1 of the 6 guideline-related questions, and none of the studies were prospective and randomized. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria were used to adjust the evidence grade based on assessment of the quality of study design and execution. Recommendations for the CVAD type, composition, or number of lumens to minimize infectious or mechanical complications are based on a limited number of studies and expert opinion of the authors, all very experienced in home infusion therapy. No studies were found that compared best solutions for routine flushing of lumens (eg, heparin versus saline) or for maintaining catheters in situ while treating CVAD mechanical or infectious complications. It is clear that studies to answer these questions are very limited, and further research is needed. These clinical guidelines were approved by the ASPEN Board of Directors.

Background Diarrhea in enteral tube-fed patients is not uncommon and can lead to unfavorable outcomes. Fiber in enteral nutrition (EN) formula might play a role in postfeeding diarrhea. Theoretically, soluble fiber is beneficial for both prevention and treatment of postfeeding diarrhea, but different types of soluble fiber may not provide the same effect. This study aims to determine whether supplementation with psyllium in standard EN reduces the incidence of diarrhea in tube-fed patients. Methods We conducted a prospective, randomized, double-blind, controlled study in general medical wards patients who were expected to receive EN for ≥5 days. Exclusion criteria were hemodynamic instability, known significant gastrointestinal problems, and recent pancreatitis. Eligible patients were randomized to receive either Mucilin SF (15.2 g/L)-added Blendera (psyllium-added formula: Psyllium group [PG]) or Blendera (fiber-free formula: Control group [CG]). All patients were given EN for 10 days or until discharge/oral intake/death. Bowel movements (BMs) were monitored using King's Stool Chart. Results Eighty-three patients were enrolled, 42 in the PG and 41 in the CG. Baseline characteristics were similar. The proportion of patients with ≥1 day of diarrhea (King's stool score ≥15) was comparable (42.9% vs 31.7%; P = 0.41, in PG and CG, respectively). There were no significant differences in the frequency of daily BMs and the median diarrhea score between PG and CG (3 vs 2, P = 0.06 and 3.8 vs 2.4, P = 0.42, respectively). Conclusion Supplementation with psyllium showed no beneficial effect on reducing incidence of diarrhea in general medical patients receiving EN. This study was registered on Thai Clinical Trials Registry (http://www.clinicaltrials.in.th: TCTR identification number TCTR20170821004).

BACKGROUND Malnutrition increases the risk of mortality and morbidity in the pediatric intensive care unit (PICU). Barriers to adequate delivery of enteral nutrition (EN) include hemodynamic instability, feeding interruptions and intolerance, and lack of standardized feeding protocols. The most recent guidelines on nutrition support for the critically ill child describe a paucity of evidence around the best method to deliver EN. There is an untested clinical assumption that bolus gastric feeding (B-GF) in intubated patients is associated with aspiration events, lung injury, and associated morbidity compared with continuous gastric feeding (C-GF). This study compared the effectiveness and safety of C-GF vs B-GF in intubated pediatric patients. METHODS We enrolled randomized patients aged 1 month-12 years who were intubated within 24 hours and received EN starting within 48 hours of admission to a C-GF or B-GF group. Goal-directed EN volume and caloric density were increased every 3 and 12 hours, respectively, to target. Feeding interruptions and intolerance events were recorded. RESULTS Twenty-five subjects were enrolled (B-GF = 11; C-GF = 14). At 24 hours, B-GF was associated with higher energy and protein delivery (P

Background The citrulline generation test (CGT) has been proposed as a tool to determine gut function. However, the increase in plasma citrulline concentration that follows a bolus dose of alanyl-glutamine may also result from a reduction in citrulline clearance due to competition with glutamine for transport. Materials and methods A swine model was developed, and stable isotope tracers were used to determine the mechanism behind the increase in plasma citrulline that follows a bolus dose of alanyl-glutamine. Plasma concentrations and enrichments were determined, and a non-steady-state model was used to calculate rates of appearance, disappearance, and conversion. Results The pig model recapitulated the increase in plasma citrulline observed in humans after a dose of alanyl-glutamine. The dipeptide was rapidly hydrolyzed to its constitutive amino acids. Both citrulline plasma concentration and citrulline rate of appearance increased by ≈45% after the bolus dose of alanyl-glutamine. The conversion of citrulline to arginine and the rate of appearance of arginine also increased. Glutamine contributed up to 25% ± 2% of the rate of appearance of citrulline. No changes in the rate of disappearance of citrulline were observed. Conclusion Our results indicate that a single bolus dose of alanyl-glutamine increases plasma citrulline concentration by increasing citrulline production without any effect on citrulline disposal. Our findings strongly indicate that the CGT assesses the metabolic response of the gut and that CGT can become a useful tool to evaluate gut mass and function.

BACKGROUND Evaluation of improvements by nutrition support to severely ill patients requires sensitive methods to demonstrate activation of protein synthesis in various tissues from groups with a limited number of patients to be statistically efficient. This study examines effects of standard parenteral nutrition (PN) on abdominal muscle transcripts of amino acid (AA) transporters, myosin heavy chains (MHCs), and the insulin-like growth factor 1 and its receptor (IGF-1/IGF-1R) in patients aimed at major surgery. METHODS Twenty-two randomized patients received steady-state PN (0.16 gN/kg/d, 30 kcal/kg/d) or saline infusions for 12 hours before operation. Blood samples and muscle biopsies were obtained at operation start. Muscle messenger RNA (mRNA) levels of AA transporters (solute carrier family members SNAT2, LAT1, LAT3, LAT4, TAUT, PAT1, CD98), IGF-1, IGF-1R, MHC isoforms (MHC1, MHC2A, MHC2X), and LAT3 protein were quantified and related to concentrations of AA, IGF-1, insulin, and metabolic substrates in blood. RESULTS Muscle mRNA LAT3, LAT4, IGF-1R, and MHC2A increased by PN infusion, with correlations to specific AA transporters and MHC isoforms (P < .01-.05). TAUT and LAT3 correlated to slow (MHC1) and fast (MHC2A, MHC2X) isoforms (P < .001-.02). Muscle IGF-1 mRNA correlated to plasma essential AAs, whereas IGF-1R mRNA was related to LAT3, MHC2A, and serum IGF-1 (P < .001-.03). CONCLUSIONS The results confirm that short-term preoperative PN activates transcription of AA transporters and myosin isoforms. Thus, combinations of methods on gene transcription and translation of muscle proteins can be applied to define efficient combinations of nutrition and hormones to catabolic patients in preoperative and postoperative settings.

Background Reduced nutrient intake is common in patients after hospitalization, contributing to increased risk for readmission and mortality. Oral nutrition supplements can improve nutrition status and clinical outcomes, but intake of food is prioritized by clinicians. This study examines the impact of a high‐protein oral nutrition supplement (S‐ONS) on nutrient intake post discharge. Methods In a subset of patients (14 S‐ONS and 16 placebo) from the NOURISH (Nutrition effect On Unplanned ReadmIssions and Survival in Hospitalized patients) trial, 24‐hour dietary recalls were conducted on 3 randomly selected days during the weeks of 30, 60, and 90 days post discharge. Nutrient intake was estimated using Nutrition Data System for Research software. Adequate energy and protein intake were defined as 30 kcal/kg/d and 1.2 g/kg/d, respectively. Dietary Reference Intakes (DRIs) were used for other nutrients. Results Less than half of patients met the requirements for energy, protein, and 12 micronutrients from food intake alone during the study. Energy and protein intakes from food were not diminished relative to placebo. Considering nutrient intake from both food and S‐ONS, 50% and 71% of patients receiving S‐ONSs met energy and protein goals respectively at 90 days (compared with 29% and 36%, in the placebo group), and 100% met the DRI for total carbohydrate, iron, phosphorus, copper, selenium, thiamin, and riboflavin at all time points, all of which were consumed at higher amounts vs placebo. Conclusion Three months of S‐ONS consumption increases intake of numerous nutrients without decreasing nutrient intake from food in older malnourished adults post discharge.

BACKGROUND The objective of this study was to assess the effect of intravenous human serum albumin administration (IV HSA) on nutrition markers, including non-serum-albumin plasma protein levels, in adult critically ill patients receiving parenteral nutrition (PN). METHODS This was a retrospective study of prospectively collected data. Patients included in an initial cohort were patients who initiated IV HSA within 24 hours of start of PN. A second cohort who did not received IV HSA during PN was manually selected, matching several variables. Subsequently, both cohorts were propensity-score matched, resulting in 2 final cohorts: the cohort receiving IV HSA (ALB) and the cohort not receiving IV HSA (NOALB). RESULTS A total of 42 patients, 21 in each cohort, entered the study. Both cohorts were similar in demographics, anthropometrics, comorbidities, diagnoses, PN composition, and severity of the disease, biochemistry, and nutrition markers. Patients in the ALB cohort received IV HSA at a dose of 30.0 g/day during 5 days. The ALB cohort presented higher values of final serum albumin level and serum albumin level change from baseline, but also presented lower values of final non-serum-albumin plasma protein levels and their change and lower final prealbumin. In addition, bilirubin in the ALB cohort increased, whereas it decreased in the NOALB cohort. CONCLUSION Patients receiving IV HSA and PN for several days increased serum albumin level, but decreased non-serum-albumin plasma protein levels. In addition, bilirubin clearance could be slightly impaired in these patients.

BACKGROUND We assessed the impact of a standardized nutrition initiative for very low-birth-weight (VLBW) infants on their nutrition and clinical outcomes. METHODS This was a prospective analysis of VLBW infants born before and after the initiation of a nutrition protocol. This protocol included trophic feeds, feeding advancement, fortification guidelines, parameters on the concentration of parenteral nutrition (PN), and the discontinuation of PN and central lines. Gastric residual monitoring was discontinued. Statistical analyses were performed with Fisher's exact and Student's t-tests. Primary outcome measures were days receiving PN, days made nil per os (NPO) after feeding initiation, necrotizing enterocolitis, and growth parameters. Secondary outcome measures were central-line days, sepsis, blood transfusions, cholestasis, osteopenia, chronic lung disease, and retinopathy of prematurity. RESULTS 136 VLBW infants were analyzed, including 77 in the preprotocol group and 59 in the postprotocol group. Infants postprotocol were found to have reduced PN days (26.1 versus [vs] 18.4, P < .01), fewer days made NPO after feeding initiation (7.2 vs 4.0, P = .02), NEC (7.8% vs 0%, P = 0.038), central-line days (26.5 vs 18.6, P < .01), cholestasis (16% vs 3%, P = .02), and blood transfusions (5.3 vs 3.1, P = .028). Growth, defined by change in z-score from birth to discharge, improved for weight (-1.3 vs -0.8, P < .01), length (-1.5 vs -1.0, P = .033), and head (-1.1 vs -0.6, P = .024). CONCLUSION Initiation of a standardized nutrition initiative for VLBW infants significantly improved growth, reduced PN use, and improved patient outcomes.

BACKGROUND Lactate production is exacerbated by surgical stress. We sought to determine whether branched-chain amino acid (BCAA) supplementation could decrease blood lactate levels in patients undergoing hepatectomy. METHODS A total of 275 consecutive patients who underwent hepatectomy of ≥2 segments were retrospectively reviewed. Blood lactate levels in patients treated with BCAA supplementation before hepatectomy (December 2011 to December 2016) were compared with levels in patients who were not pretreated (January 2008 to November 2011). RESULTS Postoperative lactate levels were significantly lower in patients who received preoperative BCAA supplementation than in those who did not (2.6 vs 3.4 mmol/L; P < .001). Intraoperative blood lactate levels, which were evaluated after induction of general anesthesia, were also lower in those who received BCAA supplementation than in those who did not (1.1 vs 1.5 mmol/L, respectively; P < .001). A multiple regression analysis revealed that preoperative BCAA supplementation was independently associated with decreased postoperative and intraoperative lactate levels (P = .030 and P < .001, respectively). CONCLUSION Preoperative BCAA supplementation decreased intraoperative and postoperative blood lactate levels in patients undergoing major hepatectomy.

Background: Recent developments in nutrition intervention indicated clinical effectiveness for pressure ulcer (PU) prevention and treatment, but it is important to assess whether they are cost-effective. The aims of this systematic review are to determine the cost-effectiveness and clinical outcomes of nutrition support in PU prevention and treatment. Methods: A systematic search of randomized controlled trials, observational studies, and statistical models that investigated cost-effectiveness and economic outcomes for prevention and/or treatment of PUs were performed using standard literature and electronic databases. Results: Fourteen studies met the inclusion criteria, which included 3 randomized controlled trials with their companion economic evaluations, 4 model-based, 2 cohort, 1 pre and post, and 1 prospective controlled trial. Risk of bias assessment for all of the uncontrolled or observational trials revealed high or serious risk of bias. Interventions that incorporated specialized nursing care appeared to be more effective in prevention and treatment of PUs, compared with single intervention studies. There is a trend of improved PU healing when additional energy/protein are provided. PU prevention ($250–$9,800) was less expensive than treatment ($2,500–$16,000). Nutrition intervention for PU prevention was cost-effective in 87.0%–99.99% of the simulation models. Conclusions: There is potential cost-saving and/or cost-effectiveness of nutrition support in the long term, as predicted by the model-based PU prevention studies in the review. Prevention of PU also appears to be more cost-effective than treatment. A multidisciplinary approach to managing PU is more likely to be cost-effective.

BACKGROUND Pasteurized donor milk is the recommended supplement for preterm infants when mother's milk volumes are insufficient. Compared with mother's milk, the macronutrient content of donor milk is thought to be lower due to pasteurization and additional container changes during processing. Given that poor growth is concerning for preterm infants, it is important to understand how processing and feeding methods influence the nutrition composition of donor milk feeds. The research aim of this study was to determine the effects of pasteurization and feeding method on the macronutrient and energy composition of donor milk. Ten donor milk pools were pasteurized, prepared according to neonatal practices, and infused through nasogastric tubes to simulate 4 feeding methods: bolus, 30 minutes, 60 minutes, and continuous feeding over 4 hours. Macronutrient concentrations were assessed after pasteurization, preparation, and each feeding method using a mid-infrared human milk analyzer. RESULTS There were no significant decreases in macronutrient content after pasteurization or bolus feeding. However, energy and fat losses increased with slower infusion rates. After continuous feeding for 4 hours, energy and fat concentrations decreased by a mean of 17.3 (15.8-18.8) kcal/dL and 2.08 (1.90-2.25) g/dL (P < .0001), respectively. CONCLUSIONS Pasteurization did not significantly reduce donor milk macronutrient and energy content; however, feeding method significantly impacted the final delivery of energy and fat.

Multicomponent lipid emulsions, such as SMOFlipid, contain intermediate amounts of essential fatty acids (EFAs) compared with traditional soybean-oil based lipid emulsions and 100% fish-oil lipid emulsions. We describe the development of moderate EFA deficiency (EFAD) and slow weight gain in an infant with intestinal failure-associated liver disease managed with SMOFlipid reduction (1 g/kg/d). Once SMOFlipid dosage was increased (2-3 g/kg/d), EFA levels normalized, adequate growth resumed, and the infant's cholestasis resolved. We recommend avoiding lipid reduction of SMOFlipid, which not only increases the risk for EFAD, but also is unnecessary given that cholestasis can be reversed on conventional doses of SMOFlipid.

BACKGROUND The milk fat globule membrane (MFGM) contains various bioactive components which have been shown to maintain gut barrier integrity. This study aimed to evaluate the protective effects of MFGM on intestinal barrier function and its possible mechanisms in a rat model of short bowel syndrome (SBS). MATERIALS AND METHODS Five-week-old male Sprague-Dawley rats were divided into 3 groups (n = 8 per group), consisting of Sham group and rats submitted to massive small-bowel resection then supplemented with either water (SBS) or 1.5g/kg/d MFGM (SBS+MFGM) by daily gavage. Rats were sacrificed on day 15 postoperation. Intestinal adaptation, gut permeability, bacterial translocation (BT), expression of tight junction proteins, mucin 1 (MUC1), and nucleotide-binding oligomerization domain leucine-rich repeat and pyrin domain-containing protein 3 (NLRP3) pathway in the ileum were evaluated. RESULTS Both SBS+MFGM and SBS groups exhibited lower body weight and higher ileum villus height than Sham group, but no difference was detected between each other. SBS group had significantly higher intestinal permeability and BT rate than other groups (P < .05). Compared with SBS rats, SBS+MFGM group showed higher expression of tight junction proteins and MUC1, lower expression of NLRP3 and caspase-1 in the ileum, as well as lower interleukin (IL)-1β but higher IL-18 levels in ileum tissue. CONCLUSIONS Supplementation of MFGM helps to modulate NLRP3 inflammasome activation and enhances gut barrier integrity in rats after massive small-bowel resection, which provides experimental support for potential applications of MGFM in intestinal barrier dysfunction, although further studies are needed.

BACKGROUND Adequate nutrition therapy in critically ill patients poses a challenge because of the variable energy and substrate needs. The objective was to investigate whether nutrition therapy involving indirect calorimetry (IC), instead of equations for assessment of energy needs, could improve the nutrition status of critically ill patients. METHODS Forty mechanically ventilated patients were randomized into a group in which energy needs were controlled by calorimetry (IC group) and a group treated with a formula-based approach reflecting standard care (SC group). The primary outcome was change in the phase angle (PhA), a bioelectrical impedance parameter related to nutrition status and prognosis. RESULTS The mean IC-based energy requirement was lower than the formula-based estimate (21.1 ± 6.4 versus [vs] 25 kcal/kg/d, P < .01). The IC group reached 98% ± 8% of the energy goal, whereas the SC group reached only 79% ± 29% (P < 0.05), although mean intake was similar in both groups. The protein intake goal was better met in the IC group (91% ± 24%) than the SC group (73% ± 33%). The PhA of the IC group did not change during treatment, whereas that of the SC group tended to decrease by 0.36° ± 0.86° (P = .077). A shorter length of stay in intensive care was observed in the IC than in the SC group (13 ± 8 vs 24 ± 20 days, P < .05). CONCLUSION Intensified individual nutrition therapy involving IC appears to be useful for improving nutrition status in critically ill patients.

Background Little is currently known about nutrition intake and energy requirements in the post-intensive care unit (ICU) hospitalization period in critically ill patients. We aimed to describe energy and protein intake, and determine the feasibility of measuring energy expenditure during the post-ICU hospitalization period in critically ill adults. Methods This is a nested cohort study within a randomized controlled trial in critically ill patients. After discharge from ICU, energy and protein intake was quantified periodically and indirect calorimetry attempted. Data are presented as n (%), mean (SD), and median (interquartile range [IQR]). Results Thirty-two patients were studied in the post-ICU hospitalization period, and 12 had indirect calorimetry. Mean age and BMI was 56 (18) years and 30 (8) kg/m2 , respectively, 75% were male, and the median estimated energy and protein requirement were 2000 [1650-2550] kcal and 112 [84-129] g, respectively. Oral nutrition either alone (n = 124 days, 55%) or in combination with enteral nutrition (n = 96 days, 42%) was the predominant mode. Over 227 total days in the post-ICU hospitalization period, a median [IQR] of 1238 [869-1813] kcal and 60 [35-89.5] g of protein was received from nutrition therapy. In the 12 patients who had indirect calorimetry, the median measured daily energy requirement was 1982 [1843-2345] kcal and daily energy deficit was -95 [-1050 to 347] kcal compared with the measured energy requirement. Conclusions Energy and protein intake in the post-ICU hospitalization period was less than estimated and measured energy requirements. Oral nutrition provided alone was the most common mode of nutrition therapy.

Premature infants are susceptible to oxidative stress, increasing the risk for serious morbidities. High-dose human milk (HM) feedings decrease morbidity risks and may reduce oxidative stress in this population. The purpose of this study was to compare oxidative stress using serial urinary FThis was a quasi-experimental design that categorized 22 premature infants into mutually exclusive comparison groups based on exposure to HM and PF. Serial urine samples (before and after first feeding, and DOL 7, 14, and 21) were used to determine urine FComparing the predominantly HM-fed and predominantly PF-fed groups over time, median FOur results demonstrate that predominantly HM feedings were associated with decreased oxidative stress, whereas PF feedings increased oxidative stress in premature infants, even after controlling for perinatal oxidant exposures of HMF or PF introduction.

Background Liver ischemia and reperfusion injury (IRI) is a major problem associated with liver surgery. This study is aimed to compare the preventive effect of an antioxidative nutrient-rich enteral diet (Ao diet) with an ordinal enteral diet (control diet) against liver IRI. Methods The Ao diet was an ordinary diet comprising polyphenols (catechin and proanthocyanidin) and enhanced levels of vitamins C and E. Male C57BL/6 mice were fed the Ao or control diet for 7 days before ischemic insult for 60 minutes, followed by reperfusion for 6 hours. The levels of inflammatory cytokines, chemokines, and antioxidant enzymes and oxidative stress were evaluated. Results After 7 days of pretreatment with the Ao diet, the serum levels of vitamins C and E in mice were markedly elevated. The levels of serum aspartate aminotransferase and alanine aminotransferase, as well as the scores of liver necrosis caused by ischemia and reperfusion, were significantly lower in the Ao diet group than in the control diet group. The gene expression levels of inflammatory cytokines and chemokines, such as interleukin-6 and CXCL1, were significantly lower in the Ao diet group. In the liver, the levels of antioxidant enzymes superoxide dismutase 1 (SOD1) and SOD2 were significantly higher and the malondialdehyde levels were significantly lower in the Ao diet group. Cell adhesion molecule expression was significantly lower, and neutrophil and macrophage infiltration was less in the Ao diet group. Conclusions Antioxidative nutrient supplementation to an ordinary enteral diet may mitigate liver IRI by causing an antioxidant effect and suppressing inflammation.

BACKGROUND Little is known about the impact of feeding adequacy by NUTrition Risk in the Critically Ill (NUTRIC) groups in critically ill patients with body mass index (BMI)

Background Tunneled central venous catheters (TCVCs) and peripherally inserted central catheters (PICC) are often used for the provision of home parenteral nutrition (HPN). There is no formal comparison being made to study the rate of catheter-related bloodstream infection (CRBSI) between TCVCs and PICC in HPN to recommend the use of 1 over the other. Methods An online MEDLINE, PubMed, and Scopus search was conducted. Studies reporting the rate of CRBSI in HPN patients were included. DerSimonian and Laird random effects meta-analyses were used to analyze comparative studies, whereas Begg and Pilote's random effects meta-analysis was used to pool and analyze single-arm studies. Results Seventeen studies (12 single-arm studies and 5 comparative studies) were included for analysis. Meta-analysis of comparative studies showed that PICC use was associated with a significantly lower rate of CRBSI (relative risk (RR) 0.40, 95% CI 0.19-0.83), whereas meta-analysis of single-arm studies revealed that the relative risk for CRBSI was not statistically significantly different from unity. Conclusion TCVC is more commonly used in long-term HPN. Our analysis of comparative studies showed a lower rate of CRBSI in HPN patients using PICC compared with TCVC; however, analysis of single-arm studies showed that the rate of CRBSI was comparable in PICC and TCVC use. The decision to which type of catheter is most suited for HPN patients should hence be based on the duration of treatment, level of care, patients' dexterity, as well patients' underlying comorbidities that may potentially contribute to other catheter-related complications.