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Aim: Late‐onset sepsis (LOS) is common in extreme prematurity. These infants are at risk of refeeding syndrome‐associated hypophosphataemia. Our objective was to investigate whether hypophosphataemia predisposes to LOS in extremely premature neonates. Methods: A retrospective case–control study of neonates born before 29 weeks' gestation in an Australian NICU from 2016 to 2020. Cases developed LOS or localised infection. Two controls, matched within 2 gestational weeks and 90 calendar days, were selected per case. Results: Amongst 48 cases and 93 controls, cases were smaller at birth (767 g vs. 901 g, P = 0.01), but were otherwise comparable. Hypophosphataemia was more common in cases (26% vs. 15%, P = 0.18). Increased intravenous protein intake in the first week was protective against LOS (OR = 0.9, 95% CI 0.76–1.00, P = 0.04); median 2.1 g/kg/day in cases, 2.3 g/kg/day in controls. Conclusions: Hypophosphataemia as part of refeeding syndrome is prevalent and under‐recognised in extremely premature neonates. We did not find an association between hypophosphataemia and LOS. Low intravenous protein may be an independent risk factor for infection. [ABSTRACT FROM AUTHOR]

Aim Methods Results Conclusions Patients with acute ischaemic stroke are more likely to develop refeeding syndrome due to increased need for nutritional support when suffering alterations of consciousness and impairment of swallowing. This study aimed to evaluate the incidence, risk factors and outcomes of refeeding syndrome in stroke patients.This was a retrospective observational study, using the prospective stroke database from hospital, included all consecutive acute ischaemic stroke patients who received enteral nutrition for more than 72 h from 1 January 2020 and 31 December 2022. Refeeding syndrome was defined as occurrence of new‐onset hypophosphataemia within 72 h after enteral feeding. Multiple logistic regression analysis was conducted to evaluate risk factors and relationships between refeeding syndrome and stroke outcomes.338 patients were included in the study. 50 patients (14.8%) developed refeeding syndrome. Higher scores on National Institutes of Health Stroke Scale and Nutritional Risk Screening 2002, albumin <30 g/L and BMI <18.5 kg/m2 were risk factors for refeeding syndrome. Moreover, refeeding syndrome was independently associated with a 3‐month modified Rankin Scale score of >2 and 6‐month mortality.Refeeding syndrome was common in stroke patients and higher baseline National Institutes of Health Stroke Scale, higher Nutritional Risk Screening 2002, albumin <30 g/L and BMI <18.5 kg/m2 were independent risk factors of refeeding syndrome. Occurrence of refeeding syndrome was significantly associated with higher 3‐month modified Rankin Scale and 6‐month mortality. [ABSTRACT FROM AUTHOR]

Objective: The StRONG trial demonstrated the safety and efficacy of higher calorie refeeding (HCR) in hospitalized adolescents and young adults with malnutrition secondary to restrictive eating disorders. Here we compare refeeding outcomes in patients with atypical anorexia nervosa (atypical AN) versus anorexia nervosa (AN) and examine the impact of caloric dose. Method: Patients were enrolled upon admission and randomized to meal‐based HCR, beginning 2000 kcal/day and advancing 200 kcal/day, or lower calorie refeeding (LCR), beginning 1400 kcal/day and advancing 200 kcal every other day. Atypical AN was defined as %median BMI (mBMI) > 85. Independent t‐tests compared groups; multivariable linear and logistic regressions examined caloric dose (kcal/kg body weight). Results: Among n = 111, mean ± SD age was 16.5 ± 2.5 yrs; 43% had atypical AN. Compared to AN, atypical AN had slower heart rate restoration (8.7 ± 4.0 days vs. 6.5 ± 3.9 days, p =.008, Cohen's d = −.56), less weight gain (3.1 ± 5.9%mBMI vs. 5.4 ± 2.9%mBMI, p <.001, Cohen's d =.51) and greater hypomagnesemia (29% vs. 11%, p =.03, OR = 3.29). These suboptimal outcomes were predicted by insufficient caloric dose (32.4 ± 6.9 kcal/kg in atypical AN vs. 43.4 ± 9.8 kcal/kg in AN, p <.001, Cohen's d = 1.27). For every 10 kcal/kg increase, heart rate was restored 1.7 days (1.0, 2.5) faster (p <.001), weight gain was 1.6%mBMI (.8, 2.4) greater (p <.001), and hypomagnesemia odds were 70% (12, 128) lower (p =.02). Discussion: Although HCR is more efficacious than LCR for refeeding in AN, it contributes to underfeeding in atypical AN by providing an insufficient caloric dose relative to the greater body weight in this diagnostic group. Public significance: The StRONG trial previously demonstrated the efficacy and safety of higher calorie refeeding in patients with malnutrition due to restrictive eating disorders. Here we show that higher calorie refeeding contributes to underfeeding in patients with atypical anorexia nervosa, including poor weight gain and longer time to restore medical stability. These findings indicate these patients need more calories to support nutritional rehabilitation in hospital. [ABSTRACT FROM AUTHOR]

Objective: We previously reported that participants with atypical anorexia nervosa (atypical AN) had higher historical and admission weights, greater eating disorder psychopathology, but similar rates of amenorrhea and weight suppression at baseline as compared to anorexia nervosa (AN); here, we compare 1‐year outcomes. Method: Weight, % median body mass index (%mBMI), Eating Disorder Examination Questionnaire (EDE‐Q) scores, resumption of menses, and rehospitalizations were examined at 3, 6, and 12 months post‐discharge. Analyses (N = 111) compared changes in %mBMI, weight suppression, and EDE‐Q scores over time between atypical AN and AN. Results: Among the participants (48 atypical AN, 63 AN), both groups gained weight but those with atypical AN had lower gains than those with AN in %mBMI (p =.02) and greater weight suppression (p =.002) over time. EDE‐Q scores improved over time, independent of weight suppression, with no significant difference between atypical AN and AN. Groups did not differ by rates of resumption of menses (80% atypical AN, 76.9% AN) or rehospitalization (29.2% atypical AN, 37.9% AN). Greater weight suppression predicted longer time to restore menses and more days of rehospitalization. Discussion: Individuals with atypical AN regained a smaller proportion of body mass and were more weight suppressed over time. Change in eating disorder cognitions, resumption of menses, and rehospitalization rates at 1‐year follow‐up did not differ between groups. There was no significant difference in weight suppression between groups for those who were psychologically improved at 12 months. Findings highlight limitations in our understanding of weight recovery in atypical AN. New metrics for recovery are urgently needed. Public Significance: Little is known about outcome in atypical anorexia nervosa (atypical AN). We examined recovery metrics in young people with atypical AN and anorexia nervosa (AN) 1 year after medical hospitalization. Individuals with atypical AN showed slower weight gain and remained further from their pre‐illness weight. There were no differences in the rates of psychological recovery, resumption of menses, or rehospitalization. New metrics are needed to assess recovery in atypical AN. [ABSTRACT FROM AUTHOR]

Background: Patients receiving parenteral nutrition (PN) may develop refeeding syndrome (RFS). This study determined RFS prevalence in hospitalized adults on PN and evaluated whether higher energy delivered by PN on day 1 of PN initiation was associated with RFS development. Methods: We reviewed the medical records of adult patients receiving PN at a Thai quaternary hospital from June 2019 to May 2022. RFS was defined based on the Nutrition Management Clinical Practice Recommendation by the Society of Parenteral and Enteral Nutrition of Thailand. The association between PN energy delivery and RFS development was determined using a generalized estimating equation for multiple logistic regression analysis adjusted for NICE guideline risk factors. Results: A total of 547 patients was included (mean age 59.8 ± 17.2 years, mean body mass index 20.7 ± 4.8). The prevalence of RFS was 45%. Factors associated with RFS included energy from PN on the first day of PN initiation (adjusted odds ratio [aOR] 1.17; 95% CI 1.04–1.33; for every 5 kcal/kg/day increase), starvation >5 days prior to PN (aOR 1.54; 95% CI 1.04–2.26), concomitant diuretic use (aOR 1.81; 95% CI 1.25–2.64), low baseline potassium level (aOR 1.79; 95% CI 1.19–2.70), and individual compounding PN (aOR 1.61; 95% CI 1.04–2.51). Conclusion: RFS was common among hospitalized patients receiving PN. The amount of energy delivered on the first day of PN was independently associated with RFS, raising a concern regarding initiation of PN with higher energy. [ABSTRACT FROM AUTHOR]

Objective: Nutritional rehabilitation and weight restoration are often critical for the treatment of eating disorders (ED), yet are restricted by the potential risk of refeeding syndrome (RFS). The primary objective was to determine the incidence of RFS. Secondary objectives were to explore predictive factors of RFS and describe its impact on treatment goals for patients with ED. Method: This retrospective observational study reviewed the nutrition management for patients admitted to a quaternary hospital for ED treatment from 2018 to 2020. Data were collected during the first 4 weeks of admission and included anthropometry, energy prescription, incidence and severity of RFS, and electrolyte and micronutrient prescription. Outcomes included incidence of RFS, energy prescription and advancement, and weight change. Results: Of 423 ED admissions, 217 patients (median [interquartile range, IQR] age 25 [21–30.5] years; 210 [97%] female) met inclusion criteria. Median (IQR) body mass index (BMI) on admission was 15.5 (14.1–17.3) kg/m2. The mean (standard deviation) length of admission was 35 (7.3) days. Median (IQR) initial energy prescription was 1500 (930–1500) kcal/day. Seventy‐three (33%) patients developed RFS; 34 (16%) mild, 27 (12%) moderate, and 12 (5%) severe. There was no association between RFS severity and admission BMI, energy prescription, or prescription of prophylactic electrolytes or micronutrients. Lower admission weight was associated with RFS (odds ratio 0.96, 95% confidence interval [0.93–1.00], p =.035). Less than half of the participants met the weight gain target (>1 kg per week) in the first 3 weeks of admission. Discussion: The incidence of severe RFS was low in this cohort and was associated with lower admission weight. Public Significance: This study is one of the largest studies to utilize consensus‐defined criteria to diagnose RFS among adult patients admitted for treatment of an ED. This population is still considered to be at risk of RFS and will require close monitoring. The results add to the growing body of research that restriction of energy prescription to prevent RFS may not require the level of conservatism traditionally practiced. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Gastric outlet obstruction can be a dangerous complication of intragastric balloons, as it can result in severe metabolic alkalosis. As weight loss procedures and medical tourism become more popular, physicians should have a high index of suspicion for complications of invasive procedures, particularly in returning travelers. Intragastric balloons for weight loss have decreased in frequency in the United States. However, they are still frequent in low‐ and middle‐income countries. Severe complications occur in less than 3% of patients who undergo this procedure. Herein, we present a case of gastric outlet obstruction, severe metabolic alkalosis, and refeeding syndrome in a patient returning from the Dominican Republic. She presented with 2 weeks of emesis and obstipation, followed by a pre‐syncope and altered mental status. An intragastric mass was observed on computerized tomography, which was characterized as an intragastric balloon and retrieved endoscopically. All metabolic derangements were corrected, and the patient improved without sequelae. As weight loss procedures and medical tourism become more popular, physicians should have a high index of suspicion for complications of invasive procedures, particularly in returning travelers. [ABSTRACT FROM AUTHOR]

Background: Use of dextrose‐containing maintenance fluids prior to parenteral nutrition (PN) initiation is speculated to reduce the risk for refeeding syndrome. We aimed to assess if the use of dextrose vs nondextrose maintenance fluids before PN initiation changes electrolyte supplementation requirements and shifts during initiation. Methods: This retrospective cohort study included patients who received nothing by mouth but received maintenance fluids ≥72 h before PN. The major end point was phosphorus supplementation over 48 h following nutrition initiation. Minor end point included other electrolyte supplementation, changes in electrolyte levels, time to discharge, and goal kilocalories per day. Results: Fifty‐three patients between August 1, 2019, and August 26, 2020, met criteria for analysis; 60% (n = 32) used a dextrose and 40% (n = 21) used a nondextrose maintenance fluid. Baseline characteristics were similar between fluid groups except for body mass index (25.1 dextrose vs 27.5 kg/m2 nondextrose), sex (43.8% female vs 52.4% male), and severe malnutrition (46.9% vs 28.6%), respectively. Phosphorus (52.5 vs 50 mmol; P = 0.33) and magnesium (24 vs 22 g; P = 0.63) supplementation 48 h following nutrition initiation were similar between groups; however, potassium supplementation was lower in the dextrose group (165.0 vs 208.7 mEq; P = 0.01). No difference was observed between groups for time to discharge following nutrition initiation or time to goal kilocalories per day. After controlling for patients who were malnourished between fluid groups using linear regression, phosphorus repletion differences remained nonsignificant. Conclusion: This study did not detect a difference in phosphorus supplementation between groups, even after controlling for patients who were malnourished. [ABSTRACT FROM AUTHOR]

Background: Patients in the intensive care unit (ICU) are at high risk for refeeding syndrome (RFS), yet there is uncertainty regarding how RFS should be operationalized in the ICU. We evaluated different definitions for RFS and tested how they associated with patient‐centered outcomes in the ICU. Methods: This was a retrospective comparison study. Patients age ≥18 years were eligible if they were newly initiated on enteral feeding while hospitalized in the ICU. Eight definitions for RFS were operationalized, including that from the American Society for Parenteral and Enteral Nutrition (ASPEN), all based on electrolyte levels from immediately before until up to 5 days after the initiation of enteral nutrition. Patients were followed for death or for ICU‐free days, a measure of healthcare utilization. Results: In all, 2123 patients were identified, including 406 (19.1%) who died within 30 days of ICU admission and 1717 (80.9%) who did not. Prevalence of RFS varied from 1.5% to 88% (ASPEN definition) depending on the RFS definition used. The excess risk for death associated with RFS varied from 33% to 92% across definitions. The development of RFS based on the ASPEN definition was associated with a greater decrease in ICU‐free days compared with other definitions, but the relationship was not statistically significant. Conclusion: Eight definitions for RFS were evaluated, none of which showed strong associations with death or ICU‐free days. It may be challenging to achieve a standardized definition for RFS that is based on electrolyte values and predicts mortality or ICU‐free days. [ABSTRACT FROM AUTHOR]

Hyperemesis gravidarum occurs in up to 2 % of pregnancies. It is customary to regard the condition as purely an obstetric issue. However, there are reasonable grounds for reframing it as a neuropsychiatric state dependent upon genetic factors and involving peptides active within the central nervous system. Neurological abnormalities can also arise due to Wernicke's encephalopathy and the electrolyte abnormalities of refeeding syndrome. Aside from rehydration and antiemetic drugs, the condition can respond well to certain psychotropic medications and to psychological interventions, it may therefore be reasonable to regard hyperemesis of pregnancy as requiring both psychiatric and medical expertise for comprehensive management. [ABSTRACT FROM AUTHOR]

Background: Patients with anorexia nervosa (AN) may experience life‐threatening malnutrition‐related complications requiring inpatient medical stabilisation. Several management guidelines have been developed but discrepancies exist because of limited high‐level evidence. Aims: To review the evidence base for recommendations contained in Victorian health services guidelines for the nutritional management of inpatients with AN. Methods: MEDLINE and Embase databases were searched for published studies on the nutritional management of inpatients with AN, combined with a manual search through citations. Studies including patients with AN aged 16 years and older were included. Case reports, small case series of <10 patients, studies of nonmedical management and studies with an exclusive paediatric population were excluded. The search results were compared with AN inpatient medical management guidelines sourced from large tertiary health services across Victoria, Australia. Results: The search yielded 584 studies, subsequently reduced to nine studies using the inclusion and exclusion criteria. The results suggest that commencing refeeding at a higher caloric value allows faster weight gain and shorter hospitalisation. Enteral tube feeding is preferential to parenteral nutrition because of infrequent and milder complications. Zinc supplementation showed a doubled rate of body mass index increase compared with placebo. Comparison with Victorian health services guidelines revealed inconsistent recommendations for high‐calorie refeeding and micronutrient supplementation. Conclusion: The evidence supports high‐calorie refeeding of 2000 kcal/day in AN inpatient medical management and zinc supplementation in improving the rate of weight restoration. This is inconsistently reflected in different Victorian health services guidelines. Updated national consensus guidelines could assist in improving consistency of evidence‐based health care. [ABSTRACT FROM AUTHOR]

Summary: Close liaison with ICU‐trained dietitians and early initiation of nutrition is a fundamental principle of care of critically ill patients– this should be done while monitoring closely for refeeding syndrome. Enteral nutrition delivered by volumetric pumps should be used where possible, though parenteral nutrition should be started early in patients with high nutritional risk factors. Malnutrition and loss of muscle mass are common in patients who are admitted to ICUs and are prognostic for patient‐centred outcomes including complications and mortality. Obesity is part of that story, and isocaloric and high‐protein provision of nutrition is important in this group of patients who comprise a growing proportion of people treated. Assessing protein stores and appropriate dosing is, however, challenging in all groups of patients. It would be beneficial to develop strategies to reduce muscle wasting as well; various strategies including amino acid supplementation, ketogenic nutrition and exercise have been trialled, but the quality of data has been inadequate to address this phenomenon. Nutritional targets are rarely achieved in practice, and all ICUs should incorporate clear guidelines to help address this. These should include local nutritional and fasting guidelines and for the management of feed intolerance, early access to post‐pyloric feeding and a multidisciplinary framework to support the importance of nutritional education. [ABSTRACT FROM AUTHOR]

Objective: The StRONG study demonstrated that higher calorie refeeding (HCR) restored medical stability faster in patients hospitalized with anorexia nervosa (AN) and atypical AN (AAN), with no increased safety events compared with standard‐of‐care lower calorie refeeding (LCR). However, some clinicians have expressed concern about potential unintended consequences of HCR (e.g., greater mealtime distress). The purpose of this study was to examine patient treatment preference and compare mealtime distress, food refusal, and affective states between treatments. Method: Participants (N = 111) in this multisite randomized clinical trial were ages 12–24 years, with AN or AAN, admitted to hospital with medical instability who received assigned study treatment (HCR or LCR). Treatment preference was assessed prior to randomization in the full sample. In a subset of participants (n = 45), linear mixed effect models were used to analyze momentary ratings of mealtime distress (pre, during, and post‐meals) and daily affective state during the hospitalization. Results: About half (55%) of participants reported a preference for LCR. Treatment assignment was not associated with food refusal, mealtime distress, or affective states in the subsample. Food refusal increased significantly over the course of refeeding (p =.018). Individuals with greater depression experienced more negative affect (p =.033), with worsening negative affect over time for individuals with higher eating disorder psychopathology (p =.023). Discussion: Despite understandable concerns about potential unintended consequences of HCR, we found no evidence that treatment acceptability for HCR differed from LCR for adolescents and young adults with AN and AAN. Public Significance: The efficacy and safety of higher calorie refeeding in hospitalized patients with anorexia nervosa has been demonstrated. However, it is not known whether higher calorie refeeding (HCR) increases meal‐time distress. This study demonstrated that HCR was not associated with increased mealtime distress, food refusal, or affective states, as compared with lower calorie refeeding. These data support HCR treatment acceptability for adolescents/young adults with anorexia nervosa and atypical anorexia nervosa. [ABSTRACT FROM AUTHOR]

Background and Objectives: Fluid shifts have been ascribed to central diabetes insipidus in patients with anorexia nervosa hospitalized for refeeding. Recent data, however, suggest that vasopressin production is not dysregulated in this population. Our objective was to describe the trajectory of fluid imbalances in relationship to kidney function, electrolyte disturbances, and acid/base balance during refeeding. Methods: A retrospective review of daily fluid balance and biochemical values was performed in 70 sequential unique patients admitted to University of California at Los Angeles Hospital Medical Stabilization Program for Eating Disorders from December 2018 to November 2020. Results: Participants (2 males/68 females) were between 10 and 24 years of age and with a median body mass index of 16.1 (14.3, 18.1) kg/m2. A severe negative fluid balance (>−900 ml/day) was observed in 80% of patients at some point during hospitalization. Serum sodium concentrations were normal on admission and remained stable during refeeding. Serum bicarbonate concentrations were 25 ± 1 mEq/dl on admission and increased above the normal range in 31% of patients. Metabolic alkalosis was inversely associated with the development of a negative fluid balance. Estimated glomerular filtration rate was impaired in 54% of patients, improved with refeeding, and was not associated with the development of a severe negative fluid balance or metabolic alkalosis. Discussion: Chronic energy deprivation alters the physiology of renal fluid and bicarbonate handling in ways that are independent of vasopressin and glomerular filtration. Further studies are warranted to understand the renal adaptations that occur during energy restriction and subsequent refeeding. Public Significance: Massive urinary fluid losses occur in patients with restrictive eating disorders hospitalized for refeeding. In addition, many patients have impaired renal bicarbonate excretion. These findings suggest that chronic energy deprivation impairs the kidney's ability to handle the shifts in fluid and acid/base balance that occur when appropriate oral nutrition is re‐introduced. [ABSTRACT FROM AUTHOR]

Refeeding syndrome (RS) is a condition characterized by electrolyte derangements, thiamin deficiency, and organ dysfunction after the provision of nutrition to an individual who had been deprived of nutrients. Published guidelines outlining the recognition and definition of RS exist for adult and children, but there are limited newborn‐specific guidelines because of a paucity of available literature and variation in reporting. We describe a small‐for‐gestational‐age, full‐term newborn with neonatal encephalopathy who underwent therapeutic hypothermia. Electrolyte derangements and lactic acidosis developed and persisted after the introduction of intravenous nutrition. After the exclusion of other etiologies, neonatal RS was suspected, and the newborn was treated with thiamin. We provide a brief review of the current literature on neonatal RS, present a case report consistent with neonatal RS, and provide suggestions for the utility of thiamin replacement in newborns with suspected neonatal RS. [ABSTRACT FROM AUTHOR]

Disease‐related malnutrition in patients in the general medical ward remains a complex syndrome, which contributes to high morbidity and mortality, and seriously interferes with recovery from acute illness. Recently, there have been important advances in the development of consensus diagnostic criteria for malnutrition, and through the recent completion of large‐scale trials, the understanding of pathophysiological pathways and evidence‐based treatment algorithms to provide nutrition care to patients at risk for malnutrition in the hospital setting has advanced. There is need to identify more specific clinical parameters and blood biomarkers, which allow a more personalized approach to the malnourished patients, because not all patients show the same response to nutrition interventions. Recent studies have suggested that some nutrition biomarkers of inflammation, kidney function and muscle health, among others, predict treatment response to nutrition interventions and may help to personalize treatments. In addition to advancing the science, there is need for more education of students and treating teams in the hospital to improve the screening of patients at hospital admission regarding nutrition risk with the start of individualized nutrition support interventions, thereby bringing optimal nutrition care to the bedside. [ABSTRACT FROM AUTHOR]

Background: Until recently, refeeding syndrome (RFS) has lacked standardized diagnostic criteria. This study sought to (1) determine whether RFS, as operationalized in the 2020 American Society for Parenteral and Enteral Nutrition (ASPEN) guideline definition, is associated with adverse clinical outcomes and (2) identify key risk factors for RFS. Methods: In this retrospective cohort study, adults hospitalized from 2015 to 2019 were included if they were ordered for enteral feeding during hospitalization. Data were collected for up to 30 days, and RFS was operationalized as per the ASPEN 2020 guidelines as a ≥10% (corresponding to mild RFS), ≥25% (moderate), and ≥50% (severe) decline in prefeeding serum phosphorus, magnesium, or potassium. The mortality associated with RFS was assessed, and risk factors for RFS were identified using multivariable logistic regression modeling. Results: Of 3854 participants, 3480 (90%) developed mild RFS. Thirty‐day mortality was higher in those without mild RFS (24%) than in those with mild RFS (18%) (P < 0.01). When RFS was reoperationalized as a 50% decline in electrolytes, 25% of patients developed RFS with a 20% 30‐day mortality. Risk factors for development of RFS included renal failure, elevated creatinine, and low platelets; additionally, prefeeding serum phosphorus level was strongly associated with development of RFS (adjusted odds ratio, 6.09; 95% confidence interval, 4.95–7.49 for those in the highest tertile of prefeeding phosphorus compared with the lowest). Conclusion: The ASPEN operationalization of RFS as a decline in baseline electrolyte values was not associated with death. Prefeeding serum phosphorus level strongly predicted severe RFS. [ABSTRACT FROM AUTHOR]

The article presents clinical study on hypophosphatemia in prematurity leading to complete heart block as Refeeding syndrome (RS) in preterm infants develops following in‐utero fetal nutrient deprivation. Topics include Metabolic derangements that develop during RS are triggered by a relatively abundant nutrient supply in the postnatal period, usually provided as parenteral nutrition; and indwelling umbilical artery catheter was placed for invasive blood pressure monitoring and blood sampling.

Objective: To examine the impact of our new rapid refeeding protocol on patients with anorexia nervosa (AN) in our Eating Disorders Program. We hypothesize that the new protocol would lead to a more rapid weight gain and a shorter length of stay, with no effect on medical complications or program completion. Method: This cohort design included consecutive inpatients and day hospital patients admitted to the program with a BMI <18 kg/m2 and a diagnosis of AN between 2007 and 2020; N = 326 patients. Main outcomes measured were rate of weight gain and length of stay. Safety indicators included electrolyte disturbances and supplementation required, complications including refeeding syndrome and completion of the program. A p value <.05 was considered statistically significant. Results: Total length of stay was 21 days shorter for patients on the rapid refeeding protocol compared to the traditional refeeding protocol. Patients on the new protocol gained 0.21 more kg/week compared to patients on the old protocol. There was no difference in completion rates between programs. Electrolyte imbalances were mild to moderate and easily treated with oral electrolyte supplementation. There were no deaths or cases of refeeding syndrome with either protocol. Discussion: This is the first Canadian study to assess the effectiveness and safety of rapid refeeding in an adult population. Rapid refeeding protocols can be safely administered and are cost effective. Shorter hospital admissions are desirable to minimize possible regression and dependency on inpatient services and positively impacts patients' quality of life. Public Significance: This study advances the idea that rapid refeeding in patients with anorexia nervosa can be administered safely and effectively with close medical monitoring. In addition, rapid refeeding leads to shorter hospital stays, with a cost‐savings to the health system. Shorter admissions are desirable to minimize possible regression and dependency on inpatient services and also positively impacts patients' quality of life. [ABSTRACT FROM AUTHOR]

Objective: Refeeding syndrome is a feared complication of refeeding patients with anorexia nervosa. There are now a number of controlled studies showing that refeeding with an initial high calorie count is more beneficial than cautious refeeding and is safe under continuous monitoring. However, there have yet not been studies in severe anorexia nervosa. Method: We present an observational study in two different samples. The first sample consists of those 1075 out of a total of 3230 patients with anorexia nervosa treated in our hospital within 4 years for whom a complete admission laboratory was available and who had an age of at least 18 years at admission. A risk score was calculated from the number of pathological laboratory values out of 12 parameters indicating either refeeding syndrome or health hazards related to malnutrition. The second sample was obtained from a special ward for patients with eating disorders medically at‐risk. During the period in question, 410 patients with anorexia nervosa were treated there. 142 patients had a BMI of 13 or less and at the same time a complete data set with the mentioned 12 laboratory parameters at admission and weekly in the following 4 weeks after admission. Results: The risk represented by the laboratory parameters is significantly and negatively correlated to BMI and much higher for the group of patients with a BMI below 13 than for those with a higher BMI (χ2 sig < 0.000). The 142 patients in the special care unit gain an average of more than 4.1 kg within 4 weeks on the high‐calorie diet. With this rapid weight gain, the risk score decreases highly significantly. Neither hypophosphatemia nor rhabdomyolysis is found under phosphate substitution. Hyperhydration occurred often, which manifests itself in the drop in haematocrit by the second week. Discussion: Under thorough medical surveillance, supplementation of phosphate and thiamine, and substitution of electrolytes whenever necessary rapid renutrition appeared to be save even in extremely malnourished inpatients with anorexia nervosa. As measured by the laboratory values, the health status of the severely malnourished patients improves significantly on a high‐calorie diet. Except for hyperhydration, there was no evidence of a refeeding syndrome. Key points: The risk, assessed by significant laboratory parameters, increases considerably with increasingly low weight.Rapid refeeding under medical supervision leads to rapid stabilization of health.Under these conditions, there was no evidence of a threatening refeeding syndrome.Even in extremely underweight patients with anorexia nervosa, rapid refeeding appears to significantly improve the risk profile. [ABSTRACT FROM AUTHOR]

Objective: To describe refeeding syndrome in an equid without a history of recognized risk factors. Case summary: Refeeding syndrome with marked hypophosphatemia developed in an aged miniature donkey gelding during treatment of suspected enterocolitis. Hypophosphatemia (manifested clinically as ileus and neuromuscular weakness) developed despite a short (3 day) history of hyporexia, increased body condition (7/9), and adherence to nutritional recommendations for critically ill equids. Nutritional support included nasogastric enteral feeding with a commercial equine nutrition product claiming to provide 100% of the National Research Council's daily recommended protein, vitamin, and mineral requirements for equids. Hypophosphatemia developed despite this enteral supplementation and was ultimately corrected by intravenous administration of sodium phosphate solution. New or unique information provided: This case report suggests that risk factors for refeeding syndrome in equids may be broader than previously recognized. Specifically, critically ill equids at risk for insulin dysregulation may have unique nutritional co‐morbidities and requirements. This report highlights the need for both broader recognition of risk factors for refeeding syndrome, and revised best‐practice nutritional guidelines and supplementation products to improve equine critical care. [ABSTRACT FROM AUTHOR]

Background: Patients with intestinal failure (IF) are prone to hypophosphatemia and shifts in magnesium and potassium levels. Although these shifts are often attributed to refeeding syndrome (RFS), the incidence of electrolyte shifts among patients with IF is unknown. We evaluated the occurrence of hypophosphatemia and other electrolyte shifts according to the functional and pathophysiological IF classifications. Methods: We consecutively included all patients' first admission to an IF unit from 2013 to 2017. Electrolyte shifts were defined as severe hypophosphatemia <0.6 mmol/L (mM) or any 2 other shifts below reference range, comprising hypomagnesemia <0.75 mM, hypophosphatemia <0.8 mM, or hypokalemia <3.5 mM. Outcomes included length of stay, central line–associated bloodstream infection, and other infections. Mortality was evaluated 6 months after discharge. Results: Of 236 patients with IF, electrolyte shifts occurred in 99 (42%), and 127 (54%) of these patients received intravenous supplementation with either phosphate, magnesium, or potassium. In patients who started parenteral nutrition, up to 62% of early‐onset shifts (<5 days) related to refeeding, and up to 63% of late‐onset shifts (≥5 days) could be ascribed to infections. Derangements occurred in 7 (18%) with type 1 IF, 53 (43%) with type 2 IF, and 39 (53%) readmitted patients with type 3 IF. Of 133 patients with IF secondary to short‐bowel syndrome, 65 (49%) developed shifts. Conclusion: In patients with IF, electrolyte shifts are frequent but not always due to RFS. Electrolyte shifts are common in patients with type 2 and those readmitted with type 3 IF. [ABSTRACT FROM AUTHOR]

Background: Initiation of parenteral nutrition (PN) after a period of starvation can be complicated by refeeding syndrome (RFS). RFS is associated with electrolyte abnormalities including hypomagnesemia, hyponatremia, and hypophosphatemia. Risk factors include recent weight loss, low body mass index, and electrolyte deficiencies; however, these associations are not strong. We hypothesized that a validated measure of nutrition risk, computed tomography (CT)-measured psoas muscle density, can be used to predict the development of hypophosphatemia associated with RFS.Methods: A retrospective analysis of surgical patients initiated on PN with an abdominal CT scan within the past 3 months was conducted. CT-measured psoas muscle density was assessed as a predictive variable for the development of electrolyte abnormalities. Daily electrolyte and clinical outcome measures were recorded.Results: One hundred nine patients were stratified based on Hounsfield unit average calculation (HUAC). The lowest 25th percentile of patients had HUAC <25. Low HUAC was associated with a significant percent decrease in phosphate levels from baseline to PN day 3 (P < .01) and significant difference in serum phosphate value on PN day 3 (P < .01). The low muscle density quartile also experienced longer days on the mechanical ventilator (P = .01) compared with patients with a higher psoas muscle density.Conclusion: Psoas muscle density predicted the development of hypophosphatemia in patients initiated on PN. This measurement may aid in identifying patients at highest risk of experiencing RFS. A mean psoas HU <25 may prompt additional precautions, including additional phosphate replacement and slower initiation of PN. [ABSTRACT FROM AUTHOR]

Aim: Current Australian eating disorder guidelines recommend a "high" energy goal intake of 12 MJ/day, however, it is unclear whether a "high" energy goal is beneficial. This study aimed to investigate the impact of goal energy intakes <12 MJ/day (low energy) compared with ≥12 MJ/day (high energy) on body composition, midarm muscle circumference, frequency of medical complications, refeeding syndrome, length of stay, body mass index (BMI) and weight gain for patients with medically compromised eating disorders. Methods: Five electronic databases (PubMed, CINAHL, Scopus, EMBASE and Web of Science) were searched in April, 2020. The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation system. Results: Four cohort studies were included (n = 656); three were rated positive and one neutral in terms of individual study bias. Evidence for the impact of higher and lower energy protocols on body fat percentage, midarm muscle circumference, frequency of medical complications, incidence of refeeding syndrome, length of stay, BMI and weight gain was of very low certainty. The certainty of evidence was downgraded to very low due to very serious risk of bias, inconsistency and imprecision. Conclusions: This review found very low certainty of evidence to support the use of high energy goal intakes for patients with medically compromised eating disorders. More robust research is warranted to establish if there are clear clinical and psychological benefits of higher energy goal intakes. [ABSTRACT FROM AUTHOR]

Objective: Refeeding hypophosphatemia (RH) is a potentially fatal complication in patients with anorexia nervosa (AN), and its dietary preventive strategy is not well established. We aimed to examine the association between carbohydrate content in the diet and the occurrence of RH in inpatients with AN via retrospective medical chart review. Method: We performed a chart review to collect data of patients with AN hospitalized at the Department of Psychosomatic Medicine of the University of Tokyo Hospital between April 1, 2012, and February 29, 2020. Receiver operating characteristic (ROC) analysis was performed to determine the cutoff point of the percentage of carbohydrate content in the diet for the occurrence of RH. Multivariate logistic regression analysis was performed with occurrence of RH as the dependent variable and the carbohydrate content of more than the identified cutoff point as the independent variable adjusting for the risk factors for RH. Results: The percentage of carbohydrate content that is higher than the cutoff point obtained from the ROC analysis (58.4%) was significantly associated with the occurrence of RH, even after adjusting for variables associated with RH in univariate logistic regression analysis (age and body mass index) as well as the average daily calorie intake (odds ratio, 5.37; 95% confidence interval, 1.60–18.1; p =.0066). Discussion We identified that diets with higher carbohydrate contents were associated with RH in inpatients with AN, even after adjusting for known risk factors. Our findings may promote the development of dietary preventive strategies against RH in inpatients with AN. [ABSTRACT FROM AUTHOR]

Objective: This study aims to compare the outcomes of higher calorie refeeding (HCR) and a lower calorie refeeding (LCR) methods among a diverse sample of young Asian adolescents admitted to a tertiary institution in Asia for management of anorexia nervosa (AN). Method: This is a retrospective case control study of Asian adolescents who were managed using an inpatient HCR protocol (2016–2017) and an LCR protocol (2010–2014). Baseline characteristics, daily change in percent median body mass index (%mBMI), and rates of refeeding hypophosphatemia were analyzed between groups. Results: A total of 125 adolescents with AN were analyzed with 61 (52%) patients in the HCR group. Mean age was 14.0 years (SD =1.5) and mean presenting %mBMI was 73.2 (SD =6.9) with mean length of stay of 11.9 days (SD = 6.6). Patients in the HCR group had significantly increased rate of change of %mBMI (M = 0.39, SD = 0.31) than patients in the LCR group (M = 0.12, SD = 0.43) (p <.001). There was an increased rate of mild hypophosphatemia in the HCR group (HCR: 46%, LCR: 22%, p =.007) but no difference in rates of moderate hypophosphatemia and no cases of severe hypophosphataemia. Lower presenting %mBMI significantly predicted the phosphate levels (p =.004). Discussion: In a sample of Asian adolescents with AN, use of an HCR protocol was associated with improved rate of inpatient weight gain. There was increased risk of mild hypophosphataemia, but not moderate to severe hypophosphataemia, suggesting that an HCR protocol can be used safely with close monitoring of phosphate levels. [ABSTRACT FROM AUTHOR]

Background: Refeeding syndrome (RS) following preterm birth has been linked to high intravenous (IV) protein intake in the presence of low electrolyte supply. In extremely low‐birth‐weight (ELBW) babies, we aimed to determine the incidence of RS and associations with birth characteristics and clinical outcomes. Method: Prospective cohort study of ELBW ProVIDe Trial participants in 6 New Zealand neonatal intensive care units. RS was defined as serum phosphate < 1.4 mmol.L−1 and total calcium > 2.8 mmol.L−1. Relationships between RS and other factors were explored using 2‐sample tests and logistic regression adjusted for sex, gestation, and birth‐weight z‐score. Results: Of 338 babies (mean [SD] birth‐weight, 780 (134) g, gestational age, 25.9 [1.7] weeks), 68 (20%) had RS. Mortality was greater in babies with RS (32% vs 11%; P <.0001). More small‐ than appropriate‐for‐gestational‐age babies developed RS (22% vs 8%; P =.001). Growth from birth to 36 weeks' corrected age was not different between babies who did and did not have RS. In logistic regression, the odds of RS decreased by 70% for each 1 mmol per kg−1.d−1 IV phosphate intake (odds ratio [OR], 0.3; CI, 0.1–0.6; P =.002) and increased by 80% for each 1 g.kg−1.d−1 IV protein intake (OR, 1.8; CI, 1.3–2.7; P =.002). Conclusions: Neonatal RS is common in this cohort of ELBW babies and is associated with increased morbidity and mortality. Optimizing phosphate and calcium intakes in IV nutrition solutions may reduce RS and its consequences. [ABSTRACT FROM AUTHOR]

Objective: This study assesses the impact of a clinical refeeding guideline on weight restoration, length of stay, rate of refeeding complications, and rehospitalizations.Method: This retrospective study included patient records of 107 participants aged 13-55 years with a diagnosis of AN, admitted for at least 7 days for renutrition before and after introduction of the refeeding guideline. Weight evolution graphs were rated by 2 clinical experts independently. Binary logistic regression models were erected to identify clinical outcomes associated independently with the guideline as well as to control for potential confounding by sociodemographic and clinical characteristics at admission.Results: The proportion of patients achieving optimal weight gain after the first 2 weeks increased significantly from 6.3% pre-guideline to 41.8% post guideline (adjusted odds ratio [AOR] = 37.6; 95% confidence interval [CI], 2.77-510.3; P = 0.006). Average length of hospitalization was reduced from 96.7 (SD 48.3) days pre-guideline to 62.2 (SD 45.5) days post guideline (AOR = 0.99; 95% CI, 0.97-1.01; P = 0.18). None of the patients developed a full refeeding syndrome. There was no significant change in the rate of rehospitalization: 48.5% pre-guideline to 43.2% post guideline (OR = 0.81; 95% CI, 0.36-1.84; P = 0.62).Discussion: The clinical guideline proved highly effective in bolstering weight gain via intensive refeeding procedures while also being safe. Harmonizing clinical practices improves quality of care for patients with anorexia and, interestingly, may decrease costs by cutting average length of stay by a third without increasing the rehospitalization rate. [ABSTRACT FROM AUTHOR]

Background: Small ruminants presented to tertiary care facilities commonly suffer from severe protein‐calorie malnutrition. Some of these patients require parenteral nutrition (PN; amino acids and dextrose with or without lipids) during hospitalization. Refeeding syndrome, a potentially fatal shift of electrolytes seen in malnourished patients during refeeding, may occur. Objective: (a) To report the prevalence of refeeding syndrome in small ruminants receiving PN and (b) to determine risk factors for the development of refeeding syndrome. Animals Hospitalized small ruminants (n = 20) that received PN from 2010 to 2018 and that had serial (≥2) monitoring of serum electrolyte concentrations after initiation of PN. Methods: Retrospective case series. Refeeding syndrome was defined as the presence of at least 2 of the following electrolyte abnormalities after initiation of PN: hypophosphatemia, hypokalemia, hypomagnesemia, or some combination of these. Data was analyzed using Fisher's exact test, followed by univariate logistic regression. Results: Eleven of 20 (55%) animals met the definition of refeeding syndrome. Mean minimum serum phosphorus concentration in animals with refeeding syndrome was 1.96 ± 0.69 mg/dL (reference range, 4.2‐7.6 mg/dL). Eleven of 20 animals survived to discharge. Survival rate did not differ significantly between refeeding cases (4/11, 36.3%) and nonrefeeding cases (7/9, 77.8%; P =.09). Mean serum phosphorus concentration was significantly lower in nonsurvivors than in survivors (1.88 ± 0.10 mg/dL vs 4.32 ± 0.70 mg/dL, P =.006). Conclusions and Clinical Importance: We report the prevalence of refeeding syndrome in small ruminants receiving PN. Clinicians should anticipate refeeding syndrome after initiation of PN and consider pre‐emptive supplementation with phosphorus, potassium, magnesium, or some combination of these. [ABSTRACT FROM AUTHOR]

Background: Initiation of parenteral nutrition (PN) can cause complications including hyperglycemia (HGL), electrolyte abnormalities, and refeeding syndrome (RFS). These concerns lead many to titrate over several days, but our practice is to titrate PN to goal within 8 hours. The aim of this study was to evaluate the safety of titrating PN to goal within 8 hours.Methods: This was a single-center, retrospective study of adult patients initiated on continuous PN with titration to goal rate in <8 hours. The primary composite outcome included the incidence of HGL, hypomagnesemia, hypophosphatemia, or hypokalemia within 24 hours of PN initiation. Secondary outcomes included analyses of patients with risk factors for HGL and RFS, critically ill patients, and individual components of the composite outcome.Results: Three hundred forty-two patients were included, with a primary outcome incidence of 24.6% (HGL 17.4%; hypokalemia 1.8%; hypomagnesemia 0.6%; hypophosphatemia 8.5%). The primary outcome was more common in the HGL group (34.3% vs 14.7%, P < 0.01) and in the ICU group (40.9% vs 20.7%, P < 0.01). Mean 24-hour blood glucose > 180 mg/dL occurred more in the HGL group (27.9% vs 7.6%, P < 0.01) and in the ICU group (34.8% vs 13.8%, P < 0.01). In patients with no risk factors, the primary outcome was 11.9%.Conclusion: Rapid PN titration was likely safe in patients without risk factors for HGL or RFS. Further evaluation of protocolized HGL management is needed to determine the risk of HGL in patients with HGL risk factors. [ABSTRACT FROM AUTHOR]

Background: Patients with anorexia nervosa (AN) are vulnerable to physiological decompensation and often require inpatient management by an eating disorders unit. Aims: Patients admitted to an Australian tertiary medical centre for medical stabilisation of AN were assessed as part of quality assurance. Analysis included: (i) medical complications during acute inpatient stabilisation; (ii) predictors of refeeding syndrome; (iii) predictors governing length of stay (LOS); and (iv) outcomes pre‐ and post‐implementation of multidisciplinary treatment guidelines. Methods: A retrosepctive analysis of 95 consecutive admissions (60 individual patients) between November 2011 and August 2017 was performed. Results: Patients had a median LOS of 9.6 days (interquartile range 5.8–19.7) and a mean weight gain of 1.4 kg (standard deviation 2.9). Medical complications included the following: hypoglycaemia (11.6%) and refeeding electrolyte derangement (26.3%). Advancing age (odds ratio (OR) 1.06 per year, P = 0.019), nasogastric tube requirement (OR 3.4, P = 0.014) and Code Grey(s) (security calls) (OR 7.1, P = 0.010) were associated with refeeding electrolyte derangement. Parameters associated with increased LOS included the following: lower body mass index (P = 0.029), Code Grey(s) (P = 0.029) and tachycardia (P = 0.013). Following multivariate analysis, the post‐guidelines implementation group required less intravenous fluid and electrolyte replacement, though had lower rates of refeeding electrolyte derangement (OR 0.33 (0.11–0.99)). Conclusion: Patients with moderate to severe AN are at risk of dangerous medical complications, and older patients may have heightened predisposition to refeeding electrolyte derangement. Early identification of medically high‐risk patients is imperative to implement timely, life‐saving interventions. [ABSTRACT FROM AUTHOR]

Objective: Refeeding hypophosphatemia (RH) is a life‐threatening complication in underweight patients with eating disorders (EDs). Although a lower body mass index (BMI) has been reported as a risk factor for RH, the exact BMI cut‐off point is not known. Herein, we aimed to identify the optimal BMI cut‐off point for RH in adults with EDs. Method: The medical charts of Japanese inpatients with EDs at our hospital between April 1, 2012 and March 31, 2017 were retrospectively reviewed. The optimal BMI cut‐off point for RH was determined via receiver operating characteristic analysis. Logistic regression analysis was subsequently performed to assess the association between RH and the BMI cut‐off point after adjusting for the propensity score, which was based on known risk factors for RH. Results: The optimal BMI cut‐off point was identified as 12.6 kg/m2. A BMI lower than the cut‐off point significantly correlated with the occurrence of RH after adjusting for the propensity score. Discussion: The optimal BMI cut‐off point for the occurrence of RH was 12.6 kg/m2 in adults with EDs. The findings of the present study may facilitate clinical decision making and early identification of patients who require prophylactic treatment for RH. [ABSTRACT FROM AUTHOR]

Background: Early hypophosphatemia is common in premature infants ≤1250 g. The aim of this study was to assess the frequency and severity of hypophosphatemia after sodium glycerophosphate supplementation from first day of life in parenteral nutrition and to address the safety of this practice.Methods: Prospective cohort study of infants ≤1250 g birth weight born in a tertiary-care level neonatal intensive care unit and supplied with sodium glycerophosphate from the first day of life. Primary outcome was the presence of hypophosphatemia (<4 mg/dL) on the first week. Data were compared with our 2014 prospective subcohort of infants ≤1250 g receiving phosphate after 48 hours of life and morbidity with that of our 2016 retrospective cohort of ≤1250 g.Results: Fifty-four neonates were included. The frequency of hypophosphatemia was 29.6%. Only 1 patient presented hypophosphatemia <2 mg/dL. Mild hypokalemia was found in 8 patients (50%). No cases of hypernatremia were observed. Patients with hypophosphatemia had significantly lower gestational age (27.4 vs 28.8 weeks, P = .032) and lower z-score birth weight (-1.68 vs -0.47; P = .001). When compared with the 2014 subcohort, we found a lower frequency of hypophosphatemia (29.6% vs 69.2%; P = .008) and a lower rate of samples with hypophosphatemia (20.4% vs 51.4%; P = .0002) and critical hypophosphatemia (0.68% vs 11.4%, P = .0005). No differences were found in morbidity or mortality.Conclusions: Sodium glycerophosphate supplementation in parenteral nutrition from the first day of life significantly decreased the frequency of hypophosphatemia. No adverse events were reported. [ABSTRACT FROM AUTHOR]

Refeeding syndrome is diagnosed based on the onset of multiple laboratory abnormalities (most commonly hypophosphatemia) and clinical signs in the setting of nutrition rehabilitation of malnourished patients. Because definitions are not uniform, a broad differential diagnosis should always include renal tubular dysfunction. Our report details a 3 year-old child with undiagnosed renal tubular dysfunction who presented with the clinical picture of refeeding syndrome with refractory electrolyte abnormalities. A diagnosis of renal Fanconi syndrome was made after urinalysis that revealed glucosuria and urine electrolyte losses. Thus, urinalysis can aid in making a positive diagnosis of refeeding syndrome. [ABSTRACT FROM AUTHOR]

Distal renal tubular acidosis is a risk factor for refeeding syndrome. Frequent measurement of serum phosphorus levels at the initiation of nutrition and rapid administration of phosphate preparations are required to prevent organ failure. [ABSTRACT FROM AUTHOR]

In the present study, we examined metabolic, morphological and neurochemical changes in male striped hamsters (Cricetulus barabensis) in response to variations in food availability. Males with low and high levels of metabolic rate (MR: L‐MR and H‐MR, respectively), defined by their activity MR, were compared. In Experiment 1, 36‐h food deprivation was found to significantly decrease MR levels, body fat content, mass of small and large intestines, and leptin gene expression in the white adipose tissues in male hamsters. Interestingly, L‐MR males displayed decreased MR during both the day and night phases of circadian cycles, whereas H‐MR males only showed a decrease in MR during the day (resting phase). These data indicate that individual differences in physical activity were associated with animals' different metabolic responses to food deprivation. In Experiment 2, both groups of males went through a 4‐week fasting and re‐feeding (re) paradigm. H‐re males showed a persistent high level of MR, with decreased body fat content and a trending decrease in leptin mRNA expression, compared to L‐re males. Together, our data indicate that male striped hamsters with different levels of physical activity display altered, adaptive changes in response to variations in food availability. The neurochemical involvement of such adaptive changes needs to be further studied. [ABSTRACT FROM AUTHOR]

Aim: Refeeding syndrome (RFS) prevalence rates vary across studies depending on the criteria used for assessment and identification. For registered dietitians, the assessment and management of RFS is highly reliant on daily serum electrolyte values; however, registered dietitians working within Australia do not currently possess laboratory test ordering privileges. We aimed to examine the opinions of registered dietitians regarding RFS identification, management and guidelines and the option of using extended scope of practice to order electrolyte monitoring autonomously. Methods: A multi‐method action research approach was used, incorporating two projects. The first was a survey examining Australian registered dietitians’ (n = 187) opinions regarding RFS identification, management and guidelines, and autonomous electrolyte monitoring. To establish if results were similar internationally, an interview was conducted with 22 registered dietitians working within 10 different countries. Data were analysed using chi‐square tests and thematic analysis. Results: Australian registered dietitians (75%) identify patients at risk of RFS at a high rate of more than once per fortnight, with 74% reporting that they have previously worked with a patient diagnosed with RFS. Results varied internationally, with respondents from eight countries reporting that RFS is a problem within acute care versus respondents from five countries having never treated a patient with RFS. The majority (≥89%) of registered dietitians desire new guidelines and the option to order patient electrolyte monitoring autonomously. Conclusions: Our findings suggest that more stringent tools for the identification of RFS are necessary. There was limited uniformity across countries, and updated practice guidelines are needed. [ABSTRACT FROM AUTHOR]

Aim: Using standardised terminology in acute care has encouraged consistency in patient care and the evaluation of outcomes. As such, the Nutrition Care Process (NCP) and Nutrition Care Process Terminology (NCPT) may assist dietitian nutritionists in the delivery of high quality nutrition care worldwide; however, limited research has been conducted examining the consistency and accuracy of its use. We aimed to examine the NCPT that dietitian nutritionists would use to formulate a diagnostic statement relating to refeeding syndrome (RFS). Methods: A multimethod action research approach was used, incorporating two projects. The first was a survey examining Australian dietitian nutritionists’ (n = 195) opinions regarding NCPT use in cases of RFS. To establish if results were similar internationally, an interview was then conducted with 22 dietitian nutritionists working within 10 different countries. Results: ‘Imbalance of nutrients’ was only identified as a correct code by 17% of respondents in project 1. No mention of this term was made in project 2. Also 86% of respondents incorrectly selected more than one diagnostic code. The majority of respondents (80%, n = 52/65) who incorrectly selected ‘Malnutrition’, without also selecting ‘Imbalance of nutrients’, selected ‘reduce intake’ as an intervention, suggesting some misunderstanding in the requirement for interrelated diagnoses, interventions and goals. Conclusions: Our findings demonstrate that there is limited accuracy and consistency in selecting nutritional diagnostic codes in relation to RFS. Respondents also demonstrated limited knowledge regarding appropriate application of the NCP and NCPT. Implementation practices may require further refinement, as accurate and consistent use is required to procure the benefits of standardised terminology. [ABSTRACT FROM AUTHOR]

Objective: To investigate the role and prognostic importance of Dvl2 in human epithelial ovarian cancer (EOC).Methods: A multimethod study was undertaken including patients with pathologically confirmed non-metastatic EOC who underwent surgery for maximum tumor resection at a center in China. Dvl2 expression was assessed by western blot using fresh EOC tissues and normal ovarian tissues obtained between June 2014 and January 2015. Additionally, retrospective data were obtained for patients treated between April 2004 and September 2009. Their tumor specimens were used in immunohistochemistry analysis. Kaplan-Meier survival plots were constructed to estimate the overall survival by Dvl2 expression, and a Cox proportional hazards model was used to analyze prognostic factors. Alterations in Dvl2 expression during the cell cycle were assessed by a starvation and refeeding assay.Results: Dvl2 expression was higher in EOC samples than in normal tissues on western blot. Overall, 124 patients were included in immunohistochemistry analysis, and Dvl2 expression level was significantly associated with the tumor grade and Ki-67 expression. Overexpression of Dvl2 was correlated with poor prognosis. The pattern of Dvl2 expression throughout the cell cycle matched that of the cell proliferation marker cyclin D1.Conclusion: Dvl2 could play a part in EOC progression and might be an independent prognostic factor. Additionally, it might be a prospective therapeutic target in the treatment of EOC. [ABSTRACT FROM AUTHOR]

Objective To describe the clinical presentation and biochemical abnormalities occurring during the successful treatment of refeeding syndrome in a cat. Case Summary A 2-year-old neutered male domestic shorthair cat presented after having been missing for 12 weeks. The cat had clinical signs of severe starvation. Common complications developed during refeeding (eg, hypophosphatemia, hypokalemia, and hemolytic anemia). The cat also developed hypoglycemia, a complication common in people but not previously reported in a cat. Hypoglycemia and electrolyte deficiencies were managed with intravenous supplementation. The cat was successfully treated and was discharged alive 7 days after presentation. New or Unique Information Provided Hypoglycemia has not been reported previously as a complication of refeeding in a cat. Frequent monitoring of electrolyte, mineral, and blood glucose concentrations is essential to successful management of refeeding syndrome. The ideal refeeding strategy is unknown at this time. Evidence suggests that a diet low in carbohydrate decreases the likelihood of metabolic derangements commonly associated with refeeding. [ABSTRACT FROM AUTHOR]

Aim: Limited research exists on how consistently dietitians are identifying refeeding syndrome risk in hospitalised patients. We aimed to describe how consistent Australian and New Zealand dietitians are at identifying refeeding syndrome risk and compare their responses to the application of refeeding syndrome guidelines and patients' electrolyte levels and supplementation provided. Methods: Dietitians from Australia and New Zealand were invited to complete an online survey. The survey inquired about demographics and asked respondents to classify the level of refeeding syndrome risk (i.e. none, some, high) in 13 case studies. Electrolytes and supplementation data were sourced from electronic patient records. Descriptive statistics and t‐tests were conducted. Results: Two hundred and ninety‐nine eligible people responded (33 ± 9 years, 95%F, 48% had ≥7 years of dietetic experience, 91% working clinically, 87% Australian). Respondents' answers were generally consistent and dietitians often reported the same level of refeeding syndrome risk as the application of NICE guidelines and patient electrolytes (49–98%). Respondents requested feedback on their responses, more detailed case information, and commented on factors that may influence their risk identification, including subsequent medical management and route of nutritional delivery. Conclusions: Dietitians were generally consistent in the identification of refeeding syndrome risk. Dietitians often reported similar levels of refeeding syndrome risk to those found with the application of refeeding guidelines and patient electrolytes and supplementation treatment. Evaluation of practice was valued by dietitians. Enhancing the evidence on which guidelines are based may improve translatability of guidelines to practice. [ABSTRACT FROM AUTHOR]

Aim: Malnutrition has been reported in the literature to be adversely associated with outcomes in paediatric malignancies. Our objective in this paper was to evaluate malnutrition as a potential predictor for adverse outcomes in febrile neutropenia associated with haematological malignancies.Methods: A prospective observational study was performed in a tertiary care teaching hospital of Kolkata, India. Forty-eight participants, suffering from haematological malignancy, were included. Participants were included if they experienced at least one episode of febrile neutropenia. For children aged <5 years, weight for height, height for age and weight for age were used as criteria for defining malnutrition, while body mass index for age was used in children ≥5 years. A total of 162 episodes of febrile neutropenia were studied.Results: Thirty patients (30/48, 62.5%) included in the study had malnutrition. In bivariate analyses at patient level, there is a strong association between malnutrition and death (odds ratio (OR) 7.286, 95% confidence interval (CI) 0.838-63.345, one-tailed P = 0.044), and life-threatening complications show a moderate trend towards significance (OR 3.333, 95% CI 0.791-14.052, one-tailed P = 0.084). Survival functions were significantly different between malnourished and non-malnourished children (log rank test χ(2)  = 4.609, degree of freedom = 1, P = 0.032). Wasting was associated with life-threatening complications in children aged <5 years (OR 14, 95% CI 1.135-172.642, one-tailed P = 0.036). Logistic regression analyses at episode level revealed that phase of treatment and respiratory system involvement were significant predictors of death, while malnutrition was not.Conclusion: Malnutrition may be a potential predictor of mortality in febrile neutropenia. [ABSTRACT FROM AUTHOR]

ABSTRACT Objective Refeeding in patients with anorexia nervosa (AN) is associated with a risk of refeeding syndrome, which is a disruption in metabolism with a variety of features including hypophosphatemia. We evaluated the risk factors for refeeding hypophosphatemia (RH) during nutritional replenishment in Japanese patients with AN. Methods We retrospectively examined clinical data for 99 female inpatients (mean age 30.9 ± 10.7 years; range, 9 − 56 years). Results RH (phosphate < 2.3 mg/dL) occurred within 4.8 ± 3.7 days of hospital admission and was still observed at 28 days after admission in 21 of the 99 cases (21.2%). Oral or intravenous phosphate was given to some patients to treat or prevent RH. Patients with RH had a significantly lower body mass index, were older, and had higher blood urea nitrogen than those without RH. Severe complications associated with RH were recorded in only one patient who showed convulsions and disturbed consciousness at Day 3 when her serum phosphate level was 1.6 mg/dL. Conclusions The significant risk factors for RH that we identified were lower body mass index, older age, and higher blood urea nitrogen at admission. No significant difference in total energy intake was seen between the RH and no RH groups, suggesting that RH may not be entirely correlated with energy intake. Precisely predicting and preventing RH is difficult, even in patients with AN who are given phosphate for prophylaxis. Thus, serum phosphate levels should be monitored for more than 5 days after admission. © 2015 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:402-406). [ABSTRACT FROM AUTHOR]

ABSTRACT Objective Given the importance of weight restoration for recovery in patients with anorexia nervosa (AN), we examined approaches to refeeding in adolescents and adults across treatment settings. Methods Systematic review of PubMed, PsycINFO, Scopus, and Clinical Trials databases (1960-2015) using terms refeeding, weight restoration, hypophosphatemia, anorexia nervosa, anorexia, and anorexic. Results Of 948 screened abstracts, 27 met these inclusion criteria: participants had AN; reproducible refeeding approach; weight gain, hypophosphatemia or cognitive/behavioral outcomes. Twenty-six studies (96%) were observational/prospective or retrospective and performed in hospital. Twelve studies published since 2010 examined approaches starting with higher calories than currently recommended (≥1400 kcal/d). The evidence supports 8 conclusions: 1) In mildly and moderately malnourished patients, lower calorie refeeding is too conservative; 2) Both meal-based approaches or combined nasogastric+meals can administer higher calories; 3) Higher calorie refeeding has not been associated with increased risk for the refeeding syndrome under close medical monitoring with electrolyte correction; 4) In severely malnourished inpatients, there is insufficient evidence to change the current standard of care; 5) Parenteral nutrition is not recommended; 6) Nutrient compositions within recommended ranges are appropriate; 7) More research is needed in non-hospital settings; 8) The long-term impact of different approaches is unknown; Discussion Findings support higher calorie approaches to refeeding in mildly and moderately malnourished patients under close medical monitoring, however the safety, long-term outcomes, and feasibility outside of hospital have not been established. Further research is also needed on refeeding approaches in severely malnourished patients, methods of delivery, nutrient compositions and treatment settings. [ABSTRACT FROM AUTHOR]

Background Limited research exists concerning how consistently and accurately student and newly-graduated dietitians are identifying refeeding syndrome risk in hospitalised patients. The present study aimed to determine the consistency of students' and newly-graduated dietitians' classification of refeeding syndrome risk, as well as agreement with the application of comparison tools such as the National Institute for Health and Care Excellence guidelines, patients' electrolytes and supplementation, and clinical dietitians previously surveyed. Methods Recently-graduated and final-year Griffith University dietetics students were invited to complete an online survey. The survey questioned demographics and asked respondents to classify the level of refeeding syndrome risk (i.e. none, some, high, unsure) in 13 case studies. Electrolytes and supplementation data were sourced from electronic patient records. Chi-squared tests, t-tests and linear regression analyses were conducted. Results Fifty-three eligible people responded [ n = 53 of 112, mean ( SD) age 26 (4) years, 89% female, 34% graduates]. Respondents' answers were generally more consistent and more likely to agree with comparison tools when two tools showed the same level of refeeding syndrome risk (49-98%, β = 0.626-1.0994, P < 0.001) than when they differed (11-49%). Respondents' level of agreement with refeeding identification guidelines, electrolyte levels, supplementation and dietitians previously surveyed did not differ by graduate status, degree level, clinical placement status or having read refeeding syndrome guidelines recently ( P > 0.05). Conclusions Students' and new graduates' identification of refeeding syndrome risk improved when there was consistency between guidelines, electrolytes and dietitians' responses. More research is needed to improve the evidence behind refeeding guidelines, with the aim of enhancing the accuracy and consistency of assessment. [ABSTRACT FROM AUTHOR]

ABSTRACT Objective Hypophosphatemia of refeeding is one of the most dangerous complications seen during the treatment of patients with anorexia nervosa. Although easily detectable and treatable, hypophosphatemia is under-recognized as a complication of refeeding. Specific risk factors for the development of hypophosphatemia are likely to exist among patients with severe anorexia nervosa. The purpose of this study was to identify clinically useful markers that may predict the development of or protection from hypophosphatemia during refeeding. Methods We conducted a retrospective case-control study of 123 patients with severe anorexia nervosa admitted for medical stabilization at the ACUTE Center for Eating Disorders between October 1, 2008 and December 31, 2013. Risk factors for refeeding hypophosphatemia were determined by multivariate logistic regression from clinical parameters and laboratory values measured at the time of admission. Results The prevalence of hypophosphatemia was 33.3% (41 of 123 patients). Higher hemoglobin was the only risk factor associated with a higher odds of developing hypophosphatemia (adjusted odds ratio [aOR], 1.56 [95% confidence interval [CI], 1.12-2.18]). Statistically significant protective factors against the development of hypophosphatemia were observed with higher body mass index (aOR, 0.54 [95% CI, 0.39-0.75]), higher serum potassium (aOR, 0.29 [95% CI, 0.14-0.62]), and higher serum prealbumin (aOR, 0.91 [95% CI, 0.84-0.99]). Discussion Four independent factors associated with refeeding hypophosphatemia were identified. Identification of findings which correlate with hypophosphatemia, or the lack thereof, has the potential to facilitate appropriate triage of patients with anorexia nervosa for closer monitoring during refeeding. © 2015 Wiley Periodicals, Inc (Int J Eat Disord 2015; 48:898-904). [ABSTRACT FROM AUTHOR]

ABSTRACT Objective Cohort study from February 2003 through May 2011 to determine weight restoration and refeeding complication outcomes for patients with anorexia nervosa (AN) treated in an integrated inpatient-partial hospital eating disorder program designed to produce rapid weight gain and weight restoration in the majority. Method Consecutive admissions (females and males, adolescents and adults; N = 361 patients, 461 admissions) at least 1.8 kg below target weight with AN or subthreshold variants were included. Main outcome measures were rates of hypophosphatemia, transfer to medicine, or death; rates of weight gain and percent achieving weight restoration. Results Hypophosphatemia was present in 7.9% of cases at admission and in 18.5% at some point during treatment. Hypophosphatemia was mild to moderate. Lower admission body mass index (BMI), but not rate of weight gain, predicted hypophosphatemia [OR = 0.65; p < .00001 (95% CI 0.57-0.76)]. Five patients (1.1%) were transferred to medicine or surgery, none because of refeeding. There were no deaths. Mean inpatient weight gain was 1.98 kg/week; mean partial hospital weight gain was 1.36 kg/week. By program discharge, 71.8% of adults reached a BMI of 19, 58.5% a BMI of 20. For adolescents, 80.4% came within 2 kg of their target weight; 76.1% came within 1 kg. Discussion Refeeding patients with AN using a hospital-based, behavioral protocol may be accomplished safely and more rapidly than generally recognized, weight restoring most patients by discharge. Helpful elements may include the program's integrated, step-down structure; multidisciplinary team approach emphasizing group therapy to effect behavior change; and close medical monitoring for those with BMI < 15. © 2015 Wiley Periodicals, Inc. (Int J Eat Disord 2015; 48:866-873) [ABSTRACT FROM AUTHOR]

Aim: Electrolyte balances have not been sufficiently evaluated in extremely preterm infants after early parenteral nutrition. We investigated the risk of early hypophosphatemia and hypokalemia in extremely preterm infants born small for gestational age (SGA) who received nutrition as currently recommended.Methods: This prospective, observational cohort study included all consecutive extremely preterm infants born at 24-27 weeks who received high amino acids and lipid perfusion from birth. We evaluated the electrolyte levels of SGA infants and infants born appropriate for gestational age (AGA) during the first five days of life.Results: The 12 SGA infants had lower plasma potassium levels from Day One compared to the 36 AGA infants and were more likely to have hypokalemia (58% vs 17%, p = 0.001) and hypophosphatemia (40% vs 9%, p < 0.01) during the five-day observation period. After adjusting for perinatal factors, SGA remained significantly associated with hypophosphatemia (odds ratio 1.39, confidence intervals 1.07-1.81, p = 0.01).Conclusion: Extremely preterm infants born SGA who were managed with currently recommended early parenteral nutrition had a high risk of early hypokalemia and hypophosphatemia. Potassium and phosphorus intakes should be set at sufficient levels from birth onwards, especially in SGA infants. [ABSTRACT FROM AUTHOR]

The dysphagic horse will frequently require nutritional support due to a failure to ingest either sufficient or any feed at all to meet its daily energy and protein requirements. There are a variety of means by which this nutritional support can be provided, the choice of which is largely dependent on the cause of the dysphagia, anticipated duration of the dysphagia, metabolic demands of the underlying disease/disorder associated with the dysphagia, any financial restraints and facilities available. This manuscript provides an overview of the various means by which nutritional support can be provided and highlights some of the advantages and disadvantages of each which may be considered when choosing the most appropriate approach. [ABSTRACT FROM AUTHOR]

Refeeding hypophosphatemia remains a serious and common complication during the early phases of nutritional rehabilitation and weight restoration for patients with anorexia nervosa. Typically, the risk of refeeding hypophosphatemia diminishes after the first 1-2 weeks of the refeeding process and thus, frequent monitoring serum phosphorus levels becomes less important as refeeding proceeds. Herein, we describe a case of persistent recurrent hypophosphatemia in a male-to-female transgender patient with severe anorexia nervosa. As transgender patients become increasingly seen in the realm of eating disorders, it is worth noting this phenomenon to mitigate adverse events. [ABSTRACT FROM AUTHOR]