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Purpose of Review: To assess the recent literature regarding parenteral nutrition to identify publications that have purported to support various beliefs about the utility of parenteral nutrition, and then to critically evaluate the data presented in those (as well as prior) publications., Recent Findings: Artificial nutrition improves nutritional markers but not clinical outcomes, suggesting that malnutrition is not causatively associated with a poor outcome. There are no convincing data that parenteral nutrition is beneficial in severely malnourished surgical patients. Glutamine supplementation of parenteral nutrition solutions may reduce the infectious complication rate, but it is unknown if glutamine-supplemented parenteral nutrition is better than no parenteral nutrition. Most, but not all, systematic reviews have demonstrated that enteral nutrition produces fewer problems than parenteral nutrition; no data suggest that either modality is better than doing no artificial nutrition. Randomized trials have not uniformly been able to demonstrate that parenteral nutrition is efficacious in acute pancreatitis. There is some, but not convincing, data that a regimen of glutamine, growth hormone, and a specialized diet will reduce the need for parenteral nutrition in patients with short bowel syndrome., Summary: It is important for clinicians to be able to critically evaluate the medical literature.

Artificial nutrition is widely advocated as adjunctive care in patients with a variety of underlying diseases. In recent years more emphasis has been placed on delivering it directly into the gastrointestinal tract through tubes in the stomach or proximal small intestine (enteral nutrition). Because the efficacy of any therapeutic intervention is best established by demonstrating it in one or more randomized controlled trials, this review focuses on data from such studies. The specific issue to be assessed is the ability of enteral nutrition to influence the mortality and morbidity of various diseases, a question that was addressed in depth in a recent systematic review. This article presents the highlights of that systematic review and puts it in context with the perspective of a practicing food and nutrition professional. Using established search strategies, 30 randomized controlled trials were identified that compared enteral nutrition to no artificial nutrition. In addition, other randomized controlled trials were identified that did provide some insight into the clinical utility of enteral nutrition. The randomized controlled trials were stratified by the underlying disease state. No high-quality evidence indicated that enteral nutrition had any beneficial effect on clinical outcome. Low-quality evidence, which tends to overestimate the treatment effect, suggested that enteral nutrition may be useful in reducing the incidence of postoperative complications and infection rates in intensive care units, improving mortality in chronic liver disease, and reducing length of stay when provided as trophic feeding to low-birth-weight neonates who are also receiving intravenous artificial nutrition. Enteral nutrition was not helpful when given during the first week to patients with dysphagic strokes. Thus, the randomized controlled trials that have compared enteral nutrition to no artificial nutrition have only found benefit when the methodologic rigor of the studies is inadequate to prevent bias from interfering with the interpretation of the data. No high-quality data are available to prove that enteral nutrition is of benefit.

Background: Both parenteral nutrition (PN) and enteral nutrition (EN) are widely advocated as adjunctive care in patients with various diseases. A systematic review of 82 randomized controlled trials (RCTs) of PN published in 2001 found little, if any, effect on mortality, morbidity, or duration of hospital stay; in some situations, PN increased infectious complication rates., Objective: The objective was to assess the effect of EN or volitional nutrition support (VNS) in individual disease states from available RCTs., Design: We conducted a systematic review. RCTs comparing EN or VNS with untreated controls, or comparing EN with PN, were identified and separated according to the underlying disease state. Meta-analysis was performed when at least three RCTs provided data. The evidence from the RCTs was summarized into one of five grades. A or B, respectively, indicated the presence of strong or weak (low-quality RCTs) evidence supporting the use of the intervention. C indicated a lack of adequate evidence to make any decision about efficacy. D indicated that limited data could not support the intervention. E indicated either that strong data found no effect, or that either strong or weak data suggested that the intervention caused harm., Patients and Settings: RCTs could include either hospitalized or nonhospitalized patients. The EN or VNS had to be provided as part of a treatment plan for an underlying disease process., Interventions: The RCT had to compare recipients of either EN or VNS with controls not receiving any type of artificial nutrition or had to compare recipients of EN with recipients of PN., Outcome Measures: These were mortality, morbidity (disease specific), duration of hospitalization, cost, or interventional complications. SUMMARY OF GRADING: A: No indication was identified. B: EN or VNS in the perioperative patient or in patients with chronic liver disease; EN in critically ill patients or low birth weight infants (trophic feeding); VNS in malnourished geriatric patients. (The low-quality trials found a significant difference in survival favoring the VNS recipients in the malnourished geriatric patient trials; two high-quality trials found nonsignificant differences that favored VNS as well.) C: EN or VNS in liver transplantation, cystic fibrosis, renal failure, pediatric conditions other than low birth weight infants, well-nourished geriatric patients, nonstroke neurologic conditions, AIDS; EN in acute pancreatitis, chronic obstructive pulmonary disease, nonmalnourished geriatric patients; VNS in inflammatory bowel disease, arthritis, cardiac disease, pregnancy, allergic patients, preoperative bowel preparation. D: EN or VNS in patients receiving nonsurgical cancer treatment or in patients with hip fractures; EN in patients with inflammatory bowel disease; VNS in patients with chronic obstructive pulmonary disease. E: EN in the first week in dysphagic, or VNS at any time in nondysphagic, stroke patients who are not malnourished; dysphagia persisting for weeks will presumably ultimately require EN., Conclusions: There is strong evidence for not using EN in the first week in dysphagic, and not using VNS at all in nondysphagic, stroke patients who are not malnourished. There is reasonable evidence for using VNS in malnourished geriatric patients. The recommendations to consider EN/VNS in perioperative/liver/critically ill/low birth weight patients are limited by the low quality of the RCTs. No evidence could be identified to justify the use of EN/VNS in other disease states.

This article discusses a study that examines the relationship between inflammatory bowel disease (IBD) and protein-calorie malnutrition (PCM). The study used a large national database to identify patients with IBD who also had PCM and assessed their use of parenteral nutrition (PN) or enteral nutrition (EN). The study found that PCM is more common in hospitalized patients with IBD and has clinical and financial consequences. The use of nutrition support, such as PN or EN, was associated with a decreased risk of readmission, but higher mortality rates. However, the study has limitations, and more research is needed to determine the effectiveness of nutrition support in patients with IBD and PCM. [Extracted from the article]

An introduction is presented in which author discusses articles on topics including focuses on reliability of diagnoses of malnutrition in included participants and the diagnoses did appear to rest on subjective interpretation of the dietitians and there was no validation of accuracy of diagnoses.

An introduction is presented in which the author discusses about the observation on malnutrition of patients with hip fractures, citing a number of randomized clinical trials of oral nutrition supplementation.

Abstract: Intravenous (parenteral) nutrition has been advocated widely as adjunctive care in patients with a variety of underlying diseases. However, the enthusiasm for this therapeutic intervention was based largely on expert opinion. Because the best way to assess the efficacy of any treatment is to test it in a randomized controlled trial, this review will focus on data that was derived from such studies. Using established search strategies, randomized controlled trials were sought that compared one of two forms of intravenous nutrition: parenteral nutrition (nitrogen and ≥10 kcal/kg/day of non-protein calories for ≥5 days) or protein-sparing therapy (nitrogen and fewer non-protein calories) with no type of artificial nutrition beyond regular food and/or standard (5%) dextrose. The randomized controlled trials were stratified by the underlying disease state. The clinical outcomes of interest were mortality, morbidity (total/infectious complications), and/or duration of hospitalization. More than 100 randomized controlled trials failed for the most part to demonstrate that intravenous nutrition had any effect on clinical outcome. There were a few exceptions. In patients undergoing attempted curative surgery for upper gastrointestinal cancer, the use of preoperative parenteral nutrition seemed to reduce the incidence of major postoperative complications. However, this benefit was only found in low-quality randomized controlled trials. Findings conflict regarding the use of parenteral nutrition in patients with acute pancreatitis or undergoing bone marrow transplantation. Parenteral nutrition was harmful when provided to patients undergoing radiation or chemotherapy for cancer. Although no randomized controlled trials exist, it is assumed that parenteral nutrition is useful in patients with an inadequate gastrointestinal tract (“short gut”). Thus, for the most part, randomized controlled trials comparing intravenous nutrition to no artificial nutrition have not shown that this medical intervention is of benefit. [Copyright &y& Elsevier]

This article presents information on various research papers related to gastroenterology and hepatology. The research paper "The Efficacy of Proton Pump Inhibitors in Nonulcer Dyspepsia: A Systematic Review and Economic Analysis," states that proton-pump inhibitors (PPI) are commonly used for patients with nonulcer dyspepsia. Several randomised clinical trials have provided conflicting results. The authors of this paper systematically reviewed the literature, looking for trials that compared a PPI with placebo or with other therapy for nonulcer dyspepsia. The authors then used a Markov model to determine the cost to keep 1 patient symptom-free for a month. Another paper titled "Meta-Analysis of Parenteral Nutrition Versus Enteral Nutrition in Patients with Acute Pancreatitis," focuses on benefits of nutritional support in patients with acute pancreatitis. The study concluded that enteral nutrition was the preferred route of nutrition support in patients with acute pancreatitis and went on to make some strong recommendations. Physicians were advised to start jejunal infusions at the time of the patient's admission to the hospital.