Parenteral Fish Oil Lipid Emulsions in the Critically Ill

Introduction: ω‐3 Polyunsaturated fatty acids contained in fish oils (FO) possess major anti‐inflammatory, antioxidant, and immunologic properties that could be beneficial during critical illness. We hypothesized that parenteral FO‐containing emulsions may improve clinical outcomes in the critically ill. Methods: We searched computerized databases from 1980–2012. We included randomized controlled trials (RCTs) conducted in critically ill adult patients that evaluated FO‐containing emulsions, either in the context of parenteral nutrition (PN) or enteral nutrition (EN). Results: A total of 6 RCTs (n = 390 patients) were included; the mean methodological score of all trials was 10 (range, 6–13). When the results of these studies were aggregated, FO‐containing emulsions were associated with a trend toward a reduction in mortality (risk ratio [RR], 0.71; 95% confidence interval [CI], 0.49–1.04; P = .08; heterogeneity I² = 0%) and a reduction in the duration of mechanical ventilation (weighted mean difference in days [WMD], ?1.41; 95% CI, ?3.43 to 0.61; P = .17). However, this strategy had no effect on infections (RR, 0.76; 95% CI, 0.42–1.36; P = .35) and intensive care unit length of stay (WMD, ?0.46; 95% CI, ?4.87 to 3.95; P = .84, heterogeneity I² = 75%). Conclusion: FO‐containing lipid emulsions may be able to decrease mortality and ventilation days in the critically ill. However, because of the paucity of clinical data, there is inadequate evidence to recommend the routine use of parenteral FO. Large, rigorously designed RCTs are required to elucidate the efficacy of parenteral FO in the critically ill.     

The Impact of Glutamine Dipeptide–Supplemented Parenteral Nutrition on Outcomes of Surgical Patients

Objective: To evaluate the impact of glutamine dipeptide–supplemented parenteral nutrition (GLN‐PN) on clinical outcomes in surgical patients. Methods: MEDLINE, EMBASE, Web of Science, and the Cochrane Controlled Clinical Trials Register were searched to retrieve the eligible studies. The studies were included if they were randomized controlled trials that evaluated the effect of GLN‐PN and standard PN on clinical outcomes of surgical patients. Clinical outcomes of interest were postoperative morbidity of infectious complication, mortality, length of hospital stay, and cost. Statistical analysis was conducted by RevMan 4.2 software from the Cochrane Collaboration. Results: Fourteen randomized controlled trials (RCTs) (N = 587) were included in this meta‐analysis. The results showed that glutamine dipeptide significantly reduced the length of hospital stay by around 4 days in the form of alanyl‐glutamine (weighted mean difference [WMD] = ?3.84; 95% confidence interval [CI] ?5.40, ?2.28; z = 4.82; P < .001) and about 5 days in the form of glycyl‐glutamine (WMD = ?5.40; 95% CI ?8.46, ?2.33; z = 3.45; P < .001). The overall effect indicated a significant decrease in the infectious complication rates of surgical patients receiving GLN‐PN (risk ratio = 0.69; 95% CI 0.50, 0.95; z = 2.26; P = .02). Conclusion: GLN‐PN was beneficial to postoperative patients by shortening the length of hospital stay and reducing the morbidity of postoperative infectious complications.     

The Consumption of Omega-3 Polyunsaturated Fatty Acids Improves Clinical Outcomes and Prognosis in Pancreatic Cancer Patients: A Systematic Evaluation

This study was aimed to systematically evaluate results of trials examining the effects of omega-3 polyunsaturated fatty acid (n-3 PUFA) consumption on body weight, lean body mass, resting energy expenditure, and overall survival in pancreatic cancer patients. We searched Medline, Pubmed, Embase, and Cochrane databases. We selected randomized controlled trials of n-3 PUFA vs. conventional nutrition in unresectable pancreatic cancer patients. We analyzed our data using the Cochrane statistical package RevMan 5.1. Eleven trials met our inclusion criteria. There was a significant increase in body weight [weighted mean difference (WMD) = 0.62; 95% confidence interval (CI), 0.54–0.69, P < 0.00001) and lean body mass (WMD = 0.96; 95% CI, 0.86–1.06, P < 0.00001), a significant decrease in resting energy expenditure (WMD = ?29.74; 95% CI, -55.89—3.59, P = 0.03), and an increase in overall survival (130–259 days vs. 63–130 days) in unresectable pancreatic cancer patients who consumed an oral nutrition supplement enriched with n-3 PUFAs compared to those who consumed conventional nutrition. This preliminary study suggests that n-3 PUFAs are safe and have a positive effect on clinical outcomes and survival in pancreatic cancer patients.     

Meta-analysis of structured triglyceride versus other lipid emulsions for parenteral nutrition

Structured triglyceride (STG) is a new emulsion synthesized from long-chain fatty acids and medium-chain fatty acids bound to the same glycerol backbone. We performed a meta-analysis to examine the safety, efficacy, and tolerability of STG for parenteral nutrition. We searched MEDLINE, EMBASE, and the Chinese Biomedicine Database, with the last search done in May 2012. Only randomized controlled trials in humans published in Chinese or English were included. Search terms included structured triglyceride and structural lipid. Methodologic quality was evaluated using the Jadad Scale. Meta-analysis was conducted using Review Manager 5.0.24 to calculate the weighted mean difference (WMD) and standardized mean difference (SMD) with 95% confidence intervals. Twenty-one studies (833 participants) published in English or Chinese were included in the analysis. STG significantly affected plasma triglycerides (WMD = ?0.15; 95% confidence interval [CI], ?0.29 to ?0.01; P = 0.04), plasma glycerol (WMD = 0.21; 95% CI, 0.01–0.41; P = 0.04), free fatty acids (WMD = 0.21; 95% CI, 0.03–0.39; P = 0.02), nitrogen balance (SMD = 1.13; 95% CI, 0.26–1.99; P = 0.01), AST (WMD = ?5.97; 95% CI, ?7.17 to ?4.76; P < 0.00001), and glucose (WMD = ?0.18; 95% CI, ?0.30 to ?0.06; P = 004), but not respiratory quotient, resting energy expenditure, alanine aminotransferase, alkaline phosphatase, gamma-glutamyl transpeptidase, bilirubin, cholesterol, serum creatinine, or vital signs. STG is rapidly metabolized without harming the liver, and positively affects nitrogen balance. STG is at least as safe and effective for parenteral nutrition as other triglycerides.     

Early versus traditional postoperative feeding in patients undergoing resectional gastrointestinal surgery: a meta-analysis

Background: A meta‐analysis evaluating surgical outcomes following nutritional provision provided proximal to the anastomosis within 24 hours of gastrointestinal surgery compared with traditional postoperative management was conducted. Methods: Databases were searched to identify randomized controlled trials comparing the outcomes of early and traditional postoperative feeding. Trials involving gastrointestinal tract resection followed by patients receiving nutritionally significant oral or enteral intake within 24 hours after surgery were included for analysis. Results: Fifteen studies involving a total of 1240 patients were analyzed. A statistically significant reduction (45%) in relative odds of total postoperative complications was seen in patients receiving early postoperative feeding (odds ratio [OR] 0.55; confidence interval [CI], 0.35 ?0.87, P = .01). No effect of early feeding was seen with relation to anastomotic dehiscence (OR 0.75; CI, 0.39–1.4, P = .39), mortality (OR 0.71; CI, 0.32–1.56, P = .39), days to passage of flatus (weighted mean difference [WMD] ?0.42; CI, ?1.12 to 0.28, P = .23), first bowel motion (WMD ?0.28; CI, ?1.20 to 0.64, P = .55), or reduced length of stay (WMD ?1.28; CI, ?2.94 to 0.38, P = .13); however, the direction of clinical outcomes favored early feeding. Nasogastric tube reinsertion was less common in traditional feeding interventions (OR 1.48; CI, 0.93–2.35, P = .10). Conclusions: Early postoperative nutrition is associated with significant reductions in total complications compared with traditional postoperative feeding practices and does not negatively affect outcomes such as mortality, anastomotic dehiscence, resumption of bowel function, or hospital length of stay.     

A New Intravenous Fat Emulsion Containing Soybean Oil,Medium‐Chain Triglycerides,Olive Oil,and Fish Oil

Background: SMOFlipid 20% is an intravenous lipid emulsion (ILE) containing soybean oil, medium‐chain triglycerides, olive oil, and fish oil developed to provide energy, essential fatty acids (FAs), and long‐chain ω‐3 FAs as a mixed emulsion containing α‐tocopherol. The aim was to assess the efficacy and safety of this new ILE in pediatric patients receiving home parenteral nutrition (HPN) compared with soybean oil emulsion (SOE). Methods: This single‐center, randomized, double‐blind study included 28 children on HPN allocated to receive either SMOFlipid 20% (n = 15) or a standard SOE (Intralipid 20%, n = 13). ILE was administered 4 to 5 times per week (goal dose, 2.0 g/kg/d) within a parenteral nutrition regimen. Assessments, including safety and efficacy parameters, were performed on day 0 and after the last study infusion (day 29). Lipid peroxidation was determined by measurement of thiobarbituric acid reactive substances (TBARS). Results: There were no significant differences in laboratory safety parameters, including liver enzymes, between the groups on day 29. The mean ± standard deviation changes in the total bilirubin concentration between the initial and final values (day 29 to day 0) were significantly different between groups: SMOFlipid group ?1.5 ± 2.4 µmol/L vs SOE group 2.3 ± 3.5 µmol/L, P < .01; 95% confidence interval [CI], ?6.2 to ?1.4). In plasma and red blood cell (RBC) phospholipids, the ω‐3 FAs C20:5ω‐3 (eicosapentaenoic acid) and + C22:6ω‐3 (docosahexaenoic acid) increased significantly in the SMOFlipid group on day 29. The ω‐3:ω‐6 FA ratio was significantly elevated with SMOFlipid 20% compared with SOE group (plasma, day 29: 0.15 ± 0.06 vs 0.07 ± 0.02, P < .01, 95% CI, 0.04–0.11; and RBC, day 29: 0.23 ± 0.07 vs 0.14 ± 0.04, P < .01, 95% CI, 0.04–0.13). Plasma α‐tocopherol concentration increased significantly more with SMOFlipid 20% (15.7 ± 15.9 vs 5.4 ± 15.2 µmol/L, P < .05; 95% CI, ?2.1 to 22.6). The low‐density lipoprotein–TBARS concentrations were not significantly different between both groups, indicating that lipid peroxidation did not differ between groups. Conclusions: SMOFlipid 20%, which contains 15% fish oil, was safe and well tolerated, decreased plasma bilirubin, and increased ω‐3 FA and α‐tocopherol status without changing lipid peroxidation.     

A Meta‐Analysis of Probiotic and Synbiotic Use in Elective Surgery

Background: Perioperative nutrition modulation of gut microbiota is increasingly used as a strategy for reducing the infective complications of elective surgery. This meta‐analysis assessed the effect of probiotic and synbiotic preparations on the incidence of postoperative sepsis. Methods: Randomized controlled trials that compared preoperative dosing of probiotics and synbiotics in patients undergoing elective general surgical procedures were included. The primary outcome measure was the postoperative sepsis rate. Pooled outcome measures were determined using random effects models. Results: Thirteen randomized controlled trials totaling 962 patients were included in this analysis (304 received synbiotics and 182 received probiotics). The incidence of postoperative sepsis was reduced in the probiotic group vs the control (pooled odds ratio [OR] = 0.42; 95% confidence interval [CI], 0.23–0.75; P = .003) and in the synbiotic group vs the control (pooled OR = 0.25; 95% CI, 0.1–0.6; P = .002). However, subgroup analysis failed to identify a significant reduction in the incidence of pneumonia, urinary tract infections, or wound infections in the postoperative phase for either treatment group. Synbiotics reduced the length of postoperative antibiotic use (weighted mean differences = ?1.71; 95% CI, ?3.2 to ?0.21; P = .03). Conclusion: Probiotic and synbiotic nutrition strategies reduce the incidence of postoperative sepsis in the elective general surgery setting. These effects appear more pronounced with the use of synbiotics. High‐powered, mechanistic studies are now required for the optimization of pro‐ and prebiotic regimens to further improve their efficacy.     

ω-3 Fatty-Acid Enriched Parenteral Nutrition in Hospitalized Patients: Systematic Review With Meta-Analysis and Trial Sequential Analysis

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.     

Characterization of posthospital bloodstream infections in children requiring home parenteral nutrition

Background: Home parenteral nutrition (HPN) is lifesaving for children with intestinal failure. Catheter‐associated bloodstream infections (CA‐BSI) are common in hospitalized patients receiving parenteral nutrition (PN), but data evaluating CA‐BSI in children receiving HPN are limited. Objective: To determine the incidence and characteristics of CA‐BSI in children receiving HPN. Methods: Medical records of 44 children receiving HPN during a 3‐year period were reviewed. End points were CA‐BSI during the initial 6 months after discharge. CA‐BSI was defined as isolation of pathogens from blood requiring antimicrobial therapy. Results: The primary indication for HPN was short bowel syndrome (46%), and 59 BSI were documented during the initial 6 months of HPN in 29 (66%) children. Of CA‐BSI, polymicrobial infections accounted for 52%; gram‐positive, 29%; gram‐negative, 17%; and fungal, 2%. CA‐BSI incidence per 1000 catheter‐days was highest during the first month posthospital discharge (72 episodes; 95% confidence interval [CI], 45.4–109.6). CA‐BSI incidence density ratio for children receiving HPN for >90 days compared with those receiving HPN for <30 days was 2.2 (P < .05). Logistic regression revealed that Medicaid insurance and age <1 year were associated with increased risk for CA‐BSI (odds ratio [OR], 4.4 [95% CI, 1.13–16.99] and 6.6 [1.50–28.49], respectively; P < .05). Conclusions: The incidence of CA‐BSI in children receiving HPN is highest during the first month posthospital discharge. Strategies to address care in the immediate posthospital discharge period may reduce the burden of infectious complications of HPN.     

Postoperative Hypoproteinemia in Cancer Patients Following Extensive Abdominal Surgery Despite Parenteral Nutritional Support

Determination of the predictors of hypoproteinemia among cancer patients following extensive surgery may enhance their nutritional management and clinical outcome. This study evaluated the predictive factors of postoperative hypoproteinemia among cancer patients following extensive abdominal surgery. An age- and gender-matched case-control study (n = 115) was conducted among cancer patients undergoing extensive (cases; n = 81) and moderate (controls; n = 34) abdominal surgery. Case patients received total parenteral nutrition (TPN), including 3 units of fresh frozen plasma and 200 mL 5% human albumin solution, for 8 postoperative days (POD). Case patients had lower mean total serum protein (TSP) levels throughout POD 8 (F value = 13.81; P = 0.001). Despite TPN, cases had greatest mean (±SD) TSP percent change on POD 1 (?24.6% ± 13.0, vs. ?12.6% ± 9.2; P < 0.0001) and did not regain preoperative levels (POD 8: ?14.3% ± 12.5 vs. 6.9% ± 13.4; P = 0.006). The likelihood of hypoproteinemia in this group was greatest on POD 3 (OR = 30.57; 95% CI 5.44–171.83). Multivariate regression analyses indicated that the determinants of postoperative hypoproteinemia were age [Adjusted OR (AOR) = 1.04; 95% CI 1.00–1.08), preoperative TSP (AOR = 0.46; 95% CI 0.23–0.92), and extensive surgery (AOR = 2.65; 95% CI 1.01–6.95). Tailored nutritional support, regarding extent of surgery, preoperative TSP, and patient age are needed to deter the occurrence of postoperative hypoproteinemia and consequent adverse surgical outcome among cancer patients.     

The Effects of Probiotics in Early Enteral Nutrition on the Outcomes of Trauma

Background: The role of probiotics in trauma patients remains unclear. We undertook a meta‐analysis of published randomized controlled trials (RCTs) to assess the effects of probiotics on the clinical outcomes of trauma patients. Methods: A systematic electronic literature search was conducted to identify RCTs comparing the use of probiotics with a control in trauma patients. Results were expressed as risk ratios (RRs) or standardized mean differences (SMDs) with accompanying 95% confidence intervals (CIs). The primary outcome measurement was the incidence of nosocomial infections. Secondary outcome measurements included the incidence of ventilator‐associated pneumonia (VAP), length of intensive care unit (ICU) stay, and mortality. The meta‐analysis was performed with the fixed‐effect or random‐effect model according to the heterogeneity. Results: Five studies involving 281 patients met our inclusion criteria. The use of probiotics was associated with a reduction in the incidence of nosocomial infections (5 trials; RR, 0.65; 95% CI, 0.45–0.94, P = .02), VAP (3 trials; RR, 0.59; 95% CI, 0.42–0.81, P = .001), and length of ICU stay (2 trials; SMD, ?0.71; 95% CI, ?1.09 to ?0.34, P < .001) but no reduction in mortality (4 trials; RR, 0.63; 95% CI, 0.32–1.26, P = .19). Conclusions: The use of probiotics is associated with a reduction in the incidence of nosocomial infections, VAP, and length of ICU stay but is not associated with an overall mortality advantage. However, the results should be interpreted cautiously due to the heterogeneity among study designs. Further large‐scale, well‐designed RCTs are needed.     

Immunonutrition Is Associated With a Decreased Incidence of Graft‐Versus‐Host Disease in Bone Marrow Transplant Recipients: A Meta‐Analysis

Introduction: Graft‐versus‐host disease (GVHD) is a serious complication of bone marrow transplantation (BMT), requiring higher doses of glucocorticoids or immunosuppressive therapies and further straining transplant recipients. Immunonutrition, such as vitamins and amino acid supplements, increase immunity and decrease inflammation and oxidative stress. This meta‐analysis examines the impact of immunonutrition on the incidence of GVHD and postoperative infections among BMT recipients. Methods: A comprehensive literature search for all published randomized controlled trials was conducted with PubMed, Cochrane Central Registry of Controlled Trials, and Google Scholar (1966–2016). Keywords in the search included variations of terms related to immunonutrition, such as “vitamin,” “glutamine,” and “transplant.” Outcomes included incidence of GVHD and infection. Results: Ten randomized controlled trials involving 681 BMT recipients were analyzed: 332 receiving immunonutrition and 349 receiving standard nutrition. Immunonutrition is correlated with a decreased incidence of GVHD by 19% (relative risk [RR] = 0.810, 95% CI: 0.695–0.945, P = .007). There was no significant difference in the incidence of infections with immunonutrition (RR = 1.016, 95% CI: 0.819–1.261, P = .885). Subgroup analysis of glutamine compared with N‐acetylcysteine, selenium, and eicosapentaenoic acid showed no significant difference in the incidence of GVHD or infections (RR = 0.913, 95% CI: 0.732–1.139, P = .419; RR = 0.951, 95% CI: 0.732–1.235; P = .708, respectively). Conclusion: The use of immunonutrition is associated with a reduced risk of GVHD in BMT recipients, potentially as a result of improved immune support and free radical scavenging. Providing immunonutrient supplements is a valuable adjunct in the routine care of BMT recipients, helping to alleviate a common and deadly complication.     

Systematic Review and Meta‐Analysis of the Utilization of Ethanol Locks in Pediatric Patients With Intestinal Failure

Background : Intestinal failure is a chronic condition related to loss of bowel length and/or function, resulting in dependence on central venous catheters for fluids and nutrition. Catheter use can be associated with significant complications, including catheter‐related bloodstream infections (CRBSIs), which can lead to loss of vascular access, advancing intestinal failure associated–liver disease and death. Our objective was to evaluate the effectiveness and safety of ethanol locks as compared with standard heparin locks in pediatric intestinal failure. Methods : Databases, including MEDLINE and EMBASE, were searched until March 2017. Titles and abstracts were reviewed independently and relevant articles reassessed by full‐text review. The main outcome was the rate of CRBSIs, while secondary outcomes were catheter replacement and repair. Results : Nine observational studies were included. The mean difference in rate of CRBSIs was 6.27 per 1000 catheter days (95% CI, 4.89–7.66) favoring ethanol locks, with a 63% overall reduction in infection rate. The mean difference in catheter replacement rate (per 1000 catheter days) was 4.56 (95% Cl, 2.68–6.43) favoring ethanol locks. The overall effect on catheter repair rate (per 1000 catheter days) was ?1.67 (95% CI, ?2.30 to ?1.05), indicating lower repair rate with heparin locks. Conclusion : Sufficient evidence was noted showing that ethanol locks reduced CRBSIs and catheter replacements. Our findings raise questions about the effect of the ethanol lock on catheter integrity based on the noted increase in repair rate. This requires further prospective evaluation and may support selective application of ethanol locks to patients with documented CRBSIs.     

Lactobacillus reuteri DSM 17938 as a Probiotic for Preterm Neonates

Introduction: Prevention of necrotizing enterocolitis (NEC) while optimizing enteral nutrition (EN) is a priority in preterm neonates. Lactobacillus reuteri DSM 17938 (L reuteri) is known to improve gut motility. Previous systematic reviews have not adequately assessed the effects of L reuteri in improving feed tolerance in preterm neonates. Objective: To assess the effects of L reuteri in preterm neonates. Design: A systematic review of randomized controlled trials (RCTs) and non‐RCTs of L reuteri was conducted. We searched the Cochrane Central Register of Controlled Trials, PubMed, EMBASE, and CINAHL databases and proceedings of Pediatric Academic Society meetings in December 2014. Results: Six RCTs (n = 1778) and 2 non‐RCTs (n = 665) were included. Meta‐analysis of RCTs estimated that the time to full feeds (mean difference [MD], –1.34 days; 95% confidence interval [CI], ?1.81 to ?0.86; 2 RCTs), duration of hospitalization (–10.77 days; 95% CI, ?13.67 to ?7.86; 3 RCTs), and late‐onset sepsis (LOS) (relative risk [RR], 0.66; 95% CI, 0.52 to 0.83; 4 RCTs) were reduced in the L reuteri group. Mortality (RR, 0.79; 95% CI, 0.57–1.09; 3 RCTs) and ≥ stage II NEC (RR, 0.69; 95% CI, 0.47–1.01; 3 RCTs) were reduced but statistically not significant. There were no adverse effects of supplementation. Both non‐RCT studies showed significant improvement in the incidence of NEC with L reuteri supplementation. Conclusions: Evidence from a limited number of studies suggests that L reuteri supplementation has the potential to reduce the risk of NEC and LOS while facilitating EN in preterm infants. Larger definitive RCTs are needed to confirm these findings.     

Malnutrition May Worsen the Prognosis of Critically Ill Children With Hyperglycemia and Hypoglycemia

Objectives: To determine whether hyperglycemia and hypoglycemia are associated with higher mortality, longer length of intensive care unit (ICU) stay, and fewer ventilator‐free days in critically ill children while taking into account the clinical severity and nutrition status. Patients and Methods: A prospective observational cohort study was conducted on 221 children admitted to the ICU. Blood glucose levels were analyzed in the first 72 hours. Potential exposure variables for adverse prognosis included hyperglycemia (blood glucose >150 mg/dL), hypoglycemia (blood glucose ≤60 mg/dL), age <1 year, sex, nutrition status, the revised Pediatric Index of Mortality (PIM 2), and the Pediatric Logistic Organ Dysfunction (PELOD). Results: Of the patients, 47.1% were malnourished. Controlling for nutrition status, both hyperglycemia and hypoglycemia increased the risk of mortality in the malnourished patients compared with the well‐nourished ones. Adjusting for clinical severity, the odds ratio of mortality was higher in malnourished patients with hyperglycemia (odds ratio [OR], 3.98; 95% confidence interval [CI], 1.14–13.94; P = .03), whereas no significant associations were detected in the well‐nourished patients. After controlling for nutrition status, hypoglycemia was associated with longer length of ICU stay (OR, 6.5; 95% CI, 1.30–32.57; P < .01) and fewer ventilator‐free days (OR, 4.11; 95% CI, 1.26–13.40; P < .01) only in the malnourished group of patients. Conclusions: Compared with the well nourished, malnourished patients with hyperglycemia are at a greater risk of mortality, independent of clinical severity. Hypoglycemia was shown to be associated with mortality, longer length of ICU stay, and fewer ventilator‐free days only in malnourished patients.     

Prospective Cohort Study Comparing the Effects of Different Artificial Nutrition Methods on Long‐Term Survival in the Elderly

Background: The effects of various artificial nutrition methods on the long‐term outcomes of elderly patients are still not well known. We aimed to compare the long‐term survival of the elderly newly administered with parenteral nutrition (PN) or enteral nutrition. Materials and Methods: This multicenter, prospective, observational cohort study was conducted on 546 elderly patients who were administered artificial nutrition. The main outcome was the survival ratio at 180 and 360 days after initiation of 3 different nutrition methods and estimated mean survival time: PN, nasal tube feeding (EN_N), and percutaneous endoscopic gastrostomy (PEG) feeding (EN_G). The incidence of systemic infection was also compared among different cohorts. Results: At 180 and 360 days after initiation of artificial nutrition, the mortality rates in the PN, EN_N, and EN_G cohorts were 52% and 63%, 32% and 41%, and 22% and 33%, respectively. Multivariate logistic regression analysis showed that, whereas PN nutrition had significant associations with a higher death rate at 180 and 360 days in all samples, there is no significant difference on the main outcome among the 3 cohorts with neurological diseases. A subgroup analysis with neurological diseases showed that the proportional hazard ratios of the PN and EN_N cohorts in comparison with the EN_G cohort were 1.13 (95% confidence interval [CI], 0.66–1.92) and 1.22 (95% CI, 0.82–1.81). Conclusion: There is no significant superiority of PEG feeding compared with nasal tube feeding or PN. Clinicians should consider the choice of nutrition support method, taking into consideration the limitation of the patient's interest.     

Malnutrition at Diagnosis Predicts Mortality in Patients With Systemic Immunoglobulin Light‐Chain Amyloidosis Independently of Cardiac Stage and Response to Treatment

Background: Nutrition status was shown to be a prognostic factor in patients with immunoglobulin light‐chain amyloidosis (AL). However, malnutrition was associated with cardiac involvement, thus suggesting potential interactions. This study aim was to clarify the association among nutrition status, cardiac stage, and mortality in AL. Methods: One hundred twenty‐eight consecutive newly diagnosed, treatment‐naïve patients with histologically confirmed AL were enrolled. Anthropometric, biochemical, and clinical variables were assessed. Results: At multivariable Cox proportional hazard analysis, body mass index (BMI) < 22 kg/m² (HR = 1.98, 95% CI = 1.09–3.56) and unintentional 6‐month weight loss (WL) ≥ 10% (HR = 1.94, 95% CI = 1.00–3.74) resulted in independent predictors of survival after controlling for hematologic response to treatment (HR = 0.27, 95% CI = 0.14–0.53) and cardiac stage (Mayo Clinic stage III, HR = 4.42, 95% CI = 2.61–7.51). There was no effect modification of malnutrition on mortality by cardiac stage (P for interaction = .27). Moderate and severe malnutrition (prevalence: 21.9% and 7.8%, respectively) similarly increased the risk of death (HR = 3.09, 95% CI = 1.75–5.46; 2.88, 95% CI = 1.23–6.72, respectively). Conclusions: In AL, malnutrition at diagnosis is a frequent comorbidity that affects the prognosis independently of hematologic response to treatment and cardiac stage. Nutrition status should be systematically considered in future intervention trials in AL. Nutrition support trials are warranted.     

Nutrition Support Team Intervention Improves Activities of Daily Living in Older Patients Undergoing In-Patient Rehabilitation in Japan: A Retrospective Cohort Study

The effect of nutrition support on activities of daily living (ADL) in individuals aged ≥75 years requiring rehabilitation is unknown. This study aimed to investigate the effect of nutrition support on ADL improvement in older patients undergoing in-patient rehabilitation in Japan. This retrospective cohort study was performed in 175 patients aged ≥75 years. The nutrition support team (NST) intervened in 85 cases. ADL was evaluated by the functional independence measure (FIM). We analyzed the effects of NST intervention on FIM efficiency. Multiple linear regression analysis revealed that NST intervention (standard partial regression coefficient, β?=?0.164; 95% confidence interval [CI] 0.003–0.229; P?=?0.044), energy intake at admission (β?=?0.179; 95% CI, 0.000–0.016; P?=?0.043), body mass index (BMI) at admission (β?=?0.227; 95% CI, 0.005–0.046; P?=?0.014), and cerebrovascular disease (β?=??0.238; 95% CI, ?0.298 to ?0.063; P?=?0.003) were independently associated with FIM efficiency. NST intervention, energy intake, and BMI on admission may affect ADL improvement in older patients undergoing in-patient rehabilitation.     

A Cohort Study of Nutrition Practices in the Intensive Care Unit Following Abdominal Aortic Aneurysm Repair

Introduction: Enteral nutrition within 48 hours of intensive care unit (ICU) admission is recommended for the ICU population. Major vascular surgery patients have a higher incidence of pre‐ and postoperative malnutrition compared with the general surgical population. Our objectives were to determine if early feeding (within 48 hours of admission) is achievable and well tolerated, identify factors that predict early feeding, and determine if there is an association between early feeding and in‐hospital mortality among abdominal aortic aneurysm (AAA) repair patients. Methods: A retrospective cohort study was conducted among 145 postsurgical AAA repair patients admitted to the ICU within 48 hours of surgery. Kaplan‐Meier methods and Cox proportional hazard multiple regression were used to analyze the data. Results: Only 35 (24%) patients received early feeding. Patients were more likely to be fed early if they were male (adjusted hazard ratio [aHR] = 2.3; 95% confidence interval [CI], 0.8–6.7; P = .13), had endovascular AAA repair (aHR = 2.9; 95% CI, 1.4–6.2; P = .006), had less blood loss (<4 L) during surgery (aHR = 2.3; 95% CI, 0.7–7.2; P = .14), and had shorter length of ventilation (<48 hours) (aHR = 2.2; 95% CI, 1.1–4.8; P = .048). Of 44 patients fed via enteral nutrition (EN), 27 (61%) achieved nutrition adequacy (>80% EN goal) during ICU admission. After controlling for other factors, 14‐day mortality was not related to feeding time (aHR = 1.1; P = .88). Conclusion: Early feeding was achieved in a minority of patients following AAA repair, was related to type of surgery and duration of mechanical ventilation, and was tolerated as well as later introduced feedings. Randomized trials are needed to determine safety and benefits of early feeding in this patient group.