The challenge of integrating a diagnosis of malnutrition in the practical application of nutrition care in the intensive care unit.

Evidence of poor nutrition status in a patient present on admission to the intensive care unit is associated with worse clinical outcomes than that for a well-nourished patient who becomes critically ill. Diagnosing malnutrition in this setting is fraught with difficulty, though, because elements of nutrition history are hard to obtain, the interpretation of anthropometric parameters is influenced by the disease process and interventions of critical care and the subjectivity of traditional assessment tools lacks precision. Determining the severity of disease drives the initial management and sets priorities in the derivation of the nutrition plan, focusing on strategies that promote survival.

Exploring the impact of arginine-supplemented immunonutrition on length of stay in the intensive care unit: A retrospective cross-sectional analysis.

Background: Arginine-supplemented enteral immunonutrition has been designed to optimize outcomes in critical care patients. Existing formulas may be isocaloric and isoproteic, yet differ in L-arginine content, energy distribution, and in source and amount of many other specialized ingredients. The individual contributions of each may be difficult to pinpoint; however, all cumulate in the body's response to illness and injury.

The importance of providing dietary fiber in medical and surgical critical care.

The early provision of soluble/insoluble fiber to the patient who is critically ill has been controversial in the past. Especially in the setting of hemodynamic instability, dysmotility, or impaired gastrointestinal transit, fear of inspissation of formula with precipitation of nonocclusive mesenteric ischemia (NOMI)/nonocclusive bowel necrosis (NOBN) limited its utilization by medical and surgical intensivists. The incidence of NOMI/NOBN has been estimated at 0.

Healthcare Resource Utilization and Cost Comparisons of High-Protein Enteral Nutrition Formulas Used in Critically Ill Patients.

High-protein enteral nutrition is advised for patients who are critically ill. Options include immunonutrition formulas of various compositions and standard high-protein formulas (StdHP). Additional research is needed on the health economic value of immunonutrition in a broad cohort of severely ill hospitalized patients.

Is this time really different? Flight-to-safety and the COVID-19 crisis.

During periods of market stress, risk-averse investors reallocate their investments from stocks to gold in a bid to hedge risks. Market participants interpret the induced gold price increase as an indication of safe-haven purchases and a signal of increased uncertainty in the general economic and financial conditions, thereby causing higher gold price volatility. The aim of this paper is to analyze whether this flight to safety effect can be observed during the COVID-19 crisis, which is considered to be a one-of-a-kind crisis and obviously of different origin compared to previous (financial) crises.

Real-World Evidence of Treatment, Tolerance, Healthcare Utilization, and Costs Among Postacute Care Adult Patients Receiving Enteral Peptide-Based Diets in the United States.

Objective: Peptide -based (PB) enteral tube feeding (ETF) formulas have been shown to reduce gastrointestinal (GI) intolerance in patients receiving enteral nutrition. However, limited data exist in relation to their use in the postacute/home care setting. We sought to assess the real-world GI tolerance, healthcare utilization, and resource use costs of 100% whey-protein PB ETF in adults in a postacute care setting and describe their demographic, clinical, and treatment characteristics.

Measuring adherence in social recovery therapy with people with first episode psychosis.

Background: The SUPEREDEN3 study, a phase II randomized controlled trial, suggests that social recovery therapy (SRT) is useful in improving functional outcomes in people with first episode psychosis. SRT incorporates cognitive behavioural therapy (CBT) techniques with case management and employment support, and therefore has a different emphasis to traditional CBT for psychosis, requiring a new adherence tool.

Aims: This paper describes the SRT adherence checklist and content of the therapy delivered in the SUPEREDEN3 trial, outlining the frequency of SRT techniques and proportion of participants who received a full therapy dose.

The 2016 ESPEN Arvid Wretlind lecture: The gut in stress.

The gut has a major influence on the course of the human stress response in critical illness for several reasons; the quantity of its immune tissue, the extent of interface with the external environment, the expanse of the microbiome, and its access to the systemic circulation. In critical illness, it is not uncommon to lose mucosal barrier function, which exposes the host to the downside effects of luminal contents and epithelial cell regulation. In that setting, the microbiome is converted to a pathobiome, upregulation of metabolic and immune responses occurs, and homeostatic defense systems are compromised.

Targeted Physician Education Positively Affects Delivery of Nutrition Therapy and Patient Outcomes: Results of a Prospective Clinical Trial.

Background: Malnutrition is a continuing epidemic among hospitalized patients. We hypothesize that targeted physician education should help reduce caloric deficits and improve patient outcomes.

Materials And Methods: We performed a prospective trial of patients (n = 121) assigned to 1 of 2 trauma groups.

"CAN WE FEED?" A mnemonic to merge nutrition and intensive care assessment of the critically ill patient.

As care of the critically ill patient grows more complex, so does the breadth of knowledge required of the intensivist to deliver quality service. Nutrition is one area of many where the complexity of care has grown and the opportunity for improving patient outcomes has become evident. The use of mnemonics has proven successful in compartmentalizing information that must be considered in complex decision-making processes.

Physician-delivered malnutrition: why do patients receive nothing by mouth or a clear liquid diet in a university hospital setting?

Background: Traditional practices of placing patients nil per os (NPO) or on clear liquid diet (CLD) deter delivery of optimal nutrition care and are not always supported by sound physiologic principles.

Objective: This perspective survey evaluated the incidence of this practice, the reasons for such orders, and the response to intervention by the Multidisciplinary Nutrition Team (MNT).

Methods: All patients admitted to University of Louisville Hospital were monitored by MNT dietitians and were candidates for the study if they were placed NPO upon CLD for ≥ 3 days.

Fast combinatorial vector field topology.

This paper introduces a novel approximation algorithm for the fundamental graph problem of combinatorial vector field topology (CVT). CVT is a combinatorial approach based on a sound theoretical basis given by Forman's work on a discrete Morse theory for dynamical systems. A computational framework for this mathematical model of vector field topology has been developed recently.

Connecting youth with health services: Systematic review.

Objective: To identify models of health care delivery that support youth access to health and mental health care.

Data Sources: Information was obtained from PubMed, Ovid MEDLINE, Web of Knowledge, and Sociological Abstracts (CSA Illumina).

Study Selection: Studies reviewed in this article provided level I, II, or III evidence.

Poor validity of residual volumes as a marker for risk of aspiration in critically ill patients.

Background And Aims: Elevated residual volumes (RV), considered a marker for the risk of aspiration, are used to regulate the delivery of enteral tube feeding. We designed this prospective study to validate such use.

Methods: Critically ill patients undergoing mechanical ventilation in the medical, coronary, or surgical intensive care units in a university-based tertiary care hospital, placed on intragastric enteral tube feeding through nasogastric or percutaneous endoscopic gastrostomy tubes, were included in this study.

Clinical use of the respiratory quotient obtained from indirect calorimetry.

Background: The respiratory quotient (RQ) obtained from indirect calorimetry (IC), defined by the ratio carbon dioxide production (VCO2)/oxygen consumption (VO2), is affected by extremes of substrate use by the body. Underfeeding, which promotes use of endogenous fat stores, should cause decreases in the RQ, whereas overfeeding, which results in lipogenesis, should cause increases in the RQ. Marked increases in VCO2 (with subsequent increases in RQ) in response to overfeeding may cause respiratory compromise in patients with limited pulmonary reserve.

Achievement of steady state optimizes results when performing indirect calorimetry.

Background: The use of steady state as the endpoint for performance of indirect calorimetry (IC) is controversial. We designed this prospective study to evaluate the necessity and significance of achieving steady state.

Methods: Patients with respiratory failure placed on mechanical ventilation in a short- or long-term acute care unit at any 1 of 3 university-based urban hospitals were eligible for the study.

Indirect calorimetry: can this technology impact patient outcome?

This review of 23 papers involving indirect calorimetry published over the past 18 months shows how our understanding of the metabolic response to injury has changed, highlights the problems introduced by use of predictive equations and alterations in indirect calorimetry testing protocol, and emphasizes the need to monitor cumulative energy balance by comparing daily caloric intake to energy expenditure.

Are patients fed appropriately according to their caloric requirements?

Background: Specific morbidity related to underfeeding and overfeeding necessitates the design of nutrition support regimens that provide calories equal to those required on the basis of energy expenditure. This prospective multicenter trial was designed to determine what percent of patients in long-term acute care facilities receive feeding appropriate to their needs and whether accuracy of feeding has an impact on patient clinical status.

Methods: Patients on mechanical ventilation who were hospitalized at 32 Vencor Hospitals over a 9-week period and who were receiving only enteral nutrition by continuous infusion at a presumed goal rate were evaluated once by indirect calorimetry (IC) while on feeding.

Immunonutrition and enteral hyperalimentation of critically ill patients.

Physicians need to be maximally aggressive in their use of total enteral nutrition (TEN) in the critically ill patient, due to its lower cost, better physiology, and lower complication rate when compared to parenteral therapy. Various components in TEN such as glutamine, arginine, RNA nucleotides, omega-3 fish oils, and fiber, may have important roles in immunonutrition by maintaining gut integrity, stimulating the immune system, and preventing bacterial translocation from the gut. For each patient, the physician must choose the optimal enteral formula for that particular disease or organ failure state to maximize nutrient substrate assimilation and tolerance.

Nutritional support in patients with inflammatory bowel disease.

Total parenteral nutrition with bowel rest has been used as primary therapy to reduce disease activity and achieve remission in patients with inflammatory bowel disease (IBD). However, results are short-lived and similar success can be attained through total enteral nutrition with highly specialized elemental or semielemental formulas. Enteral nutrition costs less than parenteral nutrition, maintains gut integrity, stimulates immunocompetence, and helps to control symptoms and overall disease activity.

Use of residual volume as a marker for enteral feeding intolerance: prospective blinded comparison with physical examination and radiographic findings.

High gastric residual volumes (RVs) are a frequent cause for cessation of total enteral nutrition (TEN). This study was designed to determine the RV that indicates intolerance or inadequate gastric emptying and to compare the RV findings in a blinded fashion with those findings obtained on physical examination and radiography. Twenty healthy normal volunteers (HNV), 8 stable patients with gastrostomy tubes (GTP), and 10 critically ill patients (CIP) were evaluated prospectively for 8 hours while receiving TEN.

Light-promoted changes in apoplastic K(+) activity in the Samanea saman pulvinus, monitored with liquid membrane microelectrodes.

The movement of Samanea saman (Jacq.) Merrill leaflets is a consequence of the re-distribution of K(+) and anions between motor cells on opposite sides of the pulvinus. We used a K(+)-sensitive microelectrode to study dynamic changes in K(+) transport through motor-cell membranes during and immediately after change in illumination.