Global availability of parenteral nutrition: Pre- and post-COVID-19 pandemic surveys

OBJECTIVE

Parenteral nutrition represents a therapeutic option for patients with type 3 intestinal failure. If used exclusively, parenteral nutrition has to be complete to provide all essential nutrients. The aim was to assess the availability of parenteral nutrition in all parts of the world, to better comprehend the global situation, and to prepare an action plan to increase access to parenteral nutrition.

METHODS

An international survey using an electronic questionnaire was conducted in August 2019 and repeated in May 2022. An electronic questionnaire was sent to 52 members or affiliates of the International Clinical Nutrition Section of the American Society for Parenteral and Enteral Nutrition. Questions addressed the availability of parenteral nutrition admixtures and their components, reimbursement, and prescribing pre- and post-COVID-19 pandemic. All participating countries were categorized by their economic status.

RESULTS

Thirty-six country representatives responded, answering all questions. Parenteral nutrition was available in all countries (100%), but in four countries (11.1%) three-chamber bags were the only option, and in six countries a multibottle system was still used. Liver-sparing amino acids were available in 18 (50%), kidney-sparing in eight (22.2%), and electrolyte-free in 11 (30.5%) countries (30.5%). In most countries (n = 28; 79.4%), fat-soluble and water-soluble vitamins were available. Trace elements solutions were unavailable in four (11.1%) countries. Parenteral nutrition was reimbursed in most countries (n = 33; 91.6%). No significant problems due to the coronavirus pandemic were reported.

CONCLUSIONS

Despite the apparent high availability of parenteral nutrition worldwide, there are some factors that may have a substantial effect on the quality of parenteral nutrition admixtures. These shortages create an environment of inequality.

The international declaration on the human right to nutritional care: A global commitment to recognize nutritional care as a human right

Access to nutritional care is frequently limited or denied to patients with disease-related malnutrition (DRM), to those with the inability to adequately feed themselves or to maintain their optimal healthy nutritional status which goes against the fundamental human right to food and health care. That is why the International Working Group for Patient's Right to nutritional care is committed to promote a human rights based approach (HRBA) in the field of clinical nutrition. Our group proposed to unite efforts by launching a global call to action against disease-related malnutrition through The International Declaration on the Human Right to Nutritional Care signed in the city of Vienna during the 44th ESPEN congress on September 5th 2022. The Vienna Declaration is a non-legally binding document that sets a shared vision and five principles for implementation of actions that would promote the access to nutritional care. Implementation programs of the Vienna Declaration should be promoted, based on international normative frameworks as The United Nations (UN) 2030 Agenda for Sustainable Development, the Rome Declaration of the Second International Conference on Nutrition and the Working Plan of the Decade of Action on Nutrition 2016-2025. In this paper, we present the general background of the Vienna Declaration, we set out an international normative framework for implementation programs, and shed a light on the progress made by some clinical nutrition societies. Through the Vienna Declaration, the global clinical nutrition network is highly motivated to appeal to public authorities, international governmental and non-governmental organizations and other scientific healthcare societies on the importance of optimal nutritional care for all patients.

Clinical nutrition and human rights: an international position paper

Worldwide Societies for Clinical Nutrition have launched a promotional campaign that advocates for all patients to have access to food and evidence-based artificially administered nutrition and hydration (AANH). The campaign is supported by the simultaneous publication of a major position paper in, Clinical Nutrition and Nutrition in Clinical Practice, the official journals of the European and North American professional societies. The working group of experts in human rights and clinical nutrition, includes representatives of the American Society for Enteral and Parenteral Nutrition (ASPEN), The European Society for Clinical Nutrition and Metabolism (ESPEN), Latin American Federation of Nutritional Therapy, Clinical Nutrition and Metabolism (FELANPE), Parenteral and Enteral Nutrition Society of Asia (PENSA) and the West African Society of Parenteral and Enteral Nutrition (WASPEN).

Signatures of natural selection in a foundation tree along Mediterranean climatic gradients

Temperature and precipitation regimes are rapidly changing, resulting in forest dieback and extinction events, particularly in Mediterranean‐type climates (MTC). Forest management that enhance forests’ resilience is urgently required, however adaptation to climates in heterogeneous landscapes with multiple selection pressures is complex. For widespread trees in MTC we hypothesized that: patterns of local adaptation are associated with climate; precipitation is a stronger factor of adaptation than temperature; functionally related genes show similar signatures of adaptation; and adaptive variants are independently sorting across the landscape. We sampled 28 populations across the geographic distribution of Eucalyptus marginata (jarrah), in South‐west Western Australia, and obtained 13,534 independent single nucleotide polymorphic (SNP) markers across the genome. Three genotype‐association analyses that employ different ways of correcting population structure were used to identify putatively adapted SNPs associated with independent climate variables. While overall levels of population differentiation were low (F_ST = 0.04), environmental association analyses found a total of 2336 unique SNPs associated with temperature and precipitation variables, with 1440 SNPs annotated to genic regions. Considerable allelic turnover was identified for SNPs associated with temperature seasonality and mean precipitation of the warmest quarter, suggesting that both temperature and precipitation are important factors in adaptation. SNPs with similar gene functions had analogous allelic turnover along climate gradients, while SNPs among temperature and precipitation variables had uncorrelated patterns of adaptation. These contrasting patterns provide evidence that there may be standing genomic variation adapted to current climate gradients, providing the basis for adaptive management strategies to bolster forest resilience in the future.

Clinical Nutrition and Human Rights. An International Position Paper

The International Working Group for Patients' Right to Nutritional Care presents its position paper regarding nutritional care as a human right intrinsically linked to the right to food and the right to health. All people should have access to food and evidence-based medical nutrition therapy including artificial nutrition and hydration. In this regard, the hospitalized malnourished ill should mandatorily have access to screening, diagnosis, nutritional assessment, with optimal and timely nutritional therapy in order to overcome malnutrition associated morbidity and mortality, while reducing the rates of disease-related malnutrition. This right does not imply there is an obligation to feed all patients at any stage of life and at any cost. On the contrary, this right implies, from an ethical point of view, that the best decision for the patient must be taken and this may include, under certain circumstances, the decision not to feed. Application of the human rights-based approach to the field of clinical nutrition will contribute to the construction of a moral, political, and legal focus to the concept of nutritional care. Moreover, it will be the cornerstone to the rationale of political and legal instruments in the field of clinical nutrition.

Clinical nutrition and human rights. An international position paper

The International Working Group for Patients' Right to Nutritional Care presents its position paper regarding nutritional care as a human right intrinsically linked to the right to food and the right to health. All people should have access to food and evidence-based medical nutrition therapy including artificial nutrition and hydration. In this regard, the hospitalized malnourished ill should mandatorily have access to screening, diagnosis, nutritional assessment, with optimal and timely nutritional therapy in order to overcome malnutrition associated morbidity and mortality, while reducing the rates of disease-related malnutrition. This right does not imply there is an obligation to feed all patients at any stage of life and at any cost. On the contrary, this right implies, from an ethical point of view, that the best decision for the patient must be taken and this may include, under certain circumstances, the decision not to feed. Application of the human rights-based approach to the field of clinical nutrition will contribute to the construction of a moral, political and legal focus to the concept of nutritional care. Moreover, it will be the cornerstone to the rationale of political and legal instruments in the field of clinical nutrition.

Parenteral Provision of Micronutrients to Pediatric Patients: An International Expert Consensus Paper

INTRODUCTION

Micronutrients (vitamins and trace elements) are essential to all nutrition. For children and neonates who are dependent upon nutrition support therapies for growth and development, the prescribed regimen must supply all essential components. This paper aims to facilitate interpretation of existing clinical guidelines into practical approaches for the provision of micronutrients in pediatric parenteral nutrition.

METHODS

An international, interdisciplinary expert panel was convened to review recent evidence-based guidelines and published literature to develop consensus-based recommendations on practical micronutrient provision in pediatric parenteral nutrition.

RESULTS

The guidelines and evidence have been interpreted as answers to 10 commonly asked questions around the practical principles for provision and monitoring of micronutrients in pediatric patients.

CONCLUSION

Micronutrients are an essential part of all parenteral nutrition and should be included in the pediatric nutrition therapy care plan.

Pharmaconutrition revisited for critically ill patients with coronavirus disease 2019 (COVID-19): Does selenium have a place?

Coronavirus disease 2019 (COVID-19) is a global pandemic causing one of the biggest challenges for critical care medicine. Mortality from COVID-19 is much greater in elderly men, many of whom succumb to acute respiratory distress syndrome (ARDS) triggered by the viral infection. Because there is no specific antiviral treatment against COVID-19, new strategies are urgently needed. Selenium is an essential trace element with antioxidant and immunomodulatory effects. Poor nutritional status increases the pathogenicity of viruses and low selenium in particular can be a determinant of viral virulence. In the past decade, selenium pharmaconutrition studies have demonstrated some reduction in overall mortality, including how reduced incidence of ventilator-associated pneumonia and infectious complications such as ARDS in the critically ill. Consequently, we postulate that intravenous selenium therapy, could be part of the therapeutic fight against COVID-19 in intensive care unit patients with ARDS and that outcomes could be affected by age, sex, and body weight. Our working hypothesis addresses the question: Could high-dose selenite pharmaconutrition, as an early pharmacologic intervention, be effective at reducing the incidence and the progression from type 1 respiratory failure (non-ARDS) to severe ARDS, multiorgan failure, and new infectious complications in patients with COVID-19 patients?

Fish Oil-Containing Lipid Emulsions in Adult Parenteral Nutrition: A Review of the Evidence

BACKGROUND

There is evidence from laboratory and animal studies that fish oil-containing intravenous lipid emulsions (FOC-IVLEs) have a beneficial effect on inflammation and the immune response, suggesting a possible clinical benefit. Clinical studies of FOC-IVLEs have reported mixed results. The aim of this review is to present findings from recent randomized controlled clinical trials and other quality clinical studies investigating the effects of administering intravenous fish oil alone or as part of a multilipid emulsion and to examine the quality of these studies in an objective, evidence-based manner.

METHODS

Studies comparing FOC-IVLEs with other IVLEs in adults were included. Thirty-four clinical studies were evaluated: 19 investigated levels of inflammatory and immune markers as an endpoint; 13 investigated rates of infection or sepsis; 3 investigated clinical outcomes in septic patients; and 29 investigated general clinical outcomes.

RESULTS

There was conflicting evidence for a beneficial effect of fish oil on levels of inflammatory and immune markers and some evidence that fish oil decreased the rate of postoperative atrial fibrillation. Studies generally reported few statistical differences in clinical outcomes and rates of infection and sepsis with FOC-IVLEs as compared with other IVLEs. The quality of reporting was generally poor, and the presented evidence for comparisons between FOC-IVLEs and other IVLEs was inconclusive or weak.

CONCLUSIONS

There is very little high-quality evidence that FOC-IVLEs have a more beneficial effect than other IVLEs on clinical outcomes in adult patients.

Interleukin-7 Dose-Dependently Restores Parenteral Nutrition–Induced Gut-Associated Lymphoid Tissue Cell Loss but Does Not Improve Intestinal Immunoglobulin A Levels

BACKGROUND

Without enteral nutrition, the mass and function of gut-associated lymphoid tissue (GALT), a center of systemic mucosal immunity, are reduced. Therefore, new therapeutic methods, designed to preserve mucosal immunity during parenteral nutrition (PN), are needed. Our recent study revealed that exogenous interleukin-7 (IL-7; 1 microg/kg twice a day) restores the GALT cell mass lost during intravenous (IV) PN but does not improve secretory immunoglobulin A (IgA) levels. Herein, we studied the IL-7 dose response to determine the optimal IL-7 dose for recovery of GALT mass and function during IV PN. We hypothesized that a high dose of IL-7 would increase intestinal IgA levels, as well as GALT cell numbers.

METHODS

Male mice (n = 42) were randomized to chow, IL-7-0, IL-7-0.1, IL-7-0.33, IL-7-1 and IL-7-3.3 groups and underwent jugular vein catheter insertion. The IL-7 groups were fed a standard PN solution and received IV injections of normal saline (IL-7-0), 0.1, 0.33, 1, or 3.3 microg/kg of IL-7 twice a day. The chow group was fed chow ad libitum. After 5 days of treatment, the entire small intestine was harvested and lymphocytes were isolated from Peyer's patches (PPs), intraepithelial (IE) spaces, and the lamina propria (LP). The lymphocytes were counted and phenotypes determined by flow cytometry (alphabetaTCR, gammadeltaTCR, CD4, CD8, B cell). IgA levels of small intestinal washings were also examined using ELISA (enzyme-linked immunoabsorbent assay).

RESULTS

IL-7 dose-dependently increased total lymphocyte numbers in PPs and the LP. The number of lymphocytes harvested from IE spaces reached a plateau at 1 microg/kg of IL-7. There were no significant differences in any phenotype percentages at any GALT sites among the groups. IgA levels of intestinal washings were significantly higher in the chow group than in any of the IL-7 groups, with similar levels in all IL-7 groups.

CONCLUSIONS

Exogenous IL-7 dose-dependently reverses PN-induced GALT cell loss, with no major changes in small intestinal IgA levels. IL-7 treatment during PN appears to have beneficial effects on gut immunity, but other therapeutic methods are needed to restore secretory IgA levels.

E-therapies in England for stress, anxiety or depression: what is being used in the NHS? A survey of mental health services

OBJECTIVE

To document the range of web and smartphone apps used and recommended for stress, anxiety or depression by the National Health Service (NHS) in England.

DESIGN

The study was conducted using Freedom of Information (FOI) requests and systematic website searches.

DATA SOURCES

Data were collected via FOI requests to NHS services between 13 February 2015 and 31 March 2015, and searches conducted on NHS apps library websites between 26 March 2015 and 2 November 2015.

DATA COLLECTION/EXTRACTION METHODS

Data were compiled from responses to: (1) FOI requests sent to all Improving Access to Psychological Therapies (IAPT) services and NHS Mental Health Trusts in England and (2) NHS apps library search results.

RESULTS

A total of 61 (54.95%) out of the then 111 IAPT service providers responded, accounting for 191 IAPT services, and all 51 of the then NHS Mental Health Trusts responded. The results were that 13 different web apps and 35 different smartphone apps for depression, anxiety or stress were available through either referral services or the online NHS Apps Libraries. The apps used and recommended vary by area and by point of access (online library/IAPT/trust).

CONCLUSIONS

Future research is required to establish the evidence base for the apps that are being used in the NHS in England. There is a need for service provision to be based on evidence and established guidelines.

Genome sequences of six Phytophthora species associated with forests in New Zealand

In New Zealand there has been a long association of Phytophthora diseases in forests, nurseries, remnant plantings and horticultural crops. However, new Phytophthora diseases of trees have recently emerged. Genome sequencing has been performed for 12 Phytophthora isolates, from six species: Phytophthora pluvialis, Phytophthora kernoviae, Phytophthora cinnamomi, Phytophthora agathidicida, Phytophthora multivora and Phytophthora taxon Totara. These sequences will enable comparative analyses to identify potential virulence strategies and ultimately facilitate better control strategies. This Whole Genome Shotgun data have been deposited in DDBJ/ENA/GenBank under the accession numbers LGTT00000000, LGTU00000000, JPWV00000000, JPWU00000000, LGSK00000000, LGSJ00000000, LGTR00000000, LGTS00000000, LGSM00000000, LGSL00000000, LGSO00000000, and LGSN00000000.

What do patients find helpful in psychotherapy? Implications for the therapeutic relationship in mental health nursing

This study examined client perception of the therapeutic impact of two models of therapy delivered by mental health nurses and clinical psychologists respectively - psychodynamic interpersonal therapy (PIT) and cognitive behavioural therapy (CBT). A non-equivalent groups design was used in order to benchmark results against Llewelyn et al.: one group received PIT and the other received CBT. This design was utilized principally because the research was conducted across two practice settings where randomization was not feasible. We used two intact groups in practice research settings that received the therapies as reported in Llewelyn et al. Sixty-one clients receiving CBT or PIT in practice research settings completed a Helpful Aspects of Therapy form after each session in order to measure client perceptions of helpful and hindering events in therapy. Only two out of the 13 impacts were rated as significantly different. PIT clients reported higher levels of 'awareness' than CBT clients, whereas CBT clients reported higher levels of problem solution than PIT clients. The results replicate Llewelyn et al.'s findings in that clients experienced theoretically different models of therapy as broadly similar in their therapeutic impact. We argue that this provides some support for the influence of 'common' rather than 'specific' factors in psychotherapy effectiveness in mental health nursing.

Update on antioxidant micronutrients in the critically ill

PURPOSE OF REVIEW

To evaluate recent evidence on pharmaconutrition with antioxidant micronutrients, for different populations of adult critically ill patients.

RECENT FINDINGS

Over the last few years, different studies have shown that high-dose trace elements and vitamins, especially parenteral selenium and zinc, may be able to improve relevant clinical outcomes in the most seriously ill patients. High-dose selenite monotherapy reduces mortality, particularly when a pharmacological loading dose is given in the early stage of severe sepsis and septic shock. Notwithstanding, the recently published REducing Deaths due to OXidative Stress study using an antioxidant cocktail and parenteral selenite, in addition to standard enteral nutrition, was unable to show any benefits for patients with multiple organ failure.

SUMMARY

There is evidence supporting the concept of pharmaconutrition with high-dose micronutrients. Selenium therapy may be able to decrease infections and reduce mortality in sepsis, but more research is needed to better understand pharmacokinetics, optimal composition, timing, duration, and dose of antioxidant cocktails for the critically ill.

[Pharmaconutrition with parenteral selenium in sepsis]

Critical illness is characterized by oxidative stress which leads to multiple organ failure, and sepsis-related organ dysfunction remains the most common cause of death in the intensive care unit. Over the last 2 decades, different antioxidant therapies have been developed to improve outcomes in septic patients. According to recent evidence, selenium therapy should be considered the cornerstone of the antioxidant strategies. Selenium given as selenious acid or sodium selenite should be considered as a drug or pharmaconutrient with prooxidant and cytotoxic effects when a loading dose in intravenous bolus form is administered, particularly in the early stage of severe sepsis/septic shock. To date, several phase ii trials have demonstrated that selenium therapy may be able to decrease mortality, improve organ dysfunction and reduce infections in critically ill septic patients. The effect of selenium therapy in sepsis syndrome must be confirmed by large, well designed phase iii clinical trials. The purpose of this review is to discuss current evidence on selenium pharmaconutrition in sepsis syndrome.

Glutamine supplementation in acute pancreatitis: a meta-analysis of randomized controlled trials

BACKGROUND

There is emerging evidence that glutamine supplementation should be considered in patients with acute and critical illness associated with a catabolic response. There are reports of glutamine supplementation in acute pancreatitis but the results of these studies are conflicting. The aim of this study was to systematically review the randomised controlled trials (RCT) of glutamine in patients with acute pancreatitis.

METHODS

The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, SCOPUS and 3 major Chinese databases were searched. The outcomes studied were mortality, total infectious complications, and length of hospital stay. A random effects model was used for meta-analysis of the outcomes in the included trials. A number of pre-specified subgroup analyses were also conducted. The summary estimates were reported as risk ratio (RR) for categorical variables and mean difference (MD) for continuous variables together with the corresponding 95% confidence interval.

RESULTS

Twelve RCT that enrolled 505 patients with acute pancreatitis were included in the final analysis. Overall, glutamine supplementation resulted in a significantly reduced risk of mortality (RR 0.30; 95% CI, 0.15 to 0.60; P < 0.001) and total infectious complications (RR 0.58; 95% CI, 0.39 to 0.87; P = 0.009) but not length of hospital stay (MD -1.35; 95% CI, -3.25 to 0.56, P = 0.17). In the subgroup analyses, only patients who received parenteral nutrition and those who received glutamine in combination with other immunonutrients demonstrated a statistically significant benefit in terms of all the studied outcomes.

CONCLUSIONS

This meta-analysis demonstrates a clear advantage for glutamine supplementation in patients with acute pancreatitis who receive total parenteral nutrition. Patients with acute pancreatitis who receive enteral nutrition do not require glutamine supplementation. Further studies are warranted to determine whether patients who receive combined enteral and parenteral nutrition need glutamine supplementation.

Selenium supplementation in the critically ill

Selenium (Se) is an essential trace element with antioxidant, immunological, and anti-inflammatory properties, which are attributed to its presence in selenoproteins, as the 21st amino acid selenocysteine. These selenoenzymes are involved in redox signaling, antioxidant defense, thyroid hormone metabolism, and immune responses. Dietary intakes differ considerably between geographical regions, due to variability of the Se food content, leading to differences in dietary reference intakes and toxicity cautions. Critical illness with systemic inflammatory response syndrome (SIRS) is characterized by Se depletion with high morbidity and mortality. Se status correlates well with clinical outcome in SIRS and may be useful as an early predictor of survival. Several investigators have evaluated the benefits of Se supplementation for the critically ill, either as monotherapy or in an antioxidant micronutrient combination. Pharmaconutrition, with high-dose Se (from 500-1600 µg/d) involving an initial loading bolus, followed by continuous infusion, appears to be safe and efficacious, with evidence that it can improve clinical outcome by reducing illness severity, infectious complications, and decreasing mortality in the intensive care unit (ICU). We now have a clearer understanding of the pharmacokinetics of the initial and transient pro-oxidant effect of an intravenous bolus of selenite and the antioxidant effect of continuous infusion. Better biomarkers to ascertain optimum Se requirements for individual patients are now needed, and clinical practice guidelines need improvement. Nevertheless, sufficient evidence is available to consider initiating high-dose intravenous Se therapy routinely in critically ill SIRS patients, immediately on admission to the ICU.

Implementing Surviving Sepsis guidelines in a district general hospital

We describe efforts made at Blackpool Victoria Hospital to implement the well-established international Surviving Sepsis guidelines. These included posters, pocket guides and stickers inserted in patient notes. All doctors and nurses in acute areas received specific information and education. Sepsis teams comprising both doctors and nurses were formed to encourage implementation and to audit and disseminate data. Data collection occurred from February to November 2009. Cases were considered prospectively at the time of initial assessment and 198 patients were identified; 169 (85%) had blood cultures taken; 146 (74%) had lactate levels measured; and 145 (74%) received antibiotics within the target time. We believe these results demonstrate relatively effective implementation of guidelines in the challenging environment of a district general hospital. Our results could be replicated easily and provide a good way of reducing patient mortality at minimal financial cost.

Clinical and nutritional benefits of cysteine-enriched protein supplements

PURPOSE OF REVIEW

To review recently published research into the use of dietary cysteine and/or its derivatives as functional food supplements that will enhance antioxidant status and improve outcome in certain diseases.

RECENT FINDINGS

L-cysteine is now widely recognized as a conditionally essential or (indispensible) sulphur amino acid. It plays a key role in the metabolic pathways involving methionine, taurine and glutathione (GSH), and may help fight chronic inflammation by boosting antioxidant status. In stressed and inflammatory states, sulphur amino acid metabolism adapts to meet the increased requirements for cysteine as a rate-limiting substrate for GSH. Critically ill patients receiving enteral or parenteral nutrition, enriched with cysteine, exhibit decreased cysteine catabolism and improved GSH synthesis. The naturally occurring cysteine-rich proteins, whey or keratin, have the potential to be manufactured into high quality, high cysteine-containing functional foods for clinical investigation.

SUMMARY

Cysteine-rich proteins, such as keratin, may have advantages over the simple amino acid or its derivatives, as nutraceuticals, to safely and beneficially improve antioxidant status in health and disease.