Role of family medicine physicians in providing nutrition support to older patients admitted to orthopedics departments: a grounded theory approach

BACKGROUND

Care of older adults requires comprehensive management and control of systemic diseases, which can be effectively managed by family physicians. Complicated medical conditions in older patients admitted to orthopedic departments (orthopedic patients) necessitate interprofessional collaboration. Nutrition is one of the essential components of management involved in improving the systemic condition of older patients. Nutrition support teams play an important role in nutrition management and can be supported by family physicians. However, the role of family physicians in nutrition support teams is not well documented. This study aimed to investigate the role of family physicians in supporting nutrition management in orthopedic patients.

METHODS

This qualitative study was conducted between January and June 2023 using constructivist grounded theory methodology. Eight family medicine physicians, three orthopedic surgeons, two nurses, two pharmacists, four rehabilitation therapists, four nutritionists, and one laboratory technician working in Japanese rural hospitals participated in the research. Data collection was performed through ethnography and semi-structured interviews. The analysis was performed iteratively during the study.

RESULTS

Using a grounded theory approach, four theories were developed regarding family physicians' role in providing nutrition support to orthopedic patients: hierarchical and relational limitation, delay of onset and detection of the need for geriatric care in orthopedic patients, providing effective family medicine in hospitals, and comprehensive management through the nutrition support team.

CONCLUSIONS

The inclusion of family physicians in nutrition support teams can help with early detection of the rapid deterioration of orthopedic patients' conditions, and comprehensive management can be provided by nutrition support teams. In rural primary care settings, family physicians play a vital role in providing geriatric care in community hospitals in collaboration with specialists. Family medicine in hospitals should be investigated in other settings for better geriatric care and to drive mutual learning among healthcare professionals.

Effect of Medical Fee Schedule Revisions on the Expansion of Nutritional Support Teams in Japan: An Interrupted Time-series Analysis

INTRODUCTION

In 2018, the fee schedule for nutrition support teams (NSTs) in Japanese hospitals was changed. The change was intended to encourage more hospitals to establish NSTs, and this study aims to investigate whether this change had the desired effect. Specifically, we will look at the proportion of hospitals with NSTs before and after the 2018 revision to see if there was a significant increase in the number of hospitals with NSTs.

METHODS

The study analyzed administrative data from 10 Japanese prefectures dating from June 2015 to September 2021 using an interrupted time-series design. The analysis focused on all acute care hospitals within these prefectures and measured the percentage of hospitals with NSTs. Subgroup analyses were conducted based on hospital size and functions. In April 2018, the intervention, a fee schedule revision, was implemented.

RESULTS

We analyzed 1,471 acute care hospitals. Immediately after the intervention, the percentage of hospitals with NSTs increased by 4.59% (95% CI = 3.92%, 5.26%) and by 0.66% (95% CI = 0.57%, 0.75%) quarterly thereafter. We observed a marked increase in NST formation among large-sized (20.9%), medium-sized (28.0%), and highly acute care hospitals (hospitals with emergency medical care centers and intensive care units, 22.3% and 23.6%, respectively). We also noted a moderate increase among hospitals with convalescent rehabilitation units (10.1%) and a modest increase among small-sized hospitals (6.9%).

CONCLUSIONS

Relaxation of the NST fee requirement increased the proportion of hospitals with NSTs in Japan, especially among larger and highly acute care hospitals.

The effects of nutritional support team intervention on postoperative immune function, nutritional statuses, inflammatory responses, clinical outcomes of elderly patients with gastric cancer

Background

To explore the effects of nutrition support team (NST) intervention on elderly patients with gastric cancer (GC).

Methods

The elderly GC patients (tumor stage I/II/III), admitted to our department from January 2015 to September 2021, were retrospectively analyzed and divided into NST group and traditional nutrition (TN) group according to nutritional management methods. The immune, inflammatory, nutrition-related indices, postoperative recovery and long-term prognosis of two groups were analyzed.

Results

A total of 258 elderly GC patients were included (NST group, n = 125; TN group, n = 133). After propensity score matching (PSM) in ratio of 1:1, 73 pairs of patients were matched. There were statistically significant differences in CD3 and CD4 level postoperative one month and IgG level postoperative one week between NST group and TN group (P < 0.05). There was no significant differences in serum CRP and IL-6 levels preoperative one day, postoperative one week and one month between two groups (P > 0.05). There were significant differences in body mass index (BMI) between the two groups postoperative one month (P < 0.05). The rate of infectious complications in TN group was significantly higher than that in NST group (P < 0.05). There was no statistically significant differences in 3-year relapse-free survival (RFS) or 3-year overall survival (OS) between NST group and TN group (P > 0.05).

Conclusions

Compared with TN management, NST intervention might be benefit to the immune function recovery and nutritional status, but there was no evidence that NST could improve the prognosis of elderly GC patients.

ESPEN practical guideline: Home enteral nutrition

This ESPEN practical guideline will inform physicians, nurses, dieticians, pharmacists, caregivers and other home enteral nutrition (HEN) providers in a concise way about the indications and contraindications for HEN, as well as its implementation and monitoring. This guideline will also inform interested patients requiring HEN. Home parenteral nutrition is not included but will be addressed in a separate ESPEN guideline. The guideline is based on the ESPEN scientific guideline published before, which consists of 61 recommendations that have been reproduced and renumbered, along with the associated commentaries that have been shorted compared to the scientific guideline. Evidence grades and consensus levels are indicated. The guideline was commissioned and financially supported by ESPEN and the members of the guideline group were selected by ESPEN.

A pre/post NST intervention study

BACKGROUND

Intensive care unit (ICU) patients are at particular risk for malnutrition with major impact for outcome and prognosis. Nutrition support teams (NST) have been proposed to improve nutrition care in ICU patients.

OBJECTIVE

To assess the effectiveness of an interdisciplinary NST on anthropometry and clinical outcome of ICU patients.

METHODS

Before NST implementation, we assessed 120 patients (before NST group; SAPS II score 44 ± 16), afterwards 60 patients (after NST group), of whom 29 received NST guidance (after NST + group; SAPS II 65 ± 19) and 31 not (after NST - group; SAPS II, 54 ± 16). The primary outcome parameter was length of stay in the hospital (hospital-LOS). Severity of disease was assessed by the APACHE II score and the nutritional risk (NUTRIC) score.

RESULTS

NST intervention resulted in a more pronounced improvement of disease severity (APACHE II, from 27 ± 8 to 18 ± 6, p < 0.001; NUTRIC, from 7 ± 2 to 4 ± 2, p < 0.001) compared to no NST intervention (APACHE II from 24 ± 7 to 21 ± 7, p < 0.05; NUTRIC from 6 ± 2 to 5 ± 2, p < 0.01). The mean hospital-LOS was not reduced, neither in the NST intervention group nor in the control group without NST intervention. NST intervention failed to improve nutritional status or mortality compared to no NST intervention.

CONCLUSION

In our study the NST intervention had a positive effect on disease severity, but failed to improve mortality, hospital-LOS or nutritional status in ICU patients, likely because of a large patient heterogeneity.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT02200874).

Buried bumper syndrome: prevention and management in the community

Percutaneous endoscopic gastrostomy (PEG) is a well-established form of artificial nutrition. Buried bumper syndrome (BBS) is a rare but severe complication related to this type of feeding tube. BBS is described as when the internal bumper migrates into the stoma tract and/or the mucosa, and the inner lining of the stomach starts to grow around and over the internal bumper. It can result in pain, infection and the loss of the feeding tube as a port of entry for delivery of nutrition, hydration and medication into the stomach. When suspected, BBS requires urgent referral into specialist hospital services. It is somewhat preventable with appropriate aftercare; however, incidents do occur. The evidence and guidance on care of PEGs differs, and more data and research are needed into the incidence of BBS and what influences it. Access to appropriate nutrition support teams is essential to support patients and their caregivers with all aspects of enteral feeding.

Hyponatremia is a Prognostic Factor in Patients Receiving Nutrition Support

BACKGROUND

Hyponatremia, the most common electrolyte disorder, has been reported to be related to increased mortality. However, the association between hyponatremia and prognoses remains unclear in patients with nutrition support team (NST) intervention. This study aimed to determine the prevalence of abnormal serum sodium levels, its relation to patient data, and the impact of hyponatremia on prognosis.

METHODS

Patients who received nutrition support at Tokushima University Hospital for the first time and whose serum sodium levels were measured at the start of NST intervention were enrolled. Patients were classified into three groups according to their serum Na levels at the start of NST intervention: hyponatremia group, normonatremia group, and hypernatremia group.

RESULTS

In the hyponatremia group compared to the normonatremia group, body weight and body mass index were significantly lower. C-reactive protein levels and urea nitrogen/creatinine ratios were significantly higher. Meanwhile, there was no significant difference in the estimated glomerular filtration rate among the groups. The prevalence of malnutrition and anemia were the highest in the hyponatremia group. The 3-year survival rate was approximately 45% in the hyponatremia group, which was the lowest of all three groups. The mortality risk ratio of the hyponatremia group to the normonatremia group was 2.29.

CONCLUSIONS

Hyponatremia in NST intervention patients is an independent prognostic predictor. Therefore, adding an assessment of serum sodium at the beginning of NST intervention can identify patients at high risk at an early stage and may improve the quality of NST activity.

Effect of whole-course nutrition management on patients with esophageal cancer undergoing concurrent chemoradiotherapy: A randomized control trial

OBJECTIVES

Malnutrition is the most common complication of patients with esophageal cancer and can lead to poor prognosis and death. Good nutritional status has been shown to help improve patient outcomes and reduce complications. In the absence of specific evidence on the effect of nutrition in patients with esophageal cancer, the purpose of this study was to investigate the effect of whole-course nutrition management on the prognosis and complications of chemoradiotherapy in patients with esophageal cancer through a randomized controlled trial.

METHODS

A total of 96 patients with esophageal cancer treated with concurrent chemoradiation were randomized to an intervention group (treated with whole-course nutrition management from the Nutrition Support Team) and a control group (treated with the general nutritional method) for approximately 6 wk. Dietary surveys and body measurements were conducted at baseline and every day thereafter. Patient-generated Subjective Global Assessment score, blood index, quality of life, and psychological condition were assessed at baseline and every week before discharge. Complications (e.g., radiation esophagitis, myelosuppression, and skin symptoms), completion rates of therapy, short-term efficacy evaluation, as well as clinical outcomes were measured.

RESULTS

A total of 85 patients completed the study (intervention group = 45; control group = 40). There were significant differences in the changes of serum albumin and total protein between the two groups throughout the trial (P < 0.05). Complications (e.g., radioactive esophagitis, skin symptom of complications) and quality of life were statistically different before and after the intervention (P < 0.05). The difference in the change of other indicators was not statistically significant.

CONCLUSIONS

Whole-course nutrition management can improve the nutritional status of patients with esophageal cancer treated with concurrent chemoradiotherapy, reduce the severity of radiation esophagitis and radiation skin reactions, improve the quality of life, and relieve depressive symptoms.

Association Between Risk Factors and Intensive Nutritional Intervention Outcomes in Elderly Individuals

Background

The purpose of this study was to identify risk factors for intensive nutritional intervention outcomes in elderly undernourished patients to help reduce the number of patients with prolonged hospital stay or without recuperation of previous activities of daily living and quality of life.

Methods

In total, 230 patients who received interventions from a nutrition support team (NST) between January 2016 and July 2018 were included. Patients were classified into two groups based on NST intervention outcomes: patients with improved nutritional status were included in the successful group, whereas those whose nutritional status did not improve, as defined by progressive illness or death, were classified into the non-successful group. We assessed patient characteristics, laboratory data, and nutrition support methods.

Results

Our multivariate Cox proportional hazard analysis showed that: 1) The presence of peripheral parenteral nutrition (hazard ratio (HR): 1.80; 95% confidence interval (CI): 1.13 - 2.88) was identified as an independent risk factor for NST intervention outcomes; 2) The energy fill rate to total energy expenditure was < 66.0% (HR: 1.61; 95% CI: 0.98 - 2.66); and 3) A geriatric nutritional risk index score < 70.0 (HR: 1.54; 95% CI: 0.92 - 2.56) tended to be negatively associated with NST intervention outcomes.

Conclusions

In addition to the nutrition therapy provided by a traditional NST, patients with the risk factors require nutritional intervention. Elderly individuals should also receive nutrition care because they have been recuperating at their home or in long-term care facilities, to prevent experiencing adverse conditions.

Apolipoproteins C-II and C-III as nutritional markers unaffected by inflammation

BACKGROUND

Rapid turnover proteins (RTPs), such as transthyretin (TTR), retinol binding protein (RBP), and transferrin (Tf), provide an accurate assessment of nutritional status but are susceptible to inflammation. Lipid-related markers, which have short half-lives in serum, may be better suited for nutritional assessment. We sought to identify sensitive nutritional markers unaffected by inflammation.

METHODS

Fasting serum samples were collected from 30 malnourished inpatients and 25 healthy volunteers. Malnourished inpatients were divided into 2 groups: a low-C-reactive protein (CRP) group (CRP < 20 mg/l, n = 15) and a high-CRP group (CRP ≥ 20 mg/l, n = 15). Lipid-related markers, traditional nutritional markers, RTPs, micronutrients, and ketone bodies were measured and compared among the groups.

RESULTS

Apolipoprotein (Apo)C-II and ApoC-III concentrations were lower in malnourished inpatients than in the control group. There was no significant difference in ApoC-II and ApoC-III between the low- and high-CRP groups. Carnitine transporters and ketone bodies did not show a significant difference among the three groups. Albumin, TTR, RBP, and Tf concentrations were lowest in the high-CRP group, intermediate in the low-CRP group, and highest in the control group.

CONCLUSIONS

These results indicate that ApoC-II and ApoC-III are appropriate nutritional biomarkers unaffected by inflammation.

Assessment of parenteral nutrition prescription in Canadian acute care settings

BACKGROUND

Parenteral nutrition (PN) prescription can be challenging in patients with complex conditions and has potential complications.

OBJECTIVE

To assess PN prescription, monitoring, and PN-related complications in a Canadian acute care setting.

METHODS

This was a prospective cohort study in which patients receiving PN were assessed by an auditor for nutritional status, PN-related prescription, monitoring, and complications. In addition, length of stay and mortality were recorded.

RESULTS

147 patients (mean ± SD 56.1 ± 16.4 y) with complex diseases (Charlson comorbidity index, median [p25-p75] 2 [1-4]) were enrolled. Before starting PN, 18.6%, 63.9%, and 17.5% of patients were classified as subjective global assessment A, B, and C, respectively. Body mass index remained unchanged during the period on PN. On average, 89% and 73% of patients received <90% of their energy and protein requirements, respectively, but 65% received oral or enteral nutrition at some point during PN. The average daily energy provided by PN increased and stabilized on day 10, reaching 87.2 ± 20.1% of the requirements. Line sepsis (6.8% of patients) and hyperglycemia (6.9%) were the most common complications. The overall mortality was 15.6%. For those alive, length of stay was 30 (range: 4-268) d. PN was discontinued because of transitioning to an oral diet (56.6%), enteral nutrition (17.6%), home PN (14.7%), palliative care (5.1%), death (4.4%), or other (1.5%).

CONCLUSION

Most patients were malnourished at the start of PN. Energy and protein provided from PN were less than requirements, and the goals were reached with delay. Mortality was high, possibly as a result of complex diseases.

Pumps, feed and sets: is procurement limiting outcomes?

This article aims to review the unique ways in which enteral feed, ancillary items and pumps are procured in the UK and to evaluate whether these are inhibiting innovation and reducing the choices of patients. There are a number of models that have been developed across the UK for the procurement of enteral feed, feeding accessories and pump. The two most common are the hospital-based nutrition support team, which may have an overarching role in the community, and the home enteral nutrition (HEN) team, a multidisciplinary community-based team with skilled health professionals dedicated to the delivery of the enteral nutrition service. While the HEN service has its advantages over other models in the community, it is primarily driven by its clinical role. The lack of significant opportunity for clinical audits and research within the service limits the prospects for service improvement, innovation and patients' choices.

Nutrition therapy using a multidisciplinary team improves survival rates in patients with liver cirrhosis

OBJECTIVES

Very few reports thus far have clinically elucidated the advantages of a nutrition support team (NST) in the field of liver diseases. The present study retrospectively analyzed whether nutrition therapy for liver cirrhosis (LC), performed by a multidisciplinary team that includes registered dieticians, improves survival rates.

METHODS

In study 1, we compared survival rates between two groups of patients with LC to elucidate the effects of nutrition management by registered dieticians. The first group was comprised of 101 patients that received no dietary counseling from a dietician, and the second group was comprised of 133 patients that received nutritional counseling following nutrition assessment. In study 2, we split the patients who received nutritional counseling in study 1 into two groups and compared their survival rates with the objective of investigating the effects of a multidisciplinary team approach on survival rate. The first group was comprised of 51 patients that, in addition to regular nutritional counseling given by a dietician, regularly attended courses on liver disease given every 3 to 6 mo. The second group was comprised of 82 patients that did not attend the liver-disease courses.

RESULTS

During study 1, 34 patients in the first group and 20 patients in the second group died, representing a significant difference (P < 0.05). This difference was even more pronounced in the subset of patients classified as Child-Pugh class A (P < 0.01), but no differences were seen among patients in classes B and C (P = 0.378). During study 2, four patients in the first group and 15 patients in the second group died, representing a significant difference (P < 0.05).

CONCLUSIONS

This study showed that nutritional intervention using a multidisciplinary team during the treatment of LC improves survival rates and quality of life of the patients.

Nutritional support teams increase percutaneous endoscopic gastrostomy uptake in motor neuron disease

AIM: To examine factors influencing percutaneous endoscopic gastrostomy (PEG) uptake and outcomes in motor neuron disease (MND) in a tertiary care centre.

METHODS: Case notes from all patients with a confirmed diagnosis of MND who had attended the clinic at the Repatriation General Hospital between January 2007 and January 2011 and who had since died, were audited. Data were extracted for demographics (age and gender), disease characteristics (date of onset, bulbar or peripheral predominance, complications), date and nature of discussion of gastrostomy insertion, nutritional status [weight measurements, body mass index (BMI)], date of gastrostomy insertion and subsequent progress (duration of survival) and quality of life (QoL) [Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised (ALSFRS-R)]. In addition, the type of clinician initiating the discussion regarding gastrostomy was recorded as Nutritional Support Team (involved in providing nutrition input viz Gastroenterologist, Speech Pathologist, Dietitian) and other (involved in non-nutritional aspects of patient care). Factors affecting placement and outcomes including length of survival, change in weight and QoL were determined.

RESULTS: Case records were available for all 86 patients (49 men, mean age at diagnosis 66.4 years). Thirty-eight patients had bulbar symptoms and 48 had peripheral disease as their presenting feature. Sixty-six patients reported dysphagia. Thirty-one patients had undergone gastrostomy insertion. The major indications for PEG placement were dysphagia and weight loss. Nine patients required immediate full feeding, whereas 17 patients initially used the gastrostomy to supplement oral intake, 4 for medication administration and 1 for hydration. Initially the PEG regime met 73% ± 31% of the estimated total energy requirements, increasing to 87% ± 32% prior to death. There was stabilization of weight in patients undergoing gastrostomy [BMI at 3 mo (22.6 ± 2.2 kg/m²) and 6 mo (22.5 ± 2.0 kg/m²) after PEG placement compared to weight at the time of the procedure (22.5 ± 3.0 kg/m²)]. However, weight loss recurred in the terminal stages of the illness. There was a strong trend for longer survival from diagnosis among MND in PEG recipients with limb onset presentation compared to similar patients who did not undergo the procedure (P = 0.063). Initial discussions regarding PEG insertion occurred earlier after diagnosis when seen by nutrition support team (NST) clinicians compared to other clinicians. (5.4 ± 7.0 mo vs 11.9 ± 13.4 mo, P = 0.028). There was a significant increase in PEG uptake (56% vs 24%, P = 0.011) if PEG discussions were initiated by the NST staff compared to other clinicians. There was no change in the ALSFRS-R score in patients who underwent PEG (pre 34.1 ± 8.6 vs post 34.8 ± 7.4), although in non-PEG recipients there was a non-significant fall in this score (33.7 ± 7.9 vs 31.6 ± 8.8). Four patients died within one month of the procedure, 4 developed bacterial site infection requiring antibiotics and 1 required endoscopic therapy for gastric bleeding. Less serious complications attributed to the procedure included persistent gastrostomy site discomfort, poor appetite, altered bowel function and bloating.

CONCLUSION: Initial discussion with NST clinicians increases PEG uptake in MND. Gastrostomy stabilizes patient weight but weight loss recurs with advancing disease.