Adaptation of nutritional risk screening tools may better predict response to nutritional treatment: a secondary analysis of the randomized controlled trial Effect of early nutritional therapy on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial (EFFORT)

BACKGROUND

Nutritional screening tools have proven valuable for predicting clinical outcomes but have failed to determine which patients would be most likely to benefit from nourishment interventions. The Nutritional Risk Screening 2002 (NRS) and the Mini Nutritional Assessment (MNA) are 2 of these tools, which are based on both nutritional parameters and parameters reflecting disease severity.

OBJECTIVES

We hypothesized that the adaptation of nutritional risk scores, by removing parameters reflecting disease severity, would improve their predictive value regarding response to a nutritional intervention while providing similar prognostic information regarding mortality at short and long terms.

METHODS

We reanalyzed data of 2028 patients included in the Swiss-wide multicenter, randomized controlled trial EFFORT (Effect of early nutritional therapy on Frailty, Functional Outcomes, and Recovery of malnourished medical inpatients Trial) comparing individualized nutritional support with usual care nutrition in medical inpatients. The primary endpoint was 30-d all-cause mortality.

RESULTS

Although stratifying patients by high compared with low NRS score showed no difference in response to nutritional support, patients with high adapted NRS showed substantial benefit, whereas patients with low adapted NRS showed no survival benefit [adjusted hazard ratio: 0.55 [95% confidence interval (CI): 0.37, 0.80]] compared with 1.17 (95% CI: 0.70, 1.93), a finding that was significant in an interaction analysis [coefficient: 0.48 (95% CI: 0.25, 0.94), P = 0.031]. A similar effect regarding treatment response was found when stratifying patients on the basis of MNA compared with the adapted MNA. Regarding the prognostic performance, both original scores were slightly superior in predicting mortality than the adapted scores.

CONCLUSIONS

Adapting the NRS and MNA by including nutritional parameters only improves their ability to predict response to a nutrition intervention, but slightly reduces their overall prognostic performance. Scores dependent on disease severity may best be considered prognostic scores, whereas nutritional risk scores not including parameters reflecting disease severity may indeed improve a more personalized treatment approach for nourishment interventions. The trial was registered at clinicaltrials.gov as NCT02517476.

Assessment of refeeding syndrome definitions and 30-day mortality in critically ill adults: A comparison study

BACKGROUND

Patients in the intensive care unit (ICU) are at high risk for refeeding syndrome (RFS), yet there is uncertainty regarding how RFS should be operationalized in the ICU. We evaluated different definitions for RFS and tested how they associated with patient-centered outcomes in the ICU.

METHODS

This was a retrospective comparison study. Patients age ≥18 years were eligible if they were newly initiated on enteral feeding while hospitalized in the ICU. Eight definitions for RFS were operationalized, including that from the American Society for Parenteral and Enteral Nutrition (ASPEN), all based on electrolyte levels from immediately before until up to 5 days after the initiation of enteral nutrition. Patients were followed for death or for ICU-free days, a measure of healthcare utilization.

RESULTS

In all, 2123 patients were identified, including 406 (19.1%) who died within 30 days of ICU admission and 1717 (80.9%) who did not. Prevalence of RFS varied from 1.5% to 88% (ASPEN definition) depending on the RFS definition used. The excess risk for death associated with RFS varied from 33% to 92% across definitions. The development of RFS based on the ASPEN definition was associated with a greater decrease in ICU-free days compared with other definitions, but the relationship was not statistically significant.

CONCLUSION

Eight definitions for RFS were evaluated, none of which showed strong associations with death or ICU-free days. It may be challenging to achieve a standardized definition for RFS that is based on electrolyte values and predicts mortality or ICU-free days.

Exploring the lived experience of renal cachexia for individuals with end-stage renal disease and the interrelated experience of their carers: Study protocol

Renal cachexia is an important consideration in the person-centred care that is needed in end-stage renal disease (ESRD). However, given that clinical guidelines relating to renal cachexia are largely absent, this is an unmet care need. To inform guidelines and future renal service planning, there is an urgency to understand individuals’ experiences of renal cachexia and the interrelated experiences of the carers in their lives. We report here the protocol for an interpretative phenomenological study which will explore this lived experience. A purposive sampling strategy will recruit individuals living with ESRD who have cachexia and their carers. A maximum of 30 participants (15 per group) dependent on saturation will be recruited across two nephrology directorates, within two healthcare trusts in the United Kingdom. Individuals with renal cachexia undergoing haemodialysis will be recruited via clinical gatekeepers and their carers will subsequently be invited to participate in the study. Participants will be offered the opportunity to have a face-to-face, virtual or telephone interview. Interviews will be audio-recorded, transcribed verbatim and analysed using interpretative phenomenological analysis. NVivo, will be used for data management. Ethical approval for this study was granted by the Office for Research Ethics Committees Northern Ireland (REC Reference: 22/NI/0107). Scientific evidence tends to focus on measurable psychological, social and quality of life outcomes but there is limited research providing in-depth meaning and understanding of the views of individuals with renal disease who are experiencing renal cachexia. This information is urgently needed to better prepare healthcare providers and in turn support individuals with ESRD and their carers. This study will help healthcare providers understand what challenges individuals with ESRD, and their carers face in relation to cachexia and aims to inform future clinical practice guidelines and develop supportive interventions which recognise and respond to the needs of this population.

Evaluation of the ASPEN guidelines for refeeding syndrome among hospitalized patients receiving enteral nutrition: A retrospective cohort study

BACKGROUND

Until recently, refeeding syndrome (RFS) has lacked standardized diagnostic criteria. This study sought to (1) determine whether RFS, as operationalized in the 2020 American Society for Parenteral and Enteral Nutrition (ASPEN) guideline definition, is associated with adverse clinical outcomes and (2) identify key risk factors for RFS.

METHODS

In this retrospective cohort study, adults hospitalized from 2015 to 2019 were included if they were ordered for enteral feeding during hospitalization. Data were collected for up to 30 days, and RFS was operationalized as per the ASPEN 2020 guidelines as a ≥10% (corresponding to mild RFS), ≥25% (moderate), and ≥50% (severe) decline in prefeeding serum phosphorus, magnesium, or potassium. The mortality associated with RFS was assessed, and risk factors for RFS were identified using multivariable logistic regression modeling.

RESULTS

Of 3854 participants, 3480 (90%) developed mild RFS. Thirty-day mortality was higher in those without mild RFS (24%) than in those with mild RFS (18%) (P < 0.01). When RFS was reoperationalized as a 50% decline in electrolytes, 25% of patients developed RFS with a 20% 30-day mortality. Risk factors for development of RFS included renal failure, elevated creatinine, and low platelets; additionally, prefeeding serum phosphorus level was strongly associated with development of RFS (adjusted odds ratio, 6.09; 95% confidence interval, 4.95-7.49 for those in the highest tertile of prefeeding phosphorus compared with the lowest).

CONCLUSION

The ASPEN operationalization of RFS as a decline in baseline electrolyte values was not associated with death. Prefeeding serum phosphorus level strongly predicted severe RFS.

A Qualitative Systematic Review of Risk Factors for Refeeding Syndrome

Objectives

Refeeding syndrome (RFS) is characterized by potentially fatal electrolyte shifts after resumption of feeding following a period of prolonged starvation. The lack of a standardized definition has made the study of RFS difficult. Early identification of patients at risk of RFS may prevent life-threatening complications and improve outcomes. However, the sensitivity of reported risk factors depends on the definition used, and many have never been validated. This study was designed to identify risks for RFS that have been identified in prior studies. It is preparatory for a larger analysis to better identify sensitive and specific risk factors for RFS.

Methods

This is a qualitative systematic review of observational studies following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies reporting the incidence of RFS were included. Risk factors were extracted whether identified in review or as a measured exposure. Risk factors were considered distinct if they were not described similarly (e.g., BMI, admit BMI, nadir BMI, BMI < 16, BMI < 18.5 were each treated as distinct).

Results

Risk factors were reviewed or studied in 43 of 49 studies that met inclusion criteria. A total of 129 distinct risk factor definitions were extracted. Of these, only 29 used definitions similar enough to other studies to be considered the same by the reviewers (range 2 to 8 studies per risk factor; median 3 studies). NICE guidelines were mentioned in 3 studies. No other published guidelines were found.

Conclusions

Creating a risk profile for patients may help tailor interventions to prevent RFS. There was a large heterogeneous number of risk factors and numerous discrepancies in description of risk factors among the studies. The low incidence of inclusion of poor intake (i.e., less than 100%) in the identified studies was of interest. Next steps will include prospective validation of identified risks, as well as AI analyses to identify and validate other risk factors and biomarkers, with the goal to develop sensitive and specific risk assessments, and effective preventive and treatment protocols.

Funding Sources

None.

Preliminary Analysis for Development of AI to Identify Hospitalized Patients for Whom Nourishment Will Provide Benefit

Objectives

A diagnosis of malnutrition is strongly associated with poorer hospital outcomes. However, no current definition of malnutrition identifies, with adequate sensitivity, patients who will respond to nutrition interventions. This retrospective cohort study is preparatory to development of machine learning artificial intelligence (AI), applied to a large study population, to find characteristics that will better identify patients who are likely to respond to nutrition support (i.e., those truly malnourished).

Methods

Electronic medical record (EMR) data for all hospital inpatients admitted at Columbia University Irving Medical Center between January 1, 2016 to February 1, 2020 was extracted from the clinical data warehouse. Those diagnosed with malnutrition, based on dietitians’ nutrition diagnosis notes, were identified. Data analyzed for this study were time to diagnosis (TTD) of malnutrition (i.e., time from admission until diagnosis note entered), hospital length-of-stay (LOS), and discharge disposition (e.g., home, nursing facility, hospice, or in-hospital mortality), as recorded in the EMR.

Results

Data were extracted for 299,689 patients. A total of 24,944 patients were diagnosed with malnutrition. There was significant correlation between TTD and LOS (correlation coefficient 0.549; P < 0.001). Using a machine learning predictive model, there was a weak correlation between TTD and discharge disposition.

Conclusions

This analysis is an initial step in our development of a novel algorithm to predict response to nutrition intervention, using machine learning AI in a large cohort. We have demonstrated our ability to extract and analyze data from the cohort. Next steps will include further analyses and development of algorithms, toward development of models to predict response to nutritional interventions in hospital inpatients.

Funding Sources

None.

Management of disease-related malnutrition for patients being treated in hospital

Disease-related malnutrition in adult patients who have been admitted to hospital is a syndrome associated with substantially increased morbidity, disability, short-term and long-term mortality, impaired recovery from illness, and cost of care. There is uncertainty regarding optimal diagnostic criteria, definitions for malnutrition, and how to identify patients who would benefit from nutritional intervention. Malnutrition has become the focus of research aimed at translating current knowledge of its pathophysiology into improved diagnosis and treatment. Researchers are particularly interested in developing nutritional interventions that reverse the negative effects of disease-related malnutrition in the hospital setting. High-quality randomised trials have provided evidence that nutritional therapy can reduce morbidity and other complications associated with malnutrition in some patients. Screening of patients for risk of malnutrition at hospital admission, followed by nutritional assessment and individualised nutritional interventions for malnourished patients, should become part of routine clinical care and multimodal treatment in hospitals worldwide.

Dietary Sodium Restriction for Heart Failure: A Systematic Review of Intervention Outcomes and Behavioral Determinants

The 1500 mg/d dietary sodium restriction commonly recommended for patients with heart failure has recently been questioned. Poor adherence to sodium-restricted diets makes assessing the efficacy of sodium restriction challenging. Therefore, successful behavioral interventions are needed. We reviewed sodium restriction trials and descriptive studies of sodium restriction to: 1) determine if sodium restriction was achieved in interventions among heart failure patients; and 2) characterize predictors of successful dietary sodium restriction. Among 638 identified studies, 10 intervention trials, and 25 descriptive studies met inclusion criteria. We used content analysis to extract information about sodium restriction and behavioral determinants of sodium restriction. Dietary sodium was reduced in 7 trials; none achieved 1500 mg/d (range 1938-4564 mg/d). The interventions implemented in the interventional trials emphasized knowledge, skills, and self-regulation strategies, but few addressed the determinants correlated with successful sodium restriction in the descriptive studies (eg, social/cultural norms, social support, taste preferences, food access, self-efficacy). Findings suggest that incorporating determinants predictive of successful dietary sodium restriction may improve the success of interventional trials. Without effective interventions to deploy in trials, the safety and efficacy of sodium restriction remains unknown.

Age Predicts Whether Tube-fed Patients Will Require Tube Feeding on Discharge: Results of a Pilot Toward Developing a Predictive Model

Objectives

There is currently no model to predict the need for long-term tube-feeding. A predictive model may reduce unnecessary feeding tube placement. This study is a pilot effort toward developing a model to predict whether patients need tube feeding on hospital discharge.

Methods

All adult patients with tube feeding orders at any time during their hospitalization at the New York Presbyterian, Milstein Hospital during the period January 1st, 2018 to December 31st,2018 were evaluated. A student t-test was performed on the difference in average age between the subjects receiving tube feeding at discharge and the subjects discharged without tube feeding.

Results

The mean age of the subjects requiring tube feeding at discharge (66.2 ± 18 years) is 2.6 years higher than that in the group without tube feeding at discharge (63.6 + 17.2 years, P = 0. 0014). The distribution of age in both groups is left-skewed. The age of the subjects requiring tube feeding at discharge is fairly more dispersed compared the age of subjects without tube feeding at discharge.

Conclusions

We found that age is significantly higher in subjects requiring tube feeding at discharge. The actual difference in age is small, and its contribution to predicting tube feeding is unknown. The next step toward building a predictive model will be to apply appropriate regression analysis to assess the predictive value of 10 preliminarily identified to determine how and whether they predict which subjects need tube feeding at discharge. These are age, sex, insurance status, race, smoking status, BMI, head or neck cancer, tracheotomy, stroke severity, and dysphasia severity.

Funding Sources

None.

Behavioral Risk Factors for Acute and Chronic Disease-Related Malnutrition

Objectives

To determine the association between mental health and substance use and the risk of developing malnutrition.

Methods

Mental health, substance abuse, and malnutrition were defined by ICD-10 codes. Diseases were classified as either acute or chronic based on the Beta Chronic Condition Indicator for ICD-10 codes. Age, sex, race, primary language, marital status, Medicaid status, cigarette use, and median household were taken from the EMR. No patients were identified with pure SRM. Cases were matched by disease status. Conditional logistic regression was used to determine odds ratio and 95% confidence intervals. Pearson chi-square test was used to assess the demographic differences between malnutrition categories.

Results

We analyzed 2356 matched pairs for CDRM and 1935 for ADRM. ADRM was associated with age, race, and primary language (all P &lt; 0.004), while CDRM was associated with race, primary language, Medicaid, and median household income (all P-value &lt; 0.037). For both ADRM and CDRM, a mental health diagnoses was associated with increased odds of malnutrition (OR: 1.370, CI: 1.169, 1.605) and (OR: 1.484, CI: 1.296, 1.700) respectively, while substance use was not associated with either sub-category of malnutrition. Among ADRM, a mental health diagnosis was associated with being 80 years and older (OR: 1.313, CI: 1.031, 1.672), Asian and Pacific Islander (OR: 1.472, CI: 1.030, 2.105) and Hispanic (OR: 2.404, CI: 1.707, 3.385) compared to White, female (OR: 0.863, CI: 0.755, 0.985), widowed (OR: 0.768, CI: 0.615, 0.959) compared to single, and being on Medicaid (0.860, CI: 0.756, 0.978). Among CDRM, a mental health diagnosis was associated with being Hispanic (OR: 2.911, CI: 2.098, 4.040), primary language being Spanish (OR: 2.771, CI: 1.112, 1.644), married and/or life partner (OR: 0.851, CI: 0.752, 0.964) and widowed (OR: 0.780, CI: 0.635, 0.958) compared to single, and on Medicaid (OR: 0.817, 0.733, 0.910).

Conclusions

This study provides the first known assessment of the relationship between mental health, substance abuse, and malnutrition diagnosed based on the AND/ASPEN guidelines. Only a mental health diagnosis, but not substance use, was associated with the development of both ADRM and CDRM. Future research with a larger sample size is needed to better understand these effects.

Funding Sources

None.

Sarcoma Does Not Predict Malnutrition in Cancer Patients: A Retrospective Cohort Study

Objectives

The association between inflammation, malnutrition, and cancer is not well understood. The aim of this study was to examine the association between inflammatory-type cancer and diagnosed malnutrition, albumin level, and age in patients with cancer.

Methods

Malnutrition and cancer diagnoses were obtained using data from hospital medical records in patients admitted for cancer between Oct. 2017 and Dec. 2018. Demographics, as well as the first and lowest albumin levels were also obtained. A simple t-test is processed between age and malnutrition status. Also a chi-square test of independence was performed to examine the relation between malnutrition and hypoalbuminemia status. Logistic regression was conducted between malnutrition status, sarcoma cancer, age, and hypoalbuminemia.

Results

The study included 4034 patients (2084 males, 1949 females). Approximately 4% of the patients were diagnosed with malnutrition. Logistic regression on malnutrition status, sarcoma, age, and hypoalbuminemia showed a significant association on global test (3, 2433, P-value = 0.013). Hypoalbuminemia (&lt; 3.9 g/dL lower-limit) was significantly associated with malnutrition (X2 1, 2433 P-value = 0.0156). Sarcoma diagnosis was not significantly associated with malnutrition (X2 1, 2433 P-value = 0.267). Age is not significantly related to malnutrition status (X2 1, 2433 p-value = 0.449). A t-test was also performed malnutrition vs no malnutrition on age, resulting in a marginally significant association for malnutrition group (M = 65.33, SD = 15.50) vs no malnutrition group (M = 67.32, SD = 17.55) (t(1) = 3.7212, P = 0.0537).

Conclusions

Sarcoma is not significantly associated with an increased risk of malnutrition. Cancer patients with hypoalbuminemia have a higher risk for malnutrition compared to the patients with normal albumin level. Additionally, age may be a predictor for cancer patients’ risk of in-hospital malnutrition.

Funding Sources

None.

Utility of Phase Angle to Identify Cachexia and Assess Mortality in End-Stage Renal Disease

Objectives

This cross-sectional analysis sought to identify cachexia and assess survival using phase angle (PA) in patients with end-stage renal disease (ESRD) receiving haemodialysis.

Methods

Patients receiving haemodialysis (n = 87, mean age 65.9 +/− 13.0) completed a Phase Angle (PA; 50 khz) measurement using bioelectrical impedance analysis. Cachexia variables were recorded according to Evans et al. definition (2008) including nutritional and functional measures (weight, Body Mass Index (BMI), Hand Grip Strength (HGS), Lean Tissue Mass (LTM), C-Reative Protein (CRP), serum albumin, haemoglobin, appetite (Functional Assessment of Anorexia/Cachexia Treatment (FAACT)) and fatigue (Functional Assessment of Chronic Illness Therapy (FACIT)). Survival was assessed at 12 months. Mann Whitney-U and Spearman correlation coefficient were conducted.

Results

The majority of patients completed follow up (n = 76). Eleven patients had died. Mean PA was not statistically different between those identified as cachectic and non-cachectic according to Evans et al. (2008) definition or between those patients that survived and died. However, patients that survived had better mean scores of weight, BMI, HGS, CRP, serum albumin and fatigue (FACIT). In addition, LTM scores were significantly better in patients that survived (P &lt; .01). Appetite scores were also significantly better in patients that survived (P &lt; .01) and those without cachexia (P = .01).

Conclusions

This study was part of a larger effort to clarity a phenotype of cachexia in ESRD. Unlike previous research, this study did not find PA useful in identifying patients at a higher risk of cachexia or death. However overall these patients had a very low mean PA. FAACT did discriminate between groups indicating self-reporting measurement tools of nutritional status were useful in identifying patients at a higher risk of cachexia and death. A larger sample and longer follow up is required to balance the limitations of this small study. Timing the administration of PA also requires consideration in future studies.

Funding Sources

Public Health Agency; Northern Ireland Kidney Research Fund.

The Effect of Malnutrition on Outcomes in Patients with Heart-Failure: A Retrospective Cohort Pilot Study

Objectives

Current retrospective studies on incidence rates for malnutrition, heart failure, and outcomes are limited in that they do not control for confounding factors, and are relatively small. We undertook a retrospective cohort study to elucidate the association between malnutrition and hospital length-of-stay (LOS), mortality and discharge destination in inpatients with heart failure.

Methods

Data was obtained from the electronic patient medical records (EMR) for inpatients at Columbia University Irving Medical Center admitted with primary diagnosis of heart failure between January 1st 2018 to December 31st 2018. A two-sided t-test was conducted between two groups of heart failure patients with and without malnutrition on outcomes of mortality, LOS and discharge destination.

Results

For N = 5598 inpatients, the median age is 74 years old, with 2567 females (45.86%) and 3031 males (54.14%). Overall mortality rate was 6.25% with 350 heart failure deceased patients. After being discharged, there were 2037 (36.39%) patients went home directly and 3211 (57.36%) patients went to some kind of rehabilitation institutions. There was a significant association in mortality in heart failure with malnutrition compared to those without malnutrition (13.98% vs 4.61%, relative risk (RR): 2.4368, P &lt; 0.001). There was a significant association for LOS in heart failure with malnutrition, compared to those without malnutrition (11 days vs 5 days, RR: 2.2, P &lt; 0.001). There was a significant association for discharge destination in heart failure with malnutrition, compared to those without malnutrition (18.27% home vs 42.75% home, RR: 1.43, P &lt; 0.001).

Conclusions

Patients with heart failure and malnutrition are at higher risk for mortality, increased LOS at the hospital and increase chance of discharging to a rehabilitation institution. Continued study of this population will include the impact of confounders such as socioeconomic status and comorbid conditions, and additional outcomes such as repeated hospitalizations.

Funding Sources

None.

Relationship Between Dietary Fiber Intake and Short-Chain Fatty Acid-Producing Bacteria During Critical Illness: A Prospective Cohort Study

BACKGROUND

Dietary fiber increases short-chain fatty acid (SCFA)-producing bacteria yet is often withheld in the intensive care unit (ICU). This study evaluated the safety and effect of fiber in ICU patients with gut microbiome sampling.

METHODS

This was a retrospective study nested within a prospective cohort. Adults were included if newly admitted to the ICU and could receive oral nutrition, enteral feedings, or no nutrition. Rectal swabs were performed at admission and 72 hours later. The primary exposure was fiber intake over 72 hours, classified in tertiles and adjusted for energy intake. The primary outcome was the relative abundance (RA) of SCFA producers via 16S RNA sequencing and the tolerability of fiber.

RESULTS

In 129 patients, median fiber intake was 13.4 g (interquartile range 0-35.4 g) over 72 hours. The high-fiber group had less abdominal distension (11% high fiber vs 28% no fiber, P < .01) and no increase in diarrhea (15% high fiber vs 13% no fiber, P = .94) or other adverse events. The median RA of SCFA producers after 72 hours was 0.40%, 0.50%, and 1.8% for the no-, low-, and high-fiber groups (P = .05 for trend). After correcting for energy intake, the median RA of SCFA producers was 0.41%, 0.32%, and 2.35% in the no-, low-, and high-corrected-fiber categories (P < .01). These associations remained significant after adjusting for clinical factors including antibiotics.

CONCLUSIONS

During the 72 hours after ICU admission, fiber was well tolerated, and higher fiber intake was associated with more SCFA-producers.

Characterizing the Clinical Impact of Refeeding Syndrome: Serum Phosphorus Decrement Does Not Impact Length of Stay (P12-038-19)

Objectives

Refeeding syndrome is characterized by rapid and severe hypokalemia, hypophosphatemia, hypomagnesemia, and/or Wernicke's encephalitis occurring subsequent to reintroduction of calories, usually after prolonged starvation. These electrolyte decrements may lead to complications such as organ failure and death, which should be prevented with effective monitoring and supplementation. However, there is poor agreement on the definition of refeeding syndrome, limited understanding of its risk factors, and, unsurprisingly, poorly described patient outcomes. This pilot evaluation is part of an ongoing study seeking to better define the syndrome and elucidate predictive factors enabling preventive and treatment strategies and develop clear guidelines.

Methods

A retrospective case-control study was performed at New York Presbyterian Hospital with inpatients admitted during 2015–2017. Patients with low levels of potassium, phosphorus, and/or magnesium within 3 days of the introduction of any oral, enteral, or parenteral source of calories were included. Type of diet and supplementation, demographics, nutritional history including weight change and intake, as well as comorbid conditions and medications, particularly those likely to cause alterations in electrolyte balance, as well as outcomes such as length of stay (LOS) and mortality were also noted for each admission.

Results

Nearly 48,000 unique qualifying admissions were identified and verified with random quality checks. Preliminary results demonstrate a significant positive relationship between the degree of initial low magnesium or potassium level, but not with phosphorus, and length of stay. Magnesium values in the lowest third of low values had mean LOS 7.1, vs 6.3 days in those with highest levels (OR 1.18; 1.09–1.29). Low potassium values, by lowest to highest quartile, were associated with mean LOS of 7.0, 6.2, 6.1 days, vs. 4.7 days in those with the highest levels (OR 1.57 (1.47–1.68); 1.37 (1.28–1.45); 1.29 (1.21–1.37)).

Conclusions

Despite identification in the literature of phosphorus as the prime component of refeeding syndrome, low levels had no impact on LOS, unlike magnesium and potassium. Next steps include comparison against a matched control group to identify factors that may increase refeeding syndrome risk.

Funding Sources

None.

Interventions for Dietary Sodium Restriction Among Patients with Heart Failure: A Mismatch in the Evidence and Intervention Design (OR22-05-19)

Objectives

Dietary sodium restriction guidelines are controversial due to a lack of studies assessing their effect on heart failure outcomes. An important aspect of this problem is the effectiveness of behavioral nutrition interventions to reduce patients’ sodium intake. We systematically reviewed randomized controlled trials (RCTs) of sodium restricted diets and descriptive studies relating mediators of behavior to successful adherence to sodium restricted diets in patients with heart failure.

Methods

We queried PubMed, CINAHL, and Cochrane databases with relevant search terms for studies published in English January 2000-December 2018. Included were RCTs of interventions for heart failure patients, with sodium restriction as a primary or secondary outcome, and quantitative and qualitative descriptive studies of adherence to sodium restricted diets. Included studies may or may not have reported clinical outcomes (health events, quality of life, etc.). Reviewers noted setting, methods, and outcomes as well as theoretical mediators of dietary behavior change in included studies. We then compared behavioral mediators addressed by the RCTs and behavioral mediators identified in the descriptive studies.

Results

Of 638 studies identified, 445 were excluded by title. 2 reviewers assessed 60 abstracts and included 36 studies in this analysis: 10 RCTs and 26 descriptive studies. 6 of 10 intervention RCTs were successful, but no interventions achieved the recommended 1500 mg/day sodium intake (mean for all studies 3271 mg/day). Interventions that reduced sodium intake were behaviorally focused, were delivered by an RN and/or RD, and included individual feedback and counseling. RCTs intervened only through knowledge, skills, and social support. Behavioral mediators identified in descriptive studies included perceived risk, perceived benefits, outcome expectations, cultural norms, social norms, social support, taste preferences, determinism, self-efficacy, knowledge, skills, and habits. These were not included in the RCTs, which signifies a mismatch between evidence-based moderators of behavior and intervention designs.

Conclusions

RCTs have been unable to achieve the recommended goal of 1500 mg/day of sodium. More effective interventions should consider evidence-based mediators, rather than focusing on knowledge and skills.

Funding Sources

Dr. Burgermaster received funding from NHLBI T32 training grant.

Identifying Malnutrition in End-stage Renal Disease (ESRD) (P12-037-19)

Objectives

Malnutrition and appetite disturbances, such as anorexia, are commonly reported amongst hemodialysis patients. Nutrition management is a complex issue in ESRD and greater understanding is needed into the associated clinical mediators in ESRD. However, there is currently limited data on anorexia and the pathophysiology framework involved.

The aim of this study was to assess the relationship between appetite score and associated clinical biomarkers as a means to identify malnutrition. This work is part of an ongoing international multicenter effort to better define and develop treatment strategies for cachexia in patients with ESRD.

Methods

A cross-sectional analysis study included 106 patients from two hemodialysis (HD) units within the United Kingdom (U.K). Appetite score was assessed using the Functional Assessment of Anorexia/Cachexia Therapy (FAACT). Clinical bio-makers included Body Mass Index (BMI), Albumin and C-reactive protein (CRP). Correlations between FAACT and clinical bio-markers were determined using Spearman's rho for non-normally distributed scales.

Results

There was no significant relationship between FAACT and albumin levels (r = 0.14; P = 0.16) or BMI (r = 0.28; P = .19). However, there was a moderate and significant negative correlation between FAACT and CRP levels (r = 0.31; P < 0.001) indicating an inverse relationship between appetite (e.g., decreased FAACT score) and CRP levels (e.g., higher inflammation).

Conclusions

We found a significant and incremental relationship between inflammation and anorexia which is supported by previous research. The FAACT may be a useful tool in identifying patients at higher risk of malnutrition-inflammation cachexia syndrome which has been associated with higher hospitalization and morality rates. Nutritional status and inflammation are important aspects of clinical practice in ESRD. A more focused approach to anorexia in ESRD is warranted.

Funding Sources

This study was funded by the Public Health Agency (Ref: STL/5179/15) and the Northern Ireland Kidney Research Fund. Noble et al., was funded by the National Institute for Health Research and the Health and Social Care Research and Development Division of the Public Health Agency Office Northern Ireland NIHR (CDV/4872/13).

A Novel Meta-Analytic Approach with Applications to Nutrition Research: A Comprehensive Analysis of Sodium Restriction (OR06-05-19)

Objectives

Since the application of meta-analysis to biomedical research, the breadth of evidence covered in published meta-analyses has diminished. Despite the imperative of literature reviews to present “state of the art” knowledge, current meta-analyses are confined to pooling only select evidence. Imposing a priori criteria on scientific evidence results in biased and myopic conclusions. These current practices, in addition to the vastness of the literature base, ensure that research evidence remains opaque, and unusable to guide research and clinical practice. For example, whether and how much dietary sodium should be restricted for healthy or at-risk populations remains controversial. New epidemiological data suggest a striking increase in mortality with sodium intake <3 g/day, confounding this discussion. Thus, a system enabling investigators to access, review, and interpret all evidence is needed.

Methods

MedAware Systems, Inc. is a platform that continuously identifies, extracts and organizes medical research data from multiple repositories. A blinded, cross-validated data extraction process, using artificial intelligence, guides two research scientists to process each study with near 100% accuracy. Intelligent software compares each data field for matches, prompting a senior scientist to review and reconcile any mismatched data fields. Over 200 methodological and clinical parameters are coded and organized, supporting comprehensive meta-analytic reviews of any medical topic.

We demonstrate this innovative technology by addressing the effects of dietary sodium intake. We identify and analyze the complete domain of studies pertaining to sodium intake and cardiovascular outcomes.

Results

To date, 368 studies have been identified. Initial review of patients, interventions, and outcomes data show extreme heterogeneity of this literature domain. This confirms the need for comprehensive evidence review, data extraction, and pooling.

Conclusions

Sodium intake literature is vast and difficult to interpret. We introduce a comprehensive process to analyze thousands of studies that traditional approaches cannot match. Our database and meta-analytic methodology profile the domain of evidence, summarizing the diversity and efficacy of sodium restriction recommendations.

Funding Sources

MedAware Systems, Inc.

Serum glutamine and hospital-acquired infections after aneurysmal subarachnoid hemorrhage

OBJECTIVE

To understand nutritional and inflammatory factors contributing to serum glutamine levels and their relationship to hospital-acquired infections (HAIs) after aneurysmal subarachnoid hemorrhage (SAH).

METHODS

A prospective observational study of patients with SAH who had measurements of daily caloric intake and C-reactive protein, transthyretin, tumor necrosis factor α receptor 1a (TNFαR1a), glutamine, and nitrogen balance performed within 4 preset time periods during the 14 days after SAH. Factors associated with glutamine levels and HAIs were analyzed with multivariable regression. HAIs were tracked daily for time-to-event analyses. Outcome 3 months after SAH was assessed by the Telephone Interview for Cognitive Status and modified Rankin Scale.

RESULTS

There were 77 patients with an average age of 55 ± 15 years. HAIs developed in 18 (23%) on mean SAH day 8 ± 3. In a multivariable linear regression model, negative nitrogen balance (p = 0.02) and elevated TNFαR1a (p = 0.04) were independently associated with higher glutamine levels during the study period. The 14-day mean glutamine levels were lower in patients who developed HAI (166 ± 110 vs 236 ± 81 μg/mL, p = 0.004). Poor admission Hunt and Hess grade (p = 0.04) and lower glutamine levels (p = 0.02) predicted time to first HAI. Low 14-day mean levels of glutamine were associated with a poor recovery on the Telephone Interview for Cognitive Status score (p = 0.03) and modified Rankin Scale score (p = 0.04) at 3 months after injury.

CONCLUSIONS

Declining glutamine levels in the first 14 days after SAH are influenced by inflammation and associated with an increased risk of HAI.

2005 American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Standards and Guidelines Survey

An online survey about the use and format of the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Standards and Guidelines documents was conducted. The survey was sent to A.S.P.E.N. members, and an acceptable number of responses were received (470, or 9% of those surveyed). Most respondents indicated an overall satisfaction with the standards and guidelines and suggested format changes, many of which will be incorporated into future guidelines and standards. The results of this survey are presented here for general interest. Changes in the process with which A.S.P.E.N. produces standards and guidelines are discussed.

Obesity, Diet, and Exercise Education for the Primary Care Clerkship Using an Articulate Storyline 2 e-Learning Module

INTRODUCTION

Despite high obesity rates nationwide, many medical schools provide insufficient nutrition education. It has been difficult to deliver nutrition education in the Columbia University College of Physicians and Surgeons primary care clerkship given its numerous clinical sites offering varied expertise. We supplemented the clerkship curriculum with an interactive e-learning module designed to provide medical students with knowledge and skills in nutrition and weight management, as well as an understanding of registered dietitians' role. The module was created using Articulate Storyline 2 software and emphasizes active learning and simulated clinical decision-making.

METHODS

Learning objectives and a curriculum were developed based on a literature review, a student focus group, and the guidance of a multidisciplinary committee. The module integrates narrated content with interactive exercises and utilizes multiple teaching styles. Participants were third-year medical students in the primary care clerkship during January-May 2016 (n = 64). Students completed a web-based evaluation survey after the module.

RESULTS

Ninety-two percent of students completed the module in 2 hours or less. Ninety-seven percent agreed that the module was easy to navigate, and 93% agreed that it contributed to their understanding of the topic. Qualitatively, students generally responded positively to the module's active learning component and its use of multiple teaching styles.

DISCUSSION

This web-based interactive learning module is an accessible tool that allows educators to simultaneously deliver information and target clinical reasoning skills. Active learning facilitates students' engagement with the content. This module is easily adaptable for other learners, including physicians and patients, and other areas of the curriculum.

A Prospective Randomized Trial of the Effects of Early Enteral Feeding After Radical Cystectomy

OBJECTIVE

To investigate the role of early feeding on recovery after radical cystectomy and urinary diversion. Enhanced recovery protocols have helped to standardize postoperative recovery. This is the first study to directly review the impact of early feeding on recovery in a randomized multi-institutional protocol.

METHODS

From 2011 to 2014, patients at 2 large hospitals were randomized after radical cystectomy to receive access to liquids and then a regular diet on postoperative days 1 and 2 or conventional care with introduction of a liquid diet after return of bowel activity, typically days 3-5. Early ambulation, use of metoclopramide, and no nasogastric tube were standard for all patients. The study was powered to detect a 50% decrease in 90-day complication rate with secondary end points of length of stay, time to bowel activity, and time to diet tolerance. The study was terminated early due to slow accrual (102 of 328).

RESULTS

Overall complications for the early vs standard groups were similar (34 vs 31, P = .86). Immediate inpatient and postdischarge complication rates were also similar (P = .63 and P = .44). Length of stay was not different (8.74 days vs 9.69 days, P = .43). Rates of ileus (27% vs 41%, P = .21) and return of bowel function (4.67 days vs 4.09 days, P = .62) were the same in arms.

CONCLUSION

Although this prospective randomized study did not meet the accrual target, early introduction of diet was well tolerated and did not show a negative or positive difference in any outcomes. Enhanced recovery protocols standardize postoperative care and early feeding is a well-tolerated addition.

Supplementation of l-Alanyl-l-Glutamine and Fish Oil Improves Body Composition and Quality of Life in Patients With Chronic Heart Failure

BACKGROUND

Skeletal muscle dysfunction and exercise intolerance are clinical hallmarks of patients with heart failure. These have been linked to a progressive catabolic state, skeletal muscle inflammation, and impaired oxidative metabolism. Previous studies suggest beneficial effects of ω-3 polyunsaturated fatty acids and glutamine on exercise performance and muscle protein balance.

METHODS AND RESULTS

In a randomized double-blind, placebo-controlled trial, 31 patients with heart failure were randomized to either l-alanyl-l-glutamine (8 g/d) and polyunsaturated fatty acid (6.5 g/d) or placebo (safflower oil and milk powder) for 3 months. Cardiopulmonary exercise testing, dual-energy x-ray absorptiometry, 6-minute walk test, hand grip strength, functional muscle testing, echocardiography, and quality of life and lateral quadriceps muscle biopsy were performed at baseline and at follow-up. Oxidative capacity and metabolic gene expression were analyzed on muscle biopsies. No differences in muscle function, echocardiography, 6-minute walk test, or hand grip strength and a nonsignificant increase in peak VO2 in the treatment group were found. Lean body mass increased and quality of life improved in the active treatment group. Molecular analysis revealed no differences in muscle fiber composition, fiber cross-sectional area, gene expression of metabolic marker genes (PGC1α, CPT1, PDK4, and GLUT4), and skeletal muscle oxidative capacity.

CONCLUSIONS

The combined supplementation of l-alanyl-l-glutamine and polyunsaturated fatty acid did not improve exercise performance or muscle function but increased lean body mass and quality of life in patients with chronic stable heart failure. These findings suggest potentially beneficial effects of high-dose nutritional polyunsaturated fatty acids and amino acid supplementations in patients with chronic stable heart failure.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01534663.

Inflammation, negative nitrogen balance, and outcome after aneurysmal subarachnoid hemorrhage

OBJECTIVE

To analyze the impact of inflammation and negative nitrogen balance (NBAL) on nutritional status and outcomes after subarachnoid hemorrhage (SAH).

METHODS

This was a prospective observational study of SAH patients admitted between May 2008 and June 2012. Measurements of C-reactive protein (CRP), transthyretin (TTR), resting energy expenditure (REE), and NBAL (g/day) were performed over 4 preset time periods during the first 14 postbleed days (PBD) in addition to daily caloric intake. Factors associated with REE and NBAL were analyzed with multivariable linear regression. Hospital-acquired infections (HAI) were tracked daily for time-to-event analyses. Poor outcome at 3 months was defined as a modified Rankin Scale score ≥ 4 and assessed by multivariable logistic regression.

RESULTS

There were 229 patients with an average age of 55 ± 15 years. Higher REE was associated with younger age (p = 0.02), male sex (p < 0.001), higher Hunt Hess grade (p = 0.001), and higher modified Fisher score (p = 0.01). Negative NBAL was associated with lower caloric intake (p < 0.001), higher body mass index (p < 0.001), aneurysm clipping (p = 0.03), and higher CRP:TTR ratio (p = 0.03). HAIs developed in 53 (23%) patients on mean PBD 8 ± 3. Older age (p = 0.002), higher Hunt Hess (p < 0.001), lower caloric intake (p = 0.001), and negative NBAL (p = 0.04) predicted time to first HAI. Poor outcome at 3 months was associated with higher Hunt Hess grade (p < 0.001), older age (p < 0.001), negative NBAL (p = 0.01), HAI (p = 0.03), higher CRP:TTR ratio (p = 0.04), higher body mass index (p = 0.03), and delayed cerebral ischemia (p = 0.04).

CONCLUSIONS

Negative NBAL after SAH is influenced by inflammation and associated with an increased risk of HAI and poor outcome. Underfeeding and systemic inflammation are potential modifiable risk factors for negative NBAL and poor outcome after SAH.

Free Fatty acids and delayed cerebral ischemia after subarachnoid hemorrhage

BACKGROUND AND PURPOSE

The purpose of this study was to understand factors related to increases in serum free fatty acid (FFA) levels and association with delayed cerebral ischemia (DCI) after subarachnoid hemorrhage.

METHODS

We performed serial measurement of systemic oxygen consumption by indirect calorimetry and FFA levels by liquid chromatography/mass spectrometry in the first 14 days after ictus in 50 consecutive patients with subarachnoid hemorrhage. Multivariable generalized estimating equation models identified associations with FFA levels in the first 14 days after SAH and Cox proportional hazards model used to identified associations with time to DCI.

RESULTS

There were 187 measurements in 50 patients with subarachnoid hemorrhage (mean age, 56±14 years old; 66% women) with a median Hunt-Hess score of 3. Adjusting for Hunt-Hess grade and daily caloric intake, n-6 and n-3 FFA levels were both associated with oxygen consumption and the modified Fisher score. Fourteen (28%) patients developed DCI on median postbleed Day 7. The modified Fisher score (P=0.01), mean n-6:n-3 FFA ratio (P=0.02), and mean oxygen consumption level (P=0.04) were higher in patients who developed DCI. In a Cox proportional hazards model, the mean n-6:n-3 FFA ratio (P<0.001), younger age (P=0.05), and modified Fisher scale (P=0.004) were associated with time to DCI.

CONCLUSIONS

Injury severity and oxygen consumption hypermetabolism are associated with higher n-FFA levels and an increased n-6:n-3 FFA ratio is associated with DCI. This may indicate a role for interventions that modulate both oxygen consumption and FFA levels to reduce the occurrence of DCI.

Relationship between C-reactive protein, systemic oxygen consumption, and delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage

BACKGROUND AND PURPOSE

Subarachnoid hemorrhage (SAH) is known to result in elevated systemic oxygen consumption (Vo(2)) and increases in high-sensitivity C-reactive protein (hsCRP), although the relationship among hsCRP, Vo(2), and delayed cerebral ischemia (DCI) after SAH remains unknown. We hypothesized that hsCRP is directly associated with Vo(2) and that elevated Vo(2) is a predictor of DCI after SAH.

METHODS

Prospective serial assessments of Vo(2) and hsCRP over 4 prespecified time periods during the first 14 days after bleed in consecutive SAH patients admitted to a single academic medical center for a 2-year period.

RESULTS

One hundred ten SAH patients met study criteria (mean age, 55±16 years; 62% women), with a median admission Hunt Hess grade of 3 (interquartile range, 2-4). In multivariate generalized estimating equation model of the first 14 days after bleed, Vo(2) was associated with younger age (P=0.01), male gender (P=0.01), and hsCRP levels (P=0.03). Twenty-four (22%) patients had DCI develop, with a median onset on day 7 after bleed (interquartile range, 5-11). The mean Vo(2) (291±65 mL/min versus 226±55 mL/min; P=0.003) was higher in DCI patients. In a multivariable Cox proportional hazards model, younger age (hazard ratio, 1.2 per 5 years; 95% CI, 1.1-1.3), a higher modified Fisher scale score (hazard ratio, 3.4 per 1-point increase; 95% CI, 1.7-6.9), and higher Vo(2) (HR, 1.2 per 50-mL/min increase; 95% CI, 1.1-1.3) were predictive of DCI.

CONCLUSIONS

Systemic oxygen consumption is associated with hsCRP levels in the first 14 days after SAH and is an independent predictor of DCI.

Parenteral Nutrition Safe Practices: Results of the 2003 American Society for Parenteral and Enteral Nutrition Survey*

BACKGROUND

The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) recently published a revision of its "Safe Practices for Parenteral Nutrition" guidelines. Because there is a paucity of published scientific evidence to support good practices related to ordering, compounding, and administering parenteral nutrition (PN), a survey was performed in the process of the revision to gain insight into the discrepancies between reported practices and previous guidelines.

METHODS

A web-based survey consisting of 45 questions was conducted (n = 651) June 1-30, 2003. Respondents were queried about primary practice setting, professional background, processes for writing PN orders, computer order entry of PN orders, problems with PN orders, and adverse events related to PN.

RESULTS

There were 651 survey responses, 90% of which were from hospital-based practitioners. Almost 75% of responders processed between 0 and 20 PN orders per day. Overall, physicians (78%) were responsible for writing PN orders, but dietitians and pharmacists had significant involvement. PN base components were most often ordered as percentage final concentration after admixture (eg, 20% dextrose), which is inconsistent with safe practice guidelines of ordering by total amount per day (eg, 200 g/day). There was no consistent method for ordering PN electrolytes. Approximately 45% of responders reported adverse events directly related to PN that required intervention. Of these events, 25% caused temporary or permanent harm, and 4.8% resulted in a near-death event or death.

CONCLUSIONS

Although the survey found consistency in PN practices for many areas queried, significant variation exists in the manner by which PN is ordered and labeled.