Patients' and caregivers' perspective on challenges and outcomes with tube feeding: Analysis of home enteral nutrition survey data

BACKGROUND

Given the growing use of home enteral nutrition (HEN), assessing the experience of consumers and caregivers is crucial to understanding the real-world subjective and objective challenges of administering HEN.

METHODS

After obtaining institutional review board approval, a survey was distributed to HEN consumers and caregivers between January 16, 2020, and July 16, 2021. Data collected included information regarding demographics, primary diagnosis, tube and connectors, HEN regimen, and overall HEN experience.

RESULTS

A total of 884 individuals responded to the survey: 673 (76.1%) responses by caregivers and 211 (23.9%) responses by patients. The study cohort included 566 (64%) children and 318 (36%) adults. The leading primary diagnosis of participants was developmental delay and motility disorder for children and adults, respectively. Low-profile gastric tubes were the most used (75.7% of children and 30.3% of adults). Notably, legacy connectors were utilized for more patients (46.7% children, 52.6% adults) compared to ISO-80369-3 connectors (38.9% children, 29.7% adults). HEN complications were prevalent, including enteral tube site infections and other tube-related complications, including clogging and kinking.

CONCLUSION

This real-world data reveals that HEN complications remain prevalent. Additionally, despite introducing ISO-80369-3 connectors many years ago, most patients continue to use legacy tubes with a significant lack of knowledge about ISO-80369-3 connectors. The survey results guide HEN providers to focus on several areas to reduce complications.

Enteral Nutrition Therapy: Historical Perspective, Utilization, and Complications

PURPOSE OF REVIEW

Enteral nutrition (EN) therapy can provide vital nutrition support for patients with various medical conditions as long as it is indicated and supported by ethical reasoning. This review seeks to offer a detailed account of the history of EN development, highlighting key milestones and recent advances in the field. Additionally, it covers common complications associated with EN and their management.

RECENT FINDINGS

After years of research and development, we have reached newer generations of enteral feeding formulations, more options for enteral tubes and connectors, and a better understanding of EN therapy challenges. Given the availability of many different formulas, selecting a feeding formula with the best evidence for specific indications for enteral feeding is recommended. Initiation of enteral feeding with standard polymeric formula remains the standard of care. Transition to small-bore connectors remains suboptimal. Evidence-based practices should be followed to recognize and reduce possible enteral feeding complications early.

Outpatient treatment with concomitant vaccine-boosted convalescent plasma for patients with immunosuppression and COVID-19

Although severe coronavirus disease 2019 (COVID-19) and hospitalization associated with COVID-19 are generally preventable among healthy vaccine recipients, patients with immunosuppression have poor immunogenic responses to COVID-19 vaccines and remain at high risk of infection with SARS-CoV-2 and hospitalization. In addition, monoclonal antibody therapy is limited by the emergence of novel SARS-CoV-2 variants that have serially escaped neutralization. In this context, there is interest in understanding the clinical benefit associated with COVID-19 convalescent plasma collected from persons who have been both naturally infected with SARS-CoV-2 and vaccinated against SARS-CoV-2 ("vax-plasma"). Thus, we report the clinical outcome of 386 immunocompromised outpatients who were diagnosed with COVID-19 and who received contemporary COVID-19-specific therapeutics (standard-of-care group) and a subgroup who also received concomitant treatment with very high titer COVID-19 convalescent plasma (vax-plasma group) with a specific focus on hospitalization rates. The overall hospitalization rate was 2.2% (5 of 225 patients) in the vax-plasma group and 6.2% (10 of 161 patients) in the standard-of-care group, which corresponded to a relative risk reduction of 65% (P = 0.046). Evidence of efficacy in nonvaccinated patients cannot be inferred from these data because 94% (361 of 386 patients) of patients were vaccinated. In vaccinated patients with immunosuppression and COVID-19, the addition of vax-plasma or very high titer COVID-19 convalescent plasma to COVID-19-specific therapies reduced the risk of disease progression leading to hospitalization.IMPORTANCEAs SARS-CoV-2 evolves, new variants of concern (VOCs) have emerged that evade available anti-spike monoclonal antibodies, particularly among immunosuppressed patients. However, high-titer COVID-19 convalescent plasma continues to be effective against VOCs because of its broad-spectrum immunomodulatory properties. Thus, we report clinical outcomes of 386 immunocompromised outpatients who were treated with COVID-19-specific therapeutics and a subgroup also treated with vaccine-boosted convalescent plasma. We found that the administration of vaccine-boosted convalescent plasma was associated with a significantly decreased incidence of hospitalization among immunocompromised COVID-19 outpatients. Our data add to the contemporary data providing evidence to support the clinical utility of high-titer convalescent plasma as antibody replacement therapy in immunocompromised patients.

Establishing healthy longevity clinics in publicly funded hospitals

Healthy longevity medicine integrates geroscience and other disciplines into clinical settings, aiming to optimize health throughout one's lifespan. Multiple factors have led to increased consumer engagement, with private clinics currently meeting the demand for guidance to improve healthy longevity. The establishment of healthy longevity clinics in publicly funded hospitals is a significant development, making longevity-focused healthcare more accessible. These clinics rely on multidisciplinary teams of physicians and allied health professionals. Diagnostics involve comprehensive evaluations of medical history, physical examinations, and various clinical tests to detect early signs of age-related functional decline. Interventions in healthy longevity medicine encompass lifestyle modifications, supplements, repurposed drugs, and social and environmental interventions. Collaboration with research institutions and industry partners is crucial for advancing healthy longevity medicine and creating standardized protocols. In this article, we review the process of creating healthy longevity clinics in public hospitals to ensure the best possible care for individuals pursuing healthy longevity.

Symptom presentation by phenotype of postural orthostatic tachycardia syndrome

Postural orthostatic tachycardia syndrome (POTS) presents heterogeneously and is diagnosed when appropriate symptoms are present in conjunction with a heart rate increase of at least 30 beats-per-minute upon standing without orthostatic hypotension. Much of the current understanding of POTS is based on clinical expertise, particularly regarding POTS phenotypes and their potential role in targeting pharmacologic treatment. This study describes the symptom presentation of POTS by phenotypes at a subspecialty POTS clinic. Data was collected prospectively during clinical visits between April 17, 2014 and February 8, 2021. This data was abstracted retrospectively by chart review. Most of the 378 study participants were female (89.9%) with a mean age 23.0 ± 4.9 years. Lightheadedness was the most common (97.6%) symptom and the most disruptive of quality of life (29.9%). Patients reported substantial functional impairment across multiple life domains, with 3.0 ± 2.8 days lost and 4.7 ± 2.3 unproductive days per week. There were no differences in symptom presentation among POTS phenotypes. POTS phenotypes are not distinguishable based on symptoms alone; if phenotyping is sought, testing is necessary. Further research is needed in better classifying POTS phenotypes with the potential goal of tailoring treatment.

Rates Among Hospitalized Patients With COVID-19 Treated With Convalescent Plasma: A Systematic Review and Meta-Analysis

Objective

To examine the association of COVID-19 convalescent plasma transfusion with mortality and the differences between subgroups in hospitalized patients with COVID-19.

Patients and Methods

On October 26, 2022, a systematic search was performed for clinical studies of COVID-19 convalescent plasma in the literature from January 1, 2020, to October 26, 2022. Randomized clinical trials and matched cohort studies investigating COVID-19 convalescent plasma transfusion compared with standard of care treatment or placebo among hospitalized patients with confirmed COVID-19 were included. The electronic search yielded 3841 unique records, of which 744 were considered for full-text screening. The selection process was performed independently by a panel of 5 reviewers. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data were extracted by 5 independent reviewers in duplicate and pooled using an inverse-variance random effects model. The prespecified end point was all-cause mortality during hospitalization.

Results

Thirty-nine randomized clinical trials enrolling 21,529 participants and 70 matched cohort studies enrolling 50,160 participants were included in the systematic review. Separate meta-analyses reported that transfusion of COVID-19 convalescent plasma was associated with a decrease in mortality compared with the control cohort for both randomized clinical trials (odds ratio [OR], 0.87; 95% CI, 0.76-1.00) and matched cohort studies (OR, 0.76; 95% CI, 0.66-0.88). The meta-analysis of subgroups revealed 2 important findings. First, treatment with convalescent plasma containing high antibody levels was associated with a decrease in mortality compared with convalescent plasma containing low antibody levels (OR, 0.85; 95% CI, 0.73 to 0.99). Second, earlier treatment with COVID-19 convalescent plasma was associated with a decrease in mortality compared with the later treatment cohort (OR, 0.63; 95% CI, 0.48 to 0.82).

Conclusion

During COVID-19 convalescent plasma use was associated with a 13% reduced risk of mortality, implying a mortality benefit for hospitalized patients with COVID-19, particularly those treated with convalescent plasma containing high antibody levels treated earlier in the disease course.

Post-COVID Conditions

Postinfectious syndromes have been described since the Spanish influenza pandemic of 1918. A similar syndrome-post-COVID condition (PCC)-is common; it occurs months after COVID-19 infection and involves fatigue, postexertional malaise, dyspnea, memory loss, diffuse pain, and orthostasis. The medical, psychosocial, and economic impact of PCC is immense. In the United States, PCC has caused widespread unemployment and billions in lost wages. Risk factors for development of PCC are female sex and severity of acute COVID-19 infection. Proposed pathophysiologic mechanisms include central nervous system inflammation, viral reservoirs, persistent spike protein, cell receptor dysregulation, and autoimmunity. Because presenting symptoms are often vague, the approach to evaluation should be comprehensive with consideration of other diseases that could masquerade as PCC. Treatments of PCC are little researched, are largely expert based, and are likely to evolve as more evidence emerges. Current therapies, which are symptom targeted, include medications and nonpharmacologic therapies such as optimizing fluid intake, compression garments, progressive activity, meditation, biofeedback, cognitive rehabilitation, and addressing concomitant mood disorders. Many patients will enjoy significant improvements in their quality of life with multimodal treatments and longitudinal care.

Inflammatory Arthritis After COVID-19: A Case Series

BACKGROUND Some patients who have recovered from acute infection with SARS-CoV-2 develop persistent symptoms that have been termed post-COVID syndrome (PoCoS). PoCoS can affect the musculoskeletal system, with arthralgia and myalgia being common. Preliminary evidence suggests that PoCoS is an immune-mediated condition that not only predisposes but also precipitates pre-existing inflammatory joint diseases such as rheumatoid arthritis and reactive arthritis. Here, we describe a series of patients who presented to our Post-COVID Clinic and were found to have inflammatory arthritis (reactive and rheumatoid arthritis). CASE REPORT We present 5 patients who developed joint pain several weeks after recovery from acute SARS-CoV-2 infection. These patients were seen in our Post-COVID Clinic and came from locations across the United States. All 5 patients were women, with age of diagnosis of COVID-19 disease between 19 and 61 years (mean 37.8 years). All patients presented with joint pain as the primary concern to the Post-COVID Clinic. Abnormal joint imaging was present in all patients. Treatments varied and included non-steroidal anti-inflammatory drugs, acetaminophen, corticosteroids, immunomodulators (golimumab), methotrexate, leflunomide, and hydroxychloroquine. CONCLUSIONS COVID-19 disease is a potential cause of inflammatory arthritis, with both rheumatoid arthritis and reactive arthritis demonstrated in our PoCoS population. Care must be taken to identify these conditions, as there are treatment ramifications.

Development of a Visit Facilitator Role to Assist Physicians in an Ambulatory Consultative Medical Practice

Objective

To decrease the electronic health record (EHR) clerical burden and improve patient/clinician satisfaction, allied health staff were trained as visit facilitators (VFs) to assist the physician in clinical and administrative tasks.

Patients and Methods

From December 7, 2020, to October 11, 2021, patients with complex medical conditions were evaluated by an internal medicine physician in an outpatient general internal medicine (GIM) consultative practice at a tertiary care institution. A VF assisted with specific tasks before, during, and after the clinical visit. Presurvey and postsurvey assessments were performed to understand the effect of the VF on clinical tasks as perceived by the physician.

Results

A total of 57 GIM physicians used a VF, and 41 (82%) physicians and 39 (79%) physicians completed the pre-VF and post-VF surveys, respectively. Physicians reported a significant reduction in time reviewing outside materials, updating pertinent information, and creating/modifying EHR orders (P<.05). Clinicians reported improved interactions with patients and on-time completion of clinical documentation. In the pre-VF survey, "too much time spent" was the most common response for reviewing outside material, placing/modifying orders, completing documentation/clinical notes, resolving in-baskets, completing dismissal letters, and completing tasks outside of work hours. In the post-VF survey, "too much time spent" was not the most common answer to any question. Satisfaction improved in all areas (P<.05).

Conclusion

VFs significantly reduced the EHR clinical burden and improved GIM physician practice satisfaction. This model can potentially be used in a wide range of medical practices.

Peptide-based formula: Clinical applications and benefits

The use of enteral nutrition (EN) continues to increase given benefits. However, with this increase in use, it is also becoming evident that enteral feeding intolerance (EFI) is also quite prevalent, leading to the inability to meet nutrition needs in many patients. Given the wide variability in the EN population as well as the number of formulas available, there is not a clear consensus regarding the best approach to EFI management. One approach that is emerging to improve EN tolerance is the use of peptide-based formulas (PBFs). PBFs refer to enteral formulas containing proteins that have been enzymatically hydrolyzed to dipeptides and tripeptides. These hydrolyzed proteins are often combined with higher medium-chain triglyceride content to generate an enteral formula that is essentially easier to absorb and utilize. Emerging data demonstrate that the use of PBF in patients with EFI may improve clinical outcomes along with a corresponding reduction in healthcare utilization and potentially the cost of care. This review aims to navigate through key clinical applications and benefits of PBF and to discuss relevant data shared in the literature.

Estradiol and Dihydrotestosterone Levels in COVID-19 Patients

OBJECTIVE

To determine differences in plasma sex hormone levels in male and female coronavirus disease 2019 (COVID-19) patients and healthy volunteers (HVs) because cell entry of severe acute respiratory syndrome coronavirus 2 occurs via the angiotensin-converting enzyme 2 receptor which is downregulated by 17β-estradiol.

PATIENTS AND METHODS

Citrated plasma samples were collected from 101 patients with COVID-19 upon presentation to the emergency department and from 40 HVs between November 1, 2020, and May 30, 2021. Plasma 17β-estradiol and 5α-dihydrotestosterone (DHT) levels were measured using enzyme-linked immunosorbent assay (pg/mL). Data are presented as median and quartiles (IQR). Wilcoxon rank sum test with a P value less than .05 was considered significant.

RESULTS

Patients with COVID-19 (median age, 49 years) included 51 males and 50 females (25 postmenopausal). Hospital admission was required for 58.8% of male patients (n = 30) and 48.0% of female patients (n = 24) (66.7% postmenopausal, n = 16) Healthy volunteers (median age, 41 years) included 20 males and 20 females (9 postmenopausal). Female patients with COVID-19 were found to have decreased 17β-estradiol levels (18.5 [IQR, 10.5-32.3] pg/mL; 41.4 [IQR, 15.5-111.0] pg/mL, P=.025), and lower 17β-estradiol to DHT ratios (0.073 [IQR, 0.052-0.159] pg/mL; 0.207 [IQR, 0.104-0.538] pg/mL, P=.015) than female HVs. Male patients with COVID-19 were found to have decreased DHT levels (302.8 [IQR, 249.9-470.8] pg/mL; 457.2 [IQR, 368.7-844.3] pg/mL, P=.005), compared with male HVs. Levels of DHT did not differ between female patients with COVID-19 and female HVs, whereas 17β-estradiol levels did not differ between male patients with COVID-19 and male HVs.

CONCLUSION

Sex hormone levels differ between patients with COVID-19 and HVs, with sex-specific patterns of hypogonadism in males and females. These alterations may be associated with disease development and severity.

Home Enteral Nutrition: A Descriptive Study

BACKGROUND

With data demonstrating benefit, the prevalence of Home Enteral Nutrition (HEN) has increased significantly over the last few decades. Despite this increase, there remains a paucity of data regarding real-world use of HEN including clinical outcomes and complications.

METHODS

Descriptive analysis of the prospectively maintained database of our specialized HEN program was undertaken. Patients who received care in our program with HEN initiation date between January 1st, 2018, and December 31st, 2020, were included in the analysis. Data regarding demographic information, anthropometrics, EN regimen, electrolytes, and nutrition therapy history were included and tracked until July 31st, 2021.

RESULTS

During the study period, 1600 patients were initiated on HEN under our care. Majority of study population needed EN therapy due to malignancy and its complications including malignant dysphagia or mechanical obstruction (60.6%) followed by neuro-degenerative diseases (7.5%). By the end of study period, majority of patients (82%) had their HEN stopped. Of these, close to half (44.2%) achieved EN goals and/or oral autonomy. Patients stayed on HEN for median of 100 (IQR 32-301) days. Overall, 53.2% of patients experienced/reported at least one HEN related complication that was addressed and clinically managed by the HEN team. Complications included tube-related, enteral feeding intolerance (EFI), and electrolyte shifts.

CONCLUSION

In our study population, HEN was most utilized to manage malignancy related complications including dysphagia. Unfortunately, complications including EFI and tube related complications remained quite prevalent. Further evaluation regarding risk factors for complications and preventive mechanisms such as increased education is indicated. This article is protected by copyright. All rights reserved.

Management of long-term home parenteral nutrition: Historical perspective, common complications, and patient education and training

Intestinal failure (IF) is a rare disease that requires ongoing intravenous supplementation to sustain growth and health. Advancements in parenteral nutrition (PN) and central venous access in the 1960s and 1970s transformed a life-limiting disease to a chronic one in which patients are able to administer hydration, electrolytes, micronutrients, and macronutrients in the comfort of their home. However, despite ongoing advancements in the field of home PN (HPN), complications-whether related to central venous catheters or PN itself-remain common and can be associated with significant morbidity and mortality. Central venous access can be associated with thrombosis, central line-associated bloodstream infection, or damage and can result in loss of access over time. PN can be associated with IF-associated liver disease or hyperglycemia. The key to preserving central venous access and quality of life and maintaining health for patients with chronic IF (CIF) is education focused on prevention and prompt management of CIF complications as they arise. This education typically takes place at the time of initiation of HPN, either in the hospital setting or in the patient's home. The present manuscript describes the historical progression of HPN, prevalence and characteristics of CIF, and an in-depth discussion of the most common catheter-related and PN-related complications and their management, along with a discussion of our education and training process.

Expanding repertoire of SARS-CoV-2 deletion mutations contributes to evolution of highly transmissible variants

The emergence of highly transmissible SARS-CoV-2 variants and vaccine breakthrough infections globally mandated the characterization of the immuno-evasive features of SARS-CoV-2. Here, we systematically analyzed 2.13 million SARS-CoV-2 genomes from 188 countries/territories (up to June 2021) and performed whole-genome viral sequencing from 102 COVID-19 patients, including 43 vaccine breakthrough infections. We identified 92 Spike protein mutations that increased in prevalence during at least one surge in SARS-CoV-2 test positivity in any country over a 3-month window. Deletions in the Spike protein N-terminal domain were highly enriched for these 'surge-associated mutations' (Odds Ratio = 14.19, 95% CI 6.15-32.75, p value = 3.41 × 10-10). Based on a longitudinal analysis of mutational prevalence globally, we found an expanding repertoire of Spike protein deletions proximal to an antigenic supersite in the N-terminal domain that may be one of the key contributors to the evolution of highly transmissible variants. Finally, we generated clinically annotated SARS-CoV-2 whole genome sequences from 102 patients and identified 107 unique mutations, including 78 substitutions and 29 deletions. In five patients, we identified distinct deletions between residues 85-90, which reside within a linear B cell epitope. Deletions in this region arose contemporaneously on a diverse background of variants across the globe since December 2020. Overall, our findings based on genomic-epidemiology and clinical surveillance suggest that the genomic deletion of dispensable antigenic regions in SARS-CoV-2 may contribute to the evasion of immune responses and the evolution of highly transmissible variants.

Mindfulness Using a Wearable Brain Sensing Device for Health Care Professionals During a Pandemic: A Pilot Program

OBJECTIVE

The purpose of this feasibility pilot study was to evaluate safety and adherence of a wearable brain sensing wellness device designed to reduce stress among healthcare professionals (HCP).

METHODS

A total of 40 HCP were invited to participate in an open-label pilot study. Participants were asked to use a brain sensing wearable device (MUSE-S™) on a daily basis to reduce their stress, for a total of 90 days. Total study participation duration was 180 days. Study enrollment began in August 2021 and ended December 2021. The exploratory outcomes included stress, depression, sleep, burn-out, resilience, quality of life, and cognition.

RESULTS

Among the 40 HCP in study, the majority were female (85%), white (87.5%) and with an average age of 41.3 ± 11.0 years (SD). Participants used the wearable device an average of 23.8 times over a 30-day period with a mean duration of 5.8 min with each use. Study results demonstrate the positive impact of guided mindfulness using the wearable device MUSE-S™ and its accompanying application (APP). A statistically significant improvement was found for a reduction in stress (P < .001) and improvement in resilience (P = .02), quality of life (P = .003), and cognition (P < .001). The majority (91.9%) of the participants indicated they felt more relaxed after using the device, and 73% indicated they would continue to use this device at end-of-study. No adverse effects were reported.

CONCLUSION

Study results show that 3 to 10 min of guided meditation during work hours through the use of a brain sensing wearable device is safe and acceptable, with associated health benefits for HCP.

Severe acute infection and chronic pulmonary disease are risk factors for developing post-COVID-19 conditions

Post-COVID-19 conditions, also known as "long COVID", has significantly impacted the lives of many individuals, but the risk factors for this condition are poorly understood. In this study, we performed a retrospective EHR analysis of 89,843 individuals at a multi-state health system in the United States with PCR-confirmed COVID-19, including 1,086 patients diagnosed with long COVID and 1,086 matched controls not diagnosed with long COVID. For these two cohorts, we evaluated a wide range of clinical covariates, including laboratory tests, medication orders, phenotypes recorded in the clinical notes, and outcomes. We found that chronic pulmonary disease (CPD) was significantly more common as a pre-existing condition for the long COVID cohort than the control cohort (odds ratio: 1.9, 95% CI: [1.5, 2.6]). Additionally, long-COVID patients were more likely to have a history of migraine (odds ratio: 2.2, 95% CI: [1.6, 3.1]) and fibromyalgia (odds ratio: 2.3, 95% CI: [1.3, 3.8]). During the acute infection phase, the following lab measurements were abnormal in the long COVID cohort: high triglycerides (meanlongCOVID: 278.5 mg/dL vs. meancontrol: 141.4 mg/dL), low HDL cholesterol levels (meanlongCOVID: 38.4 mg/dL vs. meancontrol: 52.5 mg/dL), and high neutrophil-lymphocyte ratio (meanlongCOVID: 10.7 vs. meancontrol: 7.2). The hospitalization rate during the acute infection phase was also higher in the long COVID cohort compared to the control cohort (ratelongCOVID: 5% vs. ratecontrol: 1%). Overall, this study suggests that the severity of acute infection and a history of CPD, migraine, CFS, or fibromyalgia may be risk factors for long COVID symptoms. Our findings motivate clinical studies to evaluate whether suppressing acute disease severity proactively, especially in patients at high risk, can reduce incidence of long COVID.

Dietitian Involvement Improves Consumption of Oral Nutrition Supplements in Hospitalized Patients

Hospitalized patients are at an increased risk of malnutrition due to multiple factors including, but not limited to, acute and chronic diseases especially those affecting gastrointestinal tract, surgery, appetite, and frequent nil per os while undergoing diagnostic workup. Because of this, guidelines suggest the use of oral nutritional supplements (ONS) in hospitalized patients to reduce the risk of malnutrition and its complications. The current report aims to highlights key findings from a cross-sectional survey of 99 hospitalized patients who were at risk for or diagnosed with malnutrition and prescribed ONS. Data regarding ONS prescriber information as well as number ordered and consumed were collected. Of the 2.4 ± 1.5 supplements ordered per person each day, only 1.3 ± 1.1 were consumed, and there was 48% wastage of prescribed ONS. However, dietitian involvement was associated with significant reduction in wastage. Given the need and benefit, it is imperative for the nutrition community to further explore best practices to improve ONS consumption.

Postacute Sequelae of SARS-CoV-2 Infection-Lessons Learned From a Coordinated Health System Response

Objective

To outline a consensus-designed process for triaging and managing patients with post-coronavirus disease (COVID-19) syndrome at Mayo Clinic.

Patients and Methods

We convened a central multidisciplinary team including members from the departments of general internal medicine, occupational medicine, physical medicine and rehabilitation, psychology, allergy and immunology, infectious disease, pulmonology, neurology, cardiology, and pediatrics and otorhinolaryngology with membership from all Mayo Clinic sites in Arizona, Florida, Iowa, Minnesota, and Wisconsin.

Results

Consensus recommendations were made for the best practice guidelines on triaging and managing patients. Several innovations were agreed upon, including a postacute sequelae of COVID-19-specific appointment request form for data collection, a bioregistry, a biorepository, and a postacute sequelae of COVID-19-specific treatment program.

Conclusion

Given that each clinical site had individual clinical practices, these recommendations were implemented using different models, which may provide broad applicability to other clinical settings.

Usability of a Novel Enteral Feeding System: A Summative Study

Background

Utilization of long-term home enteral nutrition (HEN) for nutrition therapy is increasing across the world. However, HEN can be a mobility-limiting experience affecting quality of life (QoL). Improvement of QoL for patients receiving HEN is a universal goal within the nutrition community. This study evaluated usability of Mobility+^®, a novel enteral feeding system (EFS).

Methods

A summative study evaluating usability of the novel EFS was conducted with novices (NV), non-novices (NN), and healthcare professionals (HCP). Subjects in NV and NN groups received familiarization training where they were introduced to the novel EFS and walked through steps to fill pouch, simulate feeding, flush (rinse), and wear the system, using the Instructions for Use (IFU) booklet, followed by a testing session where they simulated system use on their own. HCP self-trained using the IFU and instructional videos. A fill from ready-to-hang (RTH) formula bag method was also tested in HCP. Participants’ ability to loosely coil the tubing and sit, stand, and move around wearing a filled feeding pouch inside a crossbody bag was also evaluated.

Results

Forty-five participants completed the study. All participants successfully and safely simulated use of the novel EFS, with 97.8% (44/45) doing so on first attempt. All participants could wear the novel EFS in crossbody bag and move around without any use errors or safety issues.

Conclusion

The examined novel EFS can be safely used in intended use population, with or without previous experience with enteral nutrition, on provision of basic familiarization training and written IFU. Additionally, HCP can successfully self-train on this system with instructional videos.

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Stress Resilience Program for Health Care Professionals During a Pandemic: A Pilot Program

BACKGROUND

The COVID-19 pandemic has led to increased burnout and staff turnover for health care providers (HCPs). The purpose of this pilot study was to evaluate the safety and acceptability of a Stress Resilience Program (SRP) for reducing perceived stress and improving resilience among HCPs during a pandemic.

METHOD

Of the 12 HCPs expressing interest in the study, 10 were enrolled in this study. Participants attended three in-person visits (consent/screen, baseline, and end-of-study). The SRP consisted of education related to resilience enhancement and a breathing device (BreatherFit®) for combined respiratory muscle training (cRMT). Participants completed 4 weeks of cRMT and applied situational breathing strategies as needed. Outcomes measured were changes in stress (PSS-10), resilience (BRS), depression (PRIME-MD), and sleep (PSQI and Ōura Ring®).

FINDINGS

The majority of participants were male (60%) and White (60%) with an average age of 39.7 years. Changes from baseline to end-of-treatment indicated a positive trend with significant stress reduction (-3.2 ± 3.9, p = .028) and nonsignificant depression reduction (-0.5 ± 0.7, p = .05). Resilience was high at baseline and continued to stay high during the study with a nonsignificant increase at end-of-study (+0.07 ± 0.7, p = .77). No changes in overall sleep scores were noted. All participants agreed the study was worthwhile, 80% indicated they would repeat the experience, while 90% indicated they would recommend the study to others.

CONCLUSION/APPLICATION TO PRACTICE

Because of its size and portability, SRP is an easily applicable and promising option for reducing stress among HCPs during a high-stress period, such as a pandemic. Larger studies are needed.

Post-COVID-19 syndrome: persistent neuroimaging changes and symptoms 9 months after initial infection

A previously healthy and active middle-aged woman acquired COVID-19 as an occupational exposure with subsequent persistent post-COVID-19 symptoms including headache, dyspnoea on exertion, chest pressure, tachycardia, anosmia, parosmia, persistent myalgia, vertigo, cognitive decline and fatigue. She presented to a tertiary medical centre for further evaluation after 9 months of persistent symptoms and had a largely unremarkable workup with the exception of a persistently elevated monocyte chemoattractant protein 1, blunted cardiovagal response and non-specific scattered areas of low-level hypometabolism at the bilateral frontal, left precuneus, occipital and parietal regions on PET scan.

The Female-Predominant Persistent Immune Dysregulation of the Post-COVID Syndrome

OBJECTIVE

To describe the clinical data from the first 108 patients seen in the Mayo Clinic post-COVID-19 care clinic (PCOCC).

METHODS

After Institutional Review Board approval, we reviewed the charts of the first 108 patients seen between January 19, 2021, and April 29, 2021, in the PCOCC and abstracted from the electronic medical record into a standardized database to facilitate analysis. Patients were grouped into phenotypes by expert review.

RESULTS

Most of the patients seen in our clinic were female (75%; 81/108), and the median age at presentation was 46 years (interquartile range, 37 to 55 years). All had post-acute sequelae of SARS-CoV-2 infection, with 6 clinical phenotypes being identified: fatigue predominant (n=69), dyspnea predominant (n=23), myalgia predominant (n=6), orthostasis predominant (n=6), chest pain predominant (n=3), and headache predominant (n=1). The fatigue-predominant phenotype was more common in women, and the dyspnea-predominant phenotype was more common in men. Interleukin 6 (IL-6) was elevated in 61% of patients (69% of women; P=.0046), which was more common than elevation in C-reactive protein and erythrocyte sedimentation rate, identified in 17% and 20% of cases, respectively.

CONCLUSION

In our PCOCC, we observed several distinct clinical phenotypes. Fatigue predominance was the most common presentation and was associated with elevated IL-6 levels and female sex. Dyspnea predominance was more common in men and was not associated with elevated IL-6 levels. IL-6 levels were more likely than erythrocyte sedimentation rate and C-reactive protein to be elevated in patients with post-acute sequelae of SARS-CoV-2 infection.

Optimizing the Nutrition Support Care Model: Analysis of Survey Data

BACKGROUND

Malnutrition is under-recognized and under-diagnosed, despite high prevalence rates and associated poor clinical outcomes. The involvement of clinical nutrition experts, especially physicians, in the care of high-risk patients with malnutrition remains low, despite evidence demonstrating lower complication rates with nutrition support team (NST) management. To facilitate solutions, a survey was designed to elucidate the nature of NSTs and physician involvement and identify needs for novel nutrition support care models.

METHODS

This survey assessed demographics of NSTs, factors contributing to the success of NSTs, elements of nutrition education, and other barriers to professional growth.

RESULTS

Of 255 respondents, 235 complete surveys were analyzed. The geographic distribution of respondents correlated with population concentrations of the United States (r = 90.8%, p-value <0.0001). Most responding physicians (80.7%) reported being a member of NSTs, compared with 56.5% of dietitians. Of those not practicing in NSTs (N = 81, 34.4%), 12.3% reported an NST was previously present at their institution but had been disbanded. Regarding NSTs, financial concerns were common (48.9%), followed by leadership (30.6%), and healthcare professional (HCP) interest (23.4%). A majority (73.6%) of all respondents wanted additional training in nutrition, but reported insufficient protected time, ability to travel, or support from administrators or other HCPs.

CONCLUSION

Core actions resulting from this survey focused on formalizing physician roles, increasing inter-disciplinary nutrition support expertise, utilizing cost-effective screening for malnutrition, and implementing intervention protocols. Additional actions included increasing funding for clinical practice, education, and research, all within an expanded portfolio of pragmatic nutrition support care models.

CLINICAL RELEVANCY STATEMENT

Physician engagement in nutrition support continues to remain low despite the increasing prevalence of malnutrition. This problem, and the working solution, is in the context of decreased engagement of other healthcare professionals in nutrition support, as well as declining Nutrition Support Team utilization. To address these issues, the ASPEN Physician Engagement Committee (PEC) conducted a survey of healthcare professionals (HCPs) involved in nutrition support. Key findings include: (1) lack of financial support and physician champions with financial knowledge; (2) inadequate valuation of physicians and other nutrition support HCPs and NSTs, and their impact on clinical outcomes; and (3) significant barriers to primary and supplementary training for physicians in nutrition. Accordingly, the PEC recommends: (1) development of cost-effective screening and intervention for malnutrition; (2) expansion of nutrition support care models appropriately scaled to the available resources and expertise; and (3) development of a knowledge translation platform to foster transmission of novel breakthroughs while addressing research, knowledge, and practice gaps. This article is protected by copyright. All rights reserved.

Utilization of an Electronic Health Record Integrated Risk Score to Predict Hospitalization Among COVID-19 Patients

Objective:

To evaluate the performance of an Electronic Health Record (EHR) integrated risk score for COVID-19 positive outpatients to predict 30-day risk of hospitalization.

Patients and Methods:

A retrospective observational study of 67 470 patients with COVID-19 confirmed by polymerase chain reaction (PCR) test between March 12, 2020 and February 8, 2021. Risk scores were calculated based on data in the chart at the time of the incident infection.

Results:

The Mayo Clinic COVID-19 risk score consisted of 13 components included age, sex, chronic lung disease, congenital heart disease, congestive heart failure, coronary artery disease, diabetes mellitus, end stage liver disease, end stage renal disease, hypertension, immune compromised, nursing home resident, and pregnant. Univariate analysis showed all components, except pregnancy, have significant (P < .001) association with admission. The Mayo Clinic COVID-19 risk score showed a Receiver Operating Characteristic Area Under Curve (AUC) of 0.837 for the prediction of admission for this large cohort of COVID-19 positive patients.

Conclusion:

The Mayo Clinic COVID-19 risk score is a simple score that is easily integrated into the EHR with excellent predictive performance for severe COVID-19. It can be leveraged to stratify risk for severe COVID-19 at initial contact, when considering therapeutics or in the allocation of vaccine supply.

Virtual Reality for Health Care Professionals During a Pandemic: A Pilot Program

Objective:

The purpose of this pilot study was to evaluate the safety and use of a nature-based virtual reality (VR) experience among health care providers (HCP) during a pandemic.

Methods:

Twenty-four frontline HCP participated in this crossover pilot where the viewing order of the experiences were randomized. All participants attended in-person consent, baseline, and end-of-study visits. The intervention consisted of viewing 2 nature-based scenes (“walk in the woods” and “forest of focus”) through 3-D VR and with computer 4K graphic imagery. Randomization took place with regards to the viewing order (VR vs 4K computer video, scene 1 and 2). Outcomes measured were safety, acceptability and changes in intensity of anxiety feelings, resilience, emotional distress, cognitive function, and self-efficacy.

Results:

Among the 26 HCP expressing interest in the study, 24 enrolled in this study. The majority were male (58.3%), white (66.7%) and of an average age of 46.3 ± 10.5 years (standard deviation (SD)). End of the study survey showed that almost all participants (96%) would participate in the study again and recommend it to others. Twenty-three of the 24 participants also felt relaxed after seeing the imagery. With respect to anxiety (as measured by the STAI Y1), the VR “walk in the woods” had the greatest reduction from pre to post (6.4 points, SD = 5.98) followed by VR “forest of focus” (5.8 points, SD = 9.29), computer screen “forest of focus” (5.0 points, SD = 8.89), and computer screen “walk in the woods” (4.1 points, SD = 6.22). All 4 sessions had a significant decrease in score from pre to post (P-values ≤.005), but there was no significant difference in the change from pre- to post-session between the 4 groups (P-value = .5835).

Conclusion:

The use of the VR among HCP has promise for reducing stress among health care providers during a high stress period, such as a pandemic but much larger studies are needed.

Ketogenic diet and cancer: Fad or fabulous?

As the prevalence of smoking continues to decline, dietary factors are rapidly becoming the leading preventable cause of disease. Diet and obesity are also leading to a shift in cancer prevalence with increases noted in breast, liver, pancreas, and uterine cancers. Once cancer is detected, obesity is also associated with poorer outcomes with therapy as well as higher morbidity and mortality. Key factors are associated with the link between obesity and cancer including chronic inflammation, change in sex hormones, alteration in insulin-IGF-1 axis, alteration in adipokines, as well as cancer stem cells that are derived from adipose tissue. Because of these associations, a great deal of effort is being placed in implementing lifestyle changes that mitigate obesity-associated factors that contribute to development of cancer, reduce side effects of treatment, and improve survival. Ketogenic diet is emerging as an attractive option in countering obesity-related tumor-promoting factors, as it is associated with weight loss as well as a reduction in insulin resistance and inflammation. Ketogenic diet can also deprive cancer cells of glucose, a fuel source that is predominantly used by many cancer lines through aerobic glycolysis in the setting of dysregulated mitochondria. Current manuscript reviews the theoretical benefits for use of ketogenic diet in cancer as well as the data available from clinical trials.

Biomarkers of thromboinflammation correlate to COVID-19 infection and admission status in emergency department patients

Background

COVID-19-associated coagulopathy is incompletely understood.

Objectives

To characterize thrombin generation, Von Willebrand Factor (VWF), neutrophil extracellular traps (NETs), and their role in COVID-19 risk stratification in the emergency department (ED).

Patients/methods

Plasma samples from 67 ED COVID-19 patients were compared to 38 healthy volunteers (HVs). Thrombin generation (calibrated automated thrombogram, CAT) was expressed as lag time (LT, min), peak height (PH, min), and time to peak (ttPeak, min). Citrullinated nucleosomes and histones were quantified with ELISA, VWF antigen and activity (IU/dL) through latex immunoassay, Factor VIII (IU/dL) through one-stage optical clot detection, and VWF multimers with Western blot densitometry. Wilcoxon testing and multivariable logistic regression were performed. Results presented as median [Q1, Q3]; p < 0.05 significant.

Results

COVID-19 patients had longer LT (4.00 [3.26, 4.67]; 2.95 [2.67, 3.10], p < 0.001) and ttPeak (7.33 [6.33, 8.04]; 6.45 [6.00, 7.50], p = 0.004), greater VWF antigen (212 [158, 275]; 110 [91, 128], p < 0.001) and Factor VIII levels (148 [106, 190]; 106 [86, 129], p < 0.001), with decreased high molecular weight multimers (Normalized multimer ratio 0.807 [0.759, 0.869]; 0.891 [0.858, 0.966], p < 0.001), than HVs. COVID-19 patients requiring admission from the ED had longer LT and ttPeak with greater VWF antigen and Factor VIII levels than those not admitted. Two and three variable models of CAT parameters and VWF correlated with COVID-19 and admission status (C-statistics 0.677 to 0.922).

Conclusions

Thrombin generation kinetics and VWF levels, independent of NETs, may have a role in predicting admission need for COVID-19 patients.

When Pandemics Collide: the Interplay of Obesity and COVID-19

PURPOSE OF REVIEW

The COVID-19 pandemic has been associated with significant morbidity and mortality worldwide. In addition to those with advanced age and co-morbidities such as heart disease or cancer, obese individuals have also had very high rates of hospitalization, critical illness, need for ventilator support, as well as mortality. A number of factors associated with obesity have led to devastating consequences as these two pandemics have interacted.

RECENT FINDINGS

Obese individuals through a combination of structural and cellular level changes have greater risk of ischemic heart disease, diabetes, cancer, and respiratory disease, which are themselves risk-factors for acquiring COVID-19 disease. These structural changes also result in increased intra-abdominal and intra-thoracic pressure as well as a restrictive lung physiology that leads to reduction in total lung capacity, functional residual capacity, and increase in airway hyper-reactivity. Adipose tissue is also impacted in obese individuals leading to local as well as systemic inflammation, which can contribute to increased release of free fatty acids and systemic insulin resistance. Additionally, angiotensin-converting enzyme 2 and dipeptidyl peptidase 4, which act as receptors for SARS-CoV-2 are also significantly increased in obese individuals. The present manuscript reviews these structural, immune, and molecular changes associated with obesity that make obese individuals more vulnerable to acquiring severe COVID-19 and more challenging to manage associated complications.

Processed Foods - Getting Back to The Basics

PURPOSE OF REVIEW

Real-world data suggested that more than half of daily energy intake is coming from processed and ultra-processed foods in most western countries. This high consumption of processed foods is of concern, given laboratory and epidemiological studies' findings that prove overwhelming harms of processed foods on human health.

RECENT FINDINGS

Data demonstrate that consumption of processed foods is increasing with more reports linking ultra-processed foods to various medical conditions; namely, obesity, metabolic syndrome, atherosclerotic cardiovascular diseases, and certain types of cancer. Scientific community's understanding of the mechanisms and substances by which processed foods are affecting human health is expanding. Holistic approach to the current critical situation is advisable and requires collaborative public health strategies. The current review describes recent classification of processed foods and highlights the pertinent findings in the relationship between processed foods and health. It also outlines key clinical data relevant to the topic.

Blenderized food tube feeding in patients with head and neck cancer

Background

Patients with headand neck cancer (HNC) are at high risk for malnutrition before and during chemoradiation treatment. Many will also require tube feeding to address declines in energy intake, weight, and quality of life (QOL) caused by the impact of treatment on gastrointestinal (GI) symptoms. Blenderized tube feeding (BTF) may ameliorate these adverse conditions.

Methods

In this open‐label, prospective pilot study, 30 patients with HNC who required feeding tube placement were recruited to switch from standard commercial formula after 2 weeks to a commercially prepared BTF formula. Weight, body mass index (BMI), GI symptoms, and QOL scores were tracked for 6 weeks from the first week of feeding tube placement.

Results

Of the 16 patients who completed the 6‐week assessment period, weights and BMI scores for 15 patients trended upward. For most patients, QOL and oral intake increased and GI symptoms decreased over the 6‐week period, particularly during weeks 3 and 4, when the impact of treatment is particularly exacting on patients with HNC.

Conclusion

BTF effectively mitigated weight loss, GI symptoms, QOL scores, and total energy intake in this group of patients with HNC who received tube feeding for 6 weeks.

Use of telehealth in home nutrition support: Challenges and advantages

Coronavirus disease 2019 (COVID-19), after initially being detected in Wuhan, China in late 2019, quickly spread to most regions of the world, meeting World Health Organization criteria for a pandemic. Social distancing along with other measures implemented to control spread had a drastic impact on the provision of healthcare including deferred elective procedures and surgeries as well as delayed care and evaluation for emergent diagnoses such as heart attacks and strokes. In the home nutrition practice, patients began to delay routine laboratory tests and were canceling or deferring annual visits. Our group soon began to rapidly deploy telehealth to meet the needs of the home nutrition patients. Telehealth is not a new concept with descriptions of healthcare being provided at a distance with the use of telephone in the 1870s. However, widespread adoption has been limited because of regulation (licensure, prescriptions, credentialing, and privileges), lack of reimbursement, as well as adoption and availability of technology needed to carry out telehealth visits. As regulations and limits on reimbursements were waived during COVID-19 pandemic, our home nutrition practice began to evaluate core components of the care we provide for our patients and assess which could be successfully transitioned to telehealth. In addition to the history and regulation of telehealth, the current manuscript provides details regarding successful implementation of telehealth visits such as change management, selection of telehealth platform, scheduling and logistics, as well as carrying out the virtual visit including history and physical exam.

PROMIS Scales for Assessment of Persistent Post-COVID Symptoms: A Cross Sectional Study

Objective

Persistent post-COVID symptoms are estimated to occur in up to 10% of patients who have had COVID-19. These lingering symptoms may persist for weeks to months after resolution of the acute illness. This study aimed to add insight into our understanding of certain post-acute conditions and clinical findings. The primary purpose was to determine the persistent post COVID impairments prevalence and characteristics by collecting post COVID illness data utilizing Patient-Reported Outcomes Measurement Information System (PROMIS^®). The resulting measures were used to assess surveyed patients physical, mental, and social health status.

Methods

A cross-sectional study and 6-months Mayo Clinic COVID recovered registry data were used to evaluate continuing symptoms severity among the 817 positive tested patients surveyed between March and September 2020. The resulting PROMIS^® data set was used to analyze patients post 30 days health status. The e-mailed questionnaires focused on fatigue, sleep, ability to participate in social roles, physical function, and pain.

Results

The large sample size (n = 817) represented post hospitalized and other managed outpatients. Persistent post COVID impairments prevalence and characteristics were determined to be demographically young (44 years), white (87%), and female (61%). Dysfunction as measured by the PROMIS^® scales in patients recovered from acute COVID-19 was reported as significant in the following domains: ability to participate in social roles (43.2%), pain (17.8%), and fatigue (16.2%).

Conclusion

Patient response on the PROMIS^® scales was similar to that seen in multiple other studies which used patient reported symptoms. As a result of this experience, we recommend utilizing standardized scales such as the PROMIS^® to obtain comparable data across the patients’ clinical course and define the disease trajectory. This would further allow for effective comparison of data across studies to better define the disease process, risk factors, and assess the impact of future treatments.

Central Sensitization Phenotypes in Post Acute Sequelae of SARS-CoV-2 Infection (PASC): Defining the Post COVID Syndrome

OBJECTIVE

To develop and implement criteria for description of post COVID syndrome based on analysis of patients presenting for evaluation at Mayo Clinic Rochester between November 2019 and August 2020.

METHODS

A total of 465 patients with a history of testing positive for COVID-19 were identified and their medical records reviewed. After a thorough review, utilizing the DELPHI methods by an expert panel, 42 (9%) cases were identified with persistent central sensitization (CS) symptoms persisting after the resolution of acute COVID-19, herein referred to as Post COVID syndrome (PoCoS). In this report we describe the baseline characteristics of these PoCoS patients.

RESULTS

Among these 42 PoCoS patients, the mean age was 46.2 years (median age was 46.5 years). Pain (90%), fatigue (74%), dyspnea (43%), and orthostatic intolerance (38%) were the most common symptoms. The characteristics of an initial 14 patients were utilized for the development of clinical criteria via a modified Delphi Method by a panel of experts in central sensitization disorders. These criteria were subsequently applied in the identification of 28 additional cases of suspected PoCoS. A 2-reviewer system was used to analyze agreement with using the criteria, with all 28 cases determined to be either probable or possible cases by the reviewers. Inter-reviewer agreement using these proposed defining criteria was high with a Cohen's alpha of .88.

CONCLUSIONS

Here we present what we believe to be the first definitional criteria for Post COVID syndrome. These may be useful in clinical phenotyping of these patients for targeted treatment and future research.

Obesity Management Education Needs Among General Internists: A Survey

Objective

The purpose of this study was to determine self-reported knowledge, attitudes, prior experience, and perceived needs for the management of overweight and obese patients within a General Internal Medicine Practice.

Patients and Methods

An emailed cross-sectional survey was sent between June 20, 2019 and September 12, 2019 to 194 healthcare workers (93 primary care providers (PCPs) and 101 nurses) which focused on management of patients with weight issues.

Results

In total, 80 of the eligible 194 participants completed the survey (nurses = 42, PCPs = 38). Up to 87% were white, 74.7% female (74.7%). Most of the responders were either in the age group of 30’s (30%) or 50’s (30%). Among the responders, 48.8% reported some type of specialty training in weight management since their medical training with lectures being the most common form of training (36%). When asked about their interest in either weight management training or strategies to initiate weight conversations, 79% of the respondents reported an interest in education on weight management or strategies to initiate weight conversations, while 65.8% indicated they would be interested in both topics.

Conclusion

Our study suggests that healthcare workers have a self-reported need for further training in management of overweight and obese patients, irrespective of previous training in this area.

Transition to Peptide-Based Diet Improved Enteral Nutrition Tolerance and Decreased Healthcare Utilization in Pediatric Home Enteral Nutrition

Background

Home enteral nutrition (HEN) use continues to increase in children unable to meet nutritional needs through oral intake. Some patients do not tolerate standard polymeric formula (SPF), which may lead to malnutrition. Use of peptide‐based diet (PBD) has demonstrated benefits in adults, however there remains a paucity of data in pediatric population.

Methods

Retrospective review of medical records of children receiving HEN between October 2015 and October 2019 was conducted. Nutrition, tolerance, and healthcare utilization was tracked through May 2020. Children receiving PBD as initial formula or transitioned to PBD from SPF were included. Our objective was to assess gastrointestinal tolerance and impact on healthcare utilization in children receiving PBD.

Results

During study period, 30 children (mean age, 9 ± 5.44 years; 20 of 30 [66.7%] male) utilized PBDs. Twenty‐one patients started PBD directly with malnutrition as primary indication. Nine patients transitioned from SPF to PBD, most often due to intolerance of SPF (66%). After transition to PBD, no symptoms were reported in 6 of 9 (66.7%) patients, and symptoms of SPF intolerance resolved in 4 of 9 (44.5%) patients. Healthcare utilization declined significantly after transition to PBD, including mean numbers of emergency room visits (0.78 ± 1.09 to 0.11 ± 0.33; P = .025), provider visits (1.67 ± 1.32 to 0.56 ± 0.73; P = .007), and phone calls (1.22 ± 1.39 to 0.33 ± 0.50; P = .026).

Conclusions

PBD is well tolerated and can result in significant reduction in healthcare utilization in children intolerant to SPF.

The Role of Parenteral Nutrition for Incurable Cancer: Bridging Expectations and Reality

PURPOSE OF REVIEW

In this review, we examine the role for parenteral nutrition (PN) for nutritional support of patients with advanced, incurable cancer with an emphasis on bridging the divide between expectations and reality.

RECENT FINDINGS

As the rates of cancer have continued to rise worldwide, the utility of PN has continued to be studied. Due to multiple reasons, high-quality research studies have been scarce, and much of the data is based on observational studies. The recent trend appears to support the use of PN in carefully selected patients. Importantly, the effect on quality of life also should be considered when deciding to initiate PN. PN can be a supportive lifeline for patients with advanced, incurable cancer. The medical team should consider each patient individually to decide if PN should be offered. It is of paramount important for the medical team to engage in shared decision-making with the patient and caregiver(s) to ensure that PN is aligned with their goals and wishes.

The Association of Current Tobacco Status With Pain and Symptom Severity in Fibromyalgia Patients

Objective

To describe current tobacco use among patients with newly confirmed fibromyalgia and evaluate the association between tobacco use status and severity of reported pain and other fibromyalgia symptoms.

Patients and Methods

Participants in this study were adult patients (N=1068) with fibromyalgia who met American College of Rheumatology 2010/2011 clinical criteria for fibromyalgia at the time of initial presentation to a Midwest fibromyalgia clinic (June 1, 2018, through May 31, 2019). Multiple linear regression analyses were performed to assess the association of tobacco use status with the Widespread Pain Index (WPI) and Symptom Severity Scale (SSS) scores. Covariates included in these analyses included age, sex, body mass index, depression, opioid medication use, and use of fibromyalgia-specific pharmacotherapy.

Results

The patients were largely women (87.0%; n=929), white (87.9%; n=939), and with an average ± SD age of 46.6±13.9 years. The WPI and SSS scores were significantly greater in current tobacco users compared with never tobacco users (WPI effect estimate [EE] = 1.03; 95% CI, 0.30 to 1.76; type III P=.020; SSS EE = 0.47; 95% CI, 0.11 to 0.84; type III P=.036). The WPI score was negatively associated with age (EE = −0.02 per year; 95% CI, −0.03 to −0.001 per year; P=.037) and no use of opioid medication (EE = −1.08; 95% CI, −1.59 to −0.57; P<.001) while positively associated with higher body mass index (EE = 0.03 per 1 kg/m²; 95% CI, 0.001 to 0.06 per kg/m²; P=.04) and higher Patient Health Questionnaire-9 score (EE = 0.12; 95% CI, 0.08 to 0.16; P<.001).

Conclusion

The results of our study suggest that tobacco use is associated with greater pain and other symptom severity in patients with fibromyalgia. These findings have important clinical and research implications for patients with fibromyalgia who use tobacco and who may benefit from early identification and timely implementation of tobacco cessation treatment to decrease pain and improve overall quality of life.

Associations Between Experience of Early Childhood Trauma and Impact on Obesity Status, Health, as Well as Perceptions of Obesity-Related Health Care

OBJECTIVE

To evaluate the association between obesity and history of childhood trauma in an effort to define implications for the provider-patient relationship and possible causes of failure of obesity treatment.

METHODS

Multisite survey developed by the Patient-Centered Outcomes Research Institute Learning Health Systems Obesity Cohort Workgroup consisting of 49 questions with 2 questions focusing on history of being a victim of childhood physical and/or sexual abuse was mailed to 19,964 overweight or obese patients. Data collection for this survey occurred from October 27, 2017, through March 1, 2018.

RESULTS

Among the 2211 surveys included in analysis, respondents reporting being a victim of childhood abuse increased significantly with obesity (23.6%, 26.0%, 29.1%, and 36.8% for overweight, class I, class II, and class III obesity, respectively; P<.001). A higher percentage of those who reported being a victim of childhood abuse noted that their weight issues began at an earlier age (P=.002) and were more likely to have weight-related comorbidities (P<.001), even after controlling for body mass index. Impacting physician counseling on weight loss, patients who were childhood victims of abuse reported lower self-esteem (P<.001), were more likely to feel judged by their health care providers (P=.009), and less likely to feel being treated with respect (P=.045).

CONCLUSION

Overall, being a victim of childhood abuse was significantly associated with obesity, lower self-esteem and negative experiences interacting with health care providers. Health care providers should receive training to ensure open and nonjudgmental visits with obese patients and consider the role of trauma survivorship issues in patients' development of obesity and health care experiences.

Seeding of Gastrostomy Tube Site in Patient With Squamous Cell Carcinoma of the Tongue: A Case Report

Enteral nutrition (EN) is a widely used therapeutic tool to provide nutrition support for patients with various clinical conditions, including different types of cancer. Head and neck cancers, often complicated by dysphagia, are among leading indications for enteral feeding. Percutaneous endoscopic gastrostomy (PEG) and percutaneous endoscopic jejunostomy (PEJ) tubes are typically used to deliver EN. This article presents a case report of a young male with squamous cell carcinoma of the tongue. Unfortunately, he developed metastasis of his cancer at the right lateral side of the PEG placement site, requiring surgical resection of seeded growth at the PEG site. This rare complication can be challenging, as it requires a high index of suspicion to diagnose and can potentially limit nutrition support options. A number of theories have been proposed to explain seeding during PEG/PEJ placement, including direct repositioning of malignant cells during instrumentation. A specific placement technique has not been shown to be superior, as seeding was reported with all placement techniques. However, given the lack of statistically powerful studies to describe this entity, there are still gaps we need to explore to better understand seeding of feeding tubes and best practices around diagnosis and early treatment. EN continues to be an important part of caring for patients with cancer during active or palliative treatments. Understanding potential risks in the setting of cancer metastasis is beneficial to the patients and multidisciplinary teams involved. Early recognition of possible seeding of feeding tube sites is necessary to ensure subsequent timely surgical intervention.

Clinical Nutrition Research and the COVID-19 Pandemic: A Scoping Review of the ASPEN COVID-19 Task Force on Nutrition Research

The purpose of this scoping review by the American Society for Parenteral and Enteral Nutrition (ASPEN) Coronavirus Disease 2019 (COVID-19) Nutrition Task Force was to examine nutrition research applicable to the COVID-19 pandemic. The rapid pace of emerging scientific information has prompted this activity to discover research/knowledge gaps. This methodology adhered with recommendations from the Joanna Briggs Institute. There were 2301 citations imported. Of these, there were 439 articles fully abstracted, with 23 main topic areas identified across 24 article types and sourced across 61 countries and 51 specialties in 8 settings and among 14 populations. Epidemiological/mechanistic relationships between nutrition and COVID-19 were reviewed and results mapped to the Population, Intervention, Comparator, Outcome, and Time (PICO-T) questions. The aggregated data were analyzed by clinical stage: pre-COVID-19, acute COVID-19, and chronic/post-COVID-19. Research gaps were discovered for all PICO-T questions. Nutrition topics meriting urgent research included food insecurity/societal infrastructure and transcultural factors (pre-COVID-19); cardiometabolic-based chronic disease, pediatrics, nutrition support, and hospital infrastructure (acute COVID-19); registered dietitian nutritionist counseling (chronic/post-COVID-19); and malnutrition and management (all stages). The paucity of randomized controlled trials (RCTs) was particularly glaring. Knowledge gaps were discovered for PICO-T questions on pediatrics, micronutrients, bariatric surgery, and transcultural factors (pre-COVID-19); enteral nutrition, protein-energy requirements, and glycemic control with nutrition (acute COVID-19); and home enteral and parenteral nutrition support (chronic/post-COVID-19). In conclusion, multiple critical areas for urgent nutrition research were identified, particularly using RCT design, to improve nutrition care for patients before, during, and after COVID-19.

Incidence and Outcomes of Home Parenteral Nutrition in Patients With Crohn Disease in Olmsted County, Minnesota

BACKGROUND

We sought to estimate the incidence of home parenteral nutrition (HPN) use in a population-based cohort of patients with Crohn disease (CD), and to assess clinical outcomes and complications associated with HPN.

METHODS

We used the Rochester Epidemiology Project (REP) to identify residents of Olmsted County, who were diagnosed with CD between 1970 and 2011, and required HPN.

RESULTS

Fourteen out of 429 patients (3.3%) with CD received HPN (86% female). Eleven patients (79%) had moderate-severe CD and 12 patients (86%) had fistulizing disease. Thirteen patients (93%) underwent surgery, primarily due to obstruction. Among CD incidence cases, the cumulative incidence of HPN from the date of CD diagnosis was 0% at 1 year, 0.5% at 5 years, 0.8% at 10 years, and 2.4% at 20 years. Indications for HPN included short bowel syndrome in 64%, malnutrition in 29%, and bowel rest in 21%. The median duration of HPN was 2.5 years. There was an average weight gain of 1.2 kg at 6 months, an average weight loss of 1.4 kg at 1 year, and a further weight loss of 2.2 kg at 2 years from the start of HPN. Patients were hospitalized a mean of 5 times after the start of HPN, mainly due to catheter-related bloodstream infections and thrombosis.

CONCLUSIONS

Less than 4% of patients with CD need HPN. Most have moderate to severe disease with short bowel syndrome or malnutrition. Possible reasons for the patients' weight loss could be noncompliance, and increased metabolic needs because of active disease.

Use of Home Enteral Nutrition in Malnourished Post-Bariatric Surgery Patients

BACKGROUND

Bariatric surgery is by far the most effective treatment option available for successfully achieving and maintaining weight loss in the obese population, but it can also be associated with complications that lead to malnutrition. There is limited data on how enteral nutrition (EN) can be used to provide nutrition support in such cases.

METHODS

Retrospective review of our Home Enteral Nutrition (HEN) database was conducted from February 2013 to April 2018 to identify patients who received HEN because of bariatric surgery-related complication.

RESULTS

During the study period, 72 patients (86% female, mean age 50.3 ± 11.6 years) initiated HEN because of bariatric surgical complication. Most common bariatric surgery was Roux-en-Y (74%) and most common indication for HEN was malnutrition/failure to thrive (33%). HEN was most commonly provided through nasojejunal feeds and resulted in an average increase in body weight and body mass index from 74.8 kg and 26.5, respectively, before HEN to 76.9 kg and 27.2, respectively, at the end of the HEN period. Through HEN, patients received 22.2 ± 7.9 kcal/kg/d and 1.0 ± 0.3 g/kg/d protein, meeting 94% ± 17% of their energy goals and 95% ± 29% of their protein goals. Vitamin deficiencies were noted in 69% of patients at the time of HEN initiation, which improved to 10% after enteral feeds and appropriate vitamin supplementation.

CONCLUSION

HEN is safe and effective in treating malnutrition and vitamin deficiencies that might occur as a complication of bariatric surgery, leading to avoidance of parenteral nutrition support in most cases.

Clinical application of fish-oil intravenous lipid emulsion in adult home parenteral nutrition patients

BACKGROUND

High-ω-6 polyunsaturated fatty acids (PUFAs) are noted to contribute to development of intestinal failure-associated liver disease (IFALD) in home parenteral nutrition (HPN). Fish oil (FO) has been added to latest generation of lipid injectable emulsion (ILE) to increase ω-3:ω-6 PUFA ratio; however, appropriate dose of FO to treat IFALD is unknown.

METHODS

After approval of exclusive FO ILE in the US for pediatric patients, we noted 2 adult patients with ongoing IFALD despite transition to mixed-oil (MO) ILE. They were transitioned to off-label FO ILE after review of literature regarding use of FO ILE in adult HPN patients was conducted to guide management.

RESULTS

The first case involves a 40-year-old female receiving HPN with IFALD refractory to MO ILE. MO ILE (with 15% FO) was provided at 50 g/d for 3 d/wk and combined with FO ILE at 50 g/d for 4 d/wk. This combination resulted in improvement in liver studies and allowed for decrease in dextrose calories. The second case involves a 49-year-old male receiving HPN (secondary to complications of necrotizing pancreatitis) who developed IFALD. FO ILE was used as the sole source of lipids and led to improvement in liver function tests. No evidence of essential fatty acid deficiency was found in either case.

CONCLUSIONS

Current case presentations and review of literature support the use of FO ILE to increase ω-3 PUFAs in patients with IFALD refractory to MO ILE. Additional research is necessary to delineate the dose of FO ILE necessary to achieve benefit.

The Comparison of Segmental Multifrequency Bioelectrical Impedance Analysis and Dual-Energy X-ray Absorptiometry for Estimating Fat Free Mass and Percentage Body Fat in an Ambulatory Population

BACKGROUND

Despite malnutrition being associated with increased mortality and morbidity, there continues to be great difficulty in defining criteria and implementing widespread screening. Tools used to diagnose decreased fat-free mass (FFM [sarcopenia]) should be easy to use, relatively inexpensive, and safe. Bioelectrical impedance analysis (BIA) has the potential to meet these criteria, but reliability across body mass index (BMI) classes is a concern.

METHODS

A total of 176 healthy ambulatory participants (aged 18-65 years) were recruited equally (n = 44) in 4 BMI categories: (1) 18.5-24.9, (2) 25.0-29.9, (3) 30-34.9, and (4) ≥35.0. Participants were fasting overnight and had S-MFBIA (InBody 770) measurements the next morning, with DXA being performed subsequently within 30 minutes.

RESULTS

The measurement (mean ± SD) for FFM with DXA was 52.8 ± 11.0, and BIA was 53.6 ± 11.0. Delta (S-MFBIA vs DXA) was 0.8 ± 2.2 (5% limits of agreement -3.5 to +5.2), and concordance correlation coefficient (CCC) was 0.98 (95% CI, 0.97-0.98). The measurements (mean ± SD) for PBF with DXA was 37.5 ± 10.6% and S-MFBIA was 36.6 ± 11.3%. Delta (S-MFBIA vs DXA) was -0.9 ± 2.6 (5% limits of agreement 6.0 to +4.2), and CCC was 0.97 (95% CI, 0.96-0.98). The CCC according to the 4 BMI groups for FFM and PBF was between 0.96-0.98 and 0.90-0.94, respectively.

CONCLUSIONS

FFM and PBF measured by S-MFBIA had good agreement with DXA across all BMI categories measured in the current study of ambulatory participants.

Ketogenic Diet: an Endocrinologist Perspective

PURPOSE OF REVIEW

Obesity and its related comorbidities make up a large part of healthcare expenditures. Despite a wide array of options for treatment of obesity, rates of sustained weight loss continue to be low, leading patients to seek alternative treatment options. Although the first medically utilized ketogenic diet was described nearly 100 years ago, it has made a resurgence as a treatment option for obesity. Despite increased popularity in the lay public and increased use of ketogenic dietary strategies for metabolic therapy, we are still beginning to unravel the metabolic impact of long-term dietary ketosis.

RECENT FINDINGS

There are a number of recent trials that have highlighted the short- and long-term benefits of ketogenic diet on weight, glycemic control, and other endocrine functions including reproductive hormones. This review is a summary of available data on the effectiveness and durability of the ketogenic diet when compared to conventional interventions. Ketogenic dietary strategies may play a role in short-term improvement of important metabolic parameters with potential for long-term benefit. However, response may vary due to inter-individual ability to maintain long-term carbohydrate restriction.

Reduction in Healthcare Utilization With Transition to Peptide-Based Diets in Intolerant Home Enteral Nutrition Patients

BACKGROUND

Since the introduction of percutaneous endoscopic gastrostomy in the 1980s, the prevalence of home enteral nutrition (HEN) support has increased significantly. Despite these increases, many patients are unable to tolerate standard polymeric formulas (SPFs), resulting in significant healthcare resource utilization. Peptide-based diets (PBDs) have emerged as a viable option in SPF-intolerant patients; however, data in the HEN population are lacking.

METHODS

Retrospective review of our prospectively maintained HEN database was conducted to assess tolerance, efficacy, and impact on healthcare utilization in patients on PBDs.

RESULTS

From January 1, 2016, to May 1, 2018, 95 patients were placed on PBDs, with 53 patients being started directly and 42 patients being transitioned from SPFs. In patients transitioned to PBDs, symptoms of nausea and vomiting, diarrhea, abdominal pain, and distention improved significantly. Healthcare utilization also declined significantly, including mean number of phone calls (1.8 ± 1.6 to 1.1 ± 0.9, P = 0.006), mean number of emergency room visits (0.3 ± 0.6 to 0.09 ± 0.3, P = 0.015), and mean number of provider visits (1.3 ± 1.3 to 0.3 ± 0.5, P < 0.0001).

CONCLUSIONS

Overall, PBDs were well tolerated and resulted in significant improvements in symptoms of gastrointestinal distress and healthcare utilization in patients intolerant to SPFs.