Body composition radiomic features as a predictor of survival in patients with non-small cellular lung carcinoma: A multicenter retrospective study

OBJECTIVES

This study combined two novel approaches in oncology patient outcome predictions-body composition and radiomic features analysis. The aim of this study was to validate whether automatically extracted muscle and adipose tissue radiomic features could be used as a predictor of survival in patients with non-small cell lung cancer.

METHODS

The study included 178 patients with non-small cell lung cancer receiving concurrent platinum-based chemoradiotherapy. Abdominal imaging was conducted as a part of whole-body positron emission tomography/computed tomography performed before therapy. Methods used included automated assessment of the volume of interest using densely connected convolutional network classification model - DenseNet121, automated muscle and adipose tissue segmentation using U-net architecture implemented in nnUnet framework, and radiomic features extraction. Acquired body composition radiomic features and clinical data were used for overall and 1-y survival prediction using machine learning classification algorithms.

RESULTS

The volume of interest detection model achieved the following metric scores: 0.98 accuracy, 0.89 precision, 0.96 recall, and 0.92 F1 score. Automated segmentation achieved a median dice coefficient >0.99 in all segmented regions. We extracted 330 body composition radiomic features for every patient. For overall survival prediction using clinical and radiomic data, the best-performing feature selection and prediction method achieved areas under the curve-receiver operating characteristic (AUC-ROC) of 0.73 (P < 0.05); for 1-y survival prediction AUC-ROC was 0.74 (P < 0.05).

CONCLUSION

Automatically extracted muscle and adipose tissue radiomic features could be used as a predictor of survival in patients with non-small cell lung cancer.

Fully automated 3D body composition analysis and its association with overall survival in head and neck squamous cell carcinoma patients

Objectives

We developed a method for a fully automated deep-learning segmentation of tissues to investigate if 3D body composition measurements are significant for survival of Head and Neck Squamous Cell Carcinoma (HNSCC) patients.

Methods

3D segmentation of tissues including spine, spine muscles, abdominal muscles, subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT), and internal organs within volumetric region limited by L1 and L5 levels was accomplished using deep convolutional segmentation architecture - U-net implemented in a nnUnet framework. It was trained on separate dataset of 560 single-channel CT slices and used for 3D segmentation of pre-radiotherapy (Pre-RT) and post-radiotherapy (Post-RT) whole body PET/CT or abdominal CT scans of 215 HNSCC patients. Percentages of tissues were used for overall survival analysis using Cox proportional hazard (PH) model.

Results

Our deep learning model successfully segmented all mentioned tissues with Dice's coefficient exceeding 0.95. The 3D measurements including difference between Pre-RT and post-RT abdomen and spine muscles percentage, difference between Pre-RT and post-RT VAT percentage and sum of Pre-RT abdomen and spine muscles percentage together with BMI and Cancer Site were selected and significant at the level of 5% for the overall survival. Aside from Cancer Site, the lowest hazard ratio (HR) value (HR, 0.7527; 95% CI, 0.6487-0.8735; p = 0.000183) was observed for the difference between Pre-RT and post-RT abdomen and spine muscles percentage.

Conclusion

Fully automated 3D quantitative measurements of body composition are significant for overall survival in Head and Neck Squamous Cell Carcinoma patients.

Principles of minimize bleeding and the transfusion of blood and its components in operated patients - surgical aspects

One of the target of perioperative tratment in surgery is decreasing intraoperative bleeding, which increases the number of perioperative procedures, mortality and treatment costs, and also causes the risk of transfusion of blood and its components. Trying to minimize the blood loss(mainly during the operation) as well as the need to transfuse blood and its components (broadly understood perioperative period) should be standard treatment for a patient undergoing a procedure. In the case of this method, the following steps should be taken: 1) in the preoperative period: identyfication of risk groups as quickly as possible, detecting and treating anemia, applying prehabilitation, modyfying anticoagulant treatment, considering donating one's own blood in some patients and in selected cases erythropoietin preparations; 2) in the perioperative period: aim for normothermia, normovolemia and normoglycemia, use of surgical methods that reduce bleeding, such as minimally invasive surgery, high-energy coagulation, local hemostatics, prevention of surgical site infection, proper transfusion of blood and its components if it occurs; 3) in the postoperative period: monitor the condition of patients, primarily for the detection of bleeding, rapid reoperation if required, suplementation (oral administration preferred) nutrition with microelements (iron) and vitamins, updating its general condition. All these activities, comprehensively and in surgical cooperation with the anesthesiologist, should reduce the blood loss and transfusion of blood and its components.

Creating an Innovative Artificial Intelligence-Based Technology (TCRact) for Designing and Optimizing T Cell Receptors for Use in Cancer Immunotherapies: Protocol for an Observational Trial

BACKGROUND

Cancer continues to be the leading cause of mortality in high-income countries, necessitating the development of more precise and effective treatment modalities. Immunotherapy, specifically adoptive cell transfer of T cell receptor (TCR)-engineered T cells (TCR-T therapy), has shown promise in engaging the immune system for cancer treatment. One of the biggest challenges in the development of TCR-T therapies is the proper prediction of the pairing between TCRs and peptide-human leukocyte antigen (pHLAs). Modern computational immunology, using artificial intelligence (AI)-based platforms, provides the means to optimize the speed and accuracy of TCR screening and discovery.

OBJECTIVE

This study proposes an observational clinical trial protocol to collect patient samples and generate a database of pHLA:TCR sequences to aid the development of an AI-based platform for efficient selection of specific TCRs.

METHODS

The multicenter observational study, involving 8 participating hospitals, aims to enroll patients diagnosed with stage II, III, or IV colorectal cancer adenocarcinoma.

RESULTS

Patient recruitment has recently been completed, with 100 participants enrolled. Primary tumor tissue and peripheral blood samples have been obtained, and peripheral blood mononuclear cells have been isolated and cryopreserved. Nucleic acid extraction (DNA and RNA) has been performed in 86 cases. Additionally, 57 samples underwent whole exome sequencing to determine the presence of somatic mutations and RNA sequencing for gene expression profiling.

CONCLUSIONS

The results of this study may have a significant impact on the treatment of patients with colorectal cancer. The comprehensive database of pHLA:TCR sequences generated through this observational clinical trial will facilitate the development of the AI-based platform for TCR selection. The results obtained thus far demonstrate successful patient recruitment and sample collection, laying the foundation for further analysis and the development of an innovative tool to expedite and enhance TCR selection for precision cancer treatments.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04994093; https://clinicaltrials.gov/ct2/show/NCT04994093.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/45872.

Foods for Special Medical Purposes in Home Enteral Nutrition-Clinical Practice Experience. Multicenter Study

Background

Enteral nutrition (EN) with foods for special medical purposes (FSMP) is recommended for most patients on home enteral nutrition (HEN). Although there are disease-specific guidelines for energy, protein, and micronutrient provision, only a few studies are showing real-life experience in the long-term use of FSMP.

Methods

In a multicenter study, the influence of the FSMP composition and administration technique (bolus vs. continuous) on protein and energy provision in HEN was analyzed. Provision of vitamins and minerals was compared to recommended daily allowance (RDA) and upper tolerable limit (UL).

Results

Approximately, 772 patients on HEN, mostly (88.6%) with oncological and neurological diseases, were enrolled. The patients on standard FSMP received less protein and energy than those on hypercaloric and protein enriched despite receiving higher volumes of EN (p < 0.05). No differences were observed in jejunal feeding with oligomeric vs. polymeric FSMP in terms of energy, protein, and volume. Continuous gastric feeding provided more protein, energy, and volume vs. bolus feeding (p < 0.05). Significant number of patients received less than 100% RDA of vitamin D (50.5%), vitamin B3 (49%), vitamin K (21.8%), vitamin B5 (64.3%), vitamin B9 (60%). Majority of the patients received less than 100% RDA of sodium (80.2%), potassium (99%), chloride (98%), calcium (67%), magnesium (87%), fluoride (99%), and iodine (43%). Approximately, 43.63% of cancer and 49.9% of neurological patients received less than 1 g/kg/day of protein and 51.7% of cancer and 55.5% of neurological patients received less than 25 kcal/kg/day.

Conclusion

Awareness of the available compositions of FSMP and advantageous profiles of specific diets may lead to the implementation of recommendations for EN. HEN professionals need to analyze all the patient's needs and requirements to provide more tailored matching of nutritional support.

Trend Observations in Home Parenteral Nutrition. Prevalence, Hospitalizations and Costs: Results from a Nationwide Analysis of Health Care Provider Data

BACKGROUND

The population of patients on home parenteral nutrition (HPN) worldwide is growing. Since only a few counties provide data from national registries long-term observations are valuable to address this specific area of nutrition support. This study is a nationwide analysis determining the trends in the epidemiology of HPN (prevalence, age distribution, death rates), indications for HPN, causes for hospitalizations, and cost analysis of HPN reimbursement in Poland between 2010-2020.

METHODS

A retrospective analysis of data obtained from the national health fund (NHF) of Poland on adult patients on HPN.

RESULTS

The prevalence of adult patients on HPN in Poland in 2020 was 53.26 per million citizens with a 2.99-fold increase and a growing trend observed from 2010. Significant decrease in the percentage of patients between 18-34, 45-54 and an increase in patients between 65-74 and patients over 75 years old was observed. Trend analysis showed an increase in new patients between 65-74 and a decrease between 35-54. Malnutrition (34.28%), postprocedural disorders of the GI tract (19.61%), intestinal malabsorption/other intestinal diseases (20.41%) and GI obstruction due to cancer (17.36% as primary and 23.16% as secondary diagnosis) were mostly reported as the primary indications for HPN. Cancer patients were mostly gastric, ovarian and colon cancer (34.74%, 17.83% and 12.3%). HPN and total health cost reimbursement increase was 2.6 and 2.57-fold respectively. Costs of HPN and total health care costs in 2020 per patient were € 10,015 and € 16,038, respectively. Overall death risk rate during the first year of nutrition was 0.59 with a significant increase in the observation period p-trend < 0.004. A significant increase in the death rate was observed in patients above 75 years old (estimate 1.629, p-trend < 0.030). Cancer, infection, malnutrition and GI symptoms were the most common indications for hospitalizations of HPN patients. The rate of patients with a maximal length of HPN of 5 months in 2010 was 54.9% and was growing up to 78.1% in 2020.

CONCLUSIONS

The prevalence of HPN in Poland is growing. Trends of age distribution show increasing numbers of patients with more advanced age and shorter survival. Costs of HPN are comparable with other European data.

Immunonutrition Changes Inflammatory Response in Colorectal Cancer: Results from a Pilot Randomized Clinical Trial

Simple Summary

Nutritional support for patients who underwent surgery for colorectal cancer is widely accepted for reducing the incidence of perioperative complications. Immunonutrition is generally recommended to decrease the incidence of infectious complications. However, there is little clinical data regarding the impact of such treatment on tumor biology. Some basic studies show its negative impact on the development of the tumor, while others suggest it might be beneficial. Currently, there is no clinical evidence for any effect of immunonutrition on tumor tissues in vivo. Therefore, we designed this pilot randomized controlled trial to investigate the impact of immunonutrition compared with standard nutritional support in the preoperative period on the inflammatory response, cytokine expression, and leukocyte infiltration in the tumor tissue. Changes in tumor necrosis factor alpha (TNF-α), interleukin 8 or chemokine (C-X-C motif) ligand (CXCL8), and chemokine (C-X-C motif) ligand 1 (CXCL1) expression were observed after the intervention. In the immune group, a decrease in neutrophil infiltration was observed. Immunonutrition in the preoperative period influenced inflammatory response in patients with colorectal cancer.

Abstract

Introduction: Surgery is the first choice of treatment for colorectal cancer. Nutritional support in the form of oral nutritional supplements (ONSs) in the preoperative period is widely accepted for reducing the incidence of perioperative complications, and immunonutrition is generally recommended. However, there is little clinical data regarding the impact of such treatment on tumor biology. Material and Methods: In this study, tumor tissue and blood samples were collected from 26 patients during preoperative colonoscopy at the time of clinical diagnosis (sample A). Group 1 received standard ONSs (3× Nutricia Nutridrink Protein per day) for 2 weeks before surgery. In group 2, immune ONSs (2× Nestle Impact Oral) were administered for the same duration. Tumor tissue (sample B) was then retrieved from the tumor after resection. Changes in the expression levels of inflammatory cytokines (TNF-α, interleukin 8 or chemokine (C-X-C motif) ligand (CXCL8), stromal cell-derived factor 1 (SDF1a), chemokine (C-X-C motif) ligand 6 (CXCL6), chemokine (C-X-C motif) ligand (CXCL2), myeloperoxidase (MPO), and CXCL1) were assessed during the perioperative course. Results: TNF-α expression differed after intervention between the two groups (immune group 31.63 ± 13.28; control group 21.54 ± 6.84; p = 0.049) and prior to and after intervention in the control group (prior to intervention 35.68 ± 24.41; after intervention 21.54 ± 6.84; p = 0.038). Changes in CXCL8 expression in the control group occurred prior to and after intervention (prior to intervention 2975.93 ± 1484.04; after intervention 1584.85 ± 1659.84; p = 0.041). CXCL1 expression was increased in the immune group and decreased in the control group (immune group 2698.27 (1538.14–5124.70); control group 953.75 (457.85–1534.60); p = 0.032). In both groups, a decrease in superficial neutrophil infiltration was observed, but this was only statistically significant in the immune group. There was no impact of the observed differences between the two groups on surgical outcomes (morbidity, length of stay, readmissions). Conclusions: Immunonutrition in the preoperative period compared with standard nutritional support may influence inflammatory cytokine expression and leukocyte infiltration in patients with colorectal cancer.

Organizational issues of home parenteral nutrition during COVID-19 pandemic: Results from multicenter, nationwide study

Objectives

Patients on home parenteral nutrition (HPN) are prone to severe complications of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The pandemic requires adaptation of the health care standards, including epidemiologic surveillance, logistics of home supply, and monitoring. Potential lack of medical professionals may worsen the standard of care. The aim of this study was to evaluate the medical staff resources in HPN units.

Results

The study was conducted by major Polish scientific societies in clinical nutrition. A questionnaire was distributed among all Polish adult HPN centers concerning statistics from the first 3 mo of the pandemic (March through May 2020). Data on medical staff resources and organizational issues of the units were collected. Modifications of the home procedures, SARS-CoV-2 infection rates of HPN patients and health care workers (HCW) were analyzed. Influence of the pandemic on the rates of new qualifications for home artificial nutrition (HAN) was estimated. Fourteen of 17 adult Polish HPN units took part in the study. The point prevalence of HPN in Poland was 30.75/1 million citizens. Of HCWs, 344 were involved in patient care in Polish HPN units; 18.9% were physicians (49% surgeons, 18.46% internal medicine specialists, 15.38% anesthesiologists, 7.69% pediatricians, 1.54% palliative care specialists), 32.27% nurses, 5.23% dietitians, 9.01% pharmacists, 4.94% pharmacy technicians, 3.2% pharmacy assistants, 5.81% administrative workers, 3.49% physiotherapists. HAN patient-to-HCW ratios for physicians, nurses, pharmacists, dietitians were 49.5, 29.15, 111.6, and 181.6, respectively. Medium ages of physicians and nurses were 45.6 and 44.15 y, respectively. Slightly less than half (53.8%) of physicians and 31.53% of nurses worked parallelly in hospital wards. Thirty-one pharmacists overall were working in all HPN units (2.21 per unit) as were 18 dietitians (1.3 per unit). Nine patients had a confirmed COVID-19 infection (four HPN, five home enteral nutrition). All the units introduced telemedicine solutions in the first months of the pandemic. The number of new qualifications for HPN and home enteral nutrition in the units did not significantly decline from March through May in comparison with a similar period in 2019.

Conclusions

A shortage of HPN medical professionals requires attention when planning health care organization, especially during a pandemic. Severe restrictions in public health systems may not reduce the number of new qualifications for the HPN procedure. There is a need for the continuation of data collection during the evolution of the pandemic as it may have a detrimental effect on HPN including serious issues with access to professional HCWs.

In pursuit of COVID-19 surgical risk stratification to manage a limited workforce and supplies in minimally invasive surgery

The protective barriers used so far in surgery do not provide adequate protection against SARS-CoV-2 virus, and reinforced protective equipment is needed. The rapid increase in the number of patients and the worldwide panic associated with the increasingly low availability of protective equipment has resulted in a shortage of protective equipment in many hospitals. Appropriatepersonal protective equipment must be provided so that the surgical team proceeding to surgery is not excluded from the further struggle for patients' health, especially in MIS. Reckless and excessive use of maximum protective equipment may result in a severe shortage of these products when the number of infected persons requiring surgery increases. The use of a structured infection risk scheme for medical staff, depending on the results of reverse transcription polymerase chain reaction assays and COVID-19 symptoms, combined with the division of protection equipment into three groups, allows easy selection of an appropriate clothing scheme for the clinical setting.

Home Enteral Nutrition in Adults-Nationwide Multicenter Survey

Home enteral nutrition (HEN) is an important part of the health care system, with a growing population of patients around the world. The aim of our study was to analyze one of the largest cohorts of HEN patients to provide the most recent data available in European literature. A multicenter, nation-wide survey in the period of 1 January 2018–1 January 2019 was performed in Poland. Data concerning adult patients on HEN in 2018 during 1 year of observation time were analyzed: demographic characteristics, primary disease, technique of enteral feeding, diet formulation and amount of energy provided. A total of 4586 HEN patients (F: 46.7%, M: 53.3%) were included in the study. The primary diseases were: 54.5% neurological (17.4%—neurovascular, 13.7%—neurodegenerative), 33.9% cancer (20.2%—head and neck, 11.7%—gastrointestinal cancer), 2.5%—gastroenterology, 1.5%—inherited diseases. Of new registrations in 2018—cancer patients 46.3%, neurological patients 45.1%. The median age overall was: 64 yr., BMI-20.2 kg/m², NRS 2002 score—4.28. A total of 65% of patients were treated with PEG, 11.6% with surgical gastrostomy, 14.3% with naso-gastric tube and 7% with jejunostomy. Boluses were the most common method of feeding (74.4%). Gravity flow was used in 17.6% and peristaltic pump was used in 8% patients. The median energy provision was 1278 kcal/day and 24 kcal/kg/day. The most commonly used diets were: isocaloric (28.1%), protein-enriched isocaloric (20%) and protein-enriched hypercaloric (12%). The median overall duration of HEN was 354 days, 615 days for neurological and 209 days for cancer patients. A number of new registrations of cancer patients was significant and long duration of HEN in this group is encouraging. A developing spectrum of enteral formulas available enables more specified nutritional interventions.

Guidelines for the management of surgical departments in non-uniform hospitals during the COVID-19 pandemic

In the last several weeks we have been witnessing the exponentially progressing pandemic SARS-CoV-2 coronavirus. As the number of people infected with SARS-CoV2 escalates, the problem of surgical management of patients requiring urgent surgery is increasing. Patients infected with SARS-CoV2 virus but with negative test results will appear in general hospitals and may pose a risk to other patients and hospital staff. Health care workers constitutes nearly 17% of infected population in Poland, therefore early identification of infected people becomes a priority to protect human resources and to ensure continuity of the access to a surgical care. Both surgical operations, and endoscopic procedures are considered as interventions with an increased risk of infection. Therefore, determining the algorithm becomes crucial for qualifying patients for surgical treatment, but also to stratify the risk of personnel being infected during surgery and to adequately protect staff. Each hospital should be logistically prepared for the need to perform urgent surgery on a patient with suspected or confirmed infection, including personal protective equipment. Limited availability of the equipment, working under pressure and staff shortages in addition to a highly contagious pathogen necessitate a pragmatic management of human resources in health care. Instant synchronized action is needed, and clear uniform guidelines are essential for the healthcare system to provide citizens with the necessary surgical care while protecting both patients, and staff. This document presents current recommendations regarding surgery during the COVID-19 pandemic in Poland.

ESPEN practical guideline: Clinical Nutrition in inflammatory bowel disease

The present guideline is the first of a new series of "practical guidelines" based on more detailed scientific guidelines produced by ESPEN during the last few years. The guidelines have been shortened and now include flow charts that connect the individual recommendations to logical care pathways and allow rapid navigation through the guideline. The purpose of the present practical guideline is to provide an easy-to-use tool to guide nutritional support and primary nutritional therapy in inflammatory bowel disease (IBD). The guideline is aimed at professionals working in clinical practice, either in hospitals or in outpatient medicine, and treating patients with IBD. In 40 recommendations, general aspects of care in patients with IBD, and specific aspects during active disease and in remission are addressed. All recommendations are equipped with evidence grades, consensus rates, short commentaries and links to cited literature.

ESPEN guideline: Clinical nutrition in inflammatory bowel disease

INTRODUCTION

The ESPEN guideline presents a multidisciplinary focus on clinical nutrition in inflammatory bowel disease (IBD).

METHODOLOGY

The guideline is based on extensive systematic review of the literature, but relies on expert opinion when objective data were lacking or inconclusive. The conclusions and 64 recommendations have been subject to full peer review and a Delphi process in which uniformly positive responses (agree or strongly agree) were required.

RESULTS

IBD is increasingly common and potential dietary factors in its aetiology are briefly reviewed. Malnutrition is highly prevalent in IBD - especially in Crohn's disease. Increased energy and protein requirements are observed in some patients. The management of malnutrition in IBD is considered within the general context of support for malnourished patients. Treatment of iron deficiency (parenterally if necessary) is strongly recommended. Routine provision of a special diet in IBD is not however supported. Parenteral nutrition is indicated only when enteral nutrition has failed or is impossible. The recommended perioperative management of patients with IBD undergoing surgery accords with general ESPEN guidance for patients having abdominal surgery. Probiotics may be helpful in UC but not Crohn's disease. Primary therapy using nutrition to treat IBD is not supported in ulcerative colitis, but is moderately well supported in Crohn's disease, especially in children where the adverse consequences of steroid therapy are proportionally greater. However, exclusion diets are generally not recommended and there is little evidence to support any particular formula feed when nutritional regimens are constructed.

CONCLUSIONS

Available objective data to guide nutritional support and primary nutritional therapy in IBD are presented as 64 recommendations, of which 9 are very strong recommendations (grade A), 22 are strong recommendations (grade B) and 12 are based only on sparse evidence (grade 0); 21 recommendations are good practice points (GPP).

Laparoscopic colorectal cancer surgery combined with enhanced recovery after surgery protocol (ERAS) reduces the negative impact of sarcopenia on short-term outcomes

INTRODUCTION

Progressive skeletal muscle loss (sarcopenia) is a negative prognostic factor in patients treated for colorectal cancer. Nevertheless, the clinical impact of those changes in body composition has been analyzed only in patients undergoing open resections. The aim of the study was to assess whether laparoscopy may eliminate the deleterious prognostic impact of sarcopenia and whether the combination with enhanced recovery after surgery (ERAS) protocol may improve postoperative recovery also in sarcopenic patients.

METHODS

The study included 124 (73M/51F, mean age 65.9 years) patients undergoing elective laparoscopic colorectal resection for cancer. In all of them 16-item ERAS protocol was applied. The L3 skeletal muscle area identified on a preoperative CT scan was used to calculate skeletal muscle index and assess for sarcopenia and myosteatosis. The entire study group was divided into groups regarding the presence of sarcopenia or myosteatosis. The outcome measures were: length of hospital stay, complication rate and functional recovery parameters.

RESULTS

The prevalence of sarcopenia and myosteatosis was 27.4% and 38.7%, respectively. There was no association between the presence of sarcopenia or myosteatosis and postoperative complications. There were also no differences in the length of stay or readmission rates. Functional recovery (time to first flatus, oral diet tolerance and mobilization) was similar regardless of the presence of muscle depletion.

CONCLUSIONS

In contrary to traditional surgical approach, laparoscopy can reduce the negative impact of sarcopenia and myosteatosis on treatment results. ERAS protocol does not affect negatively the surgical outcomes in sarcopenic patients, compared to patients without changes in body skeletal mass.

One hundred seventy-nine consecutive bariatric operations after introduction of protocol inspired by the principles of enhanced recovery after surgery (ERAS®) in bariatric surgery

Background

Obese patients are a very large high-risk group for complications after surgical procedures. In this group, optimized perioperative care and a faster recovery to full activity can contribute to a decreased rate of postoperative complications. The introduction of ERAS^®-based protocol is now even more important in bariatric surgery centers. The results of our study support the idea of implementation of ERAS^®-based protocol in this special group of patients.

Material/Methods

This analysis included 170 patients (62 male/108 female, mean BMI 46.7 kg/m²) who had undergone laparoscopic bariatric surgery, and whose perioperative care was conducted according to a protocol inspired by ERAS^® principles. Examined factors included oral nutrition tolerance, time until mobilization after surgery, requirements for opioids, duration of hospitalization, and readmission rate.

Results

During the first 24 postoperative hours, oral administration of liquid nutrition was tolerated by 162 (95.3%) patients and 163 (95.8%) were fully mobile. In 44 (25.8%) patients it was necessary to administer opioids to relieve pain. Intravenous liquid supply was discontinued within 24 hours in 145 (85.3%) patients. The complication rate was 10.5% (mainly rhabdomyolysis and impaired passage of gastric contents). The average time of hospitalization was 2.9 days and the readmission rate was 1.7%.

Conclusions

The introduction of an ERAS^® principles-inspired protocol in our center proved technically possible and safe for our patients, and allowed for reduced hospitalization times without increased rate of complications or readmissions.

Nutritional support teams: the cooperation among physicians and pharmacists helps improve cost-effectiveness of home parenteral nutrition (HPN)

INTRODUCTION

Modern home parenteral nutrition (HPN) requires the preparation of tailored admixtures. The physicians' demands for their composition are often at the variance with pharmaceutical principles, which causes the necessity of either the preparation of ex tempore admixtures or stability testing ensuring long shelf life. Both approaches are not cost-effective. The aim of the study was to use the cooperation among physicians and pharmacists to assure both: cost-effectiveness and patient-tailored HPN admixtures.

METHODS

The first part of the study consisted of the thorough analysis of prescriptions for the most demanding 47 HPN patients (27 females and 20 males, mean age 53.1 year) treated at one HPN center to create few as possible long-shelf life admixtures. The second part of the study consisted of stability testing and modifications.

RESULTS

The analysis showed over 137 variations needed to cover all macro- and micronutrients requirements. Their cost as ex-tempore solutions was extremely high (over 110 000 EURO/month) due to logistics and similarly high if stability test for variation were to be performed (68 500 EURO). Therefore prescription was prepared de novo within team of physicians and pharmacists and four base models were designed. Water and electrolytes, particularly magnesium and calcium showed to be the major issues. Stability tests failed in one admixture due to high electrolytes concentration. It was corrected, and the new formula passes the test. Five basic models were then used for creation of new bags. Cost of such an activity were 3 700 EURO (p<0.01) CONCLUSIONS: The cooperation within the members of nutritional support team could improve the cost-effectiveness and quality of HPN.

Occurrence of gastrointestinal side effects associated with early use of commercial diets in ITU patients

BACKGROUND

The purpose of this retrospective study was to analyse the occurrence of gastrointestinal side effects in enterally fed ITU patients.

METHODS

We analysed the records of 195 ITU patients fed enterally, over at least five days, with commercial mixtures administered as 20-h infusions. Gastric retention, the number of defecations, and incidents requiring discontinuation of enteral feeding, were noted during the first 3 days of nutrition.

RESULTS

Enteral nutrition was usually started during the first week of treatment (median 4, range: 1-33). In 118 patients receiving parenteral nutrition, the median day of implementing enteral feeding was day 5; some received enteral mixtures much earlier (day 2). The mean infusion rates of enteral mixtures were: 33 mL h-1 on day 1, 58 mL h-1 on day 2, and 68 mL h-1 on day 3. Gastric retention was observed in 49 (25.1%) patients during the first day, in 37 (19.0%) on day 2, and in 25 (12.8%) on day 3. Discontinuation of enteral nutrition was necessary in 6 patients due to: surgery (1), high gastric retention (4), gastrointestinal bleeding (1). A statistically significant correlation was found between the occurrence of gastric retention, infusion rates and CRP, and between the number of defecations and infusion rates.

CONCLUSIONS

Enteral feeding with commercial diets is well tolerated when implemented gradually. Intolerance and the need for the discontinuation of enteral feeding were usually associated with a worsening of the patient's general condition and progression of the underlying disease.

Analysis of nutrition mixtures in ITU patients

BACKGROUND

The aim of this study was to analyse the composition of parenteral nutrition (PN) mixtures used in the ITU.

METHODS

Restrospective analysis involved 2124 prescriptions for individual PN bags. They were administered over an 18-month period, to 160 ITU patients with the mean APACHE II score of 26 points (range: 5-61), calculated on admission. The mortality rate was 40%. Nutrition programs were prepared individually following the 2009 ESPEN guidelines. The prescription was modified according to the individual patient's clinical condition. One hundred and sixty prescriptions were analysed on the first day of PN (T1), 139 - on the second day (T2) and 1825 on the third and subsequent days (T3).

RESULTS

The mean energy supplies were: 1381 kcal/day (range: 456-2612) on T1, 1467 kcal/day (range: 524-2860) on T2, and 1654 kcal/day (range: 390-2969) on T3. The mean supplies of amino acids, glucose and lipids were as follows: amino acids 68.3 g/day (range:20-120) on T1; 71.6 g/ day (range:27.5-125) on T2; 88.0 g/day (range:11-196) on T3; glucose 210.25 g/day (range: 120- 400) on T1; 218.34 g/day (range: 65-480) on T2; 278.5 g/day (range: 18-520) on T3; lipids 34.9 g/ day (range: 0-100) on T1; 38.7 g/day (range: 0-100) on T2; 52.66 g/day (range: 0-117) on T3. The percentages of non-protein energy from lipids were: 29.25 (0-73) on T1; 31.58 (range: 0-60) on T2; 33.5 (0-60) on T3. The following statistically significant differences were found: T2-T3- (p<0.05).

CONCLUSIONS

The compositions of nutrition bags prepared for ITU patients were consistent with the ESPEN guidelines. The composition varied on different days of nutrition. The differences in the supply of nutrition components indirectly confirm the need for individual prescriptions for ITU patients.

Home enteral nutrition in children--2010 nationwide survey of the Polish Society for Clinical Nutrition of Children

Published epidemiologic data on the administration rates of enteral/parenteral home nutrition is very limited. The aim of this first nationwide study was to assess the availability of pediatric home enteral nutrition (HEN) services in Poland. The questionnaire was sent to all regional centers providing pediatric HEN services in Poland (n = 14). The analysis included the number of pediatric patients who received HEN in 2010, their demographic characteristics and geographical distribution. Furthermore, the distributions of indications and methods of enteral nutrition administration were analyzed, along with the reasons of withdrawal from the HEN program. The number and fraction of children receiving HEN increased in 2010, from 433 (11.34 per 1 million inhabitants) on January 1st to 525 (13.75) on December 31st. Marked differences were observed in geographical distribution of this parameter, from zero to up to 30 pediatric patients per 1 million inhabitants. Median age of patients was 6 years (range: 9 months-18 years). In most cases, HEN was prescribed due to neurological disorders (n = 337, 64.2%), and administered by means of gastrostomy (n = 450, 85.71%). This study revealed the dynamic development of pediatric HEN services in Poland but also documented their potential regional shortages.