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  1. Karim SA, Ibrahim B, Tangiisuran B, Davies JG
    JPEN J Parenter Enteral Nutr, 2015 May;39(4):482-8.
    PMID: 24590009 DOI: 10.1177/0148607114525209
    Malnutrition is one of the health problems that can be prevented by appropriate nutrition care provided by healthcare providers. However, this practice is still lacking possibly because of the providers' inadequate knowledge. The aim of this study was to evaluate the self-reported knowledge, attitudes, and practices of pharmacists and doctors toward nutrition support in a tertiary care hospital setting.
  2. Ng CC, Lee ZY, Chan WY, Jamaluddin MF, Tan LJ, Sitaram PN, et al.
    JPEN J Parenter Enteral Nutr, 2020 03;44(3):425-433.
    PMID: 31173666 DOI: 10.1002/jpen.1666
    BACKGROUND: Low muscularity (LM) is associated with high mortality in the Caucasian critically ill population. Muscularity can be accurately measured by the skeletal muscle index (SMI; cm2 /m2 ) generated by computed tomography (CT). This study aimed to establish the overall and sex-specific cutoff values that predict hospital mortality in an Asian critically ill population.

    METHODS: This single-center, retrospective, observational study included patients aged ≥18 years with an abdominal CT conducted within 72 hours of admission to the intensive care unit. SMI generated from CT images at the level of the mid-third lumbar vertebra were extracted from the medical records. Area under the receiver operating characteristic curves (AUC) was generated to determine the SMI cutoff values for hospital mortality. Association between LM (defined by SMI cutoff value) and hospital mortality was further evaluated by multivariable logistic regression.

    RESULTS: In a sample of 228 patients, the overall SMI cutoff value (cm2 /m2 ) for hospital mortality was 42.0 (AUC: 0.637; sensitivity: 66.7%, specificity: 56.8%), whereas it was 46.5 in males and 35.3 in females. More males than females had LM (51.4% vs 37.5%), and >40% of overweight/obese patients had LM. Patients with LM were older and had a longer duration of mechanical ventilation and hospitalization. After adjusting for known confounders, LM independently predicted hospital mortality in the overall sample (adjusted odds ratio: 2.42; 95% CI 1.16-5.03; P = 0.003) and in both sexes.

    CONCLUSION: This study established a set of SMI cutoff values that predict hospital mortality. LM is independently associated with hospital mortality.

  3. Rosli D, Shahar S, Manaf ZA, Lau HJ, Yusof NYM, Haron MR, et al.
    JPEN J Parenter Enteral Nutr, 2021 02;45(2):277-286.
    PMID: 32740950 DOI: 10.1002/jpen.1987
    BACKGROUND: Radiation therapy is the treatment of pelvic cancers, with diarrhea often being the most frequent acute side effect. This study aimed to determine the efficacy of partially hydrolyzed guar gum (PHGG) usage in reducing radiotherapy-induced diarrhea and improving bacterial count, nutrition status, and quality of life (QoL) among cancer patients.

    METHODS: Adult patients undergoing pelvic radiation were recruited and randomly assigned to receive supplementation of either 10 g of PHGG or placebo (maltodextrin) twice daily, 14 days prior and 14 days during pelvic radiation. Diarrhea frequency, fecal samples, nutrition status, and QoL were assessed at baseline and days 14, 28 (2 weeks after pelvic radiation), and 45 (at the completion of pelvic radiation, 2 weeks' postsupplementation).

    RESULTS: A total of 30 patients (mean age 56.5 ± 10.8 years, 75% malnourished) participated. The mean of diarrhea frequency in the intervention group (IG) was higher compared with the control group (CG) from days 14 and 28 but reduced at day 45. There was a significant intervention effect after controlling for confounders (ie, baseline diarrhea, age, nutrition status) (P < .05). Bifidobacterium count increased by double among the IG at 14 days of PHGG supplementation, whereas such trend was not observed in the CG.

    CONCLUSION: Supplementation of PHGG potentially increased the bifidobacterial count and seemed to have post-supplementation effects by reducing the frequency of diarrhea upon the completion of pelvic radiation treatment.

  4. Lee ZY, Hasan MS, Day AG, Ng CC, Ong SP, Yap CSL, et al.
    PMID: 34021917 DOI: 10.1002/jpen.2194
    BACKGROUND: Nutrition risk, sarcopenia, and frailty are distinct yet inter-related. They may be due to suboptimal or prevented by optimal nutrition intake. The combination of nutrition risk (modified nutrition risk in the critically ill [mNUTRIC]), sarcopenia (SARC-CALF) and frailty (clinical frailty scale [CFS]) in a single score may better predict adverse outcomes and prioritizing resources for optimal nutrition (and exercise) in the intensive care unit (ICU).

    METHODS: This is a retrospective analysis of a single-center prospective observational study that enrolled mechanically ventilated adults with expected ≥96 hours ICU stay. SARC-F and CFS questionnaires were administered to patient's next-of-kin and mNUTRIC were calculated. Calf-circumference was measured at the right calf. Nutrition data was collected from nursing record. The high-risk scores (mNUTRIC ≥5, SARC-CALF >10 or CFS ≥4) of these variables were combined to become the NUTRIC-SF score (range: 0-3).

    RESULTS: Eighty-eight patients were analyzed. Multiple logistic model demonstrated increasing mNUTRIC score was independently associated with 60-day mortality while increasing SARC-CALF and CFS showed a strong trend towards higher 60-day mortality. Discriminative ability of NUTRIC-SF for 60-day mortality is better than it's component (AUROC 0.722, 95% confidence interval [CI] 0.677-0.868). Every increment of 300 kcal/day and 30 g/day is associated with a trend towards higher rate of discharge alive for high [≥2; Adjusted Hazard Ratio 1.453 (95% CI 0.991-2.130) for energy, 1.503 (95% CI 0.936-2.413) for protein] but not low (<2) NUTRIC-SF score.

    CONCLUSION: NUTRIC-SF score may be a clinically relevant risk stratification tool in the ICU. This article is protected by copyright. All rights reserved.

  5. Lew CCH, Lee ZY, Day AG, Heyland DK
    PMID: 34292628 DOI: 10.1002/jpen.2234
    BACKGROUND: The correlation between gastric residual volumes (GRVs) and markers of gastric emptying (GE) in critically ill patients is unclear. This particularly applies to critically ill surgical patients, as they are underrepresented in previous studies.

    METHODS: We conducted a post hoc analysis of a multicenter trial that investigated the effectiveness of a promotility drug. Pharmacokinetic markers of GE (3-O-methylglucose [3-OMG] and acetaminophen) were correlated with GRV measurements. High GRV was defined as one episode of >400 ml or two consecutive episodes of >250 ml, and delayed GE was defined as <20th percentile of the pharmacokinetic GE marker that had the strongest correlation with GE.

    RESULTS: Of 77 patients, 8 (10.4%) had high GRV, and 15 (19.5%) had delayed GE. The 3-OMG concentration at 60 min had the strongest correlation with GRV (ρ = -0.631), and high GRV had low sensitivity (46.7%) but high specificity (98.4%) in discriminating delayed GE. The positive (87.5%) and negative (88.4%) predictive values were similar. Compared with medical patients, surgical patients (n = 14, 18.2%), had a significantly higher incidence of high GRV (29% vs 6%, P = .032) and a trend toward delayed GE (36% vs 16%, P = .132).

    CONCLUSION: GRV reflects GE, and high GRV is an acceptable surrogate marker of delayed GE. From our preliminary observation, surgical patients may have a higher risk of high GRV and delayed GE. In summary, GRV should be monitored to determine whether complex investigations or therapeutic interventions are warranted.

  6. Sahathevan S, Khor BH, Yeong CH, Tan TH, Meera Mohaideen AK, Ng HM, et al.
    JPEN J Parenter Enteral Nutr, 2021 02;45(2):422-426.
    PMID: 32384179 DOI: 10.1002/jpen.1867
    BACKGROUND: Muscle wasting, prevalent in maintenance hemodialysis (HD) patients diagnosed with protein-energy wasting, represents an assessment challenge in the outpatient HD setting. Quadriceps muscle thickness (QMT) and cross-sectional area (CSA) assessment by ultrasound (US) is a potential surrogate measure for muscle wasting. We aimed to determine the validity of US to measure QMT and CSA against the gold standard-computed tomography (CT).

    METHODS: Twenty-six patients on HD underwent US and CT scans on the same day, postdialysis session. QMT for rectus femoris (RF) and vastus intermedius (VI) muscles was taken at the midpoint (MID) and two-thirds (2/3) of both thighs and CSA of the RF muscle (RFCSA ), respectively. Correlation between US and CT measurements was determined by intraclass correlation coefficient (ICC) and Bland-Altman plot.

    RESULTS: ICC (95% CI) computed between US and CT was 0.94 (0.87-0.97), 0.97 (0.93-0.99), 0.94 (0.87-0.97), 0.94 (0.86-0.97), and 0.92 (0.83-0.97) for RFMID , VIMID, RF2/3, VI2/3 , and RFCSA , respectively (all P < 0.001). Bland-Altman analysis indicated no bias in agreement between both methods.

    CONCLUSION: The US imaging offers a valid and quick bedside assessment approach to assess muscle wasting in HD patients.

  7. Sahathevan S, Khor BH, Yeong CH, Tan TH, Meera Mohaideen AK, Ng HM, et al.
    JPEN J Parenter Enteral Nutr, 2021 07;45(5):872-873.
    PMID: 34165200 DOI: 10.1002/jpen.2206
  8. Stoppe C, Lee ZY, Ortiz L, Heyland DK, Patel JJ
    PMID: 35088422 DOI: 10.1002/jpen.2338
    Vitamin C is an essential micronutrient with antioxidant properties and its use in critical illness has gained interest in recent years.1 Four systematic reviews/meta-analyses (SRMAs) have been published in 2021 alone (see Table 1 summary).2-5 These 4 SRMAs included between 8-43 randomized controlled trials evaluating vitamin C with or without thiamine and/or corticosteroids in general ICU patients and those with sepsis and septic shock. 2-5 Fujii et al performed a network meta-analysis which is a method for comparing multiple treatments using both direct and indirect evidence across trials that included studies with vitamin C monotherapy or with thiamine and/or corticosteroids.9 This article is protected by copyright. All rights reserved.
  9. Stoppe C, Dresen E, Wendt S, Elke G, Patel JJ, McKeever L, et al.
    JPEN J Parenter Enteral Nutr, 2023 Jul;47(5):604-613.
    PMID: 36912124 DOI: 10.1002/jpen.2495
    BACKGROUND: Cardiac surgery patients with a prolonged stay in the intensive care unit (ICU) are at high risk for acquired malnutrition. Medical nutrition therapy practices for cardiac surgery patients are unknown. The objective of this study is to describe the current nutrition practices in critically ill cardiac surgery patients worldwide.

    METHODS: We conducted a prospective observational study in 13 international ICUs involving mechanically ventilated cardiac surgery patients with an ICU stay of at least 72 h. Collected data included the energy and protein prescription, type of and time to the initiation of nutrition, and actual quantity of energy and protein delivered (maximum: 12 days).

    RESULTS: Among 237 enrolled patients, enteral nutrition (EN) was started, on average, 45 h after ICU admission (range, 0-277 h; site average, 53 [range, 10-79 h]). EN was prescribed for 187 (79%) patients and combined EN and parenteral nutrition in 33 (14%). Overall, patients received 44.2% (0.0%-117.2%) of the prescribed energy and 39.7% (0.0%-122.8%) of the prescribed protein. At a site level, the average nutrition adequacy was 47.5% (30.5%-78.6%) for energy and 43.6% (21.7%-76.6%) for protein received from all nutrition sources.

    CONCLUSION: Critically ill cardiac surgery patients with prolonged ICU stay experience significant delays in starting EN and receive low levels of energy and protein. There exists tremendous variability in site performance, whereas achieving optimal nutrition performance is doable.

  10. Adam A, Ibrahim NA, Tah PC, Liu XY, Dainelli L, Foo CY
    JPEN J Parenter Enteral Nutr, 2023 Nov;47(8):1003-1010.
    PMID: 37497593 DOI: 10.1002/jpen.2554
    BACKGROUND: Prevention of enteral feeding interruption (EFI) improves clinical outcomes of critically ill intensive care unit (ICU) patients. This leads to shorter ICU stays and thereby lowers healthcare costs. This study compared the cost of early use of semi-elemental formula (SEF) in ICU vs standard polymeric formula (SPF) under the Ministry of Health (MOH) system in Malaysia.

    METHODS: A decision tree model was developed based on literature and expert inputs. An epidemiological projection model was then added to the decision tree to calculate the target population size. The budget impact of adapting the different enteral nutrition (EN) formulas was calculated by multiplying the population size with the costs of the formula and ICU length of stay (LOS). A one-way sensitivity analysis (OWSA) was conducted to examine the effect each input parameter has on the calculated output.

    RESULTS: Replacing SPF with SEF would lower ICU cost by MYR 1059 (USD 216) per patient. The additional cost of increased LOS due to EFI was MYR 5460 (USD 1114) per patient. If the MOH replaces SPF with SEF for ICU patients with high EFI risk (estimated 7981 patients in 2022), an annual net cost reduction of MYR 8.4 million (USD 1.7 million) could potentially be realized in the MOH system. The cost-reduction finding of replacing SPF with SEF remained unchanged despite the input uncertainties assessed via OWSA.

    CONCLUSION: Early use of SEF in ICU patients with high EFI risk could potentially lower the cost of ICU care for the MOH system in Malaysia.

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