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BACKGROUND/OBJECTIVES: Parenteral nutrition (PN) should be provided to the malnourished patient if enteral feeding is insufficient or unsafe. A nutrition support team (NST) may improve PN services. We compared the use and complications of hospital PN before and after the implementation of an NST. SUBJECTS/METHODS: All inpatients referred for PN outside of the intensive care unit and the intestinal failure unit were prospectively included from 2009 to 2012. The NST was introduced in 2010. Quality improvement methodology was applied. RESULTS: In 2009, a mean of 16 (limits of normal variation 4-28) patients were referred for PN each month. After introduction of the NST, this rose to 26 (10-42) referrals per month. The percentage of referrals where PN was not initiated increased from 5.3% in 2009 to 10.1% in 2012 (P = 0.03). This increase was restricted to teams that infrequently referred for PN, and enteral nutrition could replace PN in 31 of 51 patients (61%) as compared with 8 of 32 (25%) patients referred from teams that frequently referred for PN (P = 0.001). The frequency of PN started owing to an insufficient oral or enteral intake decreased from 11% to 3% (P = 0.01). The catheter-related bloodstream infection rate dropped from 6.7 to 0.7 episodes per 1000 catheter days (P < 0.001). CONCLUSIONS: Introduction of an NST increased both the total PN use and the percentage of referrals where enteral nutrition could replace PN. Medical specialty influenced the referral pattern and the likelihood that a referral resulted in PN being initiated. Safety of PN catheters improved significantly following NST introduction. European Journal of Clinical Nutrition (2014) 68, 1294-1299; doi: 10.1038/ejcn.2014.186; published online 24 September 2014, INTRODUCTION Malnutrition remains a major risk factor for in-hospital morbidity and mortality. (1,2) A stepwise algorithm can be applied to patients who do not meet their nutritional requirements, (3,4) and [...]

BACKGROUND: Several guidelines recommend systematic screening for malnutrition in elderly inpatients for early dietary intakes assessment and treatment, but data demonstrating the efficacy of such interventions are scarce. The aim of this study was to evaluate a critical medical pathway for the detection and management of malnutrition in elderly inpatients. METHODS: In a 3-month prospective controlled study, 694 recently admitted inpatients were assigned to an intervention group (critical medical pathway; n = 465) or a standard care control group (n = 229). Nutritional status was assessed at the time of admission with a Mini Nutritional Assessment. A renutrition program tailored to the initial dietary assessment results was applied in the intervention group. The efficacy of the program was verified by measuring the evolution of serum insulin-like growth factor 1 (IGF-I) between admission and 3 weeks later. RESULTS: In the intervention group at baseline, 23% were malnourished, 51% were at risk and 26% were eunourished. Serum IGF-I increased in the intervention group (from 84 ± 45 µg/l to 95 [+ or -] 50 µg/l, P < 0.0001; mean ± s.d., n = 209), but remained stable in the controls (from 79 ± 43 [MICRO]g/l to 81 [+ or -] 35 [MICRO]g/l, P = 0.4;n = 99), with a statistically significant between group difference (P < 0.01). CONCLUSION: Early malnutrition assessment and targeted renutrition program in elderly inpatients were associated with an increase in serum IGF-I. It remains to be determined whether such variations are clinically relevant. European Journal of Clinical Nutrition (2013) 67, 1175-1181; doi: 10.1038/ejcn.2013.166; published online 16 October 2013 Keywords: Mini Nutritional Assessment; protein and energy malnutrition; length of stay; mortality; undernutrition; IGF-I, INTRODUCTION In Western countries, malnutrition prevalence is ~7-8% among adults and rises to 12-15% in the geriatric population. (1) Thirty to 60% of patients admitted to hospital are either malnourished [...]

BACKGROUND/OBJECTIVES: Recommendations state that all hospital patients should be screened for malnutrition and for each level of risk, a suitable care plan should be available. This study investigates current practice at ward level regarding adherence to a care plan generated from a nutrition screening tool, and then aims to improve basic nutritional support actions by modifying a care plan and finally evaluates change in practice. SUBJECTS/METHODS: Pro formas were completed on nutrition care plans of 100 patients. Subsequently, 7 focus groups were conducted, which included 30 ward staff and 6 dietitians. Care plans were re-designed using information from focus groups, followed by a second set of pro formas on the care plans of 103 patients. RESULTS: Themes regarding barriers and facilitators for completion of care plans were derived from the focus groups including: 'duplication', 'time pressures', 'leadership support', 'operational issues', 'document style' and 'training'. Pro formas before and after re-design showed that nutritional support actions increased from 13 (9%) to 98 (52%) for patients at moderate or severe risk of malnutrition (P = 0.033). CONCLUSIONS: Focus groups allowed engagement with ward staff to explore how care plans were used, which assisted in re-designing the care plan, while the pro formas identified limitations of initial procedures and then evaluated change. Subsequently, basic nutritional support actions that resulted from screening improved. The suitability of care plans to facilitate basic nutritional support and documentation was enhanced. However, improvements are still required, emphasising the necessity for continued training and a strategic approach to the delivery of basic nutritional care. doi: 10.1038/ejcn.2012.196; published online 12 December 2012 Keywords: MUST; screening; malnutrition; action plan; hospital; qualitative, INTRODUCTION Nutritional screening has been recommended by a number of reports including Food and Nutritional Care in Hospitals, (1) Nutrition Support in Adults, (2) Essence of Care (3) and Patient [...]

Background/Objectives: Nutritional intervention with oral nutritional supplements (ONS) has been shown to increase quality of life in malnourished patients. We investigated whether post-hospital supplementation with ONS is cost-effective according to international benchmarks in malnourished patients. Subjects/Methods: In total, 114 malnourished patients (50.6 [+ or -] 16.1 years, 57 female) with benign gastrointestinal disease were included and randomised to receive either ONS for 3 months and dietary counselling at discharge (intervention, n = 60) or only dietary counselling at discharge (control group, n = 54). Nutritional status was assessed with Subjective Global Assessment. Intervention patients documented daily intake of ONS; quality of life was assessed with Short-Form (SF)-36 Health Survey and SF-36 values were transformed into health-status utilities. Quality-adjusted life years (QALYs) were calculated by adopting the area under the curve method. We used two different pricing scenarios for ONS (minimum price: 2.30 € and maximum: 2.93 €/ tetrapack). The incremental cost-effectiveness ratio (ICER) of supplementation with ONS was calculated for both price scenarios. All analyses were corrected for age and gender. Results: Intervention patients consumed 2.4 ± 0.8 ONS per day. Intervention and control patients did not differ in their health status utilities at baseline (0.594 ± 0.017 vs 0.619 ± 0.018), but after 3 months, the health status utilities were significantly higher in intervention patients than in control patients (0.731 ± 0.015 vs 0.671 ± 0.016, P = 0.028). Intervention was associated with significantly higher costs (ICER: 9497 € and 12 099 €/additional QALY, respectively) but deemed cost-effective according to international thresholds ( Conclusions: A 3-month intervention with ONS increases quality of life in malnourished patients. This treatment appears to be cost-effective according to international benchmarks. European Journal of Clinical Nutrition (2011) 65, 735-742; doi: 10.1038/ejcn.2011.31; published online 16 March 2011 Keywords: disease-related malnutrition; cost-effectiveness; quality of life; nutritional supplements; quality of life adjusted life years, Introduction Disease-related malnutrition remains a major challenge in hospital, despite the growing body of evidence demonstrating both its clinical and economical consequences. Depending on the population, malnutrition affects approximately 25-50% [...]

Objective: A health economic analysis was performed to assess the cost-effectiveness of oral nutritional supplements (ONS), being a medical nutrition product, in the Netherlands. Methods: This analysis is based on a comparison of the use of ONS versus 'no use' of ONS in patients undergoing abdominal surgery. The costs and benefits of the two treatment strategies were assessed using a linear decision analytical model reflecting treatment patterns and outcomes in abdominal surgery. The incremental cost difference was based on costs associated with ONS and hospitalization. Clinical probabilities and resource utilization were based on clinical trials and published literature; cost data were derived from official price tariffs. Results: The use of ONS reduces the costs with a 252 € (7.6%) cost saving per patient. The hospitalization costs reduce from 3,318 € to 3,044 € per patient, which is a 8.3% cost saving and corresponds with 0.72 days reduction in length of stay. The use of ONS would lead to an annual cost saving of a minimum of 40.4 million € per year. Sensitivity analyses showed that the use of ONS remains cost saving compared with 'no use' of ONS. A threshold analysis on the length of stay shows that at 0.64 days, the use of ONS is still cost-effective, which is an unrealistic value. Conclusions: This analysis shows that the use of medical nutrition, ONS in this case, is a cost-effective treatment in the Netherlands and is dominant over standard care without medical nutrition: it leads to cost savings and a higher effectiveness. European Journal of Clinical Nutrition (2010) 64, 1229-1234; doi: 10.1038/ejcn.2010.147; published online 18 August 2010 Keywords: medical nutrition; cost-effectiveness; health economic model; oral nutritional supplements, Introduction Nutritional depletion in Western countries is usually caused by the joint action of an underlying disease, for example, cancer and dietary deficiency (Naber et al., 1997), also known as [...]

Objective: To evaluate diagnostic instruments for assessment of nutritional status in patients with rheumatoid arthritis (RA) in relation to objective body composition data. Subjects and methods: Study subjects include 60 in-ward patients (83% women, median age 65 years). Anthropometric measures and the nutritional tools Mini Nutritional Assessment (MNA), Subjective Global Assessment (SGA), Malnutrition Universal Screening Tool (MUST) and Nutritional Risk Screening tool 2002 (NRS-2002). Body composition was determined by dual-energy X-ray absorptiometry and fat-free mass index (FFMI; kg/[m.sup.2]) and fat mass index (FMI; kg/[m.sup.2]) were calculated. Results: Mean body mass index (BMI) for RA women and men were 24.4 and 26.9 kg/[m.sup.2], respectively. Twelve per cent of the women and none of the few men had BMI < 18.5 kg/[m.sup.2], that is, the cutoff value for malnutrition. FFMI indicated 52% of the women and 30% of the men to be malnourished. The sensitivity and specificity for BMI to detect malnutrition according to FFMI were 27 and 100%, whereas for arm muscle circumference the sensitivity was 36% and the specificity 89% and for triceps skin fold 43 and 93%, respectively. For MNA, sensitivity was 85% and specificity 39% and for SGA 46 and 82%. Both MUST and NRS-2002 had sensitivity of 45% and specificity of 19%. Conclusion: A large proportion of in-ward RA patients had reduced FFMI. Concurrent elevation of fat mass made BMI a nonreliable tool to detect malnutrition. Of the tested clinical evaluation tools, MNA might be used as a screening instrument, but because of its low specificity it should be followed by body composition determination. doi:10.1038/sj.ejcn.1602845; published online 18 July 2007 Keywords: rheumatoid arthritis; body composition; fat-free mass; fat-free mass index; nutritional questionnaires; body mass index, Introduction Rheumatoid arthritis (RA) is a chronic, systemic, autoimmune disease that causes destruction of joint cartilage and bone. In addition, the inflammation makes the patients exposed to catabolic effects. This [...]

Objective: Evaluation of the influence of intradialytic parenteral nutrition (IDPN) in patients suffering from Malnutrition-Inflammation Complex Syndrome (MICS) on nutritional status, inflammation, adipocytokines and serum lipids. Subjects: Six patients with MICS were assigned to IDPN, whereas six patients matched for age, sex, body mass index (BMI) and co-morbidity without malnutrition served as controls. Patients were recruited from Outpatient Dialysis Unit, Medical University Innsbruck and from Dialysis Unit, Hospital Feldkirch. Results: In all patients with IDPN, dry body weight increased during the interventional period whereas body weight remained stable in patients without IDPN. Tumor necrosis factor (TNF)-[alpha] levels were higher in patients with MICS compared with controls at all time points. Total cholesterol, LDL- and HDL-levels significantly increased during dialysis at all time points in controls but not in patients with MICS. Albumin, C-reactive protein, interleukin-6 (IL-6), soluble interleukin-2 receptor (sIL-2R) and adipocytokines did not differ between patients and controls during the study period. Conclusions: IDPN in patients with MICS increases body weight despite not influencing inflammatory status. Furthermore, IDPN does not induce a pro-atherogenic lipid composition enhancing the risk for atherosclerosis. Thus, IDPN is a safe and effective treatment of malnutrition in patients with MICS. doi:10.1038/sj.ejcn.1602777; published online 16 May 2007 Keywords: MICS; intradialytic parenteral nutrition; hemodialysis, Introduction In patients with end-stage renal disease (ESRD), malnutrition is a common problem and has been claimed to influence morbidity and even mortality (Capelli et al., 1994; Kopple, 1997; Kalantar-Zadeh [...]

Malnutrition may result in a phosphate-deficient state owing to a chronically insufficient phosphate intake. Concomitant iron deficiency is common and often supplemented by the intravenous route. It is not widely recognized that some parenteral iron formulations can induce hypophosphatemia. Herein we report a case of a severe and symptomatic hypophosphatemia (0.18 mM, normal range 0.8-1.4 mM) associated with an inappropriately reduced tubular reabsorption of phosphate (33%, norm >95%) in a malnourished patient with anorexia/bulimia who received 2 x 500 mg iron carboxymaltose (FCM) intravenously. Despite intravenous and oral phosphate supplements, it required 2 months to achieve a normal serum phosphate level. Our case demonstrates that in a chronically malnourished and phosphate-deficient state intravenous FCM could potentially be dangerous. If this form of iron application cannot be avoided, phosphate supplementation before and after iron infusion as well as close monitoring of phosphate levels are needed. European Journal of Clinical Nutrition (2014) 68, 531-533; doi:10.1038/ejcn.2014.20; published online 26 February 2014, INTRODUCTION Intravenous iron carboxymaltose (FCM) administration has been reported to induce hypophosphatemia. (1-4) Severe hypophosphatemia (< 0.32 mM (normal range 0.8-1.4 mM)) can result in a variety of clinical symptoms [...]

Malnutrition is a common problem in HIV-seropositive people, according to research undertaken among people attending an AIDS clinic in Paris, France. Preventing, detecting, monitoring and treating malnutrition can have a positive impact on the survival and quality of life of HIV-seropositive people. It is important to maintain patients in a good nutritional state so that they are more able to cope with nutritional disorders linked with episodes of opportunistic infections.

Total parenteral nutrition (TPN) benefits patients with malnutrition whose oral intake is insufficient to meet their daily nutritional requirement. Peripheral vein TPN is most suited for parenteral administration as it provides the energy requirements for hospitalized patients who do not exceed 2000 kcal/day. However, many patients receiving preoperative nutritional support do not withstand the metabolic and fluid overload of TPN resulting in myocardial insufficiency and impaired psychomotor functions.