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Background Since 2005, the Canadian home parenteral nutrition (HPN) registry has collected data on patients' demography, outcomes, and HPN clinical practice. At annual meetings, Canadian HPN programs review and discuss results. Aim To evaluate changes over time in patient demography, outcomes, and HPN clinical practice using the registry data. Methods This retrospective study evaluated 369 patients who were prospectively entered in the registry. Two periods were compared for the first data entry: 2005-2008 (n = 182) and 2011-2014 (n = 187). Patient demography, indications for HPN, HPN regimen, nutrition assessment, vascular access, and number of line sepsis per 1000 catheter days were evaluated. Results For 2011-2014 compared with 2005-2008, indications for HPN changed significantly, with an increased proportion of patients with cancer (37.9% vs 16.7%) and with fewer cases of short bowel syndrome (32% vs 65.5%); line sepsis rate decreased from 1.58 to 0.97 per 1000 catheter days; and the use of tunneled catheters decreased from 64.3% to 38.0% and was no longer the most frequently chosen vascular access method. In contrast, the proportion of peripherally inserted central catheters increased from 21.6% to 52.9%. In addition, there was a reduction in number and days of hospitalizations related to HPN, and favorable changes were noted in the prescription of energy, proteins, and trace elements. Conclusion The Canadian HPN registry is useful in tracking trends in demography, outcomes, and clinical practice. Results suggest a shift in patient demography and line access with improvement in line sepsis, hospitalizations, and HPN prescriptions.

The fatty acids, linoleic acid (18:2ω-6) and α-linolenic acid (18:3ω-3), are essential to the human diet. When these essential fatty acids are not provided in sufficient quantities, essential fatty acid deficiency (EFAD) develops. This can be suggested clinically by abnormal liver function tests or biochemically by an elevated Mead acid and reduced linoleic acid and arachidonic acid level, which is manifested as an elevated triene/tetraene ratio of Mead acid/arachidonic acid. Clinical features of EFAD may present later. With the introduction of novel intravenous (IV) lipid emulsions in North America, the proportion of fatty acids provided, particularly the essential fatty acids, varies substantially. We describe a case series of 3 complicated obese patients who were administered parenteral nutrition (PN), primarily using ClinOleic 20%, an olive oil-based lipid emulsion with reduced amounts of the essential fatty acids, linoleic and α-linolenic, compared with more conventional soybean oil emulsions throughout their hospital admission. Essential fatty acid profiles were obtained for each of these patients to investigate EFAD as a potential cause of abnormal liver enzymes. Although the profiles revealed reduced linoleic acid and elevated Mead acid levels, this was not indicative of the development of essential fatty acid deficiency, as reflected in the more definitive measure of triene/tetraene ratio. Instead, although the serum fatty acid panel reflected the markedly lower but still adequate dietary linoleic acid content and greatly increased oleic acid content in the parenteral lipid emulsion, the triene/tetraene ratio remained well below the level, indicating EFAD in each of these patients. The availability and use of new IV lipid emulsions in PN should encourage the clinician to review lipid metabolism based on the quantity of fatty acids provided in specific parenteral lipid emulsions and the expected impact of these lipid emulsions (with quite different fatty acid composition) on measured fatty acid profiles.

Nutrition leaders surmised graduate medical nutrition education was not well addressed because most medical and surgical specialties have insufficient resources to teach current nutrition practice. A needs assessment survey was constructed to determine resources and commitment for nutrition education from U.S. graduate medical educators to address this problem.An online survey of 36 questions was sent to 495 Accreditation Council for Graduate Medical Education (ACGME) Program Directors in anesthesia, family medicine, internal medicine, pediatrics, obstetrics/gynecology, and general surgery. Demographics, resources, and open-ended questions were included. There was a 14% response rate (72 programs), consistent with similar studies on the topic.Most (80%) of the program directors responding were from primary care programs, the rest surgical (17%) or anesthesia (3%). Program directors themselves lacked knowledge of nutrition. While some form of nutrition education was provided at 78% of programs, only 26% had a formal curriculum and physicians served as faculty at only 53%. Sixteen programs had no identifiable expert in nutrition and 10 programs stated that no nutrition training was provided. Training was variable, ranging from an hour of lecture to a month-long rotation. Seventy-seven percent of program directors stated that the required educational goals in nutrition were not met. The majority felt an advanced course in clinical nutrition should be required of residents now or in the future.Nutrition education in current graduate medical education is poor. Most programs lack the expertise or time commitment to teach a formal course but recognize the need to meet educational requirements. A broad-based, diverse universal program is needed for training in nutrition during residency.

In hospitals, length of stay (LOS) is a priority but it may be prolonged by malnutrition. This study seeks to determine the contributors to malnutrition at admission and evaluate its effect on LOS.This is a prospective cohort study conducted in 18 Canadian hospitals from July 2010 to February 2013 in patients ≥ 18 years admitted for ≥ 2 days. Excluded were those admitted directly to the intensive care unit; obstetric, psychiatry, or palliative wards; or medical day units. At admission, the main nutrition evaluation was subjective global assessment (SGA). Body mass index (BMI) and handgrip strength (HGS) were also performed to assess other aspects of nutrition. Additional information was collected from patients and charts review during hospitalization.One thousand fifteen patients were enrolled: based on SGA, 45% (95% confidence interval [CI], 42%-48%) were malnourished, and based on BMI, 32% (95% CI, 29%-35%) were obese. Independent contributors to malnutrition at admission were Charlson comorbidity index2, having 3 diagnostic categories, relying on adult children for grocery shopping, and living alone. The median (range) LOS was 6 (1-117) days. After controlling for demographic, socioeconomic, and disease-related factors and treatment, malnutrition at admission was independently associated with prolonged LOS (hazard ratio, 0.73; 95% CI, 0.62-0.86). Other nutrition-related factors associated with prolonged LOS were lower HGS at admission, receiving nutrition support, and food intake50%. Obesity was not a predictor.Malnutrition at admission is prevalent and associated with prolonged LOS. Complex disease and age-related social factors are contributors.

Given the high prevalence of malnutrition in hospitalized patients, nurses frequently encounter patients with significantly impaired nutrition status. The objective of this study was to determine nurses' attitudes and perceptions regarding the prevalence, detection, and causes of malnutrition in Canadian tertiary care and community hospitals.In this descriptive study, a survey that focused on guidelines for nutrition support of hospitalized patients was completed by Canadian nurses working on medical and surgical wards in 11 hospitals participating in the Canadian Malnutrition Task Force study.The survey was completed by 346 of 723 nurses (response rate 48%). Over 50% of nurses underestimated the documented prevalence of malnutrition in hospitalized patients. Nurses considered identification of malnourished patients very relevant (mean 8.4 on a 10-point scale) and would integrate a 3-question nutrition screen into their admission histories (92.5%). Nurses perceived lack of assistance with eating as a significant contributor to hospital malnutrition (17% felt this was a major contributor). While only 39% of nurses reported access to nutrition-related education, 92% were interested in receiving this form of updating.Nurses consider nutrition assessment important and relevant and require access to training to improve their capacity to detect malnutrition in their patients. Nurses are vital to the nutrition care of hospitalized patients and are well positioned to screen for nutrition risk and assist in nutrition management. The role of nurses in nutrition care needs to be linked to hospital policy.

Since malnutrition is common in Canadian hospitals, physicians frequently encounter patients with significantly impaired nutrition status. The objective of this study was to determine physician attitudes and perceptions regarding the detection and management of malnutrition in Canadian hospitals.A survey based on a previously developed questionnaire that focused on guidelines for nutrition support of hospitalized patients was completed by Canadian physicians working on wards in the 18 hospitals participating in the Canadian Malnutrition Task Force study. Data were analyzed descriptively and according to ward (medical vs surgical) and hospital type (academic vs community).The survey was completed by 428 of the 1220 physicians who were provided with a questionnaire and asked to participate (response rate 35%). While physicians believe that nutrition assessment should be performed at admission (364/419 [87%]), during hospitalization (363/421 [86%]), and at discharge (327/418 [78%]), most felt that this was not being done on a regular basis (admission, 140/423 [33%]; during hospitalization, 175/423 [41%]; at discharge, 121/424 [29%]). Similarly there was a gap between what was perceived to be the ideal management of hospital-related malnutrition and current practices. Physicians felt that the team's nutrition education and use of dietetic resources could be increased, and although their nutrition knowledge was limited, they felt that hospital-associated malnutrition was very relevant to the care they provided.A multidisciplinary team is needed to address hospital malnutrition, and educational strategies that target physicians are needed to promote better detection and management throughout the hospital stay.

Recent advances in nutrition therapy of the patient undergoing elective surgery have focused on greater utilization of the gut, feeding closer to the time of surgery, avoiding extensive bowel preparations or use of nasogastric tubes and drains, and measures to promote and maintain intestinal motility. Failure to have protocols in place for delivery of enteral nutrition (EN) through the perioperative period should not lead to inappropriate use of parenteral nutrition (PN) as a default therapy, because in many circumstances, standard therapy with no specialized nutrition support may be associated with better outcome. In cases where EN is not feasible and the patient shows evidence of malnutrition, surgery should be delayed 7-10 days to provide perioperative PN. For patients requiring urgent surgery where EN is not feasible, the initiation of PN postoperatively should be delayed 5-7 days. Whether alternative sources for lipid emulsion and availability of parenteral immune-modulating agents in the future can improve the risk/benefit ratio of PN and expand its use through the perioperative period awaits further study.

A significant obstacle to nutrition literacy among physicians is a paucity of physician nutrition specialists (PNSs) on medical school faculties who can effectively advocate for change in medical school and residency curricula, and who can serve as role models for incorporating nutrition into patient care. To address these issues, the Intersociety Professional Nutrition Education Consortium (IPNEC) developed a paradigm for PNSs that is designed to attract more physicians into the field; promulgated educational standards for fellowship training of PNSs; and established a unified mechanism for certifying PNSs, the American Board of Physician Nutrition Specialists (ABPNS). With a board of directors consisting of members nominated by 7 professional nutrition societies in addition to at-large members, the ABPNS incorporates broad participation by all professional nutrition societies that have substantial physician members. The ABPNS certificate is intended to be the premier comprehensive credential for physicians who wish to identify nutrition as an area of expertise. Certification is equally accessible to physicians with backgrounds in any of the specialties and subspecialties relevant to clinical nutrition. This article outlines the history and features of IPNEC and ABPNS and the consensus paradigm, training standards, and certification process they developed. We discuss achievements, opportunities, and challenges facing the maintenance of a consensus-based certification body in order to inform future initiatives designed to expand the number of physician nutrition specialists.

This study was conducted to develop evidence-based clinical practice guidelines for nutrition support (ie, enteral and parenteral nutrition) in mechanically ventilated critically ill adults.The following interventions were systematically reviewed for inclusion in the guidelines: enteral nutrition (EN) versus parenteral nutrition (PN), early versus late EN, dose of EN, composition of EN (protein, carbohydrates, lipids, immune-enhancing additives), strategies to optimize delivery of EN and minimize risks (ie, rate of advancement, checking residuals, use of bedside algorithms, motility agents, small bowel versus gastric feedings, elevation of the head of the bed, closed delivery systems, probiotics, bolus administration), enteral nutrition in combination with supplemental PN, use of PN versus standard care in patients with an intact gastrointestinal tract, dose of PN and composition of PN (protein, carbohydrates, IV lipids, additives, vitamins, trace elements, immune enhancing substances), and the use of intensive insulin therapy.The outcomes considered were mortality (intensive care unit [ICU], hospital, and long-term), length of stay (ICU and hospital), quality of life, and specific complications.We systematically searched MEDLINE and CINAHL (cumulative index to nursing and allied health), EMBASE, and the Cochrane Library for randomized controlled trials and meta-analyses of randomized controlled trials that evaluated any form of nutrition support in critically ill adults. We also searched reference lists and personal files, considering all articles published or unpublished available by August 2002. Each included study was critically appraised in duplicate using a standard scoring system.For each intervention, we considered the validity of the randomized trials or meta-analyses, the effect size and its associated confidence intervals, the homogeneity of trial results, safety, feasibility, and the economic consequences. The context for discussion was mechanically ventilated patients in Canadian ICUs.The major potential benefit from implementing these guidelines is improved clinical outcomes of critically ill patients (reduced mortality and ICU stay). Potential harms of implementing these guidelines include increased complications and costs related to the suggested interventions. SUMMARIES OF EVIDENCE AND RECOMMENDATIONS: When considering nutrition support in critically ill patients, we strongly recommend that EN be used in preference to PN. We recommend the use of a standard, polymeric enteral formula that is initiated within 24 to 48 hours after admission to ICU, that patients be cared for in the semirecumbent position, and that arginine-containing enteral products not be used. Strategies to optimize delivery of EN (starting at the target rate, use of a feeding protocol using a higher threshold of gastric residuals volumes, use of motility agents, and use of small bowel feeding) and minimize the risks of EN (elevation of the head of the bed) should be considered. Use of products with fish oils, borage oils, and antioxidants should be considered for patients with acute respiratory distress syndrome. A glutamine-enriched formula should be considered for patients with severe burns and trauma. When initiating EN, we strongly recommend that PN not be used in combination with EN. When PN is used, we recommend that it be supplemented with glutamine, where available. Strategies that maximize the benefit and minimize the risks of PN (hypocaloric dose, withholding lipids, and the use of intensive insulin therapy to achieve tight glycemic control) should be considered. There are insufficient data to generate recommendations in the following areas: use of indirect calorimetry; optimal pH of EN; supplementation with trace elements, antioxidants, or fiber; optimal mix of fats and carbohydrates; use of closed feeding systems; continuous versus bolus feedings; use of probiotics; type of lipids; and mode of lipid delivery.This guideline was peer-reviewed and endorsed by official representatives of the Canadian Critical Care Society, Canadian Critical Care Trials Group, Dietitians of Canada, Canadian Association of Critical Care Nurses, and the Canadian Society for Clinical Nutrition.This guideline is a joint venture of the Canadian Critical Care Society, the Canadian Critical Trials Group, the Canadian Society for Clinical Nutrition, and Dietitians of Canada. The Canadian Critical Care Society and the Institute of Nutrition, Metabolism, and Diabetes of the Canadian Institutes of Health Research provided funding for development of this guideline.

Patients who receive home total parenteral nutrition (TPN) frequently are supplied with solutions up to 30 days in advance of anticipated use. The purpose of this study was to determine the stability of trace elements relative to time and temperature conditions, in a typical adult TPN solution stored in a usual home environment by examining variations in delivery of intended trace elements and inadvertent trace element contamination.Trace element concentrations were determined using inductively coupled plasma-mass spectrometry technology. The effect of the delivery apparatus, storage duration (36 hours or 30 days) after compounding, and storage temperature (4 degrees C or 20 degrees C) were examined.The delivery apparatus contaminated the delivered TPN solution with cobalt but did not alter trace elements formulated into the TPN solution. Storage duration and temperature significantly decreased three (Zn, Cu, and Mn) of the six trace elements formulated into the TPN solution. Higher temperatures and longer duration of storage accelerated this decrease. Boron, Al, V, Ti, Ba, Sr, and CO were the trace elements that appeared as contaminants during storage. Boron, Al, V, and Ti contamination decreased with higher temperatures and longer duration of storage.Longer storage duration and higher storage temperature progressively reduced the deliverable concentrations of trace elements specifically formulated into the TPN solution and also of those trace elements that were not formulated into the TPN solution but that appeared as contaminants.