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Clinical Nutrition ESPEN Aug 2020Nutritional interventions may improve quality of life, morbidity and mortality in gastric cancer (GC) patients. A growing number of randomized controlled trials (RCTs)... (Meta-Analysis)
Meta-Analysis
BACKGROUND & AIMS
Nutritional interventions may improve quality of life, morbidity and mortality in gastric cancer (GC) patients. A growing number of randomized controlled trials (RCTs) evaluated different nutritional strategies - oral nutritional supplements (ONS), enteral nutrition (EN), enteral immunonutrition (EIN), parenteral nutrition (PN) and nutritional counselling - in GC patients. This systematic review and meta-analysis aims to assess the effects of these nutritional interventions on nutritional status of GC patients undergoing gastrectomy and/or chemotherapy.
METHODS
A systematic literature search was performed in Pubmed, Web of Science and Scopus databases from inception to March 2020, based on fixed inclusion and exclusion criteria. Effect sizes were estimated with mean difference (MD) or standard mean difference (SMD) with 95% confidence interval (CI) and heterogeneity was assessed by measuring inconsistency (I) based on chi-squared test. Pooled analyses and quality assessment were performed with Review Manager 5.3.
RESULTS
A total of 25 RCTs were identified, including ONS (n = 7), EN (n = 6), PN (n = 4), EIN (n = 5) and nutrition counselling (n = 3) interventions. Ten RCTs with 1838 patients were deemed eligible for pooled analyses. Body weight loss was found lower in ONS group versus control group (MD 0.77; 95% CI -0.02-1.56; p = 0.05). PN and EIN studies did not assess body weight, while all nutrition counselling studies did not show significant differences (p > 0.05). Twenty-three out of 25 studies evaluated serum protein levels - albumin (ALB) and/or prealbumin (PA) and/or transferrin (TF). ALB levels did not significantly differ (p > 0.05) in 4 ONS studies. Significant improvements of PA levels from baseline to postoperative day (POD) ≥ 7 were shown in EN compared with PN groups (MD 19.90; 95% CI 10.09-29.70; p < 0.0001). Compared with EN, EIN interventions showed no significant improvements of ALB, PA and TF levels (p > 0.05) from baseline to POD ≥ 7. Amino-acid enriched PN showed no significant improvements of ALB, PA and TF levels (p > 0.05) while the effect of omega-3 enriched PN was debated. Only three studies out of 25 evaluated total fat mass and skeletal muscle mass and no significant differences (p > 0.05) were found between ONS versus control groups.
CONCLUSIONS
Whereas our meta-analysis showed promising results from ONS and EN interventions the optimal delivery of GC nutritional support and nutritional status assessment are still unclear. Moreover, the majority of studies did not consider muscle mass and strength as nutritional parameters. This review highlights the crucial need to close this research gap, with high-quality, large RCTs, adopting effective nutritional assessment tools to evaluate the appropriateness of nutrition strategies.
Topics: Enteral Nutrition; Humans; Nutritional Status; Parenteral Nutrition; Randomized Controlled Trials as Topic; Stomach Neoplasms
PubMed: 32690170
DOI: 10.1016/j.clnesp.2020.05.007 -
European Journal of Pediatrics Jun 2023The practice of withholding feed during therapeutic hypothermia (TH) in neonates with hypoxemic ischemic encephalopathy (HIE) is based on conventions rather than... (Meta-Analysis)
Meta-Analysis
The practice of withholding feed during therapeutic hypothermia (TH) in neonates with hypoxemic ischemic encephalopathy (HIE) is based on conventions rather than evidence. Recent studies suggest that enteral feeding might be safe during TH. We systematically compared the benefits and harms of enteral feeding in infants undergoing TH for HIE. We searched electronic databases and trial registries (MEDLINE, CINAHL, Embase, Web of Science, and CENTRAL) until December 15, 2022, for studies comparing enteral feeding and non-feeding strategies. We performed a random-effects meta-analysis using RevMan 5.4 software. The primary outcome was the incidence of stage II/III necrotizing enterocolitis (NEC). Other outcomes included the incidence of any stage NEC, mortality, sepsis, feed intolerance, time to full enteral feeds, and hospital stay. Six studies ((two randomized controlled trials (RCTs) and four nonrandomized studies of intervention (NRSIs)) enrolling 3693 participants were included. The overall incidence of stage II/III NEC was very low (0.6%). There was no significant difference in the incidence of stage II/III NEC in RCTs (2 trials, 192 participants; RR, 1.20; 95% CI: 0.53 to 2.71, I, 0%) and NRSIs (3 studies, no events in either group). In the NRSIs, infants in the enteral feeding group had significantly lower sepsis rates (four studies, 3500 participants, RR, 0.59; 95% CI: 0.51 to 0.67, I-0%) and lower all-cause mortality (three studies, 3465 participants, RR: 0.43; 95% CI: 0.33 to 0.57, I-0%) than the infants in the "no feeding" group. However, no significant difference in mortality was observed in RCTs (RR: 0.70; 95% CI: 0.28 to 1.74, I-0%). Infants in the enteral feeding group achieved full enteral feeding earlier, had higher breastfeeding rates at discharge, received parenteral nutrition for a shorter duration, and had shorter hospital stays than the control group. Conclusion: In late preterm and term infants with HIE, enteral feeding appears safe and feasible during the cooling phase of TH. However, there is insufficient evidence to guide the timing of initiation, volume, and feed advancement. What is Known: • Many neonatal units withhold enteral feeding during therapeutic hypothermia, fearing an increased risk of complications (feed intolerance and necrotizing enterocolitis). • The overall risk of necrotizing enterocolitis in late-preterm and term infants is extremely low (< 1%). What is New: • Enteral feeding during therapeutic hypothermia is safe and does not increase the risk of necrotizing enterocolitis, hypoglycemia, or feed intolerance. It may reduce the incidence of sepsis and all-cause mortality until discharge.
Topics: Infant, Newborn; Humans; Infant, Premature; Enterocolitis, Necrotizing; Infant, Premature, Diseases; Sepsis; Infant, Newborn, Diseases; Hypoxia-Ischemia, Brain; Stroke; Hypothermia, Induced; Randomized Controlled Trials as Topic
PubMed: 37014443
DOI: 10.1007/s00431-023-04950-0 -
Nutrients Feb 2023The need for high quality evidence is recognized for optimizing practices of parenteral nutrition (PN). The purpose of the present systematic review is to update the... (Review)
Review
The need for high quality evidence is recognized for optimizing practices of parenteral nutrition (PN). The purpose of the present systematic review is to update the available evidence and investigate the effect of standardized PN (SPN) vs. individualized PN (IPN) on protein intake, immediate morbidities, growth, and long-term outcome in preterm infants. A literature search was performed on articles published in the period from 1/2015 to 11/2022 in PubMed and Cochrane database for trials on parenteral nutrition in preterm infants. Three new studies were identified. All new identified trials were nonrandomized observational trials using historical controls. SPN may increase weight and occipital frontal circumference gain and lower the value of maximum weight loss. More recent trials suggest that SPN may easily increase early protein intake. SPN may reduce the sepsis incidence, but overall, no significant effect was found. There was no significant effect of standardization of PN on mortality or stage ≥2 necrotizing enterocolite (NEC) incidence. In conclusion SPN may improve growth through higher nutrient (especially protein) intake and has no effect on sepsis, NEC, mortality, or days of PN.
Topics: Infant; Infant, Newborn; Humans; Infant, Premature; Sepsis; Weight Loss; Parenteral Nutrition; Incidence; Enterocolitis, Necrotizing
PubMed: 36904223
DOI: 10.3390/nu15051224 -
Clinical Nutrition ESPEN Apr 2023Peripheral parenteral nutrition (PPN) refers to the delivery of artificial nutrition via a peripheral intravenous cannula. As a nutritional intervention it remains... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Peripheral parenteral nutrition (PPN) refers to the delivery of artificial nutrition via a peripheral intravenous cannula. As a nutritional intervention it remains under-utilised in peri-operative care. This is despite purported advantages which includes avoiding the risks associated with central venous lines and preventing potential delays to the initiation of nutrition support. This systematic review and meta-analysis will detail the available evidence for PPN use in surgery.
METHODS
A comprehensive search of the EMBASE and Medline databases was undertaken to identify randomised control trials (RCTs) involving PPN use in surgical patients published until July 30th 2022. Three domains of PPN use were reviewed including: PPN compared to crystalloid intravenous fluids on nutritional and clinical outcomes; PPN compared to Central PN (CPN) on nutritional outcomes and complications; and strategies to prevent thrombophlebitis associated with PPN.
RESULTS
The meta-analysis included 8 studies which included 698 patients. Use of PPN led to reduced post-operative weight loss (% body weight change) with a mean difference of -1.45% (95% CI -2.9 to -0.01, p = 0.05). There was no statistically significant difference in terms of length of stay, infectious/non-infectious complications, surgical site infections or phlebitis. 42 RCTs were included in the systematic review. 14 RCTs compared PPN to crystalloid infusion. There was significant heterogeneity in the trial populations, interventions and measured outcomes. Most trials found that PPN may improve nitrogen balance and positively impact nutritional markers. Quality of life and post-operative complications were either improved or no difference found in trials assessing these outcomes. Four RCTs showed that PPN is a safe and feasible alternative to CPN. 22 RCTs reported on measures that may impact on thrombophlebitis rates associated with PPN. These included lower osmolality of PPN solution, cyclical PPN delivery, use of a small gauge polyurethane cannula in an upper limb vein, addition of heparin/hydrocortisone to PPN solutions and placement of a GTN patch over infusion sites.
CONCLUSION
PPN is a safe and effective mode of delivery of peri-operative nutrition. It is a feasible short-term alternative to central-line delivered PN. There are a number of strategies to reduce thrombophlebitis associated with PPN use. Further high-quality RCTs are required to assess the use of PPN in contemporary surgical practice.
Topics: Humans; Parenteral Nutrition; Nutritional Support; Parenteral Nutrition Solutions; Thrombophlebitis; Nutritional Status
PubMed: 36963880
DOI: 10.1016/j.clnesp.2023.02.004 -
Nutrition (Burbank, Los Angeles County,... May 2022We performed a systematic review to study the effect of enteral and parenteral energy intakes on neurodevelopment (NDV) and cerebral growth in preterm infants, evaluated... (Review)
Review
OBJECTIVES
We performed a systematic review to study the effect of enteral and parenteral energy intakes on neurodevelopment (NDV) and cerebral growth in preterm infants, evaluated by NDV scales, magnetic resonance imaging, and head circumference (HC).
METHODS
The MEDLINE, Scopus, and ISI Web of Knowledge databases were searched, using the following medical subject headings and terms: "Premature infants," "nutrition," "brain," "nervous system/growth," and "development." A manual search of the reference lists of all eligible articles was conducted. Studies in which the intervention applied was different energy intakes in parenteral nutrition and/or enteral nutrition (EN) during the first weeks of life and NDV was investigated were included. Data regarding nutrition and NDV were collected and analyzed.
RESULTS
Thirty-five studies were included, of which 12 were randomized controlled trials (RCTs) and 23 were cohort studies. Eight RCTs and 15 cohort studies investigated NDV using NDV scales. Of these studies, two RTCs and five cohort studies found no significant difference in NDV evaluated with the Bayley scale between neonates fed high-caloric nutrition and those who received lower energy intakes during early life. In one RCT and two cohort studies was observed a positive effect of EN on NDV. Conversely, in one cohort study, a negative correlation between parenteral energy intake and NDV was described. The analysis of the data from RCTs and cohort studies showed greater HC in the groups receiving aggressive parenteral and total enhanced nutrition, respectively. However, two RCTs and one cohort study did not report any differences in terms of HC. Inconclusive results were reported by studies that investigated cerebral growth by magnetic resonance imaging. The studies observing a positive effect of enhanced nutrition on cerebral and basal ganglia growth, caudate nucleus, cerebellum, and thalami volume investigated only the influence of EN.
CONCLUSIONS
The impact of energy intake during early life on NDV remains undefined. A positive impact on brain development encourages the administration of recommended energy intake, mainly by EN, and suggests a more cautious approach to enhanced nutritional strategies by the parenteral route. Further studies are advocated to elucidate the optimal nutritional intervention for preterm infants to improve NDV.
Topics: Energy Intake; Enteral Nutrition; Humans; Infant; Infant, Low Birth Weight; Infant, Newborn; Infant, Premature; Parenteral Nutrition
PubMed: 35306422
DOI: 10.1016/j.nut.2021.111572 -
Supportive Care in Cancer : Official... Dec 2023Up to 83% of oncology patients are affected by cancer-related malnutrition, depending on tumour location and patient age. Parenteral nutrition can be used to manage... (Review)
Review
INTRODUCTION
Up to 83% of oncology patients are affected by cancer-related malnutrition, depending on tumour location and patient age. Parenteral nutrition can be used to manage malnutrition, but there is no clear consensus as to the optimal protein dosage. The objective of this systematic literature review (SLR) was to identify studies on malnourished oncology patients receiving home parenteral nutrition (HPN) where protein or amino acid delivery was reported in g/kg bodyweight/day, and to compare outcomes between patients receiving low (< 1 g/kg bodyweight/day), standard (1-1.5 g/kg/day), and high-protein doses (> 1.5 g/kg/day).
METHODS
Literature searches were performed on 5 October 2021 in Embase, MEDLINE, and five Cochrane Library and Centre for Reviews and Dissemination databases. Searches were complemented by hand-searching of conference proceedings, a clinical trial registry, and bibliographic reference lists of included studies and relevant SLRs/meta-analyses.
RESULTS
Nineteen publications were included; sixteen investigated standard protein, two reported low protein, and one included both, but none assessed high-protein doses. Only one randomised controlled trial (RCT) was identified; all other studies were observational studies. The only study to compare two protein doses reported significantly greater weight gain in patients receiving 1.15 g/kg/day than those receiving 0.77 g/kg/day.
CONCLUSION
At present, there is insufficient evidence to determine the optimal protein dosage for malnourished oncology patients receiving HPN. Data from non-HPN studies and critically ill patients indicate that high-protein interventions are associated with increased overall survival and quality of life; further studies are needed to establish whether the same applies in malnourished oncology patients.
Topics: Humans; Neoplasms; Parenteral Nutrition, Home; Malnutrition
PubMed: 38129578
DOI: 10.1007/s00520-023-08218-z -
JPEN. Journal of Parenteral and Enteral... Aug 2020The concept of a nutrition support team (NST) was first introduced at the end of the 20th century in the US and Europe. Expected benefits include reduced (inappropriate)...
BACKGROUND
The concept of a nutrition support team (NST) was first introduced at the end of the 20th century in the US and Europe. Expected benefits include reduced (inappropriate) prescription of (par)enteral nutrition; however, to the authors' knowledge, no recent review has assessed the effectiveness of NSTs. Therefore, this systematic review evaluated the effectiveness of NSTs with respect to the prevalence of adult patients receiving (par)enteral nutrition.
METHODS
Five literature databases were searched and completed by citing searches. Studies on NSTs that were published between 2000 and 2018 in Western countries, applied a comparative design, and contained at least outcome data on the prevalence of (par)enteral nutrition were included. Analyses were mainly descriptive because of high heterogeneity that prevented meta-analyses.
RESULTS
The 27 included studies mainly originated from the UK and US. Only 1 of the included studies was a randomized trial; the other studies had a pre-post design (n = 17) or compared groups in a nonrandomized way. All but 2 studies were performed in acute care hospitals, and 5 studies focused only on intensive care patients. There was conflicting evidence of whether NSTs lead to reduction or increase in patients starting parenteral nutrition (PN); however, weak evidence suggested that NSTs might lead to an increase in the ratio of enteral nutrition to PN use and might decrease inappropriate PN use.
CONCLUSION
Although almost all studies concluded in favor of NSTs, the evidence base is weak and insufficient because of a lack of well-designed studies and successful outcomes.
Topics: Adult; Enteral Nutrition; Europe; Humans; Nutritional Support; Parenteral Nutrition; Parenteral Nutrition, Total
PubMed: 32181928
DOI: 10.1002/jpen.1811 -
Clinical Nutrition ESPEN Aug 2023There are sparse data regarding the rate of catheter salvage and long-term effectiveness of antibiotic lock treatment outcome after central line-associated bloodstream...
BACKGROUND & AIMS
There are sparse data regarding the rate of catheter salvage and long-term effectiveness of antibiotic lock treatment outcome after central line-associated bloodstream infections (CLABSI). Objectives were to analyze the effectiveness of central venous catheter (CVC) rescue strategy and its impact on catheter lifespan. Secondary objective included effectiveness of taurolidine+4% citrate in primary prevention, compared to a secondary prevention strategy, by analyzing infection incidence during two successive periods.
METHOD
Real-life 5-year observational study assessing CLABSI occurrence and CVC salvage outcomes in adult patients requiring Home Parenteral Nutrition (HPN) managed in a single-center Intestinal Failure Unit.
RESULTS
Over the 5-year period, there were 106 confirmed infections (63/143 patients (44%)). Infection incidence was 0.92/1000 catheter-days. Incidence was 1.02/1000 catheter-days during the taurolidine+4% citrate period while lower at 0.84/1000 catheter-days (p = 0.034) during the systematic taurolidine lock period. Of the total number of infections, 89 CVCs were immediately removed and 17 were salvaged. The success rate of catheter salvage with antibiotic lock was 82.4%, with 53% remaining CLABSI-free at one year. The salvage strategy extended catheter lifespan by a median 165 days (IQR 50-214). However, the rate of new infection was significantly higher in instances of salvage (71.4%) vs. removal (36%). Parenteral Nutrition (PN) ≥12 months (p = 0.002), PN (vs. hydroelectrolytic support) (p = 0.028) and self-management by patients (p = 0.049) were independent risk factors of CLABSI.
CONCLUSION
Catheter salvage appears to be an effective long-term strategy with >50% of CVCs remaining CLABSI-free at one year and a prolonged catheter life, although may expose to a more frequent and earlier infection recurrence.
CLINICAL TRIAL REGISTRATION
Cohort approved by the French CNIL (National Committee for Data Protection, authorization number CNIL 2015-25). referred to as "observational research", "non-interventional", or « non-RIPH ».
Topics: Adult; Humans; Catheter-Related Infections; Central Venous Catheters; Anti-Bacterial Agents; Parenteral Nutrition, Home; Citrates; Citric Acid; Observational Studies as Topic
PubMed: 37344059
DOI: 10.1016/j.clnesp.2023.04.026 -
Journal of Human Nutrition and... Oct 2023Home parenteral nutrition (HPN) is a specialised therapy offered to people suffering from intestinal failure. Underlying disease, HPN complications and limitations of... (Review)
Review
BACKGROUND
Home parenteral nutrition (HPN) is a specialised therapy offered to people suffering from intestinal failure. Underlying disease, HPN complications and limitations of HPN can significantly impact a person's quality-of-life (QOL). The aim of this review was to evaluate the evidence on existing non-surgical/non-pharmacological interventions aimed at improving QOL, clinical, patient-reported and economic outcomes for patients receiving parenteral nutrition therapy at home across adult and paediatric settings.
METHODS
Online databases Medline (Ovid), Embase and Cinahl were searched to identify studies published between 1937 and 31 March 2022. Identified studies were appraised using the Cochrane Collaboration risk of bias tool and Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessment.
RESULTS
Nine studies were included in this review. Interventions were focused on education (n = 4), telemedicine (n = 2), preparation of infusion mixtures (n = 1), mindfulness-based cognitive therapy (n = 1) and a multi-modal approach (n = 1). Only one study measured QOL before and after the intervention using a validated QOL tool. All studies were assessed at either some, high or critical risk of bias, resulting in low or very low-quality evidence for the interventions evaluated.
CONCLUSIONS
The findings from this review highlight the lack of high-quality non-surgical/non-pharmacological studies seeking to improve QOL for people on HPN. Because the majority of people receiving HPN are not eligible for surgical or pharmaceutical treatments, higher quality research using clinical trial design, and research focused on improving QOL is needed to inform healthcare managers about the effectiveness (and value) of alternative service delivery models for this vulnerable patient group.
Topics: Adult; Humans; Child; Quality of Life; Parenteral Nutrition, Home; Telemedicine; Health Facilities
PubMed: 37539458
DOI: 10.1111/jhn.13225 -
Clinical Nutrition ESPEN Oct 2022Scleroderma is a multi-system disease that causes hardening of connective tissue. The gastrointestinal (GI) tract is affected in 90% of patients, which may cause...
BACKGROUND & AIMS
Scleroderma is a multi-system disease that causes hardening of connective tissue. The gastrointestinal (GI) tract is affected in 90% of patients, which may cause nutritional decline. Due to the rarity of the disease, current nutritional guidelines in scleroderma are extrapolated from evidence in other chronic diseases. This systematic review examines the effects of oral nutrition supplements (ONS), enteral nutrition (EN) and parenteral nutrition (PN) on both clinical and nutritional outcomes of scleroderma patients.
METHOD
Three separate systematic searches for scleroderma and ONS, EN, and PN were performed. The searches were conducted using EMBASE, PubMed and Web of Science databases.
RESULTS
A total of 9 studies (ONS: 2, EN: 1 and PN: 6) met the inclusion and exclusion criteria and were included in the review. All patients had scleroderma and were malnourished or at risk of malnutrition [weighted average age: 53 years, Body Mass Index (BMI): 19 kg/m]. Artificial nutrition support was shown to be an effective therapy for preventing nutritional decline and reversing malnutrition but had no impact on disease progression. Mean BMI increased with home parenteral nutrition (HPN) and EN, from 15 kg/m to 21.0 kg/m. Weight was maintained with ONS, and sarcopenia decreased. Only HPN positively impacted quality of life and GI symptoms, with complication rates similar to patients with other indications.
CONCLUSION
Scleroderma patients should be routinely screened for malnutrition. Malnutrition is treated in a stepwise manner, starting with ONS, then EN and finally PN, based on GI sufficiency and tolerance of the patient. HPN is an effective therapy for patients with advanced disease and intestinal failure. However, larger, long-term, prospective studies for each nutritional therapy are required to make firm conclusions.
Topics: Enteral Nutrition; Humans; Malnutrition; Middle Aged; Parenteral Nutrition; Prospective Studies; Quality of Life
PubMed: 36184202
DOI: 10.1016/j.clnesp.2022.06.108