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Medicine Jan 2022Multiple nutritional therapies are currently available for patients with liver cirrhosis, yet many interventions have not been compared head-to-head within randomized...
IMPORTANCE
Multiple nutritional therapies are currently available for patients with liver cirrhosis, yet many interventions have not been compared head-to-head within randomized clinical trials.
OBJECTIVE
To evaluate the improvement of nutritional indicators and liver function indexes of liver cirrhosis treated with different nutrition intervention.
DATA SOURCE
We searched PubMed, Embase. com and Cochrane Library database from construction to April 3, 2020. After eliminating the duplicated or overlapping reports, 6 studies were included. We performed a Bayesian network meta-analysis by Stata 12.0 and GeMTC 0.14.3 in order to compare different nutritional interventions with consistency model.
STUDY SELECTION
Randomized clinical trials comparing 2 or more therapies in patients with cirrhosis were evaluated. Six randomized clinical trials met the selection criteria.
DATA EXTRACTION AND SYNTHESIS
Two investigators independently reviewed the full manuscripts of eligible studies and extracted information into an electronic database: patients' characteristics study design, interventions, the number of events of interest in each group.
MAIN OUTCOMES AND MEASURES
Body mass index, Child-Pugh score, model for end-stage liver disease score, total bilirubin, alanine transaminase, aspartate transaminase, total protein, Triceps skinfold, Midarm Muscle Circumference, Fischer ratio, overall survival.
RESULTS
There are 6 studies enrolling a total of 1148 patients who received different nutrition supports including parenteral nutrition (PN), enteral nutrition (EN), EN (without branched-chain amino acids), EN + intestinal probiotics, PN + EN, late evening snacks (LES), EN + LES, noLES. The direct comparisons showed that the effect of EN was better than EN (without branched-chain amino acids); EN + intestinal probiotics was better than EN and PN; PN + EN was better than them alone; EN + LES was better than LES and EN; LES was better than noLES. Although the difference of indirect comparisons between the included regimens was not statistically significant, the results showed that EN + intestinal probiotics appeared to be superior to PN + EN. While LES and EN + LES seemed to rank behind them and the difference between them was extremely small.
CONCLUSION AND RELEVANCE
Available evidence suggests that EN + intestinal probiotics appear to be the most effective strategy for patients with cirrhosis compared with other interventions.
Topics: Amino Acids, Branched-Chain; Bayes Theorem; End Stage Liver Disease; Enteral Nutrition; Humans; Liver Cirrhosis; Network Meta-Analysis; Parenteral Nutrition; Severity of Illness Index
PubMed: 35060537
DOI: 10.1097/MD.0000000000028618 -
Nutrition and Cancer 2021The use of home parenteral nutrition (HPN) in patients with incurable cancer remains controversial with significant variation worldwide. We aimed to systematically... (Meta-Analysis)
Meta-Analysis
The use of home parenteral nutrition (HPN) in patients with incurable cancer remains controversial with significant variation worldwide. We aimed to systematically evaluate the literature from 1960 to 2018 examining the use of HPN in advanced cancer patients for all intestinal failure indications and assess the potential benefits/burdens of HPN in this cohort of patients. The primary end point was survival and secondary end points were quality of life and nutritional/performance status. Meta-analysis was performed with a random effects model, where suitable. Of 493 studies retrieved, 22 met the quality inclusion criteria. Studies were mainly conducted in Western countries (Italy, USA, Canada, Germany), including a total of 3564 patients (mean age 57.8 years). Mean duration for HPN was 5.0 mo. Mean overall survival was 7.3 mo. Patients with improved performance status survived for longer on HPN. Quality of life was sparsely reported though there was no observed negative impact of PN. HPN-related complications were reported in eight studies only and were mainly catheter-related blood stream infections. In conclusion, HPN is used for several indications in advanced cancer, though there is significant heterogeneity of results. Disparities in geographical distribution of the studies may reflect variation in accessing HPN.
Topics: Cohort Studies; Humans; Middle Aged; Neoplasms; Nutritional Status; Parenteral Nutrition, Home; Quality of Life; Retrospective Studies
PubMed: 32586120
DOI: 10.1080/01635581.2020.1784441 -
Critical Care (London, England) Nov 2020Omega-3 (ω-3) fatty acid (FA)-containing parenteral nutrition (PN) is associated with significant improvements in patient outcomes compared with standard PN regimens... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Omega-3 (ω-3) fatty acid (FA)-containing parenteral nutrition (PN) is associated with significant improvements in patient outcomes compared with standard PN regimens without ω-3 FA lipid emulsions. Here, we evaluate the impact of ω-3 FA-containing PN versus standard PN on clinical outcomes and costs in adult intensive care unit (ICU) patients using a meta-analysis and subsequent cost-effectiveness analysis from the perspective of a hospital operating in five European countries (France, Germany, Italy, Spain, UK) and the US.
METHODS
We present a pharmacoeconomic simulation based on a systematic literature review with meta-analysis. Clinical outcomes and costs comparing ω-3 FA-containing PN with standard PN were evaluated in adult ICU patients eligible to receive PN covering at least 70% of their total energy requirements and in the subgroup of critically ill ICU patients (mean ICU stay > 48 h). The meta-analysis with the co-primary outcomes of infection rate and mortality rate was based on randomized controlled trial data retrieved via a systematic literature review; resulting efficacy data were subsequently employed in country-specific cost-effectiveness analyses.
RESULTS
In adult ICU patients, ω-3 FA-containing PN versus standard PN was associated with significant reductions in the relative risk (RR) of infection (RR 0.62; 95% CI 0.45, 0.86; p = 0.004), hospital length of stay (HLOS) (- 3.05 days; 95% CI - 5.03, - 1.07; p = 0.003) and ICU length of stay (LOS) (- 1.89 days; 95% CI - 3.33, - 0.45; p = 0.01). In critically ill ICU patients, ω-3 FA-containing PN was associated with similar reductions in infection rates (RR 0.65; 95% CI 0.46, 0.94; p = 0.02), HLOS (- 3.98 days; 95% CI - 6.90, - 1.06; p = 0.008) and ICU LOS (- 2.14 days; 95% CI - 3.89, - 0.40; p = 0.02). Overall hospital episode costs were reduced in all six countries using ω-3 FA-containing PN compared to standard PN, ranging from €-3156 ± 1404 in Spain to €-9586 ± 4157 in the US.
CONCLUSION
These analyses demonstrate that ω-3 FA-containing PN is associated with statistically and clinically significant improvement in patient outcomes. Its use is also predicted to yield cost savings compared to standard PN, rendering ω-3 FA-containing PN an attractive cost-saving alternative across different health care systems.
STUDY REGISTRATION
PROSPERO CRD42019129311.
Topics: Cost-Benefit Analysis; Critical Illness; Fatty Acids, Omega-3; France; Germany; Humans; Intensive Care Units; Italy; Length of Stay; Parenteral Nutrition; Spain; Time Factors; Treatment Outcome; United States
PubMed: 33143750
DOI: 10.1186/s13054-020-03356-w -
Transplantation and Cellular Therapy Feb 2021Nutritional support for patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT) has been widely debated. Enteral nutrition (EN) is recommended... (Meta-Analysis)
Meta-Analysis
Nutritional support for patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT) has been widely debated. Enteral nutrition (EN) is recommended as first-line nutritional support by the main international guidelines. However, these recommendations are based on weak evidence, and there is wide variability in the types of nutritional support among transplantation centers, with the majority providing parenteral nutrition (PN) instead of EN. Here we provide an up-to-date systematic review and meta-analysis of studies comparing EN and PN for nutritional support during the neutropenic period after allo-HSCT. The literature search strategy identified 13 papers, of which 10 compared clinical transplantation outcomes, 2 compared gut microbiota (GM) compositions, and 1 compared systemic metabolic profiles. For the meta-analysis, among the 10 clinical studies, 8 studies in which 2 groups were compared were selected: in 1 group, EN was provided as primary nutritional support in the neutropenic phase after allo-HSCT with or without the addition of PN (EN group), whereas in the other group, only PN was provided as nutritional support. The incidence rates of acute graft-versus-host disease (aGVHD) (relative risk [RR], 0.69; 95% confidence interval [CI], 0.56 to 0.86; P = .0007), aGVHD grade III-IV (RR, 0.44; 95% CI, 0.30 to 0.64; P < .0001), and gut aGVHD (RR, 0.44; 95% CI, 0.30 to 0.66; P < .0001) were lower in the EN group than in the PN group. No differences were found between the 2 groups with regard to the incidence of severe oral mucositis (RR, 0.95; 95% CI, 0.83 to 1.09; P = .46) or overall survival at day +100 (RR, 1.07; 95% CI, 0.95 to 1.21; P = .29). Other variables were too heterogeneous to perform quantitative analyses. The results of the meta-analysis showed that EN reduced the incidence of aGVHD, specifically grade III-IV and gut aGVHD. This result should prompt improved efforts to implement EN as first-line nutritional support in patients undergoing allo-HSCT. Considering the emerging evidence regarding the association between GM dysbiosis and aGVHD onset, we speculate that this protective effect could be attributed to the improved gut eubiosis observed in enterally fed patients. Further studies are warranted to better address the relationship between the GM composition, aGVHD, and the nutritional administration route during HSCT.
Topics: Enteral Nutrition; Graft vs Host Disease; Hematopoietic Stem Cell Transplantation; Humans; Nutritional Support; Parenteral Nutrition
PubMed: 33830034
DOI: 10.1016/j.jtct.2020.11.006 -
The Cochrane Database of Systematic... Apr 2020Recently conducted randomised controlled trials (RCTs) suggest that late commencement of parenteral nutrition (PN) may have clinical benefits in critically ill adults... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Recently conducted randomised controlled trials (RCTs) suggest that late commencement of parenteral nutrition (PN) may have clinical benefits in critically ill adults and children. However, there is currently limited evidence regarding the optimal timing of commencement of PN in critically ill term and late preterm infants.
OBJECTIVES
To evaluate the benefits and safety of early versus late PN in critically ill term and late preterm infants.
SEARCH METHODS
We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (5 April 2019), MEDLINE Ovid (1966 to 5 April 2019), Embase Ovid (1980 to 5 April 2019), EMCare (1995 to 5 April 2019) and MEDLINE via PubMed (1966 to 5 April 2019). We searched for ongoing or recently completed clinical trials, and also searched the grey literature and reference lists of relevant publications.
SELECTION CRITERIA
We included RCTs comparing early versus late initiation of PN in term and late preterm infants. We defined early PN as commencing within 72 hours of admission, and late PN as commencing after 72 hours of admission. Infants born at 37 weeks' gestation or more were defined as term, and infants born between 34 and 36 weeks' gestation were defined as late preterm.
DATA COLLECTION AND ANALYSIS
Two review authors independently selected the trials, extracted the data and assessed the risk of bias. Treatment effects were expressed using risk ratio (RR) and risk difference (RD) for dichotomous outcomes and mean difference (MD) for continuous data. The quality of the evidence was assessed using the GRADE approach.
MAIN RESULTS
Two RCTs were eligible for inclusion. Data were only available from a subgroup (including 209 term infants) from one RCT in children (aged from birth to 17 years) conducted in Belgium, the Netherlands and Canada. In that RCT, children with medium to high risk of malnutrition were included if a stay of 24 hours or more in the paediatric intensive care unit (PICU) was expected. Early PN and late PN were defined as initiation of PN within 24 hours and after day 7 of admission to PICU, respectively. The risk of bias for the study was considered to be low for five domains and high for two domains. The subgroup of term infants that received late PN had significantly lower risk of in-hospital all-cause mortality (RR 0.35, 95% confidence interval (CI) 0.14 to 0.87; RD -0.10, 95% CI -0.18 to -0.02; number needed to treat for an additional beneficial outcome (NNTB) = 10; 1 trial, 209 participants) and neonatal mortality (death from any cause in the first 28 days since birth) (RR 0.29, 95% CI 0.10 to 0.88; RD -0.09, 95% CI -0.16 to -0.01; NNTB = 11; 1 trial, 209 participants). There were no significant differences in rates of healthcare-associated blood stream infections, growth parameters and duration of hospital stay between the two groups. Neurodevelopmental outcomes were not reported. The quality of evidence was considered to be low for all outcomes, due to imprecision (owing to the small sample size and wide confidence intervals) and high risk of bias in the included studies.
AUTHORS' CONCLUSIONS
Whilst late commencement of PN in term and late preterm infants may have some benefits, the quality of the evidence was low and hence our confidence in the results is limited. Adequately powered RCTs, which evaluate short-term as well as long-term neurodevelopmental outcomes, are needed.
Topics: Amino Acids; Bias; Critical Illness; Cross Infection; Fat Emulsions, Intravenous; Hospital Mortality; Humans; Hypoglycemia; Infant; Infant Mortality; Infant, Newborn; Infant, Premature; Length of Stay; Lipids; Parenteral Nutrition; Parenteral Nutrition Solutions; Randomized Controlled Trials as Topic; Respiration, Artificial; Term Birth; Time Factors
PubMed: 32266712
DOI: 10.1002/14651858.CD013141.pub2 -
Clinical Nutrition ESPEN Dec 2021Chimeric Antigen Receptor (CAR) T cell therapy is a novel adoptive immunotherapy that is revolutionising the treatment of haematological malignancies and solid tumours....
BACKGROUND & AIMS
Chimeric Antigen Receptor (CAR) T cell therapy is a novel adoptive immunotherapy that is revolutionising the treatment of haematological malignancies and solid tumours. Maintaining a patient's nutritional status and implementing nutrition support interventions have been shown to improve certain patient outcomes in standard anti-cancer therapies; however, guidance for nutrition support interventions in CAR T cell therapy are lacking. The primary aim of this review was to determine the impact of nutrition support interventions on patient-centred outcomes for adult CAR T cell therapy haematology and oncology patients. The patient-centred outcomes of interest included nutritional status and dietary intake, morbidity, functional status, and mortality. Our secondary aim was to describe the nutrition implications that have been acknowledged (but not fully evaluated) in CAR T cell therapy, and to guide future research and practice.
METHODS
Four electronic databases (CENTRAL, Embase, MEDLINE and CINAHL) were searched to January 2021, with additional records identified through handsearching and snowballing. Studies considered eligible for inclusion were randomised control trials (RCT), quasi-RCTs, cohort and observational studies, assessing nutrition support interventions (oral, enteral and/or parenteral) in adult haematology and oncology patients receiving CAR T cell therapy or adoptive immunotherapy. No publication status, year or language restrictions were applied.
RESULTS
Two authors reviewed the title and abstracts of 1181 retrieved records; however no studies were eligible for inclusion in this systematic review.
CONCLUSIONS
We are currently unable to identify if there is an association between nutrition support interventions and outcomes in CAR T cell therapy for adults with haematological malignancies or solid tumours. Lower quality clinical studies and animal models were identified that permitted us to qualitatively describe the risks for poor nutritional status in this population. This empty review confirms the need for research into the potential impact of nutrition support in CAR T cell therapy, including well-designed RCTs.
Topics: Hematology; Humans; Immunotherapy, Adoptive; Neoplasms; Nutritional Support; Parenteral Nutrition; Randomized Controlled Trials as Topic
PubMed: 34857249
DOI: 10.1016/j.clnesp.2021.10.015 -
Supportive Care in Cancer : Official... Mar 2020Weight loss in cancer patients is a worrisome constitutional change predicting disease progression and shortened survival time. A logical approach to counter some of the... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
Weight loss in cancer patients is a worrisome constitutional change predicting disease progression and shortened survival time. A logical approach to counter some of the weight loss is to provide nutritional support, administered through enteral nutrition (EN) or parenteral nutrition (PN). The aim of this paper was to update the original systematic review and meta-analysis previously published by Chow et al., while also assessing publication quality and effect of randomized controlled trials (RCTs) on the meta-conclusion over time.
METHODS
A literature search was carried out; screening was conducted for RCTs published in January 2015 up until December 2018. The primary endpoints were the percentage of patients achieving no infection and no nutrition support complications. Secondary endpoints included proportion of patients achieving no major complications and no mortality. Review Manager (RevMan 5.3) by Cochrane IMS and Comprehensive Meta-Analysis (version 3) by Biostat were used for meta-analyses of endpoints and assessment of publication quality.
RESULTS
An additional seven studies were identified since our prior publication, leading to 43 papers included in our review. The results echo those previously published; EN and PN are equivalent in all endpoints except for infection. Subgroup analyses of studies only containing adults indicate identical risks across all endpoints. Cumulative meta-analysis suggests that meta-conclusions have remained the same since the beginning of publication time for all endpoints except for the endpoint of infection, which changed from not favoring to favoring EN after studies published in 1997. There was low risk of bias, as determined by assessment tool and visual inspection of funnel plots.
CONCLUSIONS
The results support the current European Society of Clinical Nutrition and Metabolism guidelines recommending enteral over parenteral nutrition, when oral nutrition is inadequate, in adult patients. Further studies comparing EN and PN for these critical endpoints appear unnecessary, given the lack of change in meta-conclusion and low publication bias over the past decades.
Topics: Enteral Nutrition; Humans; Infections; Neoplasms; Nutritional Status; Parenteral Nutrition; Randomized Controlled Trials as Topic; Weight Loss
PubMed: 31813021
DOI: 10.1007/s00520-019-05145-w -
Journal of Pain and Symptom Management Nov 2021Decision making on nutrition and hydration for cancer patients during terminal stage cause critical impacts toward patient's comfort and living quality. The management... (Review)
Review
Decision Making of Artificial Nutrition and Hydration for Cancer Patients at Terminal Stage-A Systematic Review of the Views From Patients, Families, and Healthcare Professionals.
BACKGROUND
Decision making on nutrition and hydration for cancer patients during terminal stage cause critical impacts toward patient's comfort and living quality. The management of nutrition is the main dilemma that arises in these final situations and has been the subject of intense debate over the last few decades.
AIM
To find the views of patients, families, and healthcare professionals related to how decisions are made when cancer patients are at terminal stage.
DESIGN
This systematic review used PRISMA strategy to search and used Critical Appraisal Skills Programme checklist to evaluate the papers.
DATA SOURCES
All English papers through August 2020 that contained the view of the decision making at artificial nutrition and hydration with cancer patients, families, and healthcare professionals at terminal stage were included. Selected studies were independently reviewed, and data collaboratively synthesized into core themes.
RESULTS
Most of the terminal stage cancer patients and their families initially started the decision-making process when facing the reduction of oral intake. There are two primary considerations of patients and families, one is for prolonging patients life, and the other is to maintain their life quality. The voices of patients were influential, but not determinative; families usually had influence, but seldom make the final recommendation by themselves; healthcare professionals frequently face the dilemma about their decision.
CONCLUSION
The decision of nutritional support was dynamic; the interaction between patients and families frequently be hesitated to protect the rights of life, unnecessarily prolonging lifetime. Therefore, a better understanding of the views on nutritional support and processing the clinical guideline of decision making for healthcare professional is necessary.
Topics: Decision Making; Delivery of Health Care; Health Personnel; Humans; Neoplasms; Nutritional Support; Terminal Care
PubMed: 33933623
DOI: 10.1016/j.jpainsymman.2021.04.013 -
Archives of Disease in Childhood. Fetal... Sep 2023Mucous fistula refeeding (MFR) aims to maximise bowel function when an ostomy is active after abdominal surgery, by introducing the proximal ostomy effluent into the... (Meta-Analysis)
Meta-Analysis
BACKGROUND AND OBJECTIVE
Mucous fistula refeeding (MFR) aims to maximise bowel function when an ostomy is active after abdominal surgery, by introducing the proximal ostomy effluent into the distal mucous fistula to maintain intestinal physiology. The aim of the study was to assess the effectiveness and complications of MFR in neonates following abdominal surgery.
DESIGN, SETTING AND INTERVENTIONS
Systematic review and meta-analysis of randomised controlled trials and observational studies. PubMed, Embase, Cochrane and CINAHL were searched until June 2022 for studies including neonates with ostomy receiving MFR compared with neonates with ostomy without MFR.
OUTCOMES
The primary outcome was duration of parenteral nutrition. Secondary outcomes were time to full enteral feeds, rates of cholestasis, peak total serum bilirubin, sepsis, time to reanastomosis and length of hospital stay.
RESULTS
A total of 16 observational studies were included (n=623). Compared with comparator group, neonates who received MFR had fewer days of parenteral nutrition (mean difference 37.17 days, 95% CI -63.91 to -10.4, n=244, 5 studies, GRADE: low). In addition, neonates who received MFR had lower rates of cholestasis, shorter time to reach full feeds and shorter hospital stay.
CONCLUSION
Low certainty of evidence suggests that MFR is associated with shorter duration of parenteral nutrition in neonates following abdominal surgery and stoma creation. Results of ongoing and future randomised trials may help to corroborate these findings.
Topics: Infant, Newborn; Humans; Parenteral Nutrition; Fistula; Enteral Nutrition; Cholestasis
PubMed: 36858828
DOI: 10.1136/archdischild-2022-324995 -
BMJ Supportive & Palliative Care Dec 2022To evaluate current evidence of the effect of specialised nutritional interventions on nutritional status, survival, quality of life and measures of functionality in... (Review)
Review
OBJECTIVE
To evaluate current evidence of the effect of specialised nutritional interventions on nutritional status, survival, quality of life and measures of functionality in patients with incurable cancer.
METHODS
Systematic literature review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using PubMed/MEDLINE, EMBASE, Scopus, LILACS and Cochrane Library databases. Clinical studies that evaluated different specialised nutritional interventions, such as nutritional counselling, oral nutritional supplementation (ONS), enteral nutrition (EN) and parenteral nutrition (PN), were eligible. Only studies classified as being of high methodological quality (ie, low or moderate risk of bias) were included.
RESULTS
A total of 22 studies reporting on 2448 patients were deemed eligible. Five types of specialised nutrition were observed: mixed (multimodal nature, ie, dietary counseling, ONS, physical activity and/or drugs) (n=12), ONS (n=5), PN (n=3), EN (n=1) and multidisciplinary team counselling (n=1). Benefits of any kind from the interventions were reported in 14 (63.6%) studies, mainly resulting from mixed intervention. Nutritional status improved in 12 (60.0%) of 20 studies and quality of life improved in eight (50.0%) of 16 studies. Few studies have evaluated the influence of nutritional interventions on survival and measure of functionality, and have not shown improvement in these outcomes.
CONCLUSION
Despite the limited evidence, specialised nutritional interventions can yield positive effects for patients with incurable cancer, mainly in their nutritional status and quality of life.
Topics: Humans; Quality of Life; Neoplasms; Nutritional Status; Enteral Nutrition
PubMed: 36418033
DOI: 10.1136/spcare-2022-003893