Nutrition in Clinical Practice

The suggestion that marine ω-3 fatty acids might have beneficial cardiovascular effects was first made by epidemiologic studies in Greenland Inuits published in the late 1970s. These simple observations spawned hundreds of other studies which, taken together, strongly suggest a true cardioprotective effect of ω-3 fatty acids. The strongest evidence to date that ω-3 fatty acids may be palliative has come from the publication of three randomized clinical trials, all of which reported benefits to patients with preexisting coronary artery disease. The most convincing of these was the GISSI-Prevezione study in which 5654 patients with coronary artery disease were randomized to either ω-3 fatty acids (850 mg/d) or usual care. After 3.5 years, those taking the ω-3 fatty acids had experienced a 20% reduction in overall mortality and a 45% decrease in risk for sudden cardiac death. These findings support the view that relatively small intakes of ω-3 fatty acids are indeed cardioprotective, and suggest that they may operate by stabilizing the myocardium itself.

Very-low-birth-weight (VLBW) preterm infants have an increased risk of developing metabolic bone disease (MBD) over term infants because of their decreased opportunity for intrauterine bone mineralization. Neonatal nutritionists are playing an increasingly important role in the prevention and management of MBD. The purpose of this survey study was to assess their role in the assessment, prevention, and management of MBD in VLBW infants. A total of 49 neonatal nutritionists primarily working in Level III Newborn Intensive Care Units (NICU) were surveyed to determine their clinical practice in the assessment and management of MBD. A total of 83.7% of the respondents assessed skeletal health at an average of 2.3 weeks of life with 16.3% assessing within the first week of life. The majority (93.9%) used serum phosphorus and alkaline phosphatase values in skeletal health assessment. Neonatal nutritionists tended to underestimate the incidence of MBD in their NICUs, with 79.2% estimating the incidence to be 5% or less. Parenteral nutrition (PN) was initiated by days 0 to 3 of life by 95.9% of the respondents, whereas enteral nutrition (EN) was begun on day 4 to 7 by 55.1% of respondents or on days 0 to 3 of life by 28.6% of the respondents. Optimal goals for ratios of calcium to phosphorus were reported as 1.3 to 1.7: 1 for PN by 84.7% and 1.8 to 2:1 in EN by 73.8% of the NICU nutritionists. Enteral vitamin supplements were used routinely by 70.2% of the respondents, with 53.2% using a pediatric multivitamin. Neutra-Phos (44.8%), providing phosphate, and Neo-Calglucon (37.9%), which provides calcium gluconate, were the most commonly used mineral supplements. The neonatal nutritionists surveyed played an active role in educating members of the health care team. Respondents were primarily responsible for documenting recommendations in medical records and direct communication with the NICU team on rounds (98.0%). The most common educational activities the respondents performed included: developing and revising PN order forms (77.1%), NICU handbook development (64.6%) and regular lectures to interns/residents (58.3%) and neonatologists (41.7%). The descriptive survey found that neonatal nutritionists played an increasingly proactive role in a variety of direct patient care activities, ie, risk assessment, initiation of early PN and EN, optimizing calcium and phosphorus intake and education of residents and NICU staff to promote optimal bone mineralization rates.

Standard management of infectious complications in home parenteral nutrition (HPN) patients includes hospitalization and use of IV antibiotics (1 to 4 weeks). Outpatient IV antibiotic therapy (OPIVAT) has proven to be safe, practical and cost-effective for a variety of infections. The aim of this retrospective review is to describe our experience with OPIVAT for suspected catheter-related infections in patients receiving HPN. The records of all HPN patients in our program were reviewed. Since 1993, eleven adults and seven children received HPN for a total of 5420 and 1212 days respectively. During the follow-up there were 21 febrile episodes in the adult patients, nine catheter-related infections, and 12 non-catheter-related febrile episodes. All received initially empiric antibiotic treatment (Teicoplanin or Vancomycin plus Ceftriaxone). If the patient's general condition was good, the treatment was administered at home, otherwise he or she remained in the hospital until the results of the blood cultures were available. Most of the febrile episodes treated entirely at home corresponded to non-catheter related infections. No patients developed complications related to infections. None of the patients with catheter-related bloodstream infection who received OPIVAT needed to be admitted or readmitted to the hospital during the course of the treatment. It was only necessary to remove the catheter as an inpatient in one patient with a tunnel infection. In most of the HPN programs, if the patient presents fever and no infectious focus is found, admission is recommended. IV antibiotics are started until the results of blood cultures are available. Our findings suggest that, even in the presence of catheter-related bloodstream infection, if the patient's general condition is good, antibiotic treatment can be safely administered at home.

In an effort to improve long-term follow-up and to provide an integrated approach to the care of patients receiving home parenteral nutrition (HPN), a home nutrition support service (HNSS) was formed in 1993 at a large not-for-profit Midwest Health Maintenance Organization (HMO). Because the coordination of care for these patients is managed within the HMO setting, rather than contracting this service out, continuity of care is maintained and provides ease of communication with the physicians and access to patient information. By using a case management approach with the HPN patients, the average cost of HPN per day has decreased by 54% over the past six years. The home nutrition support service in the HMO setting has been cost effective and provides a unique setting for comprehensive patient care.

Diarrhea is a significant worldwide health problem. The bacterial flora of the gastrointestinal tract plays an essential role in maintaining the integrity of the enterocyte, modulating metabolic and immunologic processes, and protecting against colonization by invasive pathogens. Disruptions of this finely tuned and stable gut flora has profound effects on the protective barrier. Antibiotics used to treat infectious diarrhea promote the emergence of resistant organisms, and multiple-antibiotic resistance has become a major public health issue. Preservation of protective species or recolonization with nonpathogenic lactobacilli, particularly Lactobacilli GG, has shown promising results in treating several forms of diarrhea, including rotavirus diarrhea, bacterial diarrhea, traveler's diarrhea, and Clostridium difficile relapsing diarrhea.

Popular demand for and interest in alternative medicine has increased considerably in recent years. Several of these therapies, if administered correctly, may be safe and effective complements to conventional medical treatment. Of greater concern is the ingestion of various herbs and chemicals marketed as dietary supplements. Unlike pharmaceutical drugs that are subject to rigorous testing, dietary supplements are exempt from FDA clinical scrutiny as a result of the Dietary Supplement Health and Education Act of 1994. Some supplements may have health benefits but many may be intrinsically dangerous when ingested alone or in combination with other supplements or drugs. Adverse effects of a few of the popular supplements are described in this article. Patients who use supplements are often guided by misconceptions or inaccurate information. Therefore, it is important that physicians and other health care professionals understand the potential associated health consequences so that they can help patients make informed decision about their use. To increase physicians' awareness about the unconventional therapies, there is a need for inclusion of alternative medicine as part of the medical curriculum.

A prospective study was conducted to evaluate the impact of home enteral tube feeding on quality of life in 39 consecutive patients treated for head and neck or esophageal cancer at the Center Francois Baclesse in Caen, France. Patients were taken as their own controls. Quality of life was evaluated using the EORTC QLQ-C30 core questionnaire, and the EORTC H&N35 and OES24 specific questionnaires. The feeding technique tolerance was evaluated using a questionnaire specifically developed for this study. Two evaluations were made, the first a week after hospital discharge (n = 39) and the second 3 weeks later (n = 30). Overall, the global health status/quality of life scale score slightly improved; among symptoms, scale scores that significantly improved (p < .05) concerned constipation, coughing, social functioning, and body image/sexuality. The physical feeding technique tolerance was acceptable while the technique was psychologically less tolerated with two-thirds of the patients longing to have the tube removed. One-third of the patients were also uncomfortable about their body image. Home enteral tube feeding was responsible for not visiting family or close relations in 15% of patients and not going out in public in 23%. We conclude that home enteral tube feeding is a physically well-accepted technique although a substantial proportion of patients may experience psychosocial distress. (Brit J Cancer 82:263–9, 2000)

Hypocaloric nutrition support has been successfully used to achieve positive nitrogen balance in obese patients. However, advanced age is associated with changes in substrate metabolism. To evaluate the efficacy of this practice in elderly patients, we retrospectively reviewed 30 obese patients requiring parenteral nutrition support. Total caloric requirements (TCR) were calculated on the basis of the Harris-Benedict equation. Patients were given a minimum of 1.5 g/kg/day protein, 75% of TCR when current body weight was >120 and ≤150% of ideal body weight (IBW), and 60% of TCR if current body weight was >150% of IBW. The patients were divided into two groups: group I (N = 18) patients were age <60 and group II (N = 12) patients were ≤60 years of age. Only one of the group I patients (143.2 ± 25.7% IBW, received 18.2 ± 3.7 keal/kg/day and 1.6 ± 0.4 g/kg/day protein), but five of the group II patients (141.3 ± 14.4% IBW, received 18.3 ± 2.6 keal/kg/day and 1.7 ± 0.3 g/kg/day protein), had negative nitrogen balance (p = .025). Apparently, elderly obese patients have limited capacity to mobilize their fat stores as energy sources and may continue to undergo protein catabolism with hypocaloric high-protein nutrition support. Therefore this form of nutrition support should be used with caution in elderly obese patients. (Am Surg 66:394–400, 2000)

Objective: To evaluate the comparative efficacy of enteral cisapride, metoclopramide, erythromycin, and placebo for promoting gastric emptying in critically ill patients with intolerance to gastric enteral nutrition (EN). Design: A randomized, crossover study. Setting: Adult medical intensive care unit at a university-affiliated private hospital and trauma intensive care unit at a university teaching hospital. Patients: Ten adult, critically ill, mechanically ventilated patients not tolerating a fiber-containing EN product defined as a single aspirated gastric residual volume >150 mL or two aspirated gastric residual volumes >120 mL during a 12-hour period. Interventions: Patients received 10 mg of cisapride, 200 mg of erythromycin ethylsuccinate, 10 mg of metoclopramide, and placebo as 20 mL of sterile water every 12 hours over 48 hours. Acetaminophen solution (1000 mg) was administered concurrently. Gastric residual volumes were assessed, and plasma acetaminophen concentrations were serially determined by TDx between 0 and 12 hours to evaluate gastric emptying. Measurements and Main Results: Gastric residual volumes during the study were not significantly different between agents. No differences in area under the concentration vs. time curve or elimination rate constant were identified between agents. Metoclopramide and cisapride had a significantly shorter mean residence time of absorption than erythromycin (6.3 ± 4.5 [SEM] mins and 10.9 ± 5.8 vs. 30.1 ± 4.5 mins, respectively [p < .05]). Metoclopramide (9.7 ± 15.3 mins) had a significantly shorter time to peak concentration compared with erythromycin and placebo (60.7 ± 8.1 and 50.9 ± 13.5 mins, respectively [p < .05]). The time to onset of absorption was significantly shorter for metoclopramide vs. cisapride (5.7 ± 4.5 vs. 22.9 ± 5.7 mins [p < .05]). Conclusion: In critically ill patients intolerant to EN, single enteral doses of metoclopramide or cisapride are effective for promoting gastric emptying in critically ill patients with gastric motility dysfunction. Additionally, metoclopramide may provide a quicker onset than cisapride. (Crit Care Med 28:438–44, 2000)