营养风险筛查在新疆地区1167例住院患者中的应用

目的评估营养风险筛查2002（NRS2002）在我院住院患者中的临床应用情况。方法采用定点连续抽样方法选择我院普外科、胸外科、消化科、呼吸科、神经科和肾病科等6个科室中符合NRS2002评定标准的1167例患者进行营养筛查，并调查其营养支持应用情况。结果患者营养不足、超重、肥胖和营养风险发生率分别为7．5％、28．7％、12．1％和33．5％。有营养风险者采用肠外与肠内营养的比率为22．3％。结论NRS2002方法简便、易行，可快速指导医生发现存在营养风险、需要进行营养支持的患者。     

Low-Protein Infant Formula and Obesity Risk

Infant formulas have been designed to mimic human milk for infants who cannot be breastfed. The overall goal is to establish similar functional outcomes to assure optimal growth, development, maturation of the immune system, and programming of the metabolic system. However, after decades of improving infant formula, growth patterns and body composition development are still different in formula-fed infants compared to breastfed infants, which could contribute to an increased risk of obesity among formula-fed infants. It has been hypothesized that the lower protein concentration of breast milk compared to infant formula influences infants’ growth and body composition. Thus, several trials in formula-fed infants with different protein intake levels have been performed to test this hypothesis. In this review, we discuss the current evidence on low-protein infant formula and obesity risk, including future perspectives and implications.     

Malnutrition Risk: Four Year Outcomes from the Health,Work and Retirement Study 2014 to 2018

This study aimed to determine four-year outcomes of community-living older adults identified at ‘nutrition risk’ in the 2014 Health, Work and Retirement Study. Nutrition risk was assessed using the validated Seniors in the Community: Risk Evaluation for Eating and Nutrition, (SCREENII-AB) by postal survey. Other measures included demographic, social and health characteristics. Physical and mental functioning and overall health-related quality of life were assessed using the 12-item Short Form Health Survey (SF-12v2). Depression was assessed using the verified shortened 10 item Center for Epidemiologic Studies Depression Scale (CES-D-10). Social provisions were determined with the 24-item Social Provisions Scale. Alcohol intake was determined by using the Alcohol Use Disorders Identification Test (AUDIT-C). Among 471 adults aged 49–87 years, 33.9% were at nutrition risk (SCREEN II-AB score ≤ 38). The direct effects of nutrition risk showed that significant differences between at-risk and not-at-risk groups at baseline remained at follow up. Over time, physical health and alcohol use scores reduced. Mental health improved over time for not-at-risk and remained static for those at-risk. Time had non-significant interactions and small effects on all other indicators. Findings highlight the importance of nutrition screening in primary care as nutrition risk factors persist over time.     

Epidemiology and Risk Factors for Bloodstream Infections in a Home Parenteral Nutrition Program

Background: An increasing number of patients with intestinal failure are receiving home parenteral nutrition (HPN). Associated complications include bloodstream infections (BSIs), but data on rates and risk factors for HPN‐related BSIs are scarce. Methods: A retrospective review was conducted of patients enrolled in the regional HPN program between 2001 and 2008. Demographic information and data on indication for HPN, duration of PN therapy, type and date of insertion of central venous access device, and blood culture results were recorded. Results: In total, 155 patients (165 courses of HPN) were included for a total of 45,876 catheter days. The mean patient age was 49 years, and 105 (64%) patients were female. A total of 105 organisms were cultured from 93 distinct episodes of BSIs. The rate of BSI was found to be 2.0 per 1000 catheter days, but excluding BSIs with a single positive culture of coagulase‐negative staphylococcus and diphtheroid bacilli, the rate of infection was 1.4 per 1000 catheter days. Male sex and underlying malignancy were significant predictors of BSI, with hazard ratios of 1.69 (95% confidence interval [CI], 1.14–2.60; P = .009) and 2.38 (95% CI, 1.53–3.50; P < .001). Conclusion: In a large heterogeneous group of HPN patients, the BSI rate ranged between 1.4 and 2.0 infections per 1000 catheter days. Isolated organisms were similar to those found in hospitalized patients. Male sex and underlying malignancy were significant risk factors for BSI. These high‐risk patients are likely to benefit from interventions aimed at reducing BSIs.     

Prevalence,Risk Factors,Clinical Consequences,and Treatment of Enteral Feed Intolerance During Critical Illness

Background: We aimed to determine the incidence of enteral feed intolerance and factors associated with intolerance and to assess the influence of intolerance on nutrition and clinical outcomes. Methods: We conducted a retrospective analysis of data from an international observational cohort study of nutrition practices among 167 intensive care units (ICUs). Data were collected on nutrition adequacy, ventilator‐free days (VFDs), ICU stay, and 60‐day mortality. Intolerance was defined as interruption of enteral nutrition (EN) due to gastrointestinal (GI) reasons (large gastric residuals, abdominal distension, emesis, diarrhea, or subjective discomfort). Logistic regression was used to determine risk factors for intolerance and their clinical significance. A sensitivity analysis restricted to sites specifying a gastric residual volume ≥200 mL to identify intolerance was also conducted. Results: Data from 1,888 ICU patients were included. The incidence of intolerance was 30.5% and occurred after a median 3 days from EN initiation. Patients remained intolerant for a mean (±SD) duration of 1.9 ± 1.3 days . Intolerance was associated with worse nutrition adequacy vs the tolerant (56% vs 64%, P < .0001), fewer VFDs (2.5 vs 11.2, P < .0001), increased ICU stay (14.4 vs 11.3 days, P < .0001), and increased mortality (30.8% vs 26.2, P = .04). The sensitivity analysis demonstrated that intolerance remained associated with negative outcomes. Although mortality was greater among the intolerant patients, this was not statistically significant. Conclusions: Intolerance occurs frequently during EN in critically ill patients and is associated with poorer nutrition and clinical outcomes.     

Risk Factors for the Development of Catheter‐Related Bloodstream Infections in Patients Receiving Home Parenteral Nutrition

Background: Risk factors for development of catheter‐related bloodstream infections (CRBSI) were studied in 125 adults and 18 children who received home parenteral nutrition (HPN). Methods: Medical records from a national home care pharmacy were reviewed for all patients that had HPN infused at least twice weekly for a minimum of two years from January 1, 2006‐December 31, 2011. Infection and risk factor data were collected during this time period on all patients although those patients who received HPN for a longer period had data collected since initiation of HPN. Results: In adults, 331 central venous catheters (CVCs) were placed. Total catheter years were 1157. Median CVC dwell time was 730 days. In children, there were 53 CVCs placed. Total catheter years were 113.1. Median CVC dwell time was 515 days. There were 147 CRBSIs (0.13/catheter year;0.35/1000 catheter days). In children there were 33 CRBSIs (0.29/catheter year;0.80/1000 days; P < .001 versus adults). In adults, univariate analysis showed use of subcutaneous infusion ports instead of tunneled catheters (P = .001), multiple lumen catheters (P = .001), increased frequency of lipid emulsion infusion (P = .001), obtaining blood from the CVC (P < 0.001), and infusion of non‐PN medications via the CVC (P < .001) were significant risk factors for CRBSI. Increased PN frequency was associated with increased risk of CRBSI (P = .001) in children, but not in adults. Catheter disinfection with povidone‐iodine was more effective than isopropyl alcohol alone. There were insufficient patients to evaluate chlorhexidine‐containing regimens. Conclusion: Numerous risk factors for CRBSI were identified for which simple and current countermeasures already exist.     

Diabetes-Specific Nutrition Formulas in the Management of Patients with Diabetes and Cardiometabolic Risk

Food-based dietary management, enhanced with evidence-based commercial products, such as diabetes-specific nutrition formulas (DSNFs), can help control the development, progression, and severity of certain chronic diseases. In this review, evidence is detailed on the use of DSNFs in patients with or at risk for diabetes and cardiometabolic-based chronic disease. Many DSNF strategies target glycemic excursions and cardiovascular physiology, taking into account various elements of healthy eating patterns. Nevertheless, significant research, knowledge, and practice gaps remain. These gaps are actionable in terms of formulating and testing relevant and pragmatic research questions, developing an educational program for the uniform distribution of information, and collaboratively writing clinical practice guidelines that incorporate the evidence base for DSNF. In sum, the benefits of DNSF as part of validated clinical practice algorithms include mitigation of chronic disease progression, cost-savings for the healthcare system, and applicability on a global scale     

A.S.P.E.N. Clinical Guidelines

Background: Children with severe intestinal failure and prolonged dependence on parenteral nutrition are susceptible to the development of parenteral nutrition–associated liver disease (PNALD). The purpose of this clinical guideline is to develop recommendations for the care of children with PN‐dependent intestinal failure that have the potential to prevent PNALD or improve its treatment. Method: A systematic review of the best available evidence to answer a series of questions regarding clinical management of children with intestinal failure receiving parenteral or enteral nutrition was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) Working Group. A consensus process was used to develop the clinical guideline recommendations prior to external and internal review and approval by the American Society for Parenteral and Enteral Nutrition Board of Directors. Questions: (1) Is ethanol lock effective in preventing bloodstream infection and catheter removal in children at risk of PNALD? (2) What fat emulsion strategies can be used in pediatric patients with intestinal failure to reduce the risk of or treat PNALD? (3) Can enteral ursodeoxycholic acid improve the treatment of PNALD in pediatric patients with intestinal failure? (4) Are PNALD outcomes improved when patients are managed by a multidisciplinary intestinal rehabilitation team?     

A.S.P.E.N. Clinical Guidelines

Background: Parenteral nutrition (PN) is a high‐alert medication available for patient care within a complex clinical process. Beyond application of best practice recommendations to guide safe use and optimize clinical outcome, several issues are better addressed through evidence‐based policies, procedures, and practices. This document provides evidence‐based guidance for clinical practices involving PN prescribing, order review, and preparation. Method: A systematic review of the best available evidence was used by an expert work group to answer a series of questions about PN prescribing, order review, compounding, labeling, and dispensing. Concepts from the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) format were applied as appropriate. The specific clinical guideline recommendations were developed using consensus prior to review and approval by the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors. The following questions were addressed: (1) Does education of prescribers improve PN ordering? (2) What is the maximum safe osmolarity of PN admixtures intended for peripheral vein administration? (3) What are the appropriate calcium intake and calcium‐phosphate ratios in PN for optimal neonatal bone mineralization? (4) What are the clinical advantages or disadvantages of commercially available premade (“premixed”) multichambered PN formulations compared with traditional/customized PN formulations? (5) What are the clinical (infection, catheter occlusion) advantages or disadvantages of 2‐in‐1 compared with 3‐in‐1 PN admixtures? (6) What macronutrient dosing limits are expected to provide for the most stable 3‐in‐1 admixtures? (7) What are the most appropriate recommendations for optimizing calcium (gluconate) and (Na‐ or K‐) phosphate compatibility in PN admixtures? (8) What micronutrient contamination is present in parenteral stock solutions currently used to compound PN admixtures? (9) Is it safe to use the PN admixture as a vehicle for non‐nutrient medication delivery? (10) Should heparin be included in the PN admixture to reduce the risk of central vein thrombosis? (11) What methods of repackaging intravenous fat emulsion (IVFE) into smaller patient‐specific volumes are safe? (12) What beyond‐use date should be used for (a) IVFE dispensed for separate infusion in the original container and (b) repackaged IVFE?     

Maternal Consumption of Non-Staple Food in the First Trimester and Risk of Neural Tube Defects in Offspring

To study the associations between maternal consumption of non-staple food in the first trimester and risk of neural tube defects (NTDs) in offspring. Data collected from a hospital-based case-control study conducted between 2006 and 2008 in Shandong/Shanxi provinces including 459 mothers with NTDs-affected births and 459 mothers without NTDs-affected births. Logistic regression models were used to examine the associations between maternal consumption of non-staple food in the first trimester and risk of NTDs in offspring. The effects were evaluated by odds ratio (OR) and 95% confidence intervals (95% CIs) with SAS9.1.3.software. Maternal consumption of milk, fresh fruits and nuts in the first trimester were protective factors for total NTDs. Compared with consumption frequency of ˂1 meal/week, the ORs for milk consumption frequency of 1–2, 3–6, ≥7 meals/week were 0.50 (95% CI: 0.28–0.88), 0.56 (0.32–0.99), and 0.59 (0.38–0.90), respectively; the ORs for fresh fruits consumption frequency of 1–2, 3–6, ≥7 meals/week were 0.29 (95% CI: 0.12–0.72), 0.22 (0.09–0.53), and 0.32 (0.14–0.71), respectively; the ORs for nuts consumption frequency of 1–2, 3–6, ≥7 meals/week were 0.60 (95% CI: 0.38–0.94), 0.49 (0.31–0.79), and 0.63 (0.36–1.08), respectively. Different effects of above factors on NTDs were found for subtypes of anencephaly and spina bifida. Maternal non-staple food consumption of milk, fresh fruits and nuts in the first trimester was associated with reducing NTDs risk in offspring.     

Nutritional Risk Needs Assessment of Community-Living Seniors: Prevalence of Nutrition Problems and Priorities for Action

A random mailed survey was sent to 425 members of a seniors recreation center in Guelph, Ontario for the purpose of identifying the prevalence of nutritional risk, specific nutrition problems, and educational format preferences of these seniors. This needs assessment was used to plan an education initiative called Action Nutrition. SCREEN, a 15-item nutritional risk screening instrument, demographic data, participation in current recreation programs, and frequency of visits to the center were included in this survey. The response rate was 62%, average age was 72 years and 59% were female. Respondents attended on average one activity per month, 60% visited the center at least once per month and 79% read the monthly newsletter. 56.7% of respondents were considered to be at nutritional risk using SCREEN and common problems were: significant weight change in 6 months; low intake of fruits and vegetables and milk products; and restriction of the diet due to health reasons. This survey determined that nutrition problems and risk are prevalent among community-living seniors, justifying the development and implementation of educational initiatives in this setting.     

危机管理在新生儿静脉营养液配置中的应用

总结4年来危机管理理念在新生儿静脉营养液配置的应用体会。通过对安全配置危机因素分析,危机前的预防和准备,危机发生时的应对措施等危机管理,增强了护士危机意识与配置能力,确保患儿静脉用药安全,赢得新生儿病区的高度认可。     

Cross‐Sectional Study of U.S. Interns' Perceptions of Clinical Nutrition Education

Background. Medical students have historically perceived a lack of training in clinical nutrition. Rapid advances in medical science have compelled significant changes in medical education pedagogy. It is unclear what effect this has had on student's perceptions. Objective. To assess interns' perception of clinical nutrition education during medical school. Design. A cross‐sectional survey of medical, surgical, and obstetric interns from 6 academic hospitals across the United States during the middle of their first year in November of 2010 (n = 289). Bivariate analysis and logistic regression was used to describe interns' perceptions and evaluate for factors that determined these perceptions. Results. A total of 122 interns responded to the survey, for a response rate of 42%. These interns represented 72 different medical schools. Only 29% of interns reported they had been sufficiently trained in nutrition. On average, interns who reported being prepared reported a mean of 4 ± 3.4 weeks of training during medical school, while unprepared interns reported a mean of 2 ± 2.6 weeks of training (P = .02). Interns with prior graduate training in nutrition (n = 18) almost exclusively reported that medical school training was insufficient (94%, P = .02). After adjusting for age, gender, internship, undergraduate training, and being a foreign graduate, only the number of weeks of training remained significantly associated with perceived preparation (P = .03). Conclusion. Most interns in medicine, surgery, and obstetrics feel unprepared to handle cases requiring knowledge of clinical nutrition. Interns feel that medical school is not adequately preparing them for the needs of clinical practice.     

Prospective Cohort Study of the Outcome of and Risk Factors for Intravascular Catheter‐Related Bloodstream Infections in Children With Intestinal Failure

Background: Children with intestinal failure (IF) have frequent catheter‐related bloodstream infections (CRBSIs). The purpose of this study was to prospectively study the clinical course of CRBSIs and to seek modifiable risk factors for CRBSIs in children with IF. Materials and Methods: Children with IF were enrolled prospectively and data on potential risk factors collected monthly. Additional data were collected when they had CRBSIs. Results: Sixteen children were enrolled, yielding 223 months of data. The rate of CRBSIs was 4.6 per 1000 catheter days. The most consistent symptom at onset of CRBSI was fever (28 of 32 cases). Elevated C‐reactive protein (CRP) was the only laboratory abnormality that was consistently associated with the onset of CRBSI (elevated in 15 of the 18 cases where it was measured). Combining all episodes in the cases that relapsed, the catheter salvage rate was 17 of 29 (59%), including 4 of 11 polymicrobial CRBSIs. Risk factors for CRBSI included double lumen tunneled central venous catheter (CVC), jugular placement of CVC, higher doses of intralipid, and having <50 cm small bowel postresection. Conclusion: The diagnosis of CRBSI should be questioned in the absence of fever and/or elevated CRP. Salvage of catheters should be attempted with all bacterial CRBSIs, assuming that the child is stable since the CVC can be retained in the majority of cases.     

The Impact of Gender and Protein Intake on the Success of Weight Maintenance and Associated Cardiovascular Risk Benefits,Independent of the Mode of Food Provision: The DiOGenes Randomized Trial

Objective: Maintenance of weight loss and associated cardiovascular benefits after following energy-restricted diets is still a challenging field, and thorough investigation is needed. The present research aimed to determine the role of protein and gender in relation to two different intervention models related to food supply, in a weight maintenance trial.

Subjects and Methods: The DiOGenes trial was a long-term, multicenter, randomized, dietary intervention study, conducted in eight European countries (Clinical Trials.gov, NCT00390637), focusing on assessing the effectiveness of weight maintenance over 6 months. This secondary analysis intended to evaluate the different benefits for weight maintenance and cardiometabolic markers of two dietary advice delivery models: “shop + instruction intervention” vs “instruction-alone intervention,” which were further categorized for gender and macronutrient intake.

Results: The weight maintenance intervention based on different macronutrient intake showed, independently of the advice delivery model, in both sexes that higher protein consumption was more effective for weight stability, showing better results in obese women (low protein: 1.65 kg in males and 0.73 Kg in females vs high protein: 1.45 kg in males and -0.93 Kg in females) . Measurements concerning cardiovascular risk markers from subjects on both structured models produced similar trends in the subsequent follow-up period, with a lower rebound in women for most of the markers analyzed.

Conclusion: The reported dietary benefits for weight sustainability should be ascribed to the macronutrient distribution (higher protein diets) rather than to the structured mode of delivery. Higher weight regain in males was noted, as well as a metabolic divergence attributable to the sex, with a better biochemical outcome in women.