Prevalence,Outcomes, and Management of Enteral Tube Feeding Intolerance: A Retrospective Cohort Study in a Tertiary Center

Background: Enteral tube feeding (ETF) is the most common form of artificial feeding in hospitalized patients, and the development of intolerance (ETFI) is the most common complication. This study aimed to determine the prevalence of ETFI, the clinical consequences, and the current management approach to ETFI in hospitalized adult patients. Materials and Methods: Adult patients receiving ETF were identified from a prospective database in the Nutrition Services at Auckland City Hospital. Further information was obtained by the review of clinical records for a 12‐month period, up to December 2014. Results: The prevalence of ETFI was 33% among 754 patients. ETFI more frequently occurred in the intensive care unit (P < .05). Patients with ETFI were less likely to reach their feeding goal rate (P < .01). Multivariate analysis showed that younger age, certain specialties, and acute mesenteric ischemia were independent predictors of ETFI (P < .05). The management of ETFI was highly variable. Medication was the most common treatment, while changes in the feeding protocol such as reducing infusion rate and stopping and changing the route of ETF were also frequently attempted. Conclusion: ETFI is a frequent problem in adult hospitalized patients receiving ETF, and it is associated with poor clinical outcomes such as inadequate nutrition and complications of feeding. While the pathophysiology is poorly understood, there also appears to be no standard evidence‐based treatment. Studies investigating the mechanisms and optimized management are therefore indicated.     

Can Vco2‐Based Estimates of Resting Energy Expenditure Replace the Need for Indirect Calorimetry in Critically Ill Children?

Background: Optimal energy provision, guided by measured resting energy expenditure (REE), is fundamental in the care of critically ill children. REE should be determined by indirect calorimetry (IC), which has limited availability. Recently, a novel equation was developed for estimating REE derived from carbon dioxide production (Vco ₂). The aim of this study was to validate the accuracy of this equation in a population of critically ill children following cardiopulmonary bypass (CPB). Methods: This is an ancillary study to a larger trial of children undergoing CPB. Respiratory mass spectrometry was used measure oxygen consumption (Vo ₂) and Vco ₂. REE was then calculated according to the established Weir equation (REE_W) and the modified, Vco ₂‐based equation (REE_CO2). The agreement between the 2 measurements was assessed using Bland‐Altman plots and mixed‐model regressions accounting for repeated measures. Results: Data from 104 patients, which included 575 paired measurements, were included. The agreement between REE_W and REE_CO2 was biased during the 72‐hour observation period post CPB, with a mean percentage error between measurements of 11% (±7%). The most important determinant of the bias with the Vco ₂‐based equation was the respiratory quotient (RQ). The percentage error between REE_W and REE_CO2 dropped to 4.4% (±2.4%) in those with an RQ between 0.8 and 1. The within‐subject variability for RQ in this cohort was wide (11%). Conclusions: IC remains the most accurate method to determine the REE of critically ill patients. Widespread availability of Vco ₂ data renders Vco ₂‐based approaches to measurement of REE attractive; however, further research is needed to ensure that REE is estimated accurately.     

Predictive Equations Are Inaccurate in the Estimation of the Resting Energy Expenditure of Children With End‐Stage Liver Disease

Background and Objectives: Malnutrition is common in children with end‐stage liver disease (ESLD) and is associated with increased morbidity and mortality. The inability to accurately estimate energy needs of these patients may contribute to their poor nutrition status. In clinical practice, predictive equations are used to calculate resting energy expenditure (cREE). The objective of this study is to assess the accuracy of commonly used equations in pediatric patients with ESLD. Methods: Retrospective study performed at the Hospital for Sick Children. Clinical, laboratory, and indirect calorimetry data from children listed for liver transplant between February 2013 and December 2014 were reviewed. Calorimetry results were compared with cREE estimated using the Food and Agriculture Organization/World Health Organization/United Nations University (FAO/WHO/UNU), Schofield [weight], and Schofield [weight and height] equations. Results: Forty‐five patients were included in this study. The median age was 9 months, and the most common indication for transplantation was biliary atresia (64%). The Schofield [weight and height], FAO/WHO/UNU, and Schofield [weight] equations were compared with indirect calorimetry and found to have a mean (SD) difference of 48.8 (344.0), 59.3 (229.8), and 206.5 (502.6) kcal/d, respectively. The FAO/WHO/UNU, Schofield [weight], and Schofield [weight and height] equations introduced a mean error of 21%, 38%, and 76%, respectively. The FAO/WHO/UNU equation tended to underestimate, whereas the Schofield equations overestimated the REE. Conclusions: Commonly used predictive equations perform poorly in infants and young children with ESLD. Indirect calorimetry should be used when available to guide energy provision, particularly in children who are already malnourished.     

Outcomes after definitive radiation therapy for localized prostate cancer in a national health care delivery system

Purpose

Accurate information regarding real-world outcomes after contemporary radiation therapy for localized prostate cancer is important for shared decision-making. Clinically relevant end points at 10 years among men treated within a national health care delivery system were examined.

Methods

National administrative, cancer registry, and electronic health record data were used for patients undergoing definitive radiation therapy with or without concurrent androgen deprivation therapy within the Veterans Health Administration from 2005 to 2015. National Death Index data were used through 2019 for overall and prostate cancer–specific survival and identified date of incident metastatic prostate cancer using a validated natural language processing algorithm. Metastasis-free, prostate cancer–specific, and overall survival using Kaplan–Meier methods were estimated.

Results

Among 41,735 men treated with definitive radiation therapy, the median age at diagnosis was 65 years and median follow-up was 8.7 years. Most had intermediate (42%) and high-risk (33%) disease, with 40% receiving androgen deprivation therapy as part of initial therapy. Unadjusted 10-year metastasis-free survival was 96%, 92%, and 80% for low-, intermediate-, and high-risk disease. Similarly, unadjusted 10-year prostate cancer–specific survival was 98%, 97%, and 90% for low-, intermediate-, and high-risk disease. The unadjusted overall survival was lower across increasing disease risk categories at 77%, 71%, and 62% for low-, intermediate-, and high-risk disease (p < .001).

Conclusions

These data provide population-based 10-year benchmarks for clinically relevant end points, including metastasis-free survival, among patients with localized prostate cancer undergoing radiation therapy using contemporary techniques. The survival rates for high-risk disease in particular suggest that outcomes have recently improved.