Miriam Theilla

Tight Calorie Control in geriatric patients following hip fracture decreases complications: A randomized, controlled study

BACKGROUND & AIMS Optimizing nutritional intake has been recommended for geriatric patients undergoing hip-fracture surgery. Whether nutritional support guided by repeated measurements of resting energy requirements (REE) improves outcomes in these patients is not known. METHODS A randomized, controlled, unblinded, prospective, cohort study comparing provision of energy with a goal determined by repeated REE measurements using indirect calorimetry, with no intervention. Oral nutritional supplements were started 24 h after surgery and the amount adjusted to make up the difference between energy received from hospital food and measured energy expenditure. RESULTS 50 Geriatric patients were included in the study. Patients in the intervention group (n = 22) received significantly higher daily energy intake than the control group (n = 28) (1121.3 ± 299.0 vs. 777.1 ± 301.2 kcal, p = 0.001). This was associated with a significantly less negative cumulative energy balance (-1229.9 ± 1763 vs. -4975.5 ± 4368 kcal, p = 0.001). A significant negative correlation was found between the cumulative energy balance and total complication rate (r = -0.417, p = 0.003) as well as for length of hospital stay (r = -0.282, p = 0.049). CONCLUSION We have demonstrated that nutritional support actively supervised by a dietician and guided by repeated measurements of REE was achievable and improved outcomes in geriatric patients following surgery for hip fractures. Clinicaltrials.gov Identifier: NCT017354435.

Impact of a Nutritional Formula Enriched in Fish Oil and Micronutrients on Pressure Ulcers in Critical Care Patients

BACKGROUND Pressure ulcers are an important source of morbidity and suffering for patients and a formidable burden on caregivers. OBJECTIVES To assess the impact of a feeding formula enriched with fish oil on healing of preexisting pressure ulcers and serum levels of C-reactive protein in critical care patients. METHODS Adult patients with pressure ulcers grade II or higher were randomly allocated to receive either a formula enriched with fish oil or an isocaloric control formula. Wound healing was assessed by using the Pressure Ulcer Scale for Healing tool on days 7, 14, and 28. Blood levels of C-reactive protein were measured on days 0, 7, and 14. RESULTS Baseline demographics did not differ between the study (n = 20) and the control (n = 20) groups. The mean score on the ulcer healing tool increased significantly (P = .02) from day 0 to day 28 in the control group (from 9.25 [SD, 2.12] to 10.75 [SD, 3.41]) compared with the study group (from 9.10 [SD, 2.84] to 9.40 [SD, 3.72]). Mean levels of C-reactive protein decreased significantly (P= .02) from day 0 to day 14 in the study group (from 191 [SD, 104.4] mg/L to 111.7 [SD, 97.8] mg/L) compared with the control group (from 145 [SD, 90] mg/L to 139 [SD, 62] mg/L). CONCLUSION Administration of a feeding formula enriched with fish oil was associated with decreased progression of pressure ulcers and a decrease in blood concentrations of C-reactive protein.

Enteral n -3 fatty acids and micronutrients enhance percentage of positive neutrophil and lymphocyte adhesion molecules: a potential mediator of pressure ulcer healing in critically ill patients

n-3 Fatty acids are recognised as influencing both wound healing and immunity. We assessed the impact of a fish oil- and micronutrient-enriched formula (study formula) on the healing of pressure ulcers and on immune function in critically ill patients in an intensive care unit. A total of forty patients with pressure ulcers and receiving nutritional support were enrolled (intervention group, n 20, received study formula; and a control group, n 20, received an isoenergetic formula). Total and differential leucocyte count and percentage of adhesion molecule positive granulocyte and lymphocyte cells (CD11a, CD11b, CD18 and CD49b) were measured on days 0, 7 and 14. Percentage of positive lymphocytes for CD54, CD49b, CD49d and CD8 were also measured on days 0, 7 and 14. The state of pressure ulcers was assessed by using the pressure ulcer scale for healing tool score on days 7, 14 and 28 of treatment. No between-group differences in patient demographics, anthropometry or diagnostic class were observed. Patients who received the study formula showed significant increases in the percentage of positive CD18 and CD11a lymphocytes and of CD49b granulocytes as compared to controls (P < 0·05). While the severity of pressure ulcers was not significantly different between the two groups on admission, severity increased significantly over time for the control group (P < 0·05), but not for the study group. The present study suggests that a fish oil- and micronutrient-enriched formula may prevent worsening of pressure ulcers and that this effect may be mediated by an effect on adhesion molecule expression.

Lipid metabolism in critical illness.

Purpose of reviewThis article describes recent findings regarding lipid metabolism in critical illness as well as in lipid therapy. Recent findingsIn critical illness, in the presence of a decrease in lipid absorption, adipose tissue lipolysis raises triglyceride levels. High-density lipoprotein and low-density lipoprotein are decreased because of impairment of lecithin–cholesterol acyltransferase, mainly in sepsis. In septic patients, lipid profile may be a predictor of survival. Nonsurvivors have lower levels of high-density lipoprotein and low-density lipoprotein. In metabolomic studies, most of the changes from baseline in septic patients were related to lipid metabolism. Lysophosphatidylcholine was also significantly lower in nonsurviving septic patients. SummaryLipid profile results are too often neglected by the clinician despite increasing knowledge in the modifications related to septic state as well as the importance of these values in the prognosis of the critically ill. Lipid administration (enterally or parenterally) should be guided by better knowledge of the lipid metabolism of the patient.

Comparison between two metabolic monitors in the measurement of resting energy expenditure and oxygen consumption in diabetic and non-diabetic ambulatory and hospitalized patients

OBJECTIVE The aim of this study was to assess the validity and reliability of the Fitmate metabolic system in measuring the oxygen consumption and resting metabolic rate (RMR) in ambulatory and hospitalized patients. METHODS We conducted a prospective simultaneous clinical comparison. We enrolled 37 patients (19 women and 18 men) for the four groups of the study. Group 1 (n = 12) included patients receiving home parenteral nutrition. Group 2 (n = 5) included diabetic overweight outpatients with body mass index >30 kg/m(2) and hemoglobin A1c > 8 g/dL. Group 3 (n = 10) included hospitalized patients receiving artificial nutrition. Group 4 (n = 10) included patients with congenital heart disease, pulmonary hypertension of any etiology, and other heart disease who have had hemodynamic evaluation during catheterization by the adult congenital team. The patients were tested successively during the same session using the Fitmate metabolic system for 15 min and the Deltatrac II metabolic monitor for 20 min, measuring resting energy expenditure and oxygen consumption. The test was conducted in random order. RESULTS No significant differences were found between Fit Mate and Deltatrac II for oxygen consumption (238 ± 18 and 240 ± 18 mL/min, respectively, P = 0.72, r = 0.86, mean ± SD absolute difference 22.32 ± 16.99 mL/min) or RMR (1659 ± 122.34 and 1625 ± 118.4 kcal/d, P = 0.28, r = 0.87, mean ± SD absolute difference 152.9 ± 111.95 kcal/d). A degree of limit of agreement (403 kcal) was observed using the Bland-Altman test. When compared with Harris-Benedict predictive equations, Fitmate was found to be superior in accuracy. CONCLUSIONS These data indicate that the Fitmate using a mask provided a fair evaluation of REE despite a large limit of agreement. It remains a reliable and valid system for measuring oxygen consumption and RMR in nonventilated patients.

Self-Evaluation of Quality of Life Among Patients Receiving Home Parenteral Nutrition: A Validation Study

BACKGROUND Home parenteral nutrition (HPN) can increase survival and quality of life (QOL) in cases of chronic intestinal failure. The present study compares a gold standard-a validated QOL assessment by Baxter et al (hereafter, HPN-QOL)-with a shorter questionnaire for QOL evaluation (hereafter, New QOL). MATERIALS AND METHODS Both questionnaires were completed by 58 patients attending the nutrition clinic of the Rabin Medical Center (Israel). A z score was used to equate means and variances. Statistical analysis was based on Pearson correlation between variances. Stepwise regression was used to evaluate the best value predictor in the New QOL for QOL during HPN. Cronbachs α was used for internal consistency, and confirmatory factor analysis was used for structural validity. RESULTS Results from the sections of the New QOL that relate to the patients general health, level of independence, and experience with handling the parenteral nutrition therapy are highly correlated with the HPN-QOL (r = 0.43 and r = 0.50, respectively). In addition, there was good correlation between the questionnaires with reference to the patients social state, mental state, and everyday functioning (r = -0.43, New QOL; r = -0.39, HPN-QOL). However, the New QOL results show no correlation between the patients physical symptoms and QOL during HPN. This was hypothesized to result from the nature of the study population. CONCLUSION The results of our new questionnaire are well correlated with the gold standard HPN-QOL. The New QOL appears to be simple and easy to use.

Energy and Protein in Critically Ill Patients with AKI: A Prospective, Multicenter Observational Study Using Indirect Calorimetry and Protein Catabolic Rate

The optimal nutritional support in Acute Kidney Injury (AKI) still remains an open issue. The present study was aimed at evaluating the validity of conventional predictive formulas for the calculation of both energy expenditure and protein needs in critically ill patients with AKI. A prospective, multicenter, observational study was conducted on adult patients hospitalized with AKI in three different intensive care units (ICU). Nutrient needs were estimated by different methods: the Guidelines of the European Society of Parenteral and Enteral Nutrition (ESPEN) for both calories and proteins, the Harris-Benedict equation, the Penn-State and Faisy-Fagon equations for energy. Actual energy and protein needs were repeatedly measured by indirect calorimetry (IC) and protein catabolic rate (PCR) until oral nutrition start, hospital discharge or renal function recovery. Forty-two patients with AKI were enrolled, with 130 IC and 123 PCR measurements obtained over 654 days of artificial nutrition. No predictive formula was precise enough, and Bland-Altman plots wide limits of agreement for all equations highlight the potential to under- or overfeed individual patients. Conventional predictive formulas may frequently lead to incorrect energy and protein need estimation. In critically ill patients with AKI an increased risk for under- or overfeeding is likely when nutrient needs are estimated instead of measured.

OP041 TIGHT CALORIE CONTROL (TICACOS) IN GERIATRIC HIP FRACTURE PATIENTS

OP041 TIGHT CALORIE CONTROL (TICACOS) IN GERIATRIC HIP FRACTURE PATIENTS R. Anbar1, Y. Beloosesky2, Z. Madar3, M. Theilla4, T. Koren-Hakim5, A. Weiss2, S. Frishman5, P. Singer4. 1Nutrition Unit and Institute for Nutrition Research, 2Geriatrics, Rabin Medical Center and Tel Aviv University, Petah Tikva, 3School of Nutritional Sciences, The Robert H. Smith Faculty of Agricultural, Food and Environmental Quality Sciences, Hebrew University, Jerusalem, 4Intensive Care and Institute for Nutrition Research, 5Nutrition Unit, Rabin Medical Center and Tel Aviv University, Petah Tikva, Israel

Use of Intravenous Lipids: What Do the Guidelines Say?

The use of intravenous lipids is very frequent in most parenteral nutrition (PN) prescriptions. In this chapter, a systematic review of the literature was performed to compare the position of the various scientific societies (mainly the European Society for Clinical Nutrition and Metabolism, the American Society for Parenteral and Enteral Nutrition, and the German and Canadian Nutrition Societies) in terms of recommendations of when intravenous lipids should be prescribed for different clinical conditions. These recommendations may be supported by strong evidence or, if not available, by expert opinion. These recommendations help the physician in his daily prescription of PN in the hospital and help the patient requiring home PN.

Mental Health Nurse’s Exposure to Workplace Violence Leads to Job Stress, Which Leads to Reduced Professional Quality of Life

Professional quality of life (ProQOL) reflects how individuals feel about their work as helpers. Psychiatric ward nurses cope with significant psychological and physical challenges, including exposure to verbal and physical violence. This study was based on two aspects of ProQOL, the positive compassion satisfaction, and the negative compassion fatigue, with the aim of investigating the relation of ProQOL to job stress and violence exposure at a large mental health center. Data were collected from 114 mental health nurses (49/63 M/F) who completed a self-administered questionnaire examining violence exposure, ProQOL, and job stress. The results showed that during the last year, almost all nurses (88.6%) experienced verbal violence, and more than half (56.1%) experienced physical violence. Only 2.6% experienced no violence. ProQOL was not associated with violence exposure but was reduced by work stress and by previous exposure to violence; nurses who perceived their work as more stressful had lower satisfaction from their work. In conclusion, although most mental health nurses are exposed to physical and verbal violence, their ProQOL is more related to job stress than to workplace violence (WPV). Hospital managements should conduct work stress reduction intervention programs and promote strategizes to reduce WPV. Further exploration of (a) factors affecting ProQOL and (b) the effect of violence coping workshops on ProQOL is warranted.