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The inconsistency of diagnostic criteria for malnutrition has confused clinicians since the 1980s. After the implementation of disease diagnosis related group payment (DRG) in China's public hospitals, the diagnosis of malnutrition and the correct documentation of nutrition-related diagnosis on the front sheet of medical records are related to the correct classification of the disease group and the medical insurance payment. Therefore, the reliable diagnostic criteria for malnutrition, especially disease-related malnutrition, is urgently needed in clinical practice. In September 2018, The global leadership Iinitiative on malnutrition (GLIM) diagnostic criteria consensus was launched. GLIM aimed to provide the explicit and unified diagnostic criteria for malnutrition in adult hospitalized patients. However, GLIM criteria was based on the voting by nutritional experts and was merely a consensus in nature. The clinical validity of GLIM criteria needs prospective verification, i.e., to demonstrate that patients with malnutrition as per GLIM criteria could have improved clinical outcomes with reasonable nutritional interventions. In November 2020, the article titled Nutritional support therapy after GLIM criteria may neglect the benefit of reducing infection complications compared with NRS 2002 was published on the journal Nutrition. It was the first study comparing nutritional risk screening 2002 (NRS 2002) and GLIM malnutrition diagnostic criteria among Chinese patients for the indication of nutritional support therapy. The clinical effectiveness of the two tools was retrospectively verified as well. Here we discussed the key points of this retrospective study, including the critical research methods, to inform the currently ongoing prospective validation of the GLIM malnutrition diagnostic criteria (the item of reduced muscle mass not included).
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Objective:To investigate the nutritional risk and prevalence of malnutrition in patients with terminal stage gastrointestinal malignant tumors in a tertiary hospital in Changsha.Methods:Cluster sampling was used to conduct a cross-sectional survey of inpatients from Departments of Gastroenterology, Gastrointestinal Surgery, Hepatobiliary Surgery and Oncology in Hunan Provincial People's Hospital from January 2019 to July 2020. Nutritional Risk Screening 2002 (NRS 2002) was used to assess the prevalence of nutritional risk with malnutrition defined as concurrent presence of BMI < 18.5 kg/m 2, poor general condition and NRS 2002 nutritional impairment score of 3. Step 2 of Global Leadership Initiative on Malnutrition (GLIM) diagnostic criteria (without whole body muscle mass) was adopted to diagnose malnutrition. Step 3 of GLIM criteria was used to evaluate the prevalence of severe malnutrition. Results:A total of 802 patients registered in the 4 departments were selected for screening via cluster sampling and 514 were enrolled according to the inclusion/exclusion criteria. The prevalence of nutritional risk in patients with terminal stage gastrointestinal cancer was 49.8% (256/514). The prevalence of malnutrition and severe malnutrition per GLIM criteria were 41.6% (214/514) and 18.3% (94/514), respectively.Conclusions:Although nutritional support therapy is not recommended for patients with end-stage cancer. This paper suggests that the prevalence of nutritional risk and malnutrition in patients with end-stage gastrointestinal cancer is not as high as described in some articles.
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In the 42 nd and 44 th workshops of CSPEN-nutritional risk-undernutrition-support-outcome-cost effectiveness ratio (NUSOC) multi-center database collaboration group, Jens Kondrup and Henrik Rasmussen described again the application of NRS 2002, the evidence-based basis of NRS 2002 development and the methodology for prospective validation of clinical effectiveness. There is no gold standard for validation. They both considered that malnutrition could be identified as a score of 3 or more for impaired nutritional status in NRS 2002. Although NRS 2002 is simple and easy to be applied, it is not comprehensive enough for malnutrition diagnosis. ASPEN and ESPEN on-line published the Global Leadership (nutritional) Initiative on Malnutrition(GLIM)diagnosis criteria in September 2018. With the gradual implementation of medicare payment based on diagnosis related groups(DRG)in China, the nutritional risk and the malnutrition diagnosis with Chinese version of ICD-10 (2016) code should be recorded in the first page of the medical records. In this terminology interpretations, the terms of nutritional risk screening(NRS 2002.01.016)and malnutrition diagnosis (GLIM-phenotypic criteria 01.028, etiologic criteria 01.029) published in Parenteral and Enteral Nutrition Terminology 2019 are discussed based on the reports given by Kondrup and Rasmussen in Beijing and Zhengzhou.
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Objective:To systematically review the methodology in clinical trial-based health economics study with cost-effectiveness ratio for nutritional drug.Methods:The literature on health economics study for nutritional drug was retrieved from PubMed and Wanfang Medical Network by October 2019. The literature was selected according to inclusion and exclusion criteria, and was assessed using the Cochrane Risk Bias Assessment Tool and Newcastle-Ottawa Scale. Its methodology such as participants and grouping, confounding factors, research perspective, cost accounting, health outcomes and health economics analysis methods, sensitivity analysis, etc, was systematically reviewed as well.Results:Four target literatures were included in this study. The participants were from gastroenterology, gastrointestinal surgery, etc. Random grouping, regression, propensity score matching method, etc, were used to control confounding factors. The research perspective needed to be clear according to the principle of health economics study. The present literatures focused on "direct medical costs" , and calculated cost-effectiveness ratio or incremental cost-effectiveness ratio to evaluate the economics of medical interventions.Conclusion:The evidence of high-quality health economics research in parenteral and enteral nutrition area in China needs to be promoted, especially in the control of confounding factors, the choice of research perspective and sensitivity analysis, which are supposed to be explored by multidisciplinary research teams in practice.
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The three steps of nutritional care in Europe, the United States and China were basically same as [Nutritional screening-assessment-intervention]. This review article discussed the second step of GLIM for diagnosis of malnutrition, when the diagnosis of malnutrition being needed. No normal range in healthy volunteer and no cut-off point based on clinical studies for FFMI in China now.
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The criteria for malnutrition assessment (diagnosis) have been developed for years.Global Leadership Initiative on Malnutrition (GLIM) criteria for the diagnosis of malnutrition was issued in September 2018,which aims to build a global consensus around core diagnostic criteria for adult malnutrition in clinical settings.In this article,GLIM malnutrition assessment (diagnosis) consensus was reviewed and analyzed.
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It is well known that parenteral and enteral nutrition support is helpful to improve clinical outcomes in patients with malnutrition or nutritional risk, and surgical nutrition has been used in China for 40 years. However, there is still insufficient awareness of malnutrition among clinical workers. There were different opinions from many experts after the publications of the European Society for Parenteral and Enteral Nutrition (ESPEN) consensus of malnutrition assessment 2015 and ESPEN guidelines on definitions and terminology of clinical nutrition 2017. Global Leadership Initiative on Malnutrition (GLIM) criteria for the diagnosis of malnutrition has also been published in 2018. Though it is lack of clinical validation, it is a big step forward. In order to achieve better prevention and treatment of malnutrition in clinical work, this present paper analyzes and compares the core contents of malnutrition assessment (diagnosis) in recent years, proposes current practical strategy for Chinese clinical workers, emphasizes that GLIM criteria cannot replace the three steps named "screening-assessment-intervention" .
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The ultimate goal of the development of parenteral and enteral nutrition is to achieve T3 transfer of translational medicine in this field. This study is an international cooperative, multicenter and observational clinical study conducted by CSPEN-NUSOC cooperative group for 15 years which is aimed to observe the effect of standardized nutritional support on clinical outcome and cost/effect and verify the clinical value parenteral and enteral nutrition through investigating the prevalence of nutritional risk and malnutrition and the application of nutritional support in adult in-patients.
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Objective To investigate the prevalence of nutritional risk (NRS2002) and malnutrition inhospitalized stroke patient and their nutritional intervention. Methods The stroke patients admitted to three de-partments of vascular neurology ward including cerebral hemorrhage, cerebral infarction and subarachnoid hemor-rhage in Beijing Tiantan Hospital from January 2018 to January 2019 were recruited using cluster sampling. Nutri-tional risk screening 2002 ( NRS 2002) was used to screen the nutritional risk of inpatients Malnutrition was as-sessed by criteria:(1) body mass index (BMI) <18. 5 kg/m2 with poorer general condition from January 2018 to January 2019;(2) Global leadership initiative on malnutrition ( GLIM) criteria were used except whole body muscle mass measurement from October 2018 to January 2019. The nutritional intervention for patients were closely observed during hospitalization. Results A total of 1532 patients were registered and1036 patients were included in the final analysis considering the inclusion and exclusion criteria. The prevalence of nutritional risk was 33. 0％ ( 342/1036) . The prevalence of malnutrition based on BMI and GLIM criteria was 0. 9％( 9/1036) and 2. 5％ (10/393) respectively. Among the 342 patients with nutritional risk, 112 patients received nutritional support therapy by tube feeding, but only 29 patients received nutritional support that met guideline standards. 81 patients received not standard nutritional support, and 2 patients received highly unregulated nutritional sup-port. No patients received sugar and electrolyte infusion, oral nutritional supplements ( ONS) , oral nutritional a-gents and compound nutrition intervention. The other 230 patients took hospital diet. Conclusion The prevalence of nutritional risk in hospitalized patients with cerebral hemorrhage, cerebral infarction or subarachnoid hemorrhage was high, and the prevalence of malnutrition was extremely low. There was a low proportion of nutri-tional support. High quality of large sample cohort studies will be conducted to show whether reasonable applica-tion of nutritional support therapy in patients with nutritional risk can improve patient outcome.
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The ultimate goal of the development of parenteral and enteral nutrition is to achieve T3 transfer of translational medicine in this field. This study is an international cooperative, multicenter and observational clinical study conducted by CSPEN-NUSOC cooperative group for 15 years which is aimed to observe the effect of standardized nutritional support on clinical outcome and cost/ effect and verify the clinical value parenteral and enteral nutrition through investigating the prevalence of nutritional risk and malnutrition and the application of nutritional support in adult in-patients.
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Clinical decision-making has been perceived as a primary cognitive activity for clinicians in daily practice,which based on the process of choosing between alternatives or options for patients.A single clinical decision might affect one patient's health outcomes,while the sum of clinical decisions made by all clinicians would play a decisive role in the allocation and utilization of health resources.Several dimensions should be taken into consideration when making clinical decisions,such as scientificity,clinical experience,economical status,medical humanities and government administration.In addition,clinical decision-making behavior should be administrated and guided by government,from the following seven aspects,so as to avoid "scientism" or " commercial alienation" phenomenon:national guidelines and standards development,academic standardization,expertise offering,medical training with human factors as well as legal punishment,medical knowledge accessibility,reimbursement restriction,and application of artificial intelligence.
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Components and compounding of parenteral nutrition solutions were different in different hospitals and different parts of China.In order to raise awareness,reduce improper compounding and improve patient safety,Pharmacy Cooperative Group of Chinese Society for Parenteral and Enteral Nutrition composed the Consensus for Parenteral Nutrition Solutions Compounding,providing evidence for standardization in this field.
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In 2017,the Ministry of Human Resources and Social Security issued the "National Basic Medical Insurance,Work-related Injury Insurance,and Maternity Insurance Drag List (2017 Edition) ",which is a major innovation in the 2009 edition of the directory.In particular,in the aspect of parenteral and enteral nutrition,the directory provides clearer indications of medication based on "nutritional risk".In this article,based on the research advances in recent years,we briefly analyzed the contents of parenteral and enteral nutrition in the 2017 edition.
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Objective To investigate the prevalence of nutritional risk and undernutrition of geriatric patients with hip fracture in the department of orthopaedics and analyze the relationship between nutritional risk scores and clinical outcomes.Methods In this prospective cohort study,the baseline demographic data of 235 elderly patients with hip fracture in the department of orthopaedics of Ningbo First Hospital were consecutively recorded from November 2013 to December 2015.The prevalence of nutritional risk and undernutrition,infectious complications,and length of hospital stay were also recorded.The infectious complications and length of hospital stay in patients in different age groups(60-69 years,70-79 years,and ≥80 years)and those with different nutritional risks(<3 points,3-4 points,and ≥5 points)were analyzed.Results All patients without PN EN support during hospitalized durations.The incidence of nutritional risk was 62.98％in 235 elderly patients with hip fracture,twenty patients were undernutritioned by multi-item standard based on Nutritional Risk Screening 2002 nutrition disorder score,and 15 patients were undernutritioned by one-item standard with body mass index.Hip arthroplasty patients had significantly higher nutritional risk than those who had undergone internal fixation(74.04％vs.54.20％,P=0.002).Patients with comorbidities had significantly higher nutritional risk than patients without comorbidities(71.56％vs.55.56％,P=0.011).There were significant differences in infectious complications(2.30％vs.3.91％vs.50.00％)and length of hospital stay[(6.35±0.87)d vs.(8.12±1.13)d vs.(10.85±1.52)d,(8.66±2.06)d vs.(10.45±2.43)d vs.(13.25 ±3.65)d] among patients with different nutritional risks(<3 points,3-4 points,and ≥5 points)(P=0.000).Conclusions Elderly patients with hip fracture has relatatively high nutritional risk.These patients tend to have more complications and longer hospital stay.
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Nutritional support therapy includes three main components:nutritional screening,nutritional assessment,and nutritional intervention.It is important to emphasize that nutritional screening and nutritional assessment are two different concepts and definitions,which are often confusing for many physicians,nurses,and dietitians.In this review,we present an overview on the main concepts about nutritional screening and nutritional assessment,highlight their features and complementarity,and discuss the future perspectives in the clinical practice.
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Objective Long-chain triacylglycerol (LCT) by three producers,each mixed with the same medium-chain triacylglycerol (MCT),were compared with the brand MCT/LCT in causing focal necrosis of hepatocytes in beagle dogs (a bioequivalence evaluation).Methods 21 beagle dogs (male,0.7-1.5 years old,10-15 kg) were used in this study.According to the sources of the LCT,the animals were divided into Group A (LCT made in China),Group B (LCT made in Japan),Group C (LCT made in Germany),and the control group (the brand 10％ MCT/LCT).Central venous port was placed via the lumber vein of the animals under general anesthesia.After 2 weeks of rehabilitation,MCT/LCT was administered through this port for 28 days at 9 g/ (kg · d) [while the routine dose used clinically was 1 g/ (kg · d)].The laboratory indexes and the pathomorphism of the liver and kidney were studied single blindly.Results Laboratory tests,including liver and kidney function,blood coagulation function and lipid metabolism,did not identify differences among emulsions with different sources of LCT.Liver biopsy at day 28 showed no focal necrosis in Group C and the control group;there was minor damage in Group B;and Group A had obvious liver necrosis.and the pathological findings of other organs are similar.No significant difference was observed in biopsies of other organs.Conclusions Emulsions with different sources of LCT varied in their damage to the liver.Generics with LCT of higher quality were equivalent to the brand MCT/LCT in terms of safety.
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Objective To evaluate the impact of fish oil (ω-3 fatty acids) parenteral nutrition (PN) on outcomes for non-ICU postoperative patients.Methods PubMed,Embase,Cochrane,China National Knowledge Infrastructure (CNKI) and Wanfang Database etc.were searched to retrieve the eligible studies published from January 2010 to June 2016.The studies included were randomized controlled trials (RCTs) that evaluated the effects of supplementation of fish oil (Omegawen) in PN regimens for postoperative patients on clinical outcomes.The methodological quality assessment was based on Jadad scale and Schulz allocation concealment tool.Meta-analysis was conducted by RevMan 5.3 software.Results 19 RCTs,1 170 surgical patients,were included.Meta-analysis indicated that short-term fish oil supplementation significantly reduced the incidence of infectious complications [RR =0.44,95％ CI (0.31,0.64),P ＜0.000 1] and shortened the length of hospital stay [MD =-0.85,95％ CI (-1.67,-0.03),P=0.04],while with no significant effect on mortality [RR =0.42,95％ CI (0.07,2.63),P =0.36] and total expenditure of hospitalization [MD =-216.60,95％ CI (-718.94,285.75),P =0.40].Sensitivity analysis showed similar results.Conclusion According to existing evidence,fish oil in PN for surgical patients could reduce the incidence of postoperative infectious com-plications and shorten the length of hospital stay.
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Objective To investigate prospectively the nutritional risks,undernutrition,and nutritional support in hospitalized patients with later but non-end-stage malignancies in a second grade hospital in Beijing.Methods All patients who were admitted in the department of oncology in this hospital from October 2011 to April 2013 were consecutively recorded.Nutritional Risk Screening (NRS 2002) was used for screening nutrition risks,the undernutrition assessment was performed on the first morning for patients meet the inclusion criteria,and nutritional support was evaluated until the discharge.For patients with no nutritional risk,NRS 2002 was repeated weekly during the hospitalization.Results A total of 305 cases of inpatients admitted,and 224cases meeting the inclusion criteria were screened by NRS 2002,among whom only 171 patients with non-endstage later stage cancer entered the final analysis.Among these 171 patients,116 (67.8％) were at nutritional risks.Furthermore,for different types of tumor,the nutritional risk was 45.7％ for lung cancer,89.4％ for digestive-tract cancers,81.3％ for liver-biliary and pancreatic cancers,and 83.3％ for head-and-neck cancers.The undernutrition rate was 12.3％ (21/171) if based on body mass index ＜ 18.5 kg/m2 and 19.9％ (34/171) if evaluated from the score of nutritional defect part of NRS 2002.Only 71 patients (61.2％) at nutritional risk received nutritional support,while 5 of 55 patients (9.1％) without nutritional risk received nutritional support.The average ratio of parenteral nutrition to enteral nutrition was 23∶ 1.Intravenous calories intake was 56.78 ± 8.20 k J/ (kg · d) ; the intake of nitrogen was 0.06 ± 0.01 g/ (kg · d),and the ratio of calories to nitrogen was 204∶ 1.Conclusions A large proportion of inpatients with non-end-stage later cancer were at nutritional risk,which is associated with tumor types.The application of nutritional support should be further standardized,particularly for patients at nutritional risk but with low nutritional support.Furthermore,whether the clinical outcome of inpatients at nutritional risk may be improved by nutritional support still requires further investigation.
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Objective To evaluate the impact of nutrition support on the clinical outcomes of gastrointestinal disease patients at nutritional risk and explore the the cost-effectiveness of various nutrition support options.Methods A prospective cohort study was designed.The patients who met the predetermined inclusion criteria were followed up during the hospital stay.Nutritional risk was determined using the Nutrition Risk Screening 2002 on admission.The information with respect to nutritional support,occurrence and treatment of complications,length of hospital stay,and discharge destination was monitored and recorded.The direct costs of nutritional support and the costs of diagnosing and treating complications were calculated after discharge.Infectious complication-free patient was used as the effectiveness indicator in the cost-effectiveness analysis.Results Patients who had received nutrition support had significantly lower infectious complications incidence (6.8％ vs.19.6％,x2 =9.0,P=0.003) and significantly higher total hospitalization costs (P =0.0001).The adjusted (by general linear model) cost of parenteral nutrition (PN) cohort,enteral nutrition (EN) cohort,PN combined EN cohort,and the cohort without nutritional support were 5635,1212,5220,and 1339 China Yuan,respectively.The incremental cost effectiveness ratios were 36 101,-794,and 33 748 China Yuan for PN,EN,and PN-EN combination groups,respectively.Conclusions For the patients at nutritional risk,nutritional support can remarkably reduce the incidence of infectious complications.The preliminary resuits of cost-effectiveness:due to lack of enough data required by health economic professional,it can not be cited directly.
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Objective To use a measurement tool to assess systematic reviews (AMSTAR) to assess the methodological quality of published meta-analyses of intravenous fish oil interventions on clinical outcomes in postoperative or intensive care unit (ICU) patients supported with parenteral nutrition (PN).Methods PubMed,EMBASE,Cochrane Library,Web of Science,Chinese Biomedical Databases,China National Knowledge Infrastructure,Wanfang Database,and some other databases were searched to retrieve the eligible studies published from January 1996 to September 2013,and the relevant journals and the references of included studies were also retrieved manually.The studies were included if they were systematic reviews or meta-analyses that evaluated the effects of fish oil-enriched PN and standard PN for postoperative or ICU patients on clinical outcome.Two reviewers screened the literature according to the inclusion criteria and extracted the data.Then the AMSTAR was used to evaluate the quality of the included studies.Results A total of five relevant meta analyses were included.Based on AMSTAR,two studies were of high quality,one of moderate quality,and the other two were of low quality.Conclusions The methodological quality of these five published metaanalyses of intravenous fish oil interventions is uneven.Further large-scale and high-quality randomized controlled trials about the impact of intravenous fish oil on clinical outcomes and cost-effectiveness analysis for postoperative and ICU patients are needed.