Analysis of the Characteristics of First Permanent Molars with Delayed Eruption / 대한소아치과학회지

The first permanent molars play a key role in maxillofacial development and occlusion. The purpose of this study is to investigate the characteristics and development stages of first molars with delayed eruption, and to evaluate their associations with congenital missing teeth. Eight-year-old patients who had delayed eruption in their first molars were classified into 75 patients with physical barriers and 77 patients without physical barriers. The development stages of the first and second molars in the delayed area were analyzed using Nolla method from the panoramic radiographs. The relationship between congenital missing teeth and delayed area was also investigated. Delayed eruption of first molars were more common in the maxilla alone. With the presence of physical barriers, male patients showed higher frequency in unilateral cases, while female patients had higher bilateral cases when there was no physical barrier. Delayed development of first molars were observed in delayed eruption area. In the absence of physical barriers, adjacent second molars were also developed slowly and the incidence of congenital missing teeth was high in delayed area. If first molars with delayed eruption are observed, clinical and radiographical follow-ups are necessary for the evaluation of their developmental stages and congenital missing teeth.

Nutritional Intervention of a Pediatric Patient with Congenital Bronchomalacia and Gastroesophageal Reflux Disease: a Case Report

Gastroesophageal reflux disease (GERD) is closely related to respiratory issues. We reported the case about the nutrition intervention given to a male infant with congenital bronchomalacia, GERD, and recurrent pneumonia. During the first and second pediatric intensive care unit (PICU) stays, his nutrition status and nutrient intake were good. However, during the 18 days of the third PICU admission, his nutrient intake decreased to 75%–80% of his estimated calorie requirement and his Z-score for weight-for-age dropped to −1.4. We conducted nutritional interventions to improve GERD symptoms and nutritional status include avoiding overfeeding by feeding small amounts frequently, using a pre-thickened formula mixed with a high-calorie formula, and feeding through transpyloric tube. As a result, his daily nutrient intakes gradually increased and his Z-score for weight-for-age was normal. In conclusion, it is important to implement individualized intensive nutritional management to ensure adequate nutrition and growth status in infants with lung disease and GERD.

Subacute Combined Degeneration Caused by Chronic Atrophic Gastritis with Spurious Elevation of Vitamin B12 Level

We report a patient who was diagnosed as subacute combined degeneration (SCD) with elevated homocysteine and methylmalonic acid levels in the situation of a spurious elevation of the vitamin B12 concentration. A false-positive elevation of the vitamin B12 level could lead to a delayed diagnosis and cause irreversible changes in the nervous systems. We therefore suggest that the homocysteine and methylmalonic acid levels should be checked in patients with a normal or elevated vitamin B12 level for whom there is a high clinical suspicion for vitamin B12 deficiency, as a further evaluation for SCD.

Effects of Nutrition Consultation on Nutritional Status in Critically Ill Surgical Patients

PURPOSE: The aim of this study was to investigate nutritional support status and effects of nutrition consultation in critically ill surgical patients. METHODS: The medical records of 76 patients, admitted between June 1 and November 30, 2013, were reviewed retrospectively. Patients were divided into 2 groups: the nutrition consultation group (n=17) and the no consultation group (n=59). Patients were also divided into 3 groups: the enteral nutrition (EN) group (n=8), the parenteral nutrition (PN) group (n=25), and the enteral and parenteral mixed nutrition (ENPN) group. Total delivered/required caloric ratio and serum albumin, serum total protein, hemoglobin and other biochemical variables were compared in each group. RESULTS: Mean daily required and delivered caloric/protein amount were EN group 60.0%, PN group 64.6%, and ENPN group 86.9%. ENPN group showed statistically significant difference when compared with EN group, PN group (P=0.005). When the proportion of patients who were fed more than 75% of the daily required calories was calculated, EN, PN, and ENPN showed 37.5%, 25.0% and 81.8%, respectively. ENPN group were significantly more supplied (P=0.007). Although neither the nutrition consultation group nor the non-consultation group received more than 80% of the daily required calories, the nutrition consultation group received 73% of the daily required calories whereas the no consultation group only received 46% (P=0.007). The total delivered/required protein ratio was approximately 69% of the nutrition consultation group and approximately 42% of the no consultation group (P=0.006). CONCLUSION: The results of providing nutritional consultation to intensive care unit patients showed an increase in the nutrition support. Nutrition education, continuous monitoring and management for nutritional support by systemic administration of a nutritional support team should be considered in order to achieve effective clinical outcomes in critically ill surgical patients.

Early Feeding Is Feasible after Emergency Gastrointestinal Surgery

PURPOSE: This study was undertaken to assess the feasibility of early feeding in patients that have undergone emergency gastrointestinal (GI) surgery. MATERIALS AND METHODS: The authors retrospectively reviewed 84 patients that underwent emergency bowel resection and/or anastomosis from March 2008 to December 2011. Patients with severe shock, intestinal ischemia, sustained bowel perforation, or short bowel syndrome were excluded. Patients were divided into the early (group E; n=44) or late (group L; n=40) group according to the time of feeding commencement. Early feeding was defined as enteral feeding that started within 48 hours after surgery. Early and late feeding groups were compared with respect to clinical data and surgical outcomes. RESULTS: The most common cause of operation was bowel perforation, and the small bowel was the most commonly involved site. No significant intergroup differences were found for causes, sites, or types of operation. However, length of stay (LOS) in the intensive care unit (1 day vs. 2 days, p=0.038) and LOS in the hospital after surgery were significantly greater (9 days vs. 12 days, p=0.012) in group L than group E; pulmonary complications were also significantly more common (13.6% vs. 47.5%, p=0.001) in group L than group E. CONCLUSION: After emergency GI surgery, early feeding may be feasible in patients without severe shock or bowel anastomosis instability.

Relationship of Delayed Parenteral Nutrition Protocol with the Clinical Outcomes in a Medical Intensive Care Unit

Although parenteral nutrition (PN) is an important treatment for patients who are unable to tolerate enteral nutrition (EN), recent international guidelines recommended that PN should be reserved and initiated only after 7 days in well-nourished patients. This retrospective study was conducted to analyze the effect on clinical outcomes of a PN protocol with PN starting 4 days after admission to the intensive care unit (ICU). Eighty-one patients who were admitted from January to March of 2012 were included in the pre-protocol group, and 74 patients who were admitted from April to June of 2012 were included in the post-protocol group. There were no significant differences between the two groups when the age, gender, and admission Acute Physiology and Chronic Health Evaluation (APACHE) II scores were compared. Significantly fewer patients in the post-protocol group were provided PN (58.1% vs. 81.3%, p = 0.002), which was initiated significantly later than in the pre-protocol group (2.7 +/- 2.2 days vs. 1.9 +/- 2.0 days, p = 0.046). Five patients (6.2%) in the pre-protocol group acquired central line-associated bloodstream infection (CLA-BSI) in the ICU, yet none of the patients in the post-protocol group developed CLA-BSI (p = 0.03). The duration of antibiotic therapy and ICU stay were significantly shorter in the post-protocol group than in the pre-protocol group. By delaying initiation of PN, short-term clinical outcomes including incidence of CLA-BSI, antibiotic use, and ICU stay might be improved. Further research should be conducted to investigate the long-term effects of the decreased nutrient intake resulting from delayed PN.

Prevalence of Malnutrition in Hospitalized Elderly Korean Patients Based on Mini Nutritional Assessment-Short Form

PURPOSE: To determine the prevalence of malnutrition in hospitalized elderly Korean patients using Mini Nutritional Assessment-Short Form (MNA-SF) in Korea. METHODS: A cross-sectional, multi-center study was performed. We enrolled 300 patients aged > or =65 years from 10 hospitals. We collected subjects' general characteristics, including age, sex, height, weight, and diagnosis. Patients' nutritional status was assessed using MNA-SF within 48 hours since hospital admission. RESULTS: The subjects were 74.2+/-6.3 years old, and 155 patients were male (51.7%). Cancer was the most common diagnosis (26.3%), followed by musculoskeletal (11.3%), neuromuscular (10.3%), pulmonary (9.0%), and cardiovascular disease (8.7%). The length of hospital stay was 8.7+/-5.9 days. According to MNA-SF, 99 patients (33.0%) were at risk of malnutrition, and 51 patients (17.0%) were malnourished. MNA-SF score showed negative correlations with age (r=-0.259, P<0.001) and hospital stay (r=-0.168, P=0.006). Patients in the malnourished or at risk of malnutrition groups were more likely to be admitted to and stayed longer in the intensive care unit (ICU) than those of normal nutritional status (8.7% vs. 17.3%, P=0.026; 1.6+/-1.0 days vs. 3.7+/-3.2 days, P=0.033). The patients who were malnourished or at risk of malnutrition were hospitalized significantly longer than those of normal nutritional status (9.8+/-6.2 vs. 7.7.+/-5.4 days, P=0.004). After adjusting for age and ICU admission, nutritional status by MNA-SF was the only risk factor for prolonged hospitalization (beta=1.384, P=0.005). CONCLUSION: About half of hospitalized elderly patients were at risk of malnutrition or malnutrition status at admission, and nutritional status was the only risk factor for longer hospital stay. Thus, more attention should be paid to the nutritional care of elderly patients to improve clinical outcomes.

Perioperative Nutritional Status Changes in Gastrointestinal Cancer Patients

PURPOSE: The presence of gastrointestinal (GI) cancer and its treatment might aggravate patient nutritional status. Malnutrition is one of the major factors affecting the postoperative course. We evaluated changes in perioperative nutritional status and risk factors of postoperative severe malnutrition in the GI cancer patients. MATERIALS AND METHODS: Nutritional status was prospectively evaluated using patient-generated subjective global assessment (PG-SGA) perioperatively between May and September 2011. RESULTS: A total of 435 patients were enrolled. Among them, 279 patients had been diagnosed with gastric cancer and 156 with colorectal cancer. Minimal invasive surgery was performed in 225 patients. PG-SGA score increased from 4.5 preoperatively to 10.6 postoperatively (p60, p<0.001), male sex (p=0.020), preoperative weight loss (p=0.008), gastric cancer (p<0.001), and open surgery (p<0.001) were indicated as risk factors of postoperative severe malnutrition. In multivariate analysis, old age, preoperative weight loss, gastric cancer, and open surgery remained significant as risk factors of severe malnutrition. CONCLUSION: The prevalence of severe malnutrition among GI cancer patients in this study increased from 2.3% preoperatively to 26.3% after an operation. Old age, preoperative weight loss, gastric cancer, and open surgery were shown to be risk factors of postoperative severe malnutrition. In patients at high risk of postoperative severe malnutrition, adequate nutritional support should be considered.

Effect of Nutritional Risk at Admission on the Length of Hospital Stay and Mortality in Gastrointestinal Cancer Patients

This retrospective study was conducted to determine whether increased length of hospital stay (LOS) and mortality are associated with nutritional risk upon hospital admission in gastrointestinal cancer patients, using a computerized screening tool developed by a university hospital. We included adult gastrointestinal cancer patients whose hospital stays ranged from 24 hours to 90 days. The sample included 4,345 patients. The average age of the patients was 60.5 +/- 11.4 years and 2,959 (68.1%) were males. The mean of LOS was 8.2 +/- 8.2 days and the mortality rate was 3.4% (n = 146). The majority of the patients were at low risk (LG) (n = 3,102 [71.4%]), while 779 patients (17.9%) were at moderate risk (MG), and 464 (10.7%) were at high risk (HG). In comparing the three groups based on nutritional risk, hospital LOS was significantly longer in the HG (11.4 +/- 11.4 days) than it was in the LG (7.7 +/- 7.9 days) and the MG (7.9 +/- 7.9 days) (p < 0.0001). Significant differences were found in the hospital mortality rate, which was the highest in the HG (13.6%) and the lowest in the LG (1.5%) (p < 0.0001). In the multiple logistic regression analysis, moderate-to-severe nutritional risk, increased age, and emergency admission were selected as significant variables for increased LOS and mortality. Further research is needed to evaluate the benefits of nutritional screening and intervention and their effect on outcomes in various disease populations.

The Use of Health Functional Foods in Gastrointestinal Cancer Patients

As an adjunct to cancer treatment, the use of health functional foods (HFFs) seems to be increasing. However, little is known for the use of HFFs among cancer patients in Korea. The aims of this study were to investigate the exposure rate of HFF use among gastrointestinal (GI) cancer patients and to examine the relationship of socio-demographic and disease-related characteristics with the use of HFFs. A total of 126 patients diagnosed with GI cancer participated in the study. A cross-sectional survey was conducted using a questionnaire. Over a half of all the patients surveyed (n = 67; 53.2%) used HFFs. Patients who were younger, had higher income, or longer duration of disease showed a trend to use HFFs more frequently, even though the tendency was not statistically significant. The most commonly used HFF was vitamin complex (n = 20; 16%), followed by red ginseng (n = 15; 12%), and sweet wormwood (Artemisia annua) (n = 11; 8.8%). About 26% of all responders expressed concerns for using HFFs. The primary concern was 'going against physician's recommendations' (36.8%). About 63% of respondents expressed a desire to consult with their physicians and follow their recommendations. More basic scientific data and educational materials regarding HFFs are required for both health-care professionals and cancer patients. A larger sample and size-controlled groups representing each cancer type will continue to be recruited for participation in this survey.

Avoidable Causes of Delayed Enteral Nutrition in Critically Ill Children

To evaluate the incidence of delayed enteral nutrition (EN) and identify avoidable causes of delay, we retrospectively reviewed medical records of 200 children (median age [range]; 37.5 [1-216] months) who stayed in the intensive care unit (ICU) for a minimum of 3 days. Among 200 children, 115 received EN following ICU admission with a median time of EN initiation of 5 days after admission. Of these, only 22 patients achieved the estimated energy requirement. A significant decrease in the final z score of weight for age from the initial assessment was observed in the non-EN group only (-1.3+/-2.17 to -1.57+/-2.35, P<0.001). More survivors than non-survivors received EN during their ICU stay (61.2% vs 30.0%, P=0.001) and received EN within 72 hr of ICU admission (19.8% vs 3.3%, P=0.033). The most common reason for delayed EN was gastrointestinal (GI) bleeding, followed by altered GI motility and hemodynamic instability. Only eight cases of GI bleeding and one case of altered GI motility were diagnosed as active GI bleeding and ileus, respectively. This study showed that the strategies to reduce avoidable withholding EN are necessary to improve the nutrition status of critically ill children.

Nutrition Support in the Intensive Care Unit of 6 Korean Tertiary Teaching Hospitals: A National Multicenter Observational Study / 대한구급학회지

BACKGROUND: Malnutrition is a frequent nutritional problem among ICU patients, and their nutritional status is known to affect clinical prognosis. We conducted this study to examine nutritional status and actual nutrition delivery in the ICU patients and its relations to clinical outcomes. METHODS: This study was a multicenter retrospective observational study based on the medical records of 163 patients admitted to ICU of tertiary teaching hospitals in Korea. We included the patients who were treated with mechanical ventilation for 3 or more days and received enteral or parenteral nutrition. RESULTS: According to albumin and total lymphocyte count levels, 54.6% of the subjects were moderately or severely malnourished. Mean percentage of calorie and protein delivery to estimated needs for 10 days were 55.8 +/- 29.3% and 46.1 +/- 30.1%, respectively. While parenteral nutrition (PN) started at 1.6 +/- 1.4 days after admission, enteral nutrition (EN) did at 3.6 +/- 2.1 days. Days to PN and EN start, the calorie and protein amount via EN or PN were significantly different among 6 hospitals. No clinical outcomes differed by the levels of calorie or protein delivery. In-hospital mortality was significantly higher in the severely malnourished group at admission as compared to the other 2 groups (54.3% vs. 31.2% vs. 27.7%, p < 0.05) CONCLUSIONS: Malnutrition prevalence is high among Korean intensive care unit patients, but current nutritional therapy practice is inconsistent across institutions and far below the international guidelines. Systematic efforts should be made to develop nutritional support guidelines for Korean ICU patients.

Higher dextrose delivery via TPN related to the development of hyperglycemia in non-diabetic critically ill patients

The beneficial effects of total parenteral nutrition (TPN) in improving the nutritional status of malnourished patients during hospital stays have been well established. However, recent randomized trials and meta-analyses have reported an increased rate of TPN-associated complications and mortality in critically ill patients. The increased risk of complications during TPN therapy has been linked to the development of hyperglycemia, especially during the first few days of TPN therapy. This retrospective study was conducted to determine whether the amount of dextrose from TPN in the 1st week in the intensive care unit (ICU) was related to the development of hyperglycemia and the clinical outcome. We included 88 non-diabetic critically ill patients who stayed in the medical ICU for more than two days. The subjects were 65 +/- 16 years old, and the mean APACHE (Acute Physiology and Chronic Health Evaluation) II score upon admission was 20.9 +/- 7.1. The subjects received 2.3 +/- 1.4 g/kg/day of dextrose intravenously. We divided the subjects into two groups according to the mean blood glucose (BG) level during the 1st week of ICU stay: or = 140 mg/dl. Baseline BG and the amount of dextrose delivered via TPN were significantly higher in the hyperglycemia group than those in the normoglycemia group. Mortality was higher in the hyperglycemia group than in the normoglycemia group (42.4% vs 12.8%, P = 0.008). The amount of dextrose from TPN was the only significant variable in the multiple linear regression analysis, which included age, APACHE II score, baseline blood glucose concentration and dextrose delivery via TPN as independent variables. We concluded that the amount of dextrose delivered via TPN might be associated with the development of hyperglycemia in critically ill patients without a history of diabetes mellitus. The amount of dextrose in TPN should be decided and adapted carefully to maintain blood glucose within the target range.

Implementation of the Head of Bed (HOB) Elevation Protocol on Clinical and Nutritional Outcomes in Critically Ill Patients with Mechanical Ventilator Support / 대한구급학회지

BACKGROUND: Although head of bed (HOB) elevation is an important strategy to prevent ventilator associated pneumonia (VAP), some observational studies have reported that the application of the semi-recumbent position was lower in patients receiving mechanical ventilator support. We performed this study to assess the effect of implementation of the HOB elevation protocol in the intensive care unit (ICU) on clinical and nutritional outcomes. METHODS: We developed a HOB elevation protocol including a flow chart to determine whether the HOB of newly admitted patients to ICU could be elevated. We measured the level of HOB elevation in patients with mechanical ventilator twice a day and 2 days a week for 5 weeks before and after the implementation of the protocol, respectively. Hemodynamic, respiratory and nutritional data were also collected, resulting in 251 observations from 35 patients and 467 observations from 66 patients before and after implementation. RESULTS: After implementing the protocol, the level of HOB elevation (16.7 +/- 9.9 vs. 23.6 +/-1 2.9, p 30degrees increased significantly (34 vs. 151, p 100 ml) occurred less frequently after implementing the protocol (50% vs. 17%, p = 0.001) CONCLUSIONS: Implementation of the protocol for HOB elevation could improve the level of HOB elevation, oxygenation parameter and enteral nutrition delivery.

Physician Compliance with Tube Feeding Protocol Improves Nutritional and Clinical Outcomes in Acute Lung Injury Patients / 대한구급학회지

BACKGROUND: Nutrition delivery is frequently interrupted or delayed by physicians' ordering patterns. We conducted this study to investigate the effect of physician compliance with tube feeding (TF) protocol on the nutritional and clinical outcomes in acute lung injury (ALI) patients. METHODS: After implementing a TF protocol, 71 ALI patients with mechanical ventilation (MV) for > or = 7 days were observed. A dietician assessed the nutritional status of the patients and established individualized nutrition plans according to the protocol. If the physicians followed the dietician's recommendation within 48 hours, the patients were classified under the compliant group (Group 1). RESULTS: Forty patients (56.3%) were classified into Group 1. Prealbumin was comparable in both groups at ICU admission but higher in Group 1 at the time of discharge from the ICU (228 +/- 81 vs 157 +/- 77 mg/dl, p = 0.025). Nitrogen balance was only improved in Group 1. The time to reach calorie goal was shorter and non-feeding days were reduced in Group 1. The proportion of parenteral nutrition to nutritional support days was lower and delivered calories on the 4th and 7th day of TF were higher in Group 1 (p < 0.001). ICU mortality/stay and hospital mortality failed to show differences but hospital stay was prolonged in the noncompliant group (Group 2) (p = 0.023). Arterial oxygen tension and PaO2/FiO2 were maintained during the 1st week of ICU stay in Group 1 but were decreased in Group 2. CONCLUSIONS: Physicians' compliance with the TF protocol contributed to the likelihood of nutritional improvement and a shorter hospital stay in ALI patients with prolonged MV.

The Calorie and Protein Intake of Critically Ill Patients Who Require Continuous Renal Replacement Therapy in the Intensive Care Unit

Forty-two percent of the patients with renal failure that requires continuous renal replacement therapy (CRRT) have been reported to have severe malnutrition, and preexisting malnutrition is a statistically significant and independent predictor of negative hospital outcomes. We performed this study to evaluate the appropriateness of the calorie and protein provided for the critically ill patients who require CRRT. One hundred forty-nine patients who received CRRT were enrolled. The demographic data, the length of the ICU stay and the mortality were recorded. The calorie/protein intake and the blood urea nitrogen (BUN), albumin and creatinine levels were used as nutritional parameters. The mean daily calorie intake during CRRT was 16.1+/-7.4 kcal/kg, which was 64% of the recommended intake. Only 10% of the patients received the recommended caloric intake and the ratio of the enteral and parenteral calories was 26%/74%. The mean protein intake was 0.58+/-0.34 g/kg, which was 38% of the recommended intake. The calorie and protein intakes at the termination of CRRT were significantly increased compared to the initial day of treatment, but they stayed under the recommended intake. The BUN, creatinine and albumin levels were significantly increased in the survival group (odds ratio for albumin: 2.73; creatinine: 2.43). A strategy to increase the nutrition provision is needed to improve the nutritional statuses and clinical outcomes of the critically ill patients who require CRRT.