Global Leadership Initiative on Malnutrition (GLIM): Guidance on validation of the operational criteria for the diagnosis of protein-energy malnutrition in adults.

BACKGROUND: The Global Leadership Initiative on Malnutrition (GLIM) created a consensus-based framework consisting of phenotypic and etiologic criteria to record the occurrence of malnutrition in adults. This is a minimum set of practicable indicators for use in characterizing a patient/client as malnourished, considering the global variations in screening and nutrition assessment, and to be used across different health care settings. As with other consensus-based frameworks for diagnosing disease states, these operational criteria require validation and reliability testing as they are currently based solely on expert opinion. METHODS: Several forms of validation and reliability are reviewed in the context of GLIM, providing guidance on how to conduct retrospective and prospective studies for criterion and construct validity. FINDINGS: There are some aspects of GLIM criteria which require refinement; research using large data bases can be employed to reach this goal. Machine learning is also introduced as a potential method to support identification of the best cut-points and combinations of operational criteria for use with the different forms of malnutrition, which the GLIM criteria were created to denote. It is noted as well that the validation and reliability testing need to occur in a variety of sectors, populations and with diverse persons completing the criteria. CONCLUSION: The guidance presented supports the conduct and publication of quality validation and reliability studies for GLIM.

Barriers and enablers in the implementation of a standardised process for nutrition care: findings from a multinational survey of dietetic professionals in 10 countries.

BACKGROUND: To explore the barriers and enablers experienced by nutrition and dietetic professionals in the implementation of the standardised Nutrition Care Process (NCP) across 10 different countries. NCP related beliefs, motivations and values were investigated and compared. METHODS: A validated online survey was disseminated to nutrition and dietetics professionals in 10 countries in the local language during 2017. Cross-sectional associations and differences between countries were explored for level of implementation, barriers/enablers and attitudes/motivation among the respondents. RESULTS: Higher NCP implementation was associated with greater occurrence of enabling aspects, as well as fewer occurrences of barriers. The most common enabler was 'recommendation by the national dietetic association' (69%) and the most common barrier was 'lack of time' (39%). A longer experience of NCP use was associated with a more positive attitude towards all NCP aspects. Differences between countries were identified, regarding both the occurrence of barriers/enablers and attitudes/motivations. CONCLUSIONS: Implementation efforts need to be tailored to country-specific contexts when implementing a new standard of care framework among nutrition and dietetic professionals. Additional research is needed to further assess the management and workplace strategies to support the development of nutrition and dietetics professionals in multidisciplinary healthcare organisations.

Relationship between immunosuppression and osteoporosis in an outpatient liver transplant clinic.

BACKGROUND: The aim of this study is to determine the relationship between immunosuppression, disease state, and osteoporosis in an outpatient liver transplant clinic. METHODS: All liver transplant recipients visiting an outpatient transplant clinic received bone density scanning with a dual-energy X-ray absorptiometry (DEXA) device of the calcaneal bone after completing a questionnaire assessing risk and medications currently being used. RESULTS: Of the 137 liver transplant (OLT) recipients completing questionnaires and receiving DEXA screening, patients with low bone density (n = 50) were older (56.6 +/- 12.7 years vs 50.2 +/- 10.1 years; P = .02) compared with normal density patients (n = 87) and were predominately female (64.0% vs 35.6%; P = .01). Based on disease state, patients with cholestatic liver failure had lower bone calcaneal area (17.3 +/- 1.3 cm2 vs 18.9 +/- 1.57 cm2; P < .01). Patients taking tacrolimus (n = 112), as compared with cyclosporine (n = 25), had a tendency toward fewer findings of low bone density (37.5% [42 of 112] vs 56.0% [14 of 25]; P = .08) but had more risk factors (3.1 +/- 1.2 vs 2.1 +/- 0.8; P = .001) and a higher prednisone dose (4.4 +/- 5.9 mg/d vs 2.1 +/- 3.8 mg/d; P = .026). For patients weaned from prednisone, the tacrolimus patients were less likely to have low bone density (36.2% vs 68.8%; P = .02). Mycophenolate mofetil did not influence bone density or area measured. CONCLUSIONS: After liver transplantation, patients taking cyclosporine were more likely to have low bone density compared with those taking tacrolimus.

Serum carnitine concentrations correlated to clinical outcome parameters in chronic hemodialysis patients.

Carnitine metabolism and the therapeutic use of carnitine has been a major area of interest in dialysis patients. The purpose of this study was to determine whether any correlations exist between carnitine status and selected clinical parameters in hemodialysis (HD) patients. This study was an observational study of data from patients receiving HD at a Midwest dialysis center. The subjects (n=49) were 60+/-16 (mean+/-SD) years of age and 48% male. Fifteen percent of the subjects had type 1 diabetes mellitus (DM), 29% had type 2 DM, and 25% had left ventricular hypertrophy (LVH). The serum-free and total carnitine, and acylcarnitine concentrations were: 40.3+11.8 microm/l, 22.8+/-7.3, and 17.5+/-5.9 microm/l, respectively. The serum acylcarnitine to free carnitine ratio (A/F) was 0.80+/-0.27. Blood urea nitrogen (BUN), parathyroid hormone and ejection fraction were positively correlated and age and left atrial dilation (cm) were negatively correlated with serum total carnitine (P<0.05). BUN and hematocrit were positively correlated (P<0.05) and age was negatively correlated with free carnitine. Subjects who used mannitol or were male had significantly higher concentrations of both free and total carnitine, respectively (P<0.05). Subjects using aspirin had lower concentrations of serum total carnitine (P<0.10). These results suggest certain subgroups of patients may need to be targeted for further studies with carnitine replacement therapy, i.e. long-term patients, older patients, patients with left verticular hypertrophy and left atrial enlargement, females and patients on aspirin therapy.

Clinical indicators associated with poor oral intake of patients with chronic renal failure.

OBJECTIVE: The purpose of this study was twofold: (1) to determine the incidence of patients with chronic renal failure (CRF) who consume less than 75% of their estimated nutritional needs, and (2) to identify factors associated with an oral intake less than 75% of the estimated nutritional needs of patients with CRF. DESIGN: Prospective, descriptive, correlational study of data obtained from patients with a diagnosis of CRF. SETTING: BryanLGH Medical Center East Campus, Lincoln, NE. PATIENTS: Sixty-six patients included on this study met the following criteria: (1) a primary or secondary underlying diagnosis of CRF and (2) not receiving parenteral or enteral (tube feeding) nutritional support on admission. INTERVENTION: Admission data (age, sex, percentage of ideal body weight, weight loss/time, type of dialysis, gastrointestinal history, blood urea nitrogen and creatinine levels, and diet) were collected from the patients' medical records and 2-day kilocalorie (kcal)/protein counts were conducted on consecutive patients admitted to the hospital. The kcal/protein counts were initiated within 24 hours of admission and consisted of six meals and all snacks the patient received. MAIN OUTCOME MEASURE: Only 15% of the patients met 75% or greater of their estimated kcal needs, and 12% met 75% or greater of their estimated protein needs. The mean kcal/kg intake was 11 kcal/kg, with a range of 0 to 27 kcal/kg, and the mean protein/kg intake was 0.42 g of protein/kg, with a range of 0 to 10 g of protein/kg. Of the variables studied for associations with decreased nutrient intake, only emesis mildly correlated with kcal intake. CONCLUSION: Less than one quarter of the patients on this study met 75% or greater of their kcal and protein needs. The average kcal and protein intakes found in this study were far less than current recommendations for hemodialysis, continuous ambulatory peritoneal dialysis, and predialysis patients. However, the results of this study could lead to earlier and more aggressive interventions in patients with CRF at risk for poor oral intake.

Surgery interns' experience with surgical procedures as medical students.

Instruction in the technical aspects of surgery begins in medical school. To identify areas of inexperience among incoming interns, we asked 40 first-year residents to indicate which bedside and emergency room procedures and operations (or parts of operations) they had performed in medical school and to rate how confident they were in performing those procedures as a result of their experiences. Respondents indicated that placement of nasogastric tubes, Foley catheters, and central lines were procedures they commonly performed (78.4% to 97.3%); they less frequently placed arterial and pulmonary arterial lines and chest tubes (21.6% to 64.9%). Many students had opportunities to assist in closure of incisions in actual operations (60%), but only 22% performed other parts of operative procedures. Opportunities to perform procedures did not correlate with the length of time spent on surgical rotations. Nearly half (49%) participated in animal surgery laboratories as part of their surgical rotation. These findings suggest that many interns have not performed some basic procedures by the time they enter their residency. Instruction in technical skills in clinical medicine, frequently surgical, represents a deficiency in medical school curricula. The general inexperience of surgical interns in performing these procedures must be remembered when assigning these duties.