Impact of a specialized oral nutritional supplement on quality of life in older adults following hospitalization: Post-hoc analysis of the NOURISH trial.

BACKGROUND & AIMS: Both during and after hospitalization, nutritional care with daily intake of oral nutritional supplements (ONS) improves health outcomes and decreases risk of mortality in malnourished older adults. In a post-hoc analysis of data from hospitalized older adults with malnutrition risk, we sought to determine whether consuming a specialized ONS (S-ONS) containing high protein and beta-hydroxy-beta-methylbutyrate (HMB) can also improve Quality of Life (QoL). METHODS: We analyzed data from the NOURISH trial-a randomized, placebo-controlled, multi-center, double-blind study conducted in patients with congestive heart failure, acute myocardial infarction, pneumonia, or chronic obstructive pulmonary disease. Patients received standard care + S-ONS or placebo beverage (target 2 servings/day) during hospitalization and for 90 days post-discharge. SF-36 and EQ-5D QoL outcomes were assessed at 0-, 30-, 60-, and 90-days post-discharge. To account for the missing QoL observations (27.7%) due to patient dropout, we used multiple imputation. Data represent differences between least squares mean (LSM) values with 95% Confidence Intervals for groups receiving S-ONS or placebo treatments. RESULTS: The study population consisted of 622 patients of mean age ±standard deviation: 77.9 ± 8.4 years and of whom 52.1% were females. Patients consuming placebo had lower (worse) QoL domain scores than did those consuming S-ONS. Specifically for the SF-36 health domain scores, group differences (placebo vs S-ONS) in LSM were significant for the mental component summary at day 90 (-4.23 [-7.75, -0.71]; p = 0.019), the domains of mental health at days 60 (-3.76 [-7.40, -0.12]; p = 0.043) and 90 (-4.88 [-8.41, -1.34]; p = 0.007), vitality at day 90 (-3.33 [-6.65, -0.01]; p = 0.049) and social functioning at day 90 (-4.02 [-7.48,-0.55]; p = 0.023). Compared to placebo, differences in LSM values for the SF-36 general health domain were significant with improvement in the S-ONS group at hospital discharge and beyond: day 0 (-2.72 [-5.33, -0.11]; p = 0.041), day 30 (-3.08 [-6.09, -0.08]; p = 0.044), day 60 (-3.95 [-7.13, -0.76]; p = 0.015), and day 90 (-4.56 [-7.74, -1.38]; p = 0.005). CONCLUSIONS: In hospitalized older adults with cardiopulmonary diseases and evidence of poor nutritional status, daily intake of S-ONS compared to placebo improved post-discharge QoL scores for mental health/cognition, vitality, social functioning, and general health. These QoL benefits complement survival benefits found in the original NOURISH trial analysis. CLINICAL TRIAL REGISTRATION: NCT01626742.

Anatomical and physiological considerations in short bowel syndrome: Emphasis on intestinal adaptation and the role of enterohormones.

Short bowel syndrome (SBS)-associated intestinal failure (IF) is a complex, life-threatening condition that requires complex care of multiple factors impacting the patient's long-term prognosis. Various etiologies result in SBS-IF, with three primary anatomical subtypes occurring following intestinal resection. Depending on the extent and segment(s) of the intestine resected, malabsorption can be nutrient specific or sweeping; however, such issues and the associated prognosis for the patient can be predicted with analysis of the residual intestine, along with baseline nutrient and fluid deficits and extent of malabsorption. The provision of parenteral nutrition/intravenous (PN-IV) fluids and antisymptomatic agents is fundamental; however, optimal management should focus on intestinal rehabilitation, wherein intestinal adaptation is prioritized and PN-IV fluids are weaned over time. Key strategies to maximize intestinal adaptation include hyperphagic consumption of an individualized SBS diet and the appropriate use of trophic agents, such as a glucagon-like peptide 2 analog.

Management of short-bowel syndrome: A survey of unmet educational needs among healthcare providers.

BACKGROUND: Management of short-bowel syndrome with intestinal failure (SBS-IF) is complex and requires a multidisciplinary approach. Because of the rarity of SBS-IF, healthcare professionals (HCPs) often lack clinical experience with the disease and may benefit from education regarding SBS-IF and its management. This study identified unmet educational needs related to the management of patients with SBS-IF. METHODS: This was a prospective, web-based survey (December 2019-January 2020) in which a series of clinical questions were posed to US HCPs after presenting three standardized SBS-IF cases to assess current practice patterns. HCPs were then asked a series of questions to identify potential knowledge gaps and unmet educational needs relating to SBS-IF management. RESULTS: Overall, 558 HCPs completed the survey, with 12%-38% having a formal SBS-IF multidisciplinary team currently available to make treatment decisions within their institution. Clinicians involved in care included gastroenterologists (93%), registered dietitians (79%), gastroenterology nurse practitioners and physician assistants (37%), registered nurses (43%), social workers (45%), and psychologists/psychiatrists (27%). There was underuse of published guidelines and limited understanding of the course of intestinal adaptation. Responses to the clinical scenarios highlighted disparities in SBS-IF care delivery, including diagnosis, management goals, medications prescribed, and nutrition practices. CONCLUSIONS: Future SBS-IF educational interventions for HCPs should aim to improve awareness and understanding of the disease, facilitate timely diagnosis, and standardize management practices to ensure patients receive optimal interdisciplinary care as widely as possible.

Utilization and validation of the Global Leadership Initiative on Malnutrition (GLIM): A scoping review.

BACKGROUND & AIMS: The diagnosis of malnutrition remains a significant challenge despite various published diagnostic criteria. In 2018, the Global Leadership Initiative on Malnutrition (GLIM) published a set of evidence-based criteria as a framework for malnutrition diagnosis in adults. A scoping review was conducted to understand how the GLIM criteria have been used in published literature and compare the reported validation methods to published validation guidance. METHODS: Dialog and Dimensions databases were searched by publication date (January 1, 2019, through January 29, 2021). Data were extracted and mapped to the research objectives. RESULTS: Seventy-nine studies were reviewed; 32% were in patients at least 65 years of age; 67% occurred in hospitals. The majority were cohort studies (61%). Fifty-seven percent employed all 5 GLIM criteria. Regarding phenotypic criteria, 92% used low BMI, and 45% applied anthropometry as a marker for muscle mass, of which 54% used calf circumference. Regarding etiologic criteria, 72% used reduced food intake/assimilation, and 85% applied inflammation/disease burden. Validation of GLIM criteria was described in 77% of publications. CONCLUSIONS: The GLIM criteria have been studied extensively since their publication. Low BMI was the phenotypic criterion used most often, whereas both reduced food intake/assimilation and inflammation/disease burden were frequently employed as the etiologic criteria. However, how the criteria were combined and how validation was conducted were not clear in most studies. Adequately powered, methodologically sound validation studies using the complete GLIM criteria are needed in various patient populations and disease settings to assess validity for the diagnosis of malnutrition.

Learn Intestinal Failure Tele-ECHO Project: An innovative online telementoring and case-based learning clinic.

Intestinal failure (IF) is a rare chronic disease requiring intravenous (IV) fluids or parenteral nutrition (PN) dependency for optimal patient health and sustenance. The complex care is best managed by specialized multidisciplinary teams. Patients who have limited access to intestinal rehabilitation centers often receive IV/PN care from clinicians lacking specialty expertise. An innovative videoconferencing project was launched in May 2019 to provide online telementoring and case-based learning in IF. The Extension for Community Healthcare Outcomes (ECHO) model was adopted to provide education and virtual support via the Learn Intestinal Failure Tele-ECHO (LIFT-ECHO) project. Online clinics include patient case presentations, moderated discussion, best-practice recommendations, and didactic continuing education lectures on IF- and PN-related topics. Participation is interprofessional and international. Via knowledge dissemination and specialty mentorship, LIFT-ECHO is expected to improve healthcare for patients with IF and transform care delivery by overcoming the limitations in access to expertise.

Reduced mortality risk in malnourished hospitalized older adult patients with COPD treated with a specialized oral nutritional supplement: Sub-group analysis of the NOURISH study.

BACKGROUND: Hospitalized, malnourished older adults with chronic obstructive pulmonary disease (COPD) have an elevated risk of readmission and mortality. OBJECTIVE: Post-hoc, sub-group analysis from the NOURISH study cohort examined the effect of a high-protein oral nutritional supplement (ONS) containing HMB (HP-HMB) in malnourished, hospitalized older adults with COPD and to identify predictors of outcomes. METHODS: The NOURISH study (n = 652) was a multicenter, randomized, placebo-controlled, double-blind trial. The COPD subgroup (n = 214) included hospitalized, malnourished (based on Subjective Global Assessment), older adults (≥65 y), with admission diagnosis of COPD who received either standard-of-care plus HP-HMB (n = 109) or standard-of-care and a placebo supplement (n = 105) prescribed 2 servings/day from within 3 days of hospital admission (baseline) and up to 90 days after discharge. The primary study outcome was a composite endpoint of incidence of death or non-elective readmission up to 90-day post-discharge, while secondary endpoints included changes in hand-grip strength, body weight, and nutritional biomarkers over time. Categorical outcomes were analyzed using Cochran-Mantel-Haenszel tests, longitudinal data by repeated measures analysis of covariance; and changes from baseline by analysis of covariance. p-values ≤ 0.05 were considered statistically significant. Multivariate logistic regression was used to model predictors of the primary outcome and components. RESULTS: In patients with COPD, 30, 60, and 90-day hospital readmission rate did not differ, but in contrast, 30, 60, and 90-day mortality risk was approximately 71% lower with HP-HMB supplementation relative to placebo (1.83%, 2.75%, 2.75% vs. 6.67%, 9.52% and 10.48%, p = 0.0395, 0.0193, 0.0113, resp.). In patients with COPD, compared to placebo, intake of HP-HMB resulted in a significant increase in handgrip strength (+1.56 kg vs. -0.34 kg, p = 0.0413) from discharge to day 30; increased body weight from baseline to hospital discharge (0.66 kg vs. -0.01 kg, p < 0.05) and, improvements in blood nutritional biomarker concentrations. The multivariate logistic regression predictors of the death, readmission or composite endpoints in these COPD patients showed that participants who were severely malnourished (p = 0.0191) and had a Glasgow prognostic score (GPS) Score of 1 or 2 had statistically significant odds of readmission or death (p = 0.0227). CONCLUSIONS: Among malnourished, hospitalized patients with COPD, supplementation with HP-HMB was associated with a markedly decreased mortality risk, and improved handgrip strength, body weight, and nutritional biomarkers within a 90-day period after hospital discharge. This post-hoc, subgroup analysis highlights the importance of early identification of nutritional risk and administration of high-protein ONS in older, malnourished patients with COPD after hospital admission and continuing after hospital discharge.

Fermentable Fibers Enhance Aspects of Innate and Adaptive Immunity in Piglets infected with Salmonella Typhimurium.

OBJECTIVE: To test the hypothesis that fermentable fiber prevents Salmonella typhimurium infection-associated symptoms by enhancing innate and adaptive immune system in neonatal pigs. METHODS: Two-d-old piglets (n=120) were randomized to receive either a nutritionally complete sow milk replacer formula (CON), or supplemented with methylcellulose (MCEL-non-fermentable), soy polysaccharides (SPS-moderately fermentable), or fructooligosaccharides (FOS-highly fermentable). On d7, piglets received an oral gavage of S. typhimurium-798, and continued receiving the same diets up to 48h post-infection. Ileal mucosal samples were obtained for further analyses. RESULTS: A reduction in chloride secretion was observed in FOS when compared to other diets (p<0.0003). The number of ileal sulfo-acidomucins was higher (p<0.05) in FOS before infection compared with other diets. NFkB was inhibited in FOS following infection (p<0.05), when compared with CON. IL-1ß expression was increased at 4h post-infection (p<0.05) in CON; however, this response was attenuated in the fiber groups. IL-6 expression was higher (p<0.05) in CON post- infection, higher in SPS at 24h (p<0.05), but unchanged in MCEL and FOS when compared to pre-infection values. FOS had a higher expression of neutrophil-chemoattractant IL-8 before infection (p<0.05) compared to other groups. CONCLUSION: The reduction in chloride secretion, proinflammatory cytokines expression and NFkB activation, and increased number of sulfo-acidomucins, and IL-8 expression in the fiber groups, indicates that the degree of fermentability impacts the innate and adaptive immune system, and could be the mechanisms by which dietary fibers reduce S. typhimurium infection-associated-symptoms in neonatal pigs and apply these results to infants.

GLIM Criteria for the Diagnosis of Malnutrition: A Consensus Report From the Global Clinical Nutrition Community.

BACKGROUND: This initiative aims to build a global consensus around core diagnostic criteria for malnutrition in adults in clinical settings. METHODS: The Global Leadership Initiative on Malnutrition (GLIM) was convened by several of the major global clinical nutrition societies. Empirical consensus was reached through a series of face-to-face meetings, telephone conferences, and e-mail communications. RESULTS: A 2-step approach for the malnutrition diagnosis was selected, that is, first screening to identify at risk status by the use of any validated screening tool, and second, assessment for diagnosis and grading the severity of malnutrition. The malnutrition criteria for consideration were retrieved from existing approaches for screening and assessment. Potential criteria were subjected to a ballot among GLIM participants that selected 3 phenotypic criteria (non-volitional weight loss, low body mass index, and reduced muscle mass) and 2 etiologic criteria (reduced food intake or assimilation, and inflammation or disease burden). To diagnose malnutrition at least 1 phenotypic criterion and 1 etiologic criterion should be present. Phenotypic metrics for grading severity are proposed. It is recommended that the etiologic criteria be used to guide intervention and anticipated outcomes. The recommended approach supports classification of malnutrition into four etiology-related diagnosis categories. CONCLUSIONS: A consensus scheme for diagnosing malnutrition in adults in clinical settings on a global scale is proposed. Next steps are to secure endorsements from leading nutrition professional societies, to identify overlaps with syndromes like cachexia and sarcopenia, and to promote dissemination, validation studies, and feedback. The construct should be re-considered every 3-5 years.

Implications of low muscle mass across the continuum of care: a narrative review.

Abnormalities in body composition can occur at any body weight. Low muscle mass is a predictor of poor morbidity and mortality and occurs in several populations. This narrative review provides an overview of the importance of low muscle mass on health outcomes for patients in inpatient, outpatient and long-term care clinical settings. A one-year glimpse at publications that showcases the rapidly growing research of body composition in clinical settings is included. Low muscle mass is associated with outcomes such as higher surgical and post-operative complications, longer length of hospital stay, lower physical function, poorer quality of life and shorter survival. As such, the potential clinical benefits of preventing and reversing this condition are likely to impact patient outcomes and resource utilization/health care costs. Clinically viable tools to measure body composition are needed for routine screening and intervention. Future research studies should elucidate the effectiveness of multimodal interventions to counteract low muscle mass for optimal patient outcomes across the healthcare continuum. Key messages Low muscle mass is associated with several negative outcomes across the healthcare continuum. Techniques to identify and counteract low muscle mass in clinical settings are needed.

Human Milk Oligosaccharides Influence Intestinal Epithelial Cell Maturation In Vitro.

OBJECTIVES: Human milk oligosaccharides (HMOs) are reported to promote epithelial cell differentiation in vitro. The aim of the present study was to assess induction of epithelial cell differentiation by individual and combined administration of 3 HMOs. METHODS: An in vitro epithelial model of the crypt-villus axis consisting of preconfluent HT-29, preconfluent Caco-2Bbe, and postconfluent Caco-2Bbe cells was used. Cultures were randomized to 17 treatments for 72 hours of incubation: low- and high-dose HMOs (3'sialyllactose [3'SL] at 0.2 and 1.0 g/L, 6'siallylactose [6'SL] at 0.4 and 1.0 g/L, and 2'fucosyllactose at 0.2 and 2.0 g/L), HMO combinations at both low and high doses, and controls (culture medium, 4 g/L pooled HMO, and lipopolysaccharide). RESULTS: High doses of individual HMOs (P < 0.05), combined HMOs (P < 0.05), and pooled HMO decreased (P < 0.001) proliferation in preconfluent HT-29 cultures. Pooled means of individual low and high treatments with 3'SL and 6'SL, combinations of 2 or 3 high-dose HMOs, and total HMO significantly reduced (P < 0.05) proliferation in preconfluent Caco-2Bbe cells. HMOs increased differentiation in preconfluent HT-29 and Caco-2Bbe cells. 3'SL and 6'SL increased alkaline phosphatase activity but did not affect disaccharidase activity in postconfluent Caco-2Bbe cells. Apoptosis and necrosis were both decreased (P < 0.001) in postconfluent Caco-2Bbe cells treated with pooled HMO. CONCLUSIONS: HMO treatments inhibited proliferation with some associated enhancement of epithelial differentiation. Effects of HMOs were additive but no specific combinations of HMOs were especially potent. These results suggest that commercially viable individual HMOs and specific combinations may promote intestinal epithelial cell maturation.

Teduglutide-Stimulated Intestinal Adaptation Is Complemented and Synergistically Enhanced by Partial Enteral Nutrition in a Neonatal Piglet Model of Short Bowel Syndrome.

BACKGROUND: Teduglutide, a glucagon-like peptide-2 (GLP-2) analogue, is available for long-term use by parenteral nutrition (PN)-dependent adults to promote intestinal adaptation but is not approved for use in pediatric patients. The objective of this study was to assess teduglutide-stimulated induced intestinal adaptation, potential synergies with partial enteral nutrition (PEN), and distinct temporal markers of adaptation in a neonatal piglet model of short bowel syndrome (SBS). MATERIALS AND METHODS: Neonatal piglets (48 hours old; n = 72) underwent an 80% jejunoileal resection and were randomized to 1 of 4 treatment groups, in a 2 × 2 factorial design, with PN or PEN (80% standard PN/20% standard enteral nutrition) and teduglutide (0.1 mg/kg/d) or control. Piglets received nutrient infusions for 4 hours, 48 hours, or 7 days. RESULTS: Teduglutide improved ( P < .05) mucosal surface area (villus height: duodenum, jejunum, ileum; crypt depth: ileum, colon; proliferation: duodenum, jejunum, ileum; colon; apoptosis: jejunum, ileum, colon) and acute nutrient processing capacity (glucose: duodenum, jejunum, ileum; glutamine: duodenum, jejunum). These effects were complemented and synergistically enhanced by PEN in both site and timing of action. Structural adaptations preceded functional adaptations, but crypt depth remained a strong indicator of adaptation, regardless of time. CONCLUSIONS: The combination of teduglutide and PEN enhances intestinal adaptation beyond that of either therapy alone.

Nondigestible Fructans Alter Gastrointestinal Barrier Function, Gene Expression, Histomorphology, and the Microbiota Profiles of Diet-Induced Obese C57BL/6J Mice.

BACKGROUND: Obesity is associated with compromised intestinal barrier function and shifts in gastrointestinal microbiota that may contribute to inflammation. Fiber provides benefits, but impacts of fiber type are not understood. OBJECTIVE: We aimed to determine the impact of cellulose compared with fructans on the fecal microbiota and gastrointestinal physiology in obese mice. METHODS: Eighteen-wk-old male diet-induced obese C57BL/6J mice (n = 6/group; 40.5 g) were fed high-fat diets (45% kcal fat) containing 5% cellulose (control), 10% cellulose, 10% short-chain fructooligosaccharides (scFOS), or 10% inulin for 4 wk. Cecal and colon tissues were collected to assess barrier function, histomorphology, and gene expression. Fecal DNA extracts were subjected to 16S ribosomal RNA amplicon-based Illumina MiSeq sequencing to assess microbiota. RESULTS: Body weight gain was greater (P < 0.05) in scFOS-fed than in 10% cellulose-fed mice. Both groups of fructan-fed mice had greater (P < 0.05) cecal crypt depth (scFOS: 141 µm; inulin: 145 µm) than both groups of cellulose-fed mice (5% and 10%: 109 µm). Inulin-fed mice had greater (P < 0.05) cecal transmural resistance (101 Ω × cm(2)) than 5% cellulose-fed controls (45 Ω × cm(2)). Inulin-fed mice had lower (P < 0.05) colonic mRNA abundance of Ocln (0.41) and Mct1 (0.35) than those fed 10% cellulose (Ocln: 1.28; Mct1: 0.90). Fructan and cellulose groups had different UniFrac distances of fecal microbiota (P < 0.05) and α diversity, which demonstrated lower (P < 0.01) species richness in fructan-fed mice. Mice fed scFOS had greater (P < 0.05) Actinobacteria (15.9%) and Verrucomicrobia (Akkermansia) (17.0%) than 5% controls (Actinobacteria: 0.07%; Akkermansia: 0.08%). Relative abundance of Akkermansia was positively correlated (r = 0.56, P < 0.01) with cecal crypt depth. CONCLUSIONS: Fructans markedly shifted gut microbiota and improved intestinal physiology in obese mice, but the mechanisms by which they affect gut integrity and inflammation in the obese are still unknown.

A Novel Neonatal Feeding Intolerance and Necrotizing Enterocolitis Risk-Scoring Tool Is Easy to Use and Valued by Nursing Staff.

BACKGROUND: Preterm infants are at increased risk of developing feeding intolerance and necrotizing enterocolitis. Comprehensive, targeted nursing assessments can evaluate the risk for and identify early signs of these conditions in an effort to prevent their destructive sequela. PURPOSE: While the long-term goal is to develop a validated risk-scoring tool for the prediction of feeding intolerance and necrotizing enterocolitis, the objective of the preliminary phase presented here is to assess the ease of use and nurses' attitudes toward a novel feeding intolerance and necrotizing enterocolitis risk-scoring tool. METHODS: A novel risk-scoring nursing tool was implemented in a University of Illinois-affiliated 48-bed level III neonatal intensive care unit. Data were collected from the electronic medical record of all preterm infants with parental consent during the initial 6-month study period. Scoring accuracy (accuracy of selection of risk factors based on electronic medical record data), ease of use, and nurses' attitudes toward the tool were assessed at the study site and by evaluators at a national neonatal nursing conference. RESULTS: Fourteen nurses scored 166 tools on the 63 enrolled infants. Sixteen tools (9.6%) contained errors. Mean study site tool ease of use was 8.1 (SD: 2.2) on a 10-point scale. Ninety percent of conference evaluators agreed/strongly agreed that the tool addressed important knowledge gaps. IMPLICATIONS FOR PRACTICE: The tool is easy to use and valued by nurses. Following validation, widespread implementation is expected to be a clinically feasible means to improve infant clinical outcomes for minimal time and financial cost. IMPLICATIONS FOR RESEARCH: Tool validation and refinement based on nursing feedback will improve its broad applicability and predictive utility.

Readmission and mortality in malnourished, older, hospitalized adults treated with a specialized oral nutritional supplement: A randomized clinical trial.

BACKGROUND: Hospitalized, malnourished older adults have a high risk of readmission and mortality. OBJECTIVE: Evaluation of a high-protein oral nutritional supplement (HP-HMB) containing beta-hydroxy-beta-methylbutyrate on postdischarge outcomes of nonelective readmission and mortality in malnourished, hospitalized older adults. DESIGN: Multicenter, randomized, placebo-controlled, double-blind trial. SETTING: Inpatient and posthospital discharge. PATIENTS: Older (≥65 years), malnourished (Subjective Global Assessment [SGA] class B or C) adults hospitalized for congestive heart failure, acute myocardial infarction, pneumonia, or chronic obstructive pulmonary disease. INTERVENTIONS: Standard-of-care plus HP-HMB (n = 328) or a placebo supplement (n = 324), 2 servings/day. MEASUREMENTS: Primary composite endpoint was 90-day postdischarge incidence of death or nonelective readmission. Other endpoints included 30- and 60-day postdischarge incidence of death or readmission, length of stay (LOS), SGA class, body weight, and activities of daily living (ADL). RESULTS: The primary composite endpoint was similar between HP-HMB (26.8%) and placebo (31.1%). No between-group differences were observed for 90-day readmission rate, but 90-day mortality was significantly lower with HP-HMB relative to placebo (4.8% vs. 9.7%; relative risk 0.49, 95% confidence interval [CI], 0.27 to 0.90; p = 0.018). The number-needed-to-treat to prevent 1 death was 20.3 (95% CI: 10.9, 121.4). Compared with placebo, HP-HMB resulted in improved odds of better nutritional status (SGA class, OR, 2.04, 95% CI: 1.28, 3.25, p = 0.009) at day 90, and an increase in body weight at day 30 (p = 0.035). LOS and ADL were similar between treatments. LIMITATIONS: Limited generalizability; patients represent a selected hospitalized population. CONCLUSIONS: Although no effects were observed for the primary composite endpoint, compared with placebo HP-HMB decreased mortality and improved indices of nutritional status during the 90-day observation period. CLINICAL TRIAL REGISTRATION: www.ClinicalTrials.govNCT01626742.

Teduglutide for Safe Reduction of Parenteral Nutrient and/or Fluid Requirements in Adults: A Systematic Review.

BACKGROUND: Teduglutide (Gattex; NPS Pharma, Bedminster, NJ), a recombinant analogue of human glucagon-like peptide 2 (GLP-2), is the first long-term medical therapy approved for the treatment of adults dependent on parenteral nutrition (PN). OBJECTIVE: To assess the efficacy and safety of teduglutide in reducing PN (parenteral nutrient and/or fluid) requirements in PN-dependent adults. METHODS: Studies were identified using predefined search criteria and multiple databases, including Medline and Embase. The search was completed to November 30, 2014, in the absence of date or study design restrictions. Citation inclusion criteria and methodological quality were assessed by 2 independent reviewers. Outcomes of interest were changes in parenteral nutrient or fluid requirements and adverse event incidence. From 2693 unique citations, 76 abstracts were reviewed. Fourteen reports met the inclusion criteria, including data from 2 phase III, double-blind, placebo-controlled clinical trials and their respective extension studies. Data extraction was performed by 2 reviewers using a standardized form. RESULTS: Teduglutide reduced PN requirements compared with placebo, whereas adverse event incidence was similar. LIMITATIONS: Number of subjects studied and length of follow-up. CONCLUSIONS: Teduglutide appears to be a safe and well-tolerated means to reduce PN dependence in adults, regardless of PN dependence duration.

A unifying vision for scientific decision making: the Academy of Nutrition and Dietetics' Scientific Integrity Principles.

In 2014, recognizing the need to have a single document to guide scientific decision making at the Academy of Nutrition and Dietetics (Academy), the Council on Research was charged with developing a scientific integrity policy for the organization. From the Council on Research, four members volunteered to lead this workgroup, which reviewed the literature and best practices for scientific integrity from well-respected organizations, including federal funders of research. It became clear that the scope of this document would be quite broad, given the many scientific activities the Academy is involved in, and that it would be unreasonable to set policy for each of these many situations. Therefore, the workgroup set about defining the scope of scientific activities to be covered and envisioned a set of guiding principles, to which policies from every organizational unit of the Academy could be compared to ensure they were in alignment. While many relevant policies exist already, such as the requirement of a signed conflict of interest disclosure for Food & Nutrition Conference & Expo speakers, the Evidence Analysis Library funding policy, and the Academy's sponsorship policy, the scientific integrity principals are unique in that they provide a unifying vision to which future policies can be compared and approved based on their alignment with the principles. The six principles outlined in this article were approved by the full Council on Research in January 2015 and approved by the Academy's Board of Directors in March 2015. This article covers the scope of the principles, presents the principles and existing related resources, and outlines next steps for the Academy to review and revise current policies and create new ones in alignment with these principles.

Evidence-based recommendations for addressing malnutrition in health care: an updated strategy from the feedM.E. Global Study Group.

The prevalence of malnutrition ranges up to 50% among patients in hospitals worldwide, and disease-related malnutrition is all too common in long-term and other health care settings as well. Regrettably, the numbers have not improved over the past decade. The consequences of malnutrition are serious, including increased complications (pressure ulcers, infections, falls), longer hospital stays, more frequent readmissions, increased costs of care, and higher risk of mortality. Yet disease-related malnutrition still goes unrecognized and undertreated. To help improve nutrition care around the world, the feedM.E. (Medical Education) Global Study Group, including members from Asia, Europe, the Middle East, and North and South America, defines a Nutrition Care Pathway that is simple and can be tailored for use in varied health care settings. The Pathway recommends screen, intervene, and supervene: screen patients' nutrition status on admission or initiation of care, intervene promptly when needed, and supervene or follow-up routinely with adjustment and reinforcement of nutrition care plans. This article is a call-to-action for health caregivers worldwide to increase attention to nutrition care.

Intestinal adaptation following resection.

Intestinal adaptation is a natural compensatory process that occurs following extensive intestinal resection, whereby structural and functional changes in the intestine improve nutrient and fluid absorption in the remnant bowel. In animal studies, postresection structural adaptations include bowel lengthening and thickening and increases in villus height and crypt depth. Functional changes include increased nutrient transporter expression, accelerated crypt cell differentiation, and slowed transit time. In adult humans, data regarding adaptive changes are sparse, and the mechanisms underlying intestinal adaptation remain to be fully elucidated. Several factors influence the degree of intestinal adaptation that occurs post resection, including site and extent of resection, luminal stimulation with enteral nutrients, and intestinotrophic factors. Two intestinotrophic growth factors, the glucagon-like peptide 2 analog teduglutide and recombinant growth hormone (somatropin), are now approved for clinical use in patients with short bowel syndrome (SBS). Both agents enhance fluid absorption and decrease requirements for parenteral nutrition (PN) and/or intravenous fluid. Intestinal adaptation has been thought to be limited to the first 1-2 years following resection in humans. However, recent data suggest that a significant proportion of adult patients with SBS can achieve enteral autonomy, even after many years of PN dependence, particularly with trophic stimulation.