Impact of parenteral nutrition standardization on costs and quality in adult patients

Background: Parenteral nutrition (PN) is a costly therapy that can also be associated with serious complications. Therefore, efforts are focusing on reducing rate of complications, and costs related to PN. Objective: The aim was to analyze the effect of the implementation of PN standardization on costs and quality criteria. Secondary aim was to assess the use of individualized PN based on patient's clinical condition. Methods: We compare the use of PN before and after the implementation of PN standardization. Demographic, clinical and PN characteristics were collected. Costs analysis was performed to study the costs associated to the two different periods. Quality criteria included were: 1) PN administration; 2) nutrition assessment (energy intake between 20-35 kcal/kg/day; protein contribution according to nitrogen balance); 3) safety and complications (hyperglycemia, hypertriglyceridemia, hepatic complications, catheter-related infection); 4) global efficacy (as serum albumin increase). Chi-square test was used to compare percentages; logistic regression analysis was performed to evaluate the use of customized PN. Results: 296 patients were included with a total of 3,167 PN compounded. During the first period standardized PN use was 47.5% vs 85.7% within the second period (p < 0.05). No differences were found in the quality criteria tested. Use of individualized PN was related to critical care patients, hypertriglyceridemia, renal damage, and long-term PN. Mean costs of the PN decreased a 19.5%. Annual costs savings would be € 86,700. Conclusions: The use of customized or standard PN has shown to be efficient and flexible to specific demands; however customized PN was significantly more expensive.

Outcomes of a general hospital-based Home Parenteral Nutrition (HPN) program: report of our experience from a 26-year period

Background: Home parenteral nutrition (HPN) was introduced in Spain in the late 1980s. Our hospital was a pioneering medical centre in this field. Aim: Analyze outcomes of our HPN program. Methods: Retrospective study of patients receiving HPN between 1986-2012. Study variables are expressed as frequency, mean ± SD (range), median [interquartile range]. Parametrics, non-parametrics test and survival analysis (p < 0.05) were applied. Results: 91 patients (55 females and 36 males, mean age: 50.6 ± 5 yrs.) who received HPN for an accrual period of 55,470 days (median: 211 days [range: 63-573]) were included. The most prevalent underlying condition was cancer (49.5%), with the commonest HPN indication being short bowel syndrome (41.1%). The most frequently used catheter type was the tunneled catheter (70.7%). The complication rate was 3.58/1,000 HPN days (2.68, infection; 0.07, occlusion; 0.07 thrombosis; and 0.59, metabolic complications). Complications were consistently associated with both the underlying condition and HPN length. Infections were most frequent within the first 1,000 days of HPN. Liver disease incidence was related to HPN duration. HPN could be discontinued in 42.3% of patients. Ten-year survival rate was 42%, and varied across the underlying conditions. Conclusions: In the present series, the commonest reason for HPN was cancer. Our complication rate is in keeping with that reported in the literature. The overall survival rate was 42%, and varied across the underlying conditions.

Critical energy deficit and mortality in critically ill patients

Objective: We investigate the influence of caloric and protein deficit on mortality and length of hospital stay of critically ill patients. Methods: A cohort prospective study including 100 consecutive patients in a tertiary intensive care unit (ICU) receiving enteral or parenteral nutrition. The daily caloric and protein deficit were collected each day for a maximum of 30 days. Energy deficits were divided into critical caloric deficit (≥ 480 kcal/day) and non-critical caloric deficit (≤ 480 kcal/day); and in critical protein deficit (≥ 20 g/day) and non-critical protein deficit (≤ 20 g/day). The findings were correlated with hospital stay and mortality. Results: The mortality rate was 33%. Overall, the patients received 65.4% and 67.7% of the caloric and protein needs. Critical caloric deficit was found in 72% of cases and critical protein deficit in 70% of them. There was a significant correlation between length of stay and accumulated caloric deficit (R = 0.37; p < 0.001) and protein deficit (R = 0.28; p < 0.001). The survival analysis showed that mortality was greater in patients with both critical caloric (p < 0.001) and critical protein deficits (p < 0.01). The Cox regression analysis showed that critical protein deficit was associated with higher mortality (HR 0.25, 95% CI 0.07-0.93, p = 0.03). Conclusions: The incidence of caloric and protein deficit in the ICU is high. Both caloric and protein deficits increase the length of hospital stay, and protein deficit greater than 20 g/day is an independent factor for mortality in critical care unit.

Nutrition and health claims in products directed at children via television in Spain in 2012

Objective: To describe the use of nutrition and health claims in products directed at children via television in Spain and to analyse their nutrient profile. Methods: A cross-sectional study of television food advertisements over 7 days in five Spanish television channels popular among children. The products were classified as core, non-core or miscellaneous, and as either healthy or less healthy, according to the United Kingdom Nutrient Profile Model. We registered all claims contained on the product (packaging and labelling) and its advertisement. We calculated the frequency distributions of health and nutrition claims. Results: During the 420 hours of broadcasting, 169 food products were identified, 28.5% in the dairy group and 60.9% in the non-core category. A total of 53.3% of products contained nutrition claims and 26.6% contained health claims; 62.2% of the products with claims were less healthy. Low-fat dairy products were the food category containing the highest percentage of health and nutrition claims. Conclusion: Over half of all food products marketed to children via television in Spain made some type of nutrition or health claim. Most of these products were less healthy, which could mislead Spanish consumers.

New clinical practice guideline on enteral feeding in very low birth weight infants: first part

Introduction: The nutrition of very low birth weight (VLBW) infants is aimed at promoting a similar growth to that occurring in the uterus. However, in practice this is difficult to achieve and extrauterine growth restriction is frequent. The current tendency is to avoid this restriction by means of early parenteral and enteral nutrition. Nonetheless, uncertainty about many of the practices related with nutrition has resulted in a great variation in the way it is undertaken. In 2009 and 2011 in our hospital there was an unexpected increase in necrotizing enterocolitis. To check to see whether our nutrition policy was involved, we undertook a systematic review and drew up clinical practice guidelines (CPG) about enteral feeding in VLBW infants. New considerations about the duration of the fortification and the use of probiotics have led to an update of these CPG. Methods: A total of 21 clinical questions were designed dealing with the type of milk, starting age, mode of administration, rate and volume of the increments, fortification, use of probiotics and protocol. After conducting a systematic search of the available evidence, the information was contrasted and summarized in order to draw up the recommendations. The quality of the evidence and the strength of the recommendations were determined from the SIGN scale Comment: These CPG aim to help physicians in their decision making. The protocolized application of well-proven measurements reduces the variation in clinical practice and improves results.

New clinical practice guideline on enteral feeding in very low birth weight infants: second part

Introduction: The nutrition of very low birth weight (VLBW) infants is aimed at promoting a similar growth to that occurring in the uterus. However, in practice this is difficult to achieve and extrauterine growth restriction is frequent. The current tendency is to avoid this restriction by means of early parenteral and enteral nutrition. Nonetheless, uncertainty about many of the practices related with nutrition has resulted in a great variation in the way it is undertaken. In 2009 and 2011 in our hospital there was an unexpected increase in necrotizing enterocolitis. To check to see wether our nutrition policy was involved, we underlook a systematic review and drewup clinical practice guidelines (CPG) about enteral feeding in VLBW infants. New considerations about the duration of the fortification and the use of probiotics have led to an update of these CPG. Methods: A total of 21 clinical questions were designed dealing with the type of milk, starting age, mode of administration, rate and volume of the increments, fortification, use of probiotics and protocol. Afete conducting a systematic search of the available evidence, the information was contrasted and summarized in order to draw up the recommendations. The quality of the evidence and the strength of the recommendations were determined from the SIGN scale. Comment: These CPG aim to help physicians in their decision making. The protocolized application of well-proven measurements reduces the variation in clinical practice and improves results.

Effects of oat bran and nutrition counseling on the lipid and glucose profile and anthropometric parameters of hypercholesterolemia patients

Background: In order to prevent chronic, non communicable disease, it is essential that lifestyle is modified to include a diet high in fiber. Aim: To assess the effect oat bran (OB) in conjunction with nutrition counseling (NC) have on lipid and glucose profile, anthropometric parameters, quality of diet, and ingestion of ultraprocessed foods (UPF) and additives in hypercholesterolemia sufferers. Method: This was a 90-day, double-blind, placebo-controlled, block-randomized trial undertaken on 132 men and women with LDL-c ≥ 130 mg/dL. The participants were sorted into two groups: OB Group (OBG) and Placebo Group (PLG), and were given NC and 40g of either OB or rice flour, respectively. Lipid and glucose profile were assessed, as were the anthropometric data, quality of diet (Diet Quality Index revised for the Brazilian population - DQI-R) and whether or not UPF or additives were consumed. Results: Both groups showed a significant decrease in anthropometric parameters and blood pressure, as well as a significant reduction in total and LDL cholesterol. There was also an improvement in DQI-R in both groups and a decrease in consumption of UPF. Blood sugar, HOMA-IR and QUICKI values were found to be significantly lower only in the OBG. Conclusion: Our findings in lipid profile and anthropometric parameters signify that NC has a beneficial effect, which is attributable to the improved quality of diet and reduced consumption of UPF. Daily consumption of 40 g of OB was found to be of additional benefit, in decreasing insulin-resistance parameters.

Estudio comparativo de la eficacia y seguridad de una nutrición parenteral formulada con dos lípidos distintos: SMOFlipid® frente a Clinoleic®: estudio preliminar

Introducción: la composición lipídica de las fórmulas de nutrición parenteral (NP) se postula como posible factor de evolución clínica. Objetivo: evaluar las diferencias en eficacia y seguridad de dos emulsiones lipídicas en NP. Material y métodos: estudio clínico prospectivo de pacientes posquirúrgicos sometidos a NP durante más de 7 días en un periodo de 2 años. Se administraron de forma indistinta 2 tipos de emulsiones lipídicas: enriquecida con ácidos grasos omega 3 (SMOFlipid Fresenius Kabi®) o con ácido oleico omega 9 (Clinoleic Baxter®). Se analizaron variables epidemiológicas, analíticas, complicaciones infecciosas y mortalidad. Resultados: se estudió un total de 154 pacientes con edad media de 64,36 ± 13,73 años, de los que 95 eran hombres (61%), 78 (51%) recibieron SMOFlipid® y 76 (49%) Clinoleic®. La estancia media fue de 16,91 ± 4,23 días, la duración de la NP 9,68 ± 3,25 días y la mortalidad del 11%. Se diagnosticaron 58 (37%) infecciones. No existieron diferencias significativas en cuanto a los parámetros analíticos lipídicos, hepáticos o nutricionales (medidos al inicio y al 7.º día) ni en su evolución (estancia media, complicaciones infecciosas ni mortalidad) entre los dos grupos de pacientes. Conclusión: los pacientes sometidos a NP presentan similares características evolutivas con independencia de la emulsión lipídica utilizada. La bibliografía actual apunta a un beneficio de la disminución del aporte de ácidos grasos omega 9, pero no se han encontrado diferencias significativas entre las fórmulas comparadas.