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1.
Energy delivery guided by indirect calorimetry in critically ill patients: a systematic review and meta-analysis.
Duan, JY, Zheng, WH, Zhou, H, Xu, Y, Huang, HB
Critical care (London, England). 2021;(1):88
Abstract
BACKGROUND The use of indirect calorimetry (IC) is increasing due to its precision in resting energy expenditure (REE) measurement in critically ill patients. Thus, we aimed to evaluate the clinical outcomes of an IC-guided nutrition therapy compared to predictive equations strategy in such a patient population. METHODS We searched PubMed, EMBASE, and Cochrane library databases up to October 25, 2020. Randomized controlled trials (RCTs) were included if they focused on energy delivery guided by either IC or predictive equations in critically ill adults. We used the Cochrane risk-of-bias tool to assess the quality of the included studies. Short-term mortality was the primary outcome. The meta-analysis was performed with the fixed-effect model or random-effect model according to the heterogeneity. RESULTS Eight RCTs with 991 adults met the inclusion criteria. The overall quality of the included studies was moderate. Significantly higher mean energy delivered per day was observed in the IC group, as well as percent delivered energy over REE targets, than the control group. IC-guided energy delivery significantly reduced short-term mortality compared with the control group (risk ratio = 0.77; 95% CI 0.60 to 0.98; I2 = 3%, P = 0.03). IC-guided strategy did not significantly prolong the duration of mechanical ventilation (mean difference [MD] = 0.61 days; 95% CI - 1.08 to 2.29; P = 0.48), length of stay in ICU (MD = 0.32 days; 95% CI - 2.51 to 3.16; P = 0.82) and hospital (MD = 0.30 days; 95% CI - 3.23 to 3.83; P = 0.87). Additionally, adverse events were similar between the two groups. CONCLUSIONS This meta-analysis indicates that IC-guided energy delivery significantly reduces short-term mortality in critically ill patients. This finding encourages the use of IC-guided energy delivery during critical nutrition support. But more high-quality studies are still needed to confirm these findings.
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2.
Systematic review on immunonutrition in partial pancreatoduodenectomy.
Takagi, K, Umeda, Y, Yoshida, R, Yagi, T, Fujiwara, T
Langenbeck's archives of surgery. 2020;(5):585-593
Abstract
BACKGROUND The effect of immunonutrition (IM) on postoperative outcomes has been investigated in gastrointestinal cancer surgery; however, strong evidence regarding IM in partial pancreatoduodenectomy (PD) is lacking. This study evaluated the effect of IM on short-term outcomes in patients undergoing PD. METHODS A systematic literature review of randomized controlled trials was conducted to identify the studies investigating the IM effect on outcomes in PD. Random-effects meta-analyses were conducted to calculate the pooled risk ratio (RR). Studies were evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. RESULTS Five studies were included in the meta-analysis. IM was associated with a lower incidence of overall complications (RR 0.74; 95% confidence interval (CI) 0.58, 0.94; P = 0.01; I2 = 0%) and infectious complications (RR 0.60; 95% CI 0.42, 0.84; P = 0.003; I2 = 0%). However, no significant association was noted in the incidence of major complications (RR 0.68; 95% CI 0.41, 1.12; P = 0.13), mortality (RR 0.79; 95% CI 0.16, 3.99; P = 0.78), postoperative pancreatic fistula (RR 0.92, 95% CI 0.59, 1.46; P = 0.74), and delayed gastric emptying (RR 1.09; 95% CI 0.55, 2.15; P = 0.81). CONCLUSIONS IM administration in PD can prevent the incidence of overall and infectious complications postoperatively (GRADE recommendation: moderate). However, IM has no impact on major complications, mortality, and PD-specific complications (GRADE recommendation: low).
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3.
Impact of oral preoperative and perioperative immunonutrition on postoperative infection and mortality in patients undergoing cancer surgery: systematic review and meta-analysis with trial sequential analysis.
Buzquurz, F, Bojesen, RD, Grube, C, Madsen, MT, Gögenur, I
BJS open. 2020;(5):764-775
Abstract
BACKGROUND Infectious complications occur in 4-22 per cent of patients undergoing surgical resection of malignant solid tumours. Improving the patient's immune system in relation to oncological surgery with immunonutrition may play an important role in reducing postoperative infections. A meta-analysis was undertaken to evaluate the potential clinical benefits of immunonutrition on postoperative infections and 30-day mortality in patients undergoing oncological surgery. METHODS PubMed, Embase and Cochrane Library databases were searched to identify eligible studies. Eligible studies had to include patients undergoing elective curative surgery for a solid malignant tumour and receiving immunonutrition orally before surgery, including patients who continued immunonutrition into the postoperative period. The main outcome was overall infectious complications; secondary outcomes were surgical-site infection (SSI) and 30-day mortality, described by relative risk (RR) with trial sequential analysis (TSA). Risk of bias was assessed according to Cochrane methodology. RESULTS Some 22 RCTs with 2159 participants were eligible for meta-analysis. Compared with the control group, immunonutrition reduced overall infectious complications (RR 0·58, 95 per cent c.i. 0·48 to 0·70; I2 = 7 per cent; TSA-adjusted 95 per cent c.i. 0·28 to 1·21) and SSI (RR 0·65, 95 per cent c.i. 0·50 to 0·85; I2 = 0 per cent; TSA-adjusted 95 per cent c.i. 0·21 to 2·04). Thirty-day mortality was not altered by immunonutrition (RR 0·69, 0·33 to 1·40; I2 = 0 per cent). CONCLUSION Immunonutrition reduced overall infectious complications, even after controlling for random error, and also reduced SSI. The quality of evidence was moderate, and mortality was not affected by immunonutrition (low quality). Oral immunonutrition merits consideration as a means of reducing overall infectious complications after cancer surgery.
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The potential role of nutrition on lens pathology: a systematic review and meta-analysis.
Sideri, O, Tsaousis, KT, Li, HJ, Viskadouraki, M, Tsinopoulos, IT
Survey of ophthalmology. 2019;(5):668-678
Abstract
Oxidative stress is one of the main mechanisms of lens opacification, and certain nutritional antioxidants are suspected to have a protective effect. To examine the role of these nutritional antioxidants on cataract prevention, we searched major databases and reviewed current evidence regarding the protective effect of nutritive antioxidants. We included observational studies that investigate the association between one or more of the following micronutrients and cataract: vitamin A, vitamin C, vitamin E, lutein, zeaxanthin, α- and β-carotene. Two independent authors extracted data and assessed their quality. We pooled results for overall cataract incidence for all types of cataract and separately for nuclear, cortical, and posterior subcapsular cataract. We did not perform sensitivity analysis. Twenty-five studies were included in the qualitative and 24 in the quantitative part of the study, with a total of 295,821 participants over 30 years old. Results from pooled analysis showed a protective effect of antioxidants on cataract, but not all of them reached statistical significance. Statistically significant results were reached for vitamin C (odds ratio [OR] = 0.88, 95% confidence interval [CI] [0.81, 0.97]), beta-carotene (OR = 0.89, 95% CI [0.83, 0.95]), and lutein and zeaxanthin (OR = 0.92, 95% CI [0.85, 0.99]). We did not find statistically significant results for vitamin E (OR = 0.84, 95% CI [0.70, 1.01]), vitamin A (OR = 0.90, 95% CI [0.80, 1.00]), or alpha-carotene (OR = 0.92, 95% CI [0.85, 1.00]). The present study shows a relation between certain antioxidants and cataract, but further studies, especially interventional, are needed to confirm this hypothesis.
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Effects of Nutrition Therapy in Older Stroke Patients Undergoing Rehabilitation: A Systematic Review and Meta-Analysis.
Sakai, K, Kinoshita, S, Tsuboi, M, Fukui, R, Momosaki, R, Wakabayashi, H
The journal of nutrition, health & aging. 2019;(1):21-26
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Abstract
OBJECTIVE To systematically review evidence on the effects of nutrition therapy in older stroke patients undergoing rehabilitation and identify its effectiveness using meta-analysis. METHODS PubMed (MEDLINE), EMBASE (via Dialog), Cochrane Central Register of Controlled Trial, World Health Organization International Clinical Trials Registry Platform and Ichu-shi Web were searched for relevant articles. Randomized controlled trials investigating the effects of nutrition therapy compared to control interventions in older stroke patients undergoing rehabilitation were considered eligible. The primary outcome was activities of daily living (ADL), and secondary outcomes were all-cause mortality, infections, pneumonia incidence, disability level, walking ability, fall, stroke recurrence, and quality of life. The risk of bias of each trial was assessed using the Cochrane Collaboration Tool, and the quality of the body of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS Eight randomized controlled trials with a total of 5484 participants were included in the meta-analysis. The meta-analysis for ADL showed no significant effects (mean difference, 4.16; 95% confidence interval [CI], -0.88 to 9.20; I2=53%, low-quality evidence). The meta-analyses for secondary outcomes revealed a significant effect of reduced infections (risk ratio, 0.65; 95% CI, 0.51 to 0.84; I2=0%; low-quality evidence), with no significant effects on the other outcomes. CONCLUSION Nutrition therapy had no statistically significant effect on ADL. However, it reduced the incidence of infections. More high-quality trials are warranted to clarify the effects of nutrition therapy in older stroke patients undergoing rehabilitation.
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Effectiveness of multidisciplinary nutritional support in older hospitalised patients: A systematic review and meta-analyses.
Rasmussen, NML, Belqaid, K, Lugnet, K, Nielsen, AL, Rasmussen, HH, Beck, AM
Clinical nutrition ESPEN. 2018;:44-52
Abstract
Malnutrition is common in older hospitalised patients. As the aetiology is multifactorial, nutritional care should involve a multidisciplinary team. However, the knowledge of the effectiveness of this strategy is limited. This systematic review aims at investigating the effectiveness of multidisciplinary nutritional support on mortality, readmissions and quality of life (QoL) in patients aged 65 years and above during hospitalisation and after discharge compared to usual practise. We conducted a series of systematic literature search from 2013 to 2017, with additional studies hand-searched from reference lists of retrieved publications. Eligible studies were controlled trials with a multidisciplinary nutritional intervention during hospitalisation and after discharge in older (65+) patients. A intervention by more than one profession incorporating a nutritional component was defined as "Multidisciplinary". The nutritional intervention included use of oral nutritional supplements (ONS), improved nutritional care, and/or dietary counselling. For quality assessment of studies, "Cochrane Collaboration's tool for assessing risk of bias" was used. Conduction of meta-analyses were by combining data from homogenous trials. The search resulted in five studies fulfilling the inclusion criteria, but varied in quality and type of interventions used. 598 patients were included. Meta-analyses found improved QoL (MD 0.13 (0.02, 0.23), P = 0.01) and indicated tendencies towards lower mortality (OR 0.50 (0.22, 1.14), P = 0.10), in the intervention group vs. control group. Meta-analysis showed no difference between intervention and control group regarding readmissions during intervention (OR 1.04 (0.40, 2.70)) or at a 26 weeks follow-up (OR 0.84 (0.18, 3.82)) Although a small number of studies and a relatively small sample size, a suggestion is that provision of multidisciplinary nutritional support may have a positive effect on mortality and improves quality of life in older patients. There is a need for more high-quality studies including multidisciplinary nutritional support to verify these findings. Study registration in PROSPERO is no. CRD42016047997.
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Chinese guidelines for the assessment and provision of nutrition support therapy in critically ill children.
Zhu, XM, Qian, SY, Lu, GP, Xu, F, Wang, Y, Liu, CF, Ren, XX, Zhang, YC, Gao, HM, Zhou, T, et al
World journal of pediatrics : WJP. 2018;(5):419-428
Abstract
BACKGROUND This document represents the first evidence-based guidelines to describe best practices in nutrition therapy in critically ill children (> 1 month and < 18 years), who are expected to require a length of stay more than 2 or 3 days in a Pediatric Intensive Care Unit admitting medical patients domain. METHODS A total of 25,673 articles were scanned for relevance. After careful review, 88 studies appeared to answer the pre-identified questions for the guidelines. We used the grading of recommendations, assessment, development and evaluation criteria to adjust the evidence grade based on the quality of design and execution of each study. RESULTS The guidelines emphasise the importance of nutritional assessment, particularly the detection of malnourished patients. Indirect calorimetry (IC) is recommended to estimate energy expenditure and there is a creative value in energy expenditure, 50 kcal/kg/day for children aged 1-8 years during acute phase if IC is unfeasible. Enteral nutrition (EN) and early enteral nutrition remain the preferred routes for nutrient delivery. A minimum protein intake of 1.5 g/kg/day is suggested for this patient population. The role of supplemental parenteral nutrition (PN) has been highlighted in patients with low nutritional risk, and a delayed approach appears to be beneficial in this group of patients. Immune-enhancing cannot be currently recommended neither in EN nor PN. CONCLUSION Overall, the pediatric critically ill population is heterogeneous, and an individualized nutrition support with the aim of improving clinical outcomes is necessary and important.
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Intensive nutritional care for patients treated with radiotherapy in head and neck cancer: a randomized study and meta-analysis.
Roussel, LM, Micault, E, Peyronnet, D, Blanchard, D, Guarnieri, S, Choussy, O, Géry, B, Béquignon, A, Joubert, C, Parienti, JJ, et al
European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery. 2017;(2):977-987
Abstract
Nutritional care improves quality of life (QOL) in head and neck cancer patients treated with radiotherapy. The aim of our study was to determine whether intensive nutritional care (INC) would further improve QOL. In addition to a control group based on European and American guidelines, patients included in the INC group received six meetings with a dietitian. QOL was measured after radiotherapy using the EORTC QLQ-C30. We performed a meta-analysis to determine the best nutritional care. In the 87 patients, the QOL scores, weight, energy, and protein intakes were similar between the INC group (n = 43) and the control group (n = 44). The meta-analysis revealed no heterogeneity and significant differences in QOL (three studies) (p = 0.46) or weight changes after radiotherapy (four studies) (p = 0.06). The nutritional care specified in the European and American guidelines is composed of well-defined recommendations, and appears sufficient to maintain QOL without further intervention.
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Meta-analysis of immunonutrition in major abdominal surgery.
Probst, P, Ohmann, S, Klaiber, U, Hüttner, FJ, Billeter, AT, Ulrich, A, Büchler, MW, Diener, MK
The British journal of surgery. 2017;(12):1594-1608
Abstract
BACKGROUND The objective of this study was to evaluate the potential benefits of immunonutrition in major abdominal surgery with special regard to subgroups and influence of bias. METHODS A systematic literature search from January 1985 to July 2015 was performed in MEDLINE, Embase and CENTRAL. Only RCTs investigating immunonutrition in major abdominal surgery were included. Outcomes evaluated were mortality, overall complications, infectious complications and length of hospital stay. The influence of different domains of bias was evaluated in sensitivity analyses. Evidence was rated according to the GRADE Working Group grading of evidence. RESULTS A total of 83 RCTs with 7116 patients were included. Mortality was not altered by immunonutrition. Taking all trials into account, immunonutrition reduced overall complications (odds ratio (OR) 0·79, 95 per cent c.i. 0·66 to 0·94; P = 0·01), infectious complications (OR 0·58, 0·51 to 0·66; P < 0·001) and shortened hospital stay (mean difference -1·79 (95 per cent c.i. -2·39 to -1·19) days; P < 0·001) compared with control groups. However, these effects vanished after excluding trials at high and unclear risk of bias. Publication bias seemed to be present for infectious complications (P = 0·002). Non-industry-funded trials reported no positive effects for overall complications (OR 1·13, 0·88 to 1·46; P = 0·34), whereas those funded by industry reported large effects (OR 0·66, 0·48 to 0·91; P = 0·01). CONCLUSION Immunonutrition after major abdominal surgery did not seem to alter mortality (GRADE high quality of evidence). Immunonutrition reduced overall complications, infectious complications and shortened hospital stay (GRADE low to moderate). The existence of bias lowers confidence in the evidence (GRADE approach).
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Perioperative ω-3 Polyunsaturated Fatty Acid Nutritional Support in Gastrointestinal Cancer Surgical Patients: A Systematic Evaluation.
Ma, YJ, Liu, L, Xiao, J, Cao, BW
Nutrition and cancer. 2016;(4):568-76
Abstract
This study was a systematic evaluation of the beneficial effects of n-3 polyunsaturated fatty acid (PUFA) in abdominal cancer surgical patients. A literature search of the databases PubMed, Medline, Cochrane, and EMBASE was conducted for studies published up to November 2014 in English language journals. Randomized controlled trials (RCTs) examining the effects of n-3 PUFA intake relative to conventional nutrition in surgical patients were included. The main outcomes were the duration of systemic inflammatory response syndrome (SIRS), length of hospital stay (LOS), serum C-reactive protein (CRP) levels, and postoperative complications. We identified 15 RCTs among 158 relevant trials. The results indicated the associations between n-3 PUFA intake and reduced LOS [mean differences (MDs), -2.47 d; 95% confidence intervals (CIs), -3.25 to -1.69], duration of SIRS (MD, -0.57 d; 95% CI, -0.92 to -0.22), and serum CRP levels (MD, -3.97 mg/l; 95% CI, -7.88 to -0.07) compared with consumption of conventional nutrition, as well as reduced incidence of postoperative infectious complications (risk ratio, 0.66; 95% CI, 0.49-0.87). This systematic evaluation suggests that n-3 PUFA significantly reduces the postoperative infectious complication rate, and shortens hospitalization and SIRS duration, particularly in malnourished gastrointestinal cancer patients.