Rationale: In 2016, a completely revised second version of the ‘Handbook Nutrition in Cancer’ (HNC, in Dutch) by the Dutch Dietitians Oncology Group (DDOG) was published. In this project, the DDOG evaluated similarities and potential discrepancies between DDOG recommendations and the ESPEN guidelines for the identification, prevention and treatment of reversible elements of malnutrition during and after cancer treatment.Methods: The recommendations of the DDOG, as published in the HCN, were systematically compared with the ESPEN guidelines on nutrition in cancer patients. guidelines. However, DDOG recommendations are more detailed, comprehensive, and practical.The DDOG and the ESPEN guidelines differ in that the DDOG 1) recommends the comprehensive PG-SGA and PG-SGA Short Form for screening and nutritional assessment; 2) recommends to start artificial nutrition at an earlier stage; 3) does not recommend increasing the ratio of energy from fat/energy from carbohydrates in weight-losing cancer patients with insulin resistance; 4) includes a less conservative recommendation on increasing energy intake for prevention of refeeding syndrome; and 5) supports a longer period of corticosteroid use to increase appetite (4-8 weeks vs ESPEN 1-3 weeks).AdditionallyResults: Overall, the DDOG recommendations are in line with the ESPEN , the DDOG does not include a specific advice for parenteral nutrition composition during intensive chemotherapy, and includes the advice to avoid fatty fish/fish oil 24 hours before and after specific chemotherapy treatment.Both guidelines recommend nutritional care to be accompanied by exercise training.Conclusion: The DDOG and ESPEN recommendations are generally in line with each other, but the DDOG recommendations are more specific and practical. DDOG and ESPEN are complementary to each other.
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Introduction:The recently published 2018 ESPEN Guidelines on Clinical Nutrition in the Intensive Care Unit [1] represents a valuable revision of the 2006 Enteral Nutrition Guidelines [2] and the 2009 Parenteral Nutrition Guidelines [3] published earlier by this European group. The guidelines committee members have done an excellent job in putting thismanuscript together, providing directives that are clear, concise, brief, and most importantly, transparent. They included only studies published since 2000 for use in their meta-analyses, commenting that this time of transition heralded a new era in the literature involving higher quality randomized control trials (RCTs) and methodologic innovations such as trial registry. Not mentioned (but felt by many within the nutrition community) was the sense that this particular time was a tipping point, following the publication of Van den Berghe’s seminal paper on intensive insulin therapy [4]. Studies published in nutrition prior to this date were felt to reflect an older more antiquated style of management that was less effective. These authors utilized the persistent inflammation catabolism syndrome (PICS) system where four parameters (the patient, intervention, controls, and outcomes) are clearly described, which in turn direct the questions that the guideline committee members were to address. Quality of evidence was assessed by GRADE methodology, and a cut-off date of August 2017 for data entry from the literature was clearly identified. Not all of the recommendations were based on RCTs. The authors are to be commended in that they provided recommendations based on Level 4 low-quality evidence, in areas where RCTs were not available, clearly taking advantage of the group of experts on the committee to provide practical guidance for clinicians where there was a paucity of literature to support evidence-based practices.
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Emerging evidence suggests that exogenous protein/amino acid supplementation has the potential to improve the recovery of critically ill patients. After a careful review of the published evidence, experts have concluded that critically ill patients should receive up to 2.0-2.5 g/kg/d of protein. Despite this, however, recent review of current International Nutrition Survey data suggests that protein in critically ill patients is underprescribed and grossly underdelivered. Furthermore, the survey suggests that most of protein administration comes from enteral nutrition (EN) despite the availability of products and protocols that enhance the delivery of protein/amino acids in the intensive care unit (ICU) setting. While future research clarifies the dose, timing, and composition for exogenous protein administration, as well as identification of patients who will benefit the most, ongoing process improvement initiatives should target a concerted effort to increase protein intake in the critically ill. This assertion follows from the notion that current patients are possibly being harmed while we wait for confirmatory evidence. Further research should also develop better tools to enable bedside practitioners to monitor optimal or adequate protein intake for individual patients. Finally, exploring the effect of combining adequate protein delivery with early mobility and/or resistance exercise in the ICU setting has the greatest potential for improving the functional outcomes of survivors of critical illness and warrants further study.
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Malnutrition is a serious and widespread health problem in community-dwelling older adults who receive care in hospital and at home. Hospital and home care nurses and nursing assistants have a key role in the delivery of high-quality multidisciplinary nutritional care. Nursing nutritional care in current practice, however, is still suboptimal, which impacts its quality and continuity. There appear to be at least two reasons for this. First, there is a lack of evidence for nutritional care interventions to be carried out by nurses. Second, there are several factors, that influence nurses’ and nursing assistants’ current behaviour, such as lack of knowledge, moderate awareness of the importance and neutral attitudes. This results in a lack of attention towards nutritional care. Therefore, there is a need to generate more evidence and to focus on targeting the factors that influence nurses’ and nursing assistants’ current behaviour to eventually promote behaviour change. To increase the likelihood of successfully changing their behaviour, an evidence-based educational intervention is appropriate. This might lead to enhancing nutritional care and positively impact nutritional status, health and well-being of community-dwelling older adults. The general objectives of this thesis are: 1) To understand the current state of evidence regarding nutrition-related interventions and factors that influence current behaviour in nutritional care for older adults provided by hospital and home care nurses and nursing assistants to prevent and treat malnutrition. 2) To develop an educational intervention for hospital and home care nurses and nursing assistants to promote behaviour change by affecting factors that influence current behaviour in nutritional care for older adults and to describe the intervention development and feasibility.
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Rationale: Inadequate operationalisation of the multidimensial concept of malnutrition may result in inadequate evaluation of nutritional status. In this review we aimed to assess content validity of methods used to assess malnutrition in cancer patients, according to domains directly derived from European Society for Clinical Nutrition and Metabolism (ESPEN) and American Society for Parenteral and Enteral Nutrition (ASPEN) definitions for malnutrition. Methods: Studies on malnutrition in adult cancer patients published between 1999 and 2013 were considered eligible. Methods to assess malnutrition were classified using 13 indicators within three domains that the malnutrition definitions of ESPEN and ASPEN have in common: A) Nutrient balance; B) Changes in body shape, body area and body composition; and C) Body function.Content validity index per method (M-CVIA-C) was calculated by averaging indicator scores weighted per domain, quantifying to what extent the methods covered the construct of malnutrition. Acceptable content validity was defined as M-CVIA-C ≥0.80.Results: 40 Different methods within 166 articles were identified. Median M-CVIA-C was 0.22 (interquartile range: 0.08-0.53). None of the methods reached M-CVIA-C=0.80. Mini Nutritional Assessment (MNA; M-CVIA-C=0.75), Nutritional Screening Questionnaire (NSQ; M-CVIA-C=0.56) and Scored Patient-Generated Subjective Global Assessment (PG-SGA; M-CVIA-C=0.53) were responsible for the top 25% of M-CVIA-C scores. Conclusion: Content validity of methods that assess malnutrition in cancer patients varies widely and is unacceptable in terms of M-CVIA-C. MNA, NSQ and PG-SGA showed highest scores in terms of content validity. Conflict of interest: None.
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Insight into protein requirements of intensive care unit (ICU) patients is urgently needed, but at present, it is unrealistic to define protein requirements for different diagnostic groups of critical illness or at different stages of illness. No large randomized controlled trials have randomized protein delivery, adequately addressed energy intake, and evaluated relevant clinical outcomes. As a pragmatic approach, experimental studies have focused on protein requirements of heterogeneous ICU patients. Data are scarce and the absolute value of protein requirements therefore is an approximation. Experimental studies indicate a protein requirement of >1.2 g/kg protein, which is supported by several outcome-based observational studies. Protein intake levels of up to 2.0-2.5 g/kg appear to be safe. A higher level of personalized treatment, within 1.2 and 2.5 g/kg, must involve identification of patients with low muscle protein mass that might benefit most from adequate protein nutrition in the ICU.
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ObjectiveTo identify malnutrition assessment methods in cancer patients and assess their content validity based on internationally accepted definitions for malnutrition.Study Design and SettingSystematic review of studies in cancer patients that operationalized malnutrition as a variable, published since 1998. Eleven key concepts, within the three domains reflected by the malnutrition definitions acknowledged by European Society for Clinical Nutrition and Metabolism (ESPEN) and the American Society for Parenteral and Enteral Nutrition (ASPEN): A: nutrient balance; B: changes in body shape, body area and body composition; and C: function, were used to classify content validity of methods to assess malnutrition. Content validity indices (M-CVIA–C) were calculated per assessment method. Acceptable content validity was defined as M-CVIA–C ≥ 0.80.
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Evaluating protein kinetics in the critically ill population remains a very difficult task. Heterogeneity in the intensive care unit (ICU) population and wide spectrum of disease processes creates complexity in assessing protein kinetics. Traditionally, protein has been delivered in the context of total energy. Focus on energy delivery has recently come into question, as the importance of supplemental protein in patient outcomes has been shown in several recent trials. The ICU patient is prone to catabolism, immobilization, and impaired immunity, which is a perfect storm for massive loss of lean body tissue with a unidirectional flow of amino acids from muscle to immune tissue for immunoglobulin production, as well as liver for gluconeogenesis and acute phase protein synthesis. The understanding of protein metabolism in the ICU has been recently expanded with the discovery of how the mammalian target of rapamycin complex 1 is regulated. The concept of "anabolic resistance" and identifying the quantity of protein required to overcome this resistance is gaining support among critical care nutrition circles. It appears that a minimum of at least 1.2 g/kg/d with levels up to 2.0 g/kg/d of protein or amino acids appears safe for delivery in the ICU setting and may yield a better clinical outcome.
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Background: Advanced medical technologies (AMTs), such as respiratory support or suction devices, are increasingly used in home settings and incidents may well result in patient harm. Information about risks and incidents can contribute to improved patient safety, provided that those are reported and analysed systematically. Objectives: To identify the frequency of incidents when using AMTs in home settings, the effects on patient outcomes and the actions taken by nurses following identification of incidents. Methods: A cross-sectional study of 209 home care nurses in the Netherlands working with infusion therapy, parenteral nutrition or morphine pumps, combining data from a questionnaire and registration forms covering more than 13 000 patient contacts. Descriptive statistics were used. Results: We identified 140 incidents (57 adverse events; 83 near misses). The frequencies in relation to the number of patient contacts were 2.7% for infusion therapy, 1.3% for parenteral nutrition and 2.6% for morphine pumps. The main causes were identified as related to the product (43.6%), the organisation of care (27.9%), the nurse as a user (15.7%) and the environment (12.9%). 40% of all adverse events resulted in mild to severe harm to the patient. Incidents had been discussed in the team (70.7%), with the patient/informal caregiver(s) (50%), or other actions had been taken (40.5%). 15.5% of incidents had been formally reported according to the organisation's protocol. Conclusions: Most incidents are attributed to product failures. Although such events predominantly cause no harm, a significant proportion of patients do suffer some degree of harm. There is considerable underreporting of incidents with AMTs in home care. This study has identified a discrepancy in quality circles: learning takes place at the team level rather than at the organisational level.
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Background Advanced medical technologies (AMTs), such as respiratory support or suction devices, are increasingly used in home settings and incidents may well result in patient harm. Information about risks and incidents can contribute to improved patient safety, provided that those are reported and analysed systenaticaly. Objectives To identify the frequency of incidents when using AMTs in home settings, the effects on patient outcomes and the actions taken by nurses following identification of incidents. Methods A cross- sectional study of 209 home care nurses in the Netherlands working with infusion therapy, parenteral nutrition or morphine pumps, combining data from a questionnaire and registration forms covering more than 13 000 patient contacts. Descriptive statistics were used. Results We identified 140 incidents (57 adverse events; 83 near misses). The frequencies in relation to the number of patient contacts were 2.7% for infusion therapy, 1.3% for parenteral nutrition and 2.6% for morphine pumps. The main causes were identified as related to the product (43.6%), the organisation of care (27.9%), the nurse as a user (15.7%) and the environment (12.9%). 40% of all adverse events resulted in mild to severe harm to the patient. Incidents had been discussed in the team (70.7%), with the patient/informal caregiver(s) (50%), or other actions had been taken (40.5%). 15.5% of incidents had been formally reported according to the organisation’s protocol. Conclusions Most incidents are attributed to product failures. Although such events predominantly cause no harm, a significant proportion of patients do suffer some degree of harm. There is considerable underreporting of incidents with AMTs in home care. This study has identified a discrepancy in quality circles: learning takes place at the team level rather than at the organisational level.
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