Publications by authors named "Stanislaw Klek"

95 Publications

Correlation of hemoglobin A and outcomes in patients hospitalized with COVID-19.

Endocr Pract 2021 Jul 17. Epub 2021 Jul 17.

Division of Endocrinology, Diabetes and Metabolism, NYU Long Island School of Medicine, Mineola, NY. Electronic address:

Background: Diabetes is a known risk factor for severe coronavirus disease 2019 (COVID-19). We conducted this study to determine if there is a correlation between hemoglobin A (HbA) level and poor outcomes in hospitalized patients with diabetes and COVID-19.

Methods: This is a retrospective, single-center, observational study of patients with diabetes (as defined by an HbA ≥ 6.5% or known medical history of diabetes) who had a confirmed case of COVID-19 and required hospitalization. All patients were admitted to our institution between March 3, 2020 and May 5, 2020. HbA results for each patient were divided into quartiles; 5.1-6.7% (32-50 mmol/mol), 6.8-7.5% (51-58 mmol/mol), 7.6-8.9% (60-74 mmol/mol), and >9% (>75 mmol/mol). The primary outcome was in-hospital mortality. Secondary outcomes included admission to an intensive care unit, invasive mechanical ventilation, acute kidney injury, acute thrombosis, and length of hospital stay.

Results: Five hundred and six patients were included. The number of deaths within quartiles 1 through 4 were 30 (25%), 37 (27%), 34 (27%) and 24 (19%), respectively. There was no statistical difference in the primary or secondary outcomes between the quartiles except acute kidney injury was less frequent in quartile 4.

Conclusions: There is no significant association between HbA level and adverse clinical outcomes in patients with diabetes who are hospitalized with COVID-19. HbA should not be used for risk stratification in these patients.
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http://dx.doi.org/10.1016/j.eprac.2021.07.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8286241PMC
July 2021

ESPEN practical guideline: Clinical nutrition in surgery.

Clin Nutr 2021 Jul 19;40(7):4745-4761. Epub 2021 Apr 19.

Institute for Nutrition Research, Rabin Medical Center, Beilison Hospital, Petah Tikva, Israel.

Early oral feeding is the preferred mode of nutrition for surgical patients. Avoidance of any nutritional therapy bears the risk of underfeeding during the postoperative course after major surgery. Considering that malnutrition and underfeeding are risk factors for postoperative complications, early enteral feeding is especially relevant for any surgical patient at nutritional risk, especially for those undergoing upper gastrointestinal surgery. The focus of this guideline is to cover both nutritional aspects of the Enhanced Recovery After Surgery (ERAS) concept and the special nutritional needs of patients undergoing major surgery, e.g. for cancer, and of those developing severe complications despite best perioperative care. From a metabolic and nutritional point of view, the key aspects of perioperative care include the integration of nutrition into the overall management of the patient, avoidance of long periods of preoperative fasting, re-establishment of oral feeding as early as possible after surgery, the start of nutritional therapy immediately if a nutritional risk becomes apparent, metabolic control e.g. of blood glucose, reduction of factors which exacerbate stress-related catabolism or impaired gastrointestinal function, minimized time on paralytic agents for ventilator management in the postoperative period, and early mobilization to facilitate protein synthesis and muscle function.
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http://dx.doi.org/10.1016/j.clnu.2021.03.031DOI Listing
July 2021

Enhanced Recovery after Surgery (ERAS) Protocol Is a Safe and Effective Approach in Patients with Gastrointestinal Fistulas Undergoing Reconstruction: Results from a Prospective Study.

Nutrients 2021 Jun 7;13(6). Epub 2021 Jun 7.

2nd Department of General Surgery, Jagiellonian University Medical College, Jakubowskiego 2, 30-688 Kraków, Poland.

Background And Aims: An enterocutaneous fistula (ECF) poses a major surgical problem. The definitive surgical repair of persistent fistulas remains a surgical challenge with a high rate of re-fistulation and mortality, and the reasons for that is not the surgical technique alone. Enhanced Recovery after Surgery (ERAS) is an evidence-based multimodal perioperative protocol proven to reduce postoperative complications. The aim of the study was to assess the clinical value of the ERAS protocol in surgical patients with ECF.

Methods: ERAS protocol was used in all patients scheduled for surgery for ECF at the Stanley Dudrick's Memorial Hospital in Skawina between 2011 and 2020. A multidisciplinary team (MDT) was in charge of the program and performed annual audits. A consecutive series of 100 ECF patients (44 females, 56 males, mean age 54.1 years) were evaluated. Postoperative complications rate, readmission rate, length of hospital stay, prevalence of postoperative nausea and vomiting were assessed. Registered under ClinicalTrials.gov Identifier no. NCT04771832.

Results: ERAS protocol was successfully introduced for ECF surgeries; however, eight modifications to the ERAS program was performed in 2015. They led to improvement of surgical outcomes: reduction of postoperative nausea and vomiting (15 vs. 17% patients, = 0.025), overall complication rate (11 vs. 10, = 0.021), median length of hospital stay (overall and after surgery, = 0.022 and 0.002, respectively).

Conclusions: ERAS protocol can be successfully used for ECF patients. Prescheduled audits can contribute to the improvement of care.
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http://dx.doi.org/10.3390/nu13061953DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8229866PMC
June 2021

From hospital unit to intestinal failure center: Twenty years of history.

Clin Nutr 2021 Jun 27;40(6):3787-3792. Epub 2021 Apr 27.

Department of Clinical Nursing, Institute of Nursing and Midwifery, Faculty of Health Care, Jagiellonian University, Krakow, Poland.

Aim: Home parenteral nutrition (HPN) is one of the most demanding medical therapies as it is the only option for patients for intestinal failure (IF). No unequivocal policy on how to start and progress with HPN has ever been presented. The IF Center at the Stanley Dudrick's Memorial Hospital in Skawina is one of the biggest centers in Poland, celebrating its twentieth birthday last year. It offered the unique chance to present how to create and grow the IF center, increasing the quality of care. The above became the aim of this study.

Methods: A retrospective analysis of all medical records of HPN patients from the University Hospital and Stanley Dudrick's Memorial Hospital in Skawina. Patient profile, clinical course and treatment outcomes were assessed. The evolution of all aspects of HPN is presented. A brief historical perspective has been added to better illustrate the center's growth and transformation.

Results: 608 patients (363 female, 245 male, mean age 55.55 year) from all over Poland were treated between December 1999 and December 2019. The most frequent indication for HPN was mechanical obstruction (277, 45.7%), followed by short bowel syndrome (SBS, 208, 34.3%) and intestinal fistula (46, 7.59%). The most common primary disease was cancer (n = 267), followed by mesenteric ischemia (n = 104), and surgical complications (n = 62). 314 patients (51.8%) died. 73 (12.04%) were successfully weaned off PN. The catheter infection rate reached 0.39/1000 catheter days.

Conclusions: the founding of the HPN center and its further development is possible provided that there is team of dedicated people, supported by hospital base. The real growth opportunity is guaranteed by the reimbursement. It is necessary to adapt to the changing circumstances.
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http://dx.doi.org/10.1016/j.clnu.2021.04.027DOI Listing
June 2021

Efficacy of Hybrid Closed-Loop Insulin Delivery System in a Hospital Setting: A Case Series.

AACE Clin Case Rep 2021 May-Jun;7(3):184-188. Epub 2021 Jan 6.

Division of Endocrinology, NYU Long Island School of Medicine, Mineola, New York.

Objective: We report a case series of 4 patients with type 1 diabetes who used hybrid closed-loop insulin pumps (Medtronic MiniMed 670 G) during hospitalization.

Methods: Clinical data and point-of-care glucose values are presented for each patient. Glucose values are shown graphically while in manual mode as well as in auto mode.

Results: The first case was a 30-year-old man admitted for pancreatitis. Mean point-of-care blood glucose was 165.7 mg/dL while in auto mode, without hypoglycemia, compared with 221 mg/dL while in manual mode. The second case was a 28-year-old woman who was admitted for a laparoscopic cholecystectomy. Mean point-of-care blood glucose in auto mode was 131.3 mg/dL, without hypoglycemia, compared with 117.6 mg/dL while in manual mode. The third case was a 46-year-old man admitted to the intensive care unit for influenzal pneumonia. Mean point-of-care blood glucose in auto mode was 159.1 mg/dL without hypoglycemia, compared with 218.5 mg/dL while in manual mode. The fourth case was a 60-year-old man who remained in auto mode throughout his hospitalization except for a period when he removed his pump for an endoscopic retrograde cholangiopancreatography and endoscopic ultrasound. His mean point-of-care blood glucose while in auto mode was 156.8 mg/dL without hypoglycemia.

Conclusion: These case reports support the use of hybrid closed-loop insulin-pump therapy in the inpatient setting to maintain inpatient glycemic targets and avoid hypoglycemia when part of an institution-sanctioned strategy for safe use of insulin pumps that includes point-of-care blood glucose monitoring.
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http://dx.doi.org/10.1016/j.aace.2020.12.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8165117PMC
January 2021

Immunonutrition Changes Inflammatory Response in Colorectal Cancer: Results from a Pilot Randomized Clinical Trial.

Cancers (Basel) 2021 Mar 22;13(6). Epub 2021 Mar 22.

2nd Department of General Surgery, Jagiellonian University Medical College, 31-008 Krakow, Poland.

Introduction: Surgery is the first choice of treatment for colorectal cancer. Nutritional support in the form of oral nutritional supplements (ONSs) in the preoperative period is widely accepted for reducing the incidence of perioperative complications, and immunonutrition is generally recommended. However, there is little clinical data regarding the impact of such treatment on tumor biology.

Material And Methods: In this study, tumor tissue and blood samples were collected from 26 patients during preoperative colonoscopy at the time of clinical diagnosis (sample A). Group 1 received standard ONSs (3× Nutricia Nutridrink Protein per day) for 2 weeks before surgery. In group 2, immune ONSs (2× Nestle Impact Oral) were administered for the same duration. Tumor tissue (sample B) was then retrieved from the tumor after resection. Changes in the expression levels of inflammatory cytokines (TNF-α, interleukin 8 or chemokine (C-X-C motif) ligand (CXCL8), stromal cell-derived factor 1 (SDF1a), chemokine (C-X-C motif) ligand 6 (CXCL6), chemokine (C-X-C motif) ligand (CXCL2), myeloperoxidase (MPO), and CXCL1) were assessed during the perioperative course.

Results: TNF-α expression differed after intervention between the two groups (immune group 31.63 ± 13.28; control group 21.54 ± 6.84; = 0.049) and prior to and after intervention in the control group (prior to intervention 35.68 ± 24.41; after intervention 21.54 ± 6.84; = 0.038). Changes in CXCL8 expression in the control group occurred prior to and after intervention (prior to intervention 2975.93 ± 1484.04; after intervention 1584.85 ± 1659.84; = 0.041). CXCL1 expression was increased in the immune group and decreased in the control group (immune group 2698.27 (1538.14-5124.70); control group 953.75 (457.85-1534.60); = 0.032). In both groups, a decrease in superficial neutrophil infiltration was observed, but this was only statistically significant in the immune group. There was no impact of the observed differences between the two groups on surgical outcomes (morbidity, length of stay, readmissions).

Conclusions: Immunonutrition in the preoperative period compared with standard nutritional support may influence inflammatory cytokine expression and leukocyte infiltration in patients with colorectal cancer.
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http://dx.doi.org/10.3390/cancers13061444DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8005085PMC
March 2021

Organizational issues of home parenteral nutrition during COVID-19 pandemic: Results from multicenter, nationwide study.

Nutrition 2021 06 13;86:111202. Epub 2021 Feb 13.

Department of General Surgery and Clinical Nutrition, Centre of Postgraduate Medical Education, Warsaw, Poland.

Objectives: Patients on home parenteral nutrition (HPN) are prone to severe complications of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The pandemic requires adaptation of the health care standards, including epidemiologic surveillance, logistics of home supply, and monitoring. Potential lack of medical professionals may worsen the standard of care. The aim of this study was to evaluate the medical staff resources in HPN units.

Results: The study was conducted by major Polish scientific societies in clinical nutrition. A questionnaire was distributed among all Polish adult HPN centers concerning statistics from the first 3 mo of the pandemic (March through May 2020). Data on medical staff resources and organizational issues of the units were collected. Modifications of the home procedures, SARS-CoV-2 infection rates of HPN patients and health care workers (HCW) were analyzed. Influence of the pandemic on the rates of new qualifications for home artificial nutrition (HAN) was estimated. Fourteen of 17 adult Polish HPN units took part in the study. The point prevalence of HPN in Poland was 30.75/1 million citizens. Of HCWs, 344 were involved in patient care in Polish HPN units; 18.9% were physicians (49% surgeons, 18.46% internal medicine specialists, 15.38% anesthesiologists, 7.69% pediatricians, 1.54% palliative care specialists), 32.27% nurses, 5.23% dietitians, 9.01% pharmacists, 4.94% pharmacy technicians, 3.2% pharmacy assistants, 5.81% administrative workers, 3.49% physiotherapists. HAN patient-to-HCW ratios for physicians, nurses, pharmacists, dietitians were 49.5, 29.15, 111.6, and 181.6, respectively. Medium ages of physicians and nurses were 45.6 and 44.15 y, respectively. Slightly less than half (53.8%) of physicians and 31.53% of nurses worked parallelly in hospital wards. Thirty-one pharmacists overall were working in all HPN units (2.21 per unit) as were 18 dietitians (1.3 per unit). Nine patients had a confirmed COVID-19 infection (four HPN, five home enteral nutrition). All the units introduced telemedicine solutions in the first months of the pandemic. The number of new qualifications for HPN and home enteral nutrition in the units did not significantly decline from March through May in comparison with a similar period in 2019.

Conclusions: A shortage of HPN medical professionals requires attention when planning health care organization, especially during a pandemic. Severe restrictions in public health systems may not reduce the number of new qualifications for the HPN procedure. There is a need for the continuation of data collection during the evolution of the pandemic as it may have a detrimental effect on HPN including serious issues with access to professional HCWs.
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http://dx.doi.org/10.1016/j.nut.2021.111202DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7881293PMC
June 2021

Continuous Subcutaneous Insulin Infusions vs. Multiple Daily Injections of Insulin in Hospitalized Patients: Glycemic Trends in the First 24 Hours of Admission.

J Diabetes Sci Technol 2021 Feb 10:1932296821991136. Epub 2021 Feb 10.

Department of Medicine, NYU Long Island School of Medicine, Mineola, NY, USA.

Background: Continuous subcutaneous insulin infusion (CSII) is a common diabetes treatment modality. Glycemic outcomes of patients using CSII in the first 24 hours of hospitalization have not been well studied. This timeframe is of particular importance because insulin pump settings are programmed to achieve tight outpatient glycemic targets which could result in hypoglycemia when patients are hospitalized.

Methods: This retrospective cohort study evaluated 216 hospitalized adult patients using CSII and 216 age-matched controls treated with multiple daily injections (MDI) of insulin. Patients using CSII did not make changes to pump settings in the first 24 hours of admission. Blood glucose (BG) values within the first 24 hours of admission were collected. The primary outcome was frequency of hypoglycemia (BG < 70 mg/dL). Secondary outcomes were frequency of severe hypoglycemia (BG < 40 mg/dL) and hyperglycemia (BG ≥ 180 mg/dL).

Results: There were significantly fewer events of hypoglycemia [incident rate ratio (IRR) 0.61, 95% confidence interval (CI) 0.42-0.88,  = 0.007] and hyperglycemia (IRR 0.79, 95% CI 0.65-0.96,  = 0.02) in the CSII group compared to the MDI group. There was a trend toward fewer events of severe hypoglycemia in the CSII group (IRR 0.15, 95% CI 0.02-0.93,  = 0.06).

Conclusions: Patients using CSII experienced fewer events of both hypoglycemia and hyperglycemia in the first 24 hours of hospital admission than those treated with MDI. Our study demonstrates that CSII use is safe and effective for the treatment of diabetes within the first 24 hours of hospital admission.
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http://dx.doi.org/10.1177/1932296821991136DOI Listing
February 2021

Intravenous lipid emulsions and liver function in adult chronic intestinal failure patients: Results after 5 y of home parenteral nutrition.

Nutrition 2021 02 18;82:111029. Epub 2020 Oct 18.

Second Department of General Surgery, Jagiellonian University Medical College, Department of Endoscopic, Metabolic and Soft Tissue Tumors Surgery, Krakow, Poland.

Objectives: Intravenous lipid emulsions (ILE) are an essential component of parenteral nutrition (PN); however, pure soybean oil emulsion is considered a risk factor for intestinal failure-associated liver disease (IFALD). Limited data are available on the effect of different ILEs on the liver during long-term PN, and to our knowledge, no study has evaluated outcomes beyond 12 mo. Therefore, the aim of the present study was to assess the influence of mixed ILEs on liver function during long-term PN.

Methods: A randomized, open-label clinical trial was performed at the Intestinal Failure Center in Skawina, Poland. Sixty-seven patients (35 F, 32 M; mean age, 53.2 years) receiving home parenteral nutrition (HPN) due to stable chronic intestinal failure (CIF) were randomized to receive one of the following three ILEs: medium/long-chain triacylglycerides (MCT/LCT), olive oil/soybean oil (OO/SO), or a combination of SO/MCT/OO/fish oil (FO) (SMOFlipid). Patients were followed for 5 y. Liver function was assessed clinically and with biochemical parameters (total bilirubin, serum glutamyl oxalate transaminase, serum glutamyl pyruvate transaminase, γ-glutamyl transpeptidase, and alkaline phosphatase) at baseline and after 24 and 60 mo.

Results: The most common etiology for CIF was vascular, followed by Crohn's disease, surgical complications, and radiation enteritis. HPN was effective in improving nutritional status and was associated with low rates of catheter infections and clinical complications. No significant differences were observed between groups in median concentrations serum glutamyl oxalate transaminase, serum glutamyl pyruvate transaminase, γ-glutamyl transpeptidase, or alkaline phosphatase at 24 or 60 mo. A significant reduction in median bilirubin concentration was observed in the SMOFlipid group at 60 mo compared with baseline (6.8 umol/L; interquartile range, 5.2-8.5 versus 7.7 umol/L; interquartile range, 4.9-12.4; P = 0.0138).

Conclusions: Mixed ILEs are safe and effective for use in patients on long-term HPN. A multicomponent ILE with FO can provide additional benefits in terms of liver function during long-term HPN.
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http://dx.doi.org/10.1016/j.nut.2020.111029DOI Listing
February 2021

Omega-3 fatty acid-containing parenteral nutrition in ICU patients: systematic review with meta-analysis and cost-effectiveness analysis.

Crit Care 2020 11 3;24(1):634. Epub 2020 Nov 3.

Department of Clinical Medicine, Sapienza University of Rome, Piazzale Aldo Moro, 5, 00185, Rome, RM, Italy.

Background: Omega-3 (ω-3) fatty acid (FA)-containing parenteral nutrition (PN) is associated with significant improvements in patient outcomes compared with standard PN regimens without ω-3 FA lipid emulsions. Here, we evaluate the impact of ω-3 FA-containing PN versus standard PN on clinical outcomes and costs in adult intensive care unit (ICU) patients using a meta-analysis and subsequent cost-effectiveness analysis from the perspective of a hospital operating in five European countries (France, Germany, Italy, Spain, UK) and the US.

Methods: We present a pharmacoeconomic simulation based on a systematic literature review with meta-analysis. Clinical outcomes and costs comparing ω-3 FA-containing PN with standard PN were evaluated in adult ICU patients eligible to receive PN covering at least 70% of their total energy requirements and in the subgroup of critically ill ICU patients (mean ICU stay > 48 h). The meta-analysis with the co-primary outcomes of infection rate and mortality rate was based on randomized controlled trial data retrieved via a systematic literature review; resulting efficacy data were subsequently employed in country-specific cost-effectiveness analyses.

Results: In adult ICU patients, ω-3 FA-containing PN versus standard PN was associated with significant reductions in the relative risk (RR) of infection (RR 0.62; 95% CI 0.45, 0.86; p = 0.004), hospital length of stay (HLOS) (- 3.05 days; 95% CI - 5.03, - 1.07; p = 0.003) and ICU length of stay (LOS) (- 1.89 days; 95% CI - 3.33, - 0.45; p = 0.01). In critically ill ICU patients, ω-3 FA-containing PN was associated with similar reductions in infection rates (RR 0.65; 95% CI 0.46, 0.94; p = 0.02), HLOS (- 3.98 days; 95% CI - 6.90, - 1.06; p = 0.008) and ICU LOS (- 2.14 days; 95% CI - 3.89, - 0.40; p = 0.02). Overall hospital episode costs were reduced in all six countries using ω-3 FA-containing PN compared to standard PN, ranging from €-3156 ± 1404 in Spain to €-9586 ± 4157 in the US.

Conclusion: These analyses demonstrate that ω-3 FA-containing PN is associated with statistically and clinically significant improvement in patient outcomes. Its use is also predicted to yield cost savings compared to standard PN, rendering ω-3 FA-containing PN an attractive cost-saving alternative across different health care systems.

Study Registration: PROSPERO CRD42019129311.
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http://dx.doi.org/10.1186/s13054-020-03356-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7607851PMC
November 2020

THYROTOXIC PERIODIC PARALYSIS IN A COMPETITIVE BODYBUILDER WITH THYROTOXICOSIS FACTITIA.

AACE Clin Case Rep 2020 Sep-Oct;6(5):e252-e256. Epub 2020 Sep 21.

Department of Medicine, NYU Long Island School of Medicine, Mineola, New York.

Objective: We report a case of thyrotoxic periodic paralysis (TPP) in a bodybuilder who developed paralysis secondary to thyrotoxicosis factitia after taking a supplement containing thyroid hormone. Interestingly, the patient had no intrinsic thyroid disease. Prompt recognition of thyrotoxicosis is critical to avoid progression of paralysis and subsequent complications.

Methods: We discuss a 27-year-old body builder who presented after a 3-day bodybuilding competition with sudden upper and lower extremity paralysis. He admitted to taking anabolic steroids, a supplement containing an unknown amount of thyroid hormone for 2 weeks, and furosemide 40 mg twice daily with near-complete fluid restriction for 3 days.

Results: Laboratory results showed a thyroid-stimulating hormone (TSH) level of <0.010 μIU/mL (normal, 0.3 to 5.8 μIU/mL), normal total triiodothyronine level, elevated free thyroxine level of 3.6 ng/dL (normal, 0.8 to 1.9 ng/dL), and potassium level of 1.9 mEq/L (normal, 3.7 to 5.2 mEq/L). Thyroid peroxidase antibody, thyroid-stimulating immunoglobulin, and thyroglobulin antibody levels were normal. Thyroid uptake was 1% (normal, 8 to 25%) after administration of I-123 and thyroglobulin level was 9 ng/mL (normal, 1.4 to 29.2 ng/mL). The patient was treated with normal saline infusion, magnesium supplementation and a total of 230 mEq of potassium within 12 hours of hospitalization. Muscle weakness resolved within this time period and potassium level normalized. By the third day of hospitalization free thyroxine level also normalized and TSH improved to 0.1 mIU/L.

Conclusion: TPP is a rare complication of thyrotoxicosis that should be considered in bodybuilders who are presenting with acute muscle weakness.
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http://dx.doi.org/10.4158/ACCR-2020-0154DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7511107PMC
September 2020

High Dose Intravenous Fish Oil Reduces Inflammation-A Retrospective Tale from Two Centers.

Nutrients 2020 Sep 19;12(9). Epub 2020 Sep 19.

General Surgery Unit, Stanley Dudrick's Memorial Hospital, 15 Tyniecka Street, 32-050 Skawina, Poland.

Aim: Patients on parenteral nutrition (PN) are prone to inflammation. This may aggravate an existing proinflammatory state and become a critical factor in the development of liver dysfunction (LD). Intravenous fish oil may attenuate this inflammatory state, but data on its use in adults are scarce. The aim of this study was to investigate the effects of adding a pure fish oil intravenous lipid emulsion (ILE) into short- and long-term PN in patients either at risk of, or with existing, inflammation.

Methods: A retrospective analysis of 61 patients (32 female, 29 male, mean age 51.5 ± 12.6 years) who received all-in-one PN, including amino acids, glucose, and lipids supplemented with pure fish oil ILE, was performed. Pure fish oil ILE (Omegaven®, Fresenius Kabi, Bad Homburg, Germany) was used along with the standard ILE to reach a fish oil dose of 0.4-0.5 g fish oil/kg/d. Diagnoses were chronic intestinal failure (CIF, = 20), Crohn's disease (CD, = 22), and ulcerative colitis (UC, = 19). The observation period was 12 months for CIF and 21 days for UC and CD.

Results: A reduction in inflammation was noticeable in all patients and became statistically significant in CD (hsCRP < 0.0001, ESR = 0.0034, procalcitonin = 0.0014, Il-6 = 0.001) and UC groups (hsCRP and ESR < 0.0001, Il-6 = 0.0001, TNF-α = 0.0113). In the CIF group, the total bilirubin concentration ( = 0.2157) and aspartate transaminase SGOT ( = 0.1785) did not vary over time.

Conclusions: PN with pure fish oil ILE reduces some inflammatory parameters in IBD and maintains liver function parameters in CIF patients. Fish oil might become a valuable ingredient in both short- and long-term PN in patients at risk of liver dysfunction.
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http://dx.doi.org/10.3390/nu12092865DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7551918PMC
September 2020

In pursuit of COVID-19 surgical risk stratification to manage a limited workforce and supplies in minimally invasive surgery.

Wideochir Inne Tech Maloinwazyjne 2020 Sep 10;15(3):416-423. Epub 2020 May 10.

Department of General Surgery and Clinical Nutrition, Medical Centre of Postgraduate Education, Warsaw, Poland.

The protective barriers used so far in surgery do not provide adequate protection against SARS-CoV-2 virus, and reinforced protective equipment is needed. The rapid increase in the number of patients and the worldwide panic associated with the increasingly low availability of protective equipment has resulted in a shortage of protective equipment in many hospitals. Appropriatepersonal protective equipment must be provided so that the surgical team proceeding to surgery is not excluded from the further struggle for patients' health, especially in MIS. Reckless and excessive use of maximum protective equipment may result in a severe shortage of these products when the number of infected persons requiring surgery increases. The use of a structured infection risk scheme for medical staff, depending on the results of reverse transcription polymerase chain reaction assays and COVID-19 symptoms, combined with the division of protection equipment into three groups, allows easy selection of an appropriate clothing scheme for the clinical setting.
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http://dx.doi.org/10.5114/wiitm.2020.95073DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7457190PMC
September 2020

Cost-Effectiveness of Parenteral Nutrition Containing ω-3 Fatty Acids in Hospitalized Adult Patients From 5 European Countries and the US.

JPEN J Parenter Enteral Nutr 2020 Jul 26. Epub 2020 Jul 26.

Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy.

Background: ω-3 Fatty acid (FA)-containing parenteral nutrition (PN) is associated with improvements in patient outcomes and with reductions in hospital length of stay (HLOS) vs standard PN regimens (containing non-ω-3 FA lipid emulsions). We present a cost-effectiveness analysis of ω-3 FA-containing PN vs standard PN in 5 European countries (France, Germany, Italy, Spain, UK) and the US.

Methods: This pharmacoeconomic model was based on estimates of ω-3 efficacy reported in a recent meta-analysis and data from country-specific sources. It utilized a probabilistic discrete event simulation model to compare ω-3 FA-containing PN with standard PN in a population of critically ill and general ward patients. The influence of model parameters was evaluated using probabilistic and deterministic sensitivity analyses.

Results: Overall costs were reduced with ω-3 FA-containing PN in all 6 countries compared with standard PN, ranging from €1741 (±€1284) in Italy to €5576 (±€4193) in the US. Expenses for infections and HLOS were lower in all countries for ω-3 FA-containing PN vs standard PN, with the largest cost differences for both in the US (infection: €825 ± €4001; HLOS: €4879 ± €1208) and the smallest savings in the UK for infections and in Spain for HLOS (€63 ± €426 and €1636 ± €372, respectively).

Conclusion: This cost-effectiveness analysis in 6 countries demonstrates that the superior clinical efficacy of ω-3 FA-containing PN translates into significant decreases in mean treatment cost, rendering it an attractive cost-saving alternative to standard PN across different healthcare systems.
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http://dx.doi.org/10.1002/jpen.1972DOI Listing
July 2020

Home medical nutrition during SARS-CoV-2 pandemic - A position paper.

Clin Nutr ESPEN 2020 08 11;38:196-200. Epub 2020 May 11.

Nutrimed Home Nutrition Center, Rzeszow, Poland.

Background: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of a worldwide rapidly spreading illness, Coronavirus Disease 2019 (COVID-19). Patients fed enterally and parenterally at home are exposed to the same risk of infection as the general population, but more prone to complications than others. Therefore the guidance for care-givers and care-takers of these patients is needed.

Methods: The literature search identified no relevant systematic reviews or studies on the subject. Therefore a panel of 21 experts from 13 home medical nutrition (HMN) centres in Poland was formed. Twenty-three key issues relevant to the management of SARS-CoV-2 infection or COVID-19 in the HMN settings were identified and discussed. Some statements diverge from the available nutrition, surgical or ICU guidelines, some are based on the best available experience. Each topic was discussed and assessed during two Delphi rounds subsequently. Statements were graded strong or weak based on the balance between benefit and harm, resource and cost implications, equity, and feasibility.

Results: the panel issued 23 statements, all of them were graded strong. Two scored 85.71% agreement, eleven 95.23%, and ten 100%. The topics were: infection control, enrolment to HMN, logistics and patient information.

Conclusions: the position paper present pragmatic statements for HMN to be implemented in places without existing protocols for SARS-CoV-2 pandemic. They represent the state of knowledge available at the moment and may change should new evidence occurs.
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http://dx.doi.org/10.1016/j.clnesp.2020.05.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7211693PMC
August 2020

Home Enteral Nutrition in Adults-Nationwide Multicenter Survey.

Nutrients 2020 Jul 14;12(7). Epub 2020 Jul 14.

Gromkowski Citi Hospital Wroclaw, Clinical Nutrition Unit, 51-149 Wroclaw, Poland.

Home enteral nutrition (HEN) is an important part of the health care system, with a growing population of patients around the world. The aim of our study was to analyze one of the largest cohorts of HEN patients to provide the most recent data available in European literature. A multicenter, nation-wide survey in the period of 1 January 2018-1 January 2019 was performed in Poland. Data concerning adult patients on HEN in 2018 during 1 year of observation time were analyzed: demographic characteristics, primary disease, technique of enteral feeding, diet formulation and amount of energy provided. A total of 4586 HEN patients (F: 46.7%, M: 53.3%) were included in the study. The primary diseases were: 54.5% neurological (17.4%-neurovascular, 13.7%-neurodegenerative), 33.9% cancer (20.2%-head and neck, 11.7%-gastrointestinal cancer), 2.5%-gastroenterology, 1.5%-inherited diseases. Of new registrations in 2018-cancer patients 46.3%, neurological patients 45.1%. The median age overall was: 64 yr., BMI-20.2 kg/m, NRS 2002 score-4.28. A total of 65% of patients were treated with PEG, 11.6% with surgical gastrostomy, 14.3% with naso-gastric tube and 7% with jejunostomy. Boluses were the most common method of feeding (74.4%). Gravity flow was used in 17.6% and peristaltic pump was used in 8% patients. The median energy provision was 1278 kcal/day and 24 kcal/kg/day. The most commonly used diets were: isocaloric (28.1%), protein-enriched isocaloric (20%) and protein-enriched hypercaloric (12%). The median overall duration of HEN was 354 days, 615 days for neurological and 209 days for cancer patients. A number of new registrations of cancer patients was significant and long duration of HEN in this group is encouraging. A developing spectrum of enteral formulas available enables more specified nutritional interventions.
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http://dx.doi.org/10.3390/nu12072087DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7400937PMC
July 2020

Perioperative nutrition: Recommendations from the ESPEN expert group.

Clin Nutr 2020 11 18;39(11):3211-3227. Epub 2020 Apr 18.

Klinik für Allgemein-, Viszeral- und Onkologische Chirurgie, Klinikum St. Georg gGmbH, Delitzscher Straße 141, 04129, Leipzig, Germany.

Background & Aims: Malnutrition has been recognized as a major risk factor for adverse postoperative outcomes. The ESPEN Symposium on perioperative nutrition was held in Nottingham, UK, on 14-15 October 2018 and the aims of this document were to highlight the scientific basis for the nutritional and metabolic management of surgical patients.

Methods: This paper represents the opinion of experts in this multidisciplinary field and those of a patient and caregiver, based on current evidence. It highlights the current state of the art.

Results: Surgical patients may present with varying degrees of malnutrition, sarcopenia, cachexia, obesity and myosteatosis. Preoperative optimization can help improve outcomes. Perioperative fluid therapy should aim at keeping the patient in as near zero fluid and electrolyte balance as possible. Similarly, glycemic control is especially important in those patients with poorly controlled diabetes, with a stepwise increase in the risk of infectious complications and mortality per increasing HbA1c. Immobilization can induce a decline in basal energy expenditure, reduced insulin sensitivity, anabolic resistance to protein nutrition and muscle strength, all of which impair clinical outcomes. There is a role for pharmaconutrition, pre-, pro- and syn-biotics, with the evidence being stronger in those undergoing surgery for gastrointestinal cancer.

Conclusions: Nutritional assessment of the surgical patient together with the appropriate interventions to restore the energy deficit, avoid weight loss, preserve the gut microbiome and improve functional performance are all necessary components of the nutritional, metabolic and functional conditioning of the surgical patient.
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http://dx.doi.org/10.1016/j.clnu.2020.03.038DOI Listing
November 2020

ESPEN guideline on home parenteral nutrition.

Clin Nutr 2020 06 18;39(6):1645-1666. Epub 2020 Apr 18.

University of Hohenheim, Institute of Nutritional Medicine, Stuttgart, Germany.

This guideline will inform physicians, nurses, dieticians, pharmacists, caregivers and other home parenteral nutrition (HPN) providers, as well as healthcare administrators and policy makers, about appropriate and safe HPN provision. This guideline will also inform patients requiring HPN. The guideline is based on previous published guidelines and provides an update of current evidence and expert opinion; it consists of 71 recommendations that address the indications for HPN, central venous access device (CVAD) and infusion pump, infusion line and CVAD site care, nutritional admixtures, program monitoring and management. Meta-analyses, systematic reviews and single clinical trials based on clinical questions were searched according to the PICO format. The evidence was evaluated and used to develop clinical recommendations implementing Scottish Intercollegiate Guidelines Network methodology. The guideline was commissioned and financially supported by ESPEN and members of the guideline group were selected by ESPEN.
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http://dx.doi.org/10.1016/j.clnu.2020.03.005DOI Listing
June 2020

Guidelines for the management of surgical departments in non-uniform hospitals during the COVID-19 pandemic.

Pol Przegl Chir 2020 Apr;92(2):48-59

Klinika Chirurgii Ogólnej i Żywienia Klinicznego, Centrum Medyczne Kształcenia Podyplomowego w Warszawie.

In the last several weeks we have been witnessing the exponentially progressing pandemic SARS-CoV-2 coronavirus. As the number of people infected with SARS-CoV2 escalates, the problem of surgical management of patients requiring urgent surgery is increasing. Patients infected with SARS-CoV2 virus but with negative test results will appear in general hospitals and may pose a risk to other patients and hospital staff. Health care workers constitutes nearly 17% of infected population in Poland, therefore early identification of infected people becomes a priority to protect human resources and to ensure continuity of the access to a surgical care. Both surgical operations, and endoscopic procedures are considered as interventions with an increased risk of infection. Therefore, determining the algorithm becomes crucial for qualifying patients for surgical treatment, but also to stratify the risk of personnel being infected during surgery and to adequately protect staff. Each hospital should be logistically prepared for the need to perform urgent surgery on a patient with suspected or confirmed infection, including personal protective equipment. Limited availability of the equipment, working under pressure and staff shortages in addition to a highly contagious pathogen necessitate a pragmatic management of human resources in health care. Instant synchronized action is needed, and clear uniform guidelines are essential for the healthcare system to provide citizens with the necessary surgical care while protecting both patients, and staff. This document presents current recommendations regarding surgery during the COVID-19 pandemic in Poland.
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http://dx.doi.org/10.5604/01.3001.0014.1039DOI Listing
April 2020

Stanley J. Dudrick: A man who dared to change what we used to know.

Clin Nutr 2020 05 10;39(5):1305-1308. Epub 2020 Mar 10.

Ipanema Trust, Auckland, New Zealand.

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http://dx.doi.org/10.1016/j.clnu.2020.03.004DOI Listing
May 2020

Re. 100-y anniversary of the Harris and Benedict equation.

Nutrition 2020 05 2;73:110716. Epub 2020 Jan 2.

Department of General, Gastroenterological and Oncological Surgery, Clinical Center of Medical University of Warsaw, Warsaw, Poland.

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http://dx.doi.org/10.1016/j.nut.2019.110716DOI Listing
May 2020

Use of Intravenous Lipid Emulsions With Parenteral Nutrition: Practical Handling Aspects.

JPEN J Parenter Enteral Nutr 2020 02;44 Suppl 1:S74-S81

and the Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA.

A number of topics important to the handling of intravenous lipid emulsions (ILEs) were discussed at the international summit. ILE handling includes the preparation and the administration steps in the typical use of parenteral nutrition (PN). The discussion and consensus statements addressed several issues, including standardization of the PN process, use of commercially available multi-chamber PN or compounded PN bags, the supervision by a pharmacist with expertise, limiting ILE repackaging, and infusion duration.
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http://dx.doi.org/10.1002/jpen.1737DOI Listing
February 2020

Use of Lipids in Adult Patients Requiring Parenteral Nutrition in the Home Setting.

JPEN J Parenter Enteral Nutr 2020 02;44 Suppl 1:S39-S44

Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA.

It is estimated that over 25,000 Americans receive home parenteral nutrition (HPN), mostly because of intestinal failure (IF). Although there is significant variability in the fluid and energy needs of patients receiving HPN, intravenous lipid emulsions (ILEs) are an essential part of the macronutrient composition, serving as an excellent source of non-protein energy, as well as supplying essential fatty acids. However, the long-term use of ILEs in particular may be associated with some detrimental health effects, such as intestinal failure associated liver disease (IFALD). Although there is lack of unifying diagnosis, IFALD can present as cholestasis, steatosis, or fibrosis, with a prevalence that ranges between 5% and 43%. The development of IFALD tends to be multifactorial. Risk factors of IFALD can include those related to IF, inflammation/infection, and long-term parenteral nutrition. Some studies have shown a link between development of IFALD and ILE dose, especially if the dose is >1 g/kg/d, with high ω-6:ω-3 polyunsaturated fatty acid (PUFA) ratio and phytosterol content being theorized as some contributing factors. Thus, efforts have been made to use alternative oils (olive oil, medium-chain triglycerides, and fish oil) to reduce the soybean-oil content of ILE, which tends to be high in ω-6 PUFA and phytosterols. Although additional long-term clinical data are emerging, this strategy, as reviewed in the current manuscript, has shown to provide some benefit in both prevention and treatment of IFALD and other sequelae of HPN.
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http://dx.doi.org/10.1002/jpen.1755DOI Listing
February 2020

Lipid Use in Hospitalized Adults Requiring Parenteral Nutrition.

JPEN J Parenter Enteral Nutr 2020 02;44 Suppl 1:S28-S38

Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA.

In hospitalized patients, lipid emulsions are an integral part of balanced parenteral nutrition. Traditionally, a single lipid source, soybean oil, has been given to patients and was usually regarded as just a source of energy and to prevent essential fatty-acid deficiency. However, mixtures of different lipid emulsions have now become widely available, including mixtures of soybean oil, medium-chain triglycerides, olive oil, and fish oil. Fish oil is high in the ω-3 polyunsaturated fatty acids docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA). There is a growing body of evidence that these ω-3 fatty acids can exert beneficial immunomodulatory, anti-inflammatory, and inflammation-resolution effects across a wide range of patient groups including surgical, cancer, and critically ill patients. At least in part, these effects are realized via potent specialized pro-resolution mediators (SPMs). Moreover, parenteral nutrition including ω-3 fatty acids can result in additional clinical benefits over the use of standard lipid emulsions, such as reductions in infection rates and length of hospital and intensive care unit stay. Clinical and experimental evidence is reviewed regarding lipid emulsion use in a variety of hospitalized patient groups, including surgical, critically ill, sepsis, trauma, and acute pancreatitis patients. Practical aspects of lipid emulsion use in critically ill patients are also considered, such as how to determine and fulfill energy expenditure, how and when to consider parenteral nutrition, duration of infusion, and safety monitoring.
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http://dx.doi.org/10.1002/jpen.1733DOI Listing
February 2020

Lipids in Parenteral Nutrition: Biological Aspects.

JPEN J Parenter Enteral Nutr 2020 02;44 Suppl 1:S21-S27

Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA.

Lipid emulsions are an integral part of parenteral nutrition, and traditionally have been regarded as an energy-dense source of calories and essential fatty acids. For many years, lipids used in parenteral nutrition have been based on vegetable oils (eg, soybean-oil emulsions). However, soybean-oil emulsions may not have an optimal fatty-acid composition under some circumstances when used as the only lipid source, as soybean oil is particularly abundant in the ω-6 polyunsaturated fatty acid (PUFA), linoleic acid. Hence, a progressive series of more complex lipid emulsions have been introduced, typically combining soybean oil with 1 or more alternative oils, such as medium-chain triglycerides (MCTs) and/or olive oil and/or fish oil. The wide range of lipid emulsions now available for parenteral nutrition offers opportunities to alter the supply of different fatty acids, which potentially modifies functional properties, with effects on inflammatory processes, immune response, and hepatic metabolism. Fish oil has become an important component of modern, composite lipid emulsions, in part owing to a growing evidence base concerning its biological effects in a variety of preclinical models. These biological activities of fish oil are mainly attributed to its ω-3 PUFA content, particularly docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA). DHA and EPA have known mechanisms of action, anti-inflammatory, immunomodulatory, and antioxidative properties. Specialized proresolving mediators, such as resolvins, protectins, and maresins, are synthesized directly from DHA and EPA, are key for the resolution of inflammation, and improve outcomes in many cell- and animal-based models and, recently, in some clinical settings.
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http://dx.doi.org/10.1002/jpen.1756DOI Listing
February 2020

Lipids in Parenteral Nutrition: Introduction.

JPEN J Parenter Enteral Nutr 2020 02;44 Suppl 1:S5-S6

Department of General and Oncology Surgery with Intestinal Failure Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland.

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http://dx.doi.org/10.1002/jpen.1739DOI Listing
February 2020

Summary of Proceedings and Expert Consensus Statements From the International Summit "Lipids in Parenteral Nutrition".

JPEN J Parenter Enteral Nutr 2020 02;44 Suppl 1:S7-S20

Department of General and Oncology Surgery, Intestinal Failure Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland.

Background: The 2018 Lipids in Parenteral Nutrition summit involved a panel of experts in clinical nutrition, lipid metabolism, and pharmacology, to assess the current state of knowledge and develop expert consensus statements regarding the use of intravenous lipid emulsions in various patient populations and clinical settings. The main purpose of the consensus statements is to assist healthcare professionals by providing practical guidance on common clinical questions related to the provision of lipid emulsions as part of parenteral nutrition (PN).

Methods: The summit was designed to allow interactive discussion and consensus development. The resulting consensus statements represent the collective opinion of the members of the expert panel, which was informed and supported by scientific evidence and clinical experience.

Results: The current article summarizes the key discussion topics from the summit and provides a set of consensus statements designed to complement existing evidence-based guidelines. Lipid emulsions are a major component of PN, serving as a condensed source of energy and essential fatty acids. In addition, lipids modulate a variety of biologic functions, including inflammatory and immune responses, coagulation, and cell signaling. A growing body of evidence suggests that lipid emulsions containing ω-3 fatty acids from fish oil confer important clinical benefits via suppression of inflammatory mediators and activation of pathways involved in the resolution of inflammation.

Conclusions: This article provides a set of expert consensus statements to complement formal PN guideline recommendations.
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http://dx.doi.org/10.1002/jpen.1746DOI Listing
February 2020

Pharmacoeconomics of Parenteral Nutrition with ω-3 Fatty Acids in Hospitalized Adults.

JPEN J Parenter Enteral Nutr 2020 02;44 Suppl 1:S68-S73

Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA.

The inclusion of ω-3 fatty acids as part of parenteral nutrition is associated with clinical benefits such as a reduced likelihood of infectious complications and shorter hospital and intensive care unit (ICU) stays. As healthcare resources are limited, pharmacoeconomic analyses have been performed, typically modeling studies, using cost and outcomes data to investigate the cost-effectiveness of parenteral nutrition regimens including ω-3 fatty acids from fish oil compared with standard parenteral nutrition without such ω-3 fatty acids. This review covers pharmacoeconomic studies encompassing Italian, French, German, and UK hospitals for ICU and non-ICU hospitalized patients, and for ICU patients in China. The results show that the use of parenteral nutrition including ω-3 fatty acids more than offsets any additional acquisition costs in all national scenarios investigated to date, indicating that parenteral nutrition including ω-3 fatty acids is a clinically and economically beneficial strategy compared with standard parenteral nutrition.
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http://dx.doi.org/10.1002/jpen.1775DOI Listing
February 2020

Protein Requirements in Critical Illness: Do We Really Know Why to Give So Much?

JPEN J Parenter Enteral Nutr 2020 05 11;44(4):589-598. Epub 2020 Feb 11.

General Surgery Unit, Stanley Dudrick's Memorial Hospital, Skawina, Poland.

The protein and energy requirements of critically ill patients treated in intensive care units (ICUs) have been actively discussed recently. Currently published clinical recommendations and reviews suggest significant increases of protein provision to 2-2.5 g/kg/d in some populations of ICU patients. However, a detailed analysis of the main sources of these recommendations reveals a number of serious contradictions, as well as an absence of obvious evidence supporting the allotment of high doses of protein. We went through these recommendations and reviewed cited articles and other studies, and we have separated our arguments against excessive protein provision into sections.
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http://dx.doi.org/10.1002/jpen.1792DOI Listing
May 2020

ESPEN practical guideline: Clinical Nutrition in inflammatory bowel disease.

Clin Nutr 2020 03 13;39(3):632-653. Epub 2020 Jan 13.

Norwich Medical School, University of East Anglia, Norwich, United Kingdom.

The present guideline is the first of a new series of "practical guidelines" based on more detailed scientific guidelines produced by ESPEN during the last few years. The guidelines have been shortened and now include flow charts that connect the individual recommendations to logical care pathways and allow rapid navigation through the guideline. The purpose of the present practical guideline is to provide an easy-to-use tool to guide nutritional support and primary nutritional therapy in inflammatory bowel disease (IBD). The guideline is aimed at professionals working in clinical practice, either in hospitals or in outpatient medicine, and treating patients with IBD. In 40 recommendations, general aspects of care in patients with IBD, and specific aspects during active disease and in remission are addressed. All recommendations are equipped with evidence grades, consensus rates, short commentaries and links to cited literature.
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http://dx.doi.org/10.1016/j.clnu.2019.11.002DOI Listing
March 2020
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