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Koo V, Brace H, Shahzad A, Lynn N. The challenges of implementing Enhanced Recovery Programme in urology. INTERNATIONAL JOURNAL OF UROLOGICAL NURSING 2013. [DOI: 10.1111/ijun.12006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Pradignac A, Kazma C, Ilic J. À qui et comment prescrire des compléments nutritionnels oraux à l’hôpital et à domicile ? NUTR CLIN METAB 2013. [DOI: 10.1016/j.nupar.2012.11.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Bouteloup C, Besnard I. Nutrition chez le patient adulte atteint de cancer : quand et comment prescrire des compléments nutritionnels oraux (CNO) hors pharmaconutrition ? NUTR CLIN METAB 2012. [DOI: 10.1016/j.nupar.2012.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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104
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Burden S, Todd C, Hill J, Lal S. Pre-operative nutrition support in patients undergoing gastrointestinal surgery. Cochrane Database Syst Rev 2012; 11:CD008879. [PMID: 23152265 DOI: 10.1002/14651858.cd008879.pub2] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Post-operative management in gastrointestinal (GI) surgery is becoming well established with 'Enhanced Recovery After Surgery' protocols starting 24 hours prior to surgery with carbohydrate loading and early oral or enteral feeding given to patients the first day following surgery. However, whether or not nutritional intervention should be initiated earlier in the preoperative period remains unclear. Poor pre-operative nutritional status has been linked consistently to an increase in post-operative complications and poorer surgical outcome. OBJECTIVES To review the literature on preoperative nutritional support in patients undergoing gastrointestinal surgery (GI). SEARCH METHODS The searches were initially run in March 2011 and subsequently updated in February 2012. Databases including all EBM Reviews (Cochrane DSR, ACP Journal Club, DARE, CCTR, CMR, HTA and NHSEED) MEDLINE, EMBASE, AMED, British Nursing Index Archive using OvidSP were included and a search was run on each database separately after which duplicates were excluded. SELECTION CRITERIA The inclusion criteria were randomised controlled trials that evaluated pre-operative nutritional support in GI surgical participants using a nutritional formula delivered by a parenteral, enteral or oral route. The primary outcomes included post-operative complications and length of hospital stay. DATA COLLECTION AND ANALYSIS Two observers screened the abstracts for inclusion in the review and performed data extraction. Bias was assessed for each of the included studies using the bias assessment tables in the Cochrane Software Review Manager (version 5.1, Cochrane Collaboration). The trials were analysed using risk ratios with Mantel-Haenszel in fixed effects methods displayed with heterogeneity. Meta-analyses were undertaken on trials evaluating immune enhancing (IE) nutrition, standard oral supplements, enteral and parenteral nutrition (PN) which were administered pre-operatively.Study characteristics were summarised in tables. Dichotomous and ratio data were entered into meta-analyses for the primary outcomes. These were then summarised in tables with assumed and corresponding risk with relative effect giving 95% confidence intervals. MAIN RESULTS The searches identified 9900 titles and, after excluding duplicates, 6433 titles were initially screened. After the initial title screen, 6266 were excluded. Abstracts were screened for 167 studies and 33 articles were identified as meeting the inclusion criteria, of which 13 were included in the review after an assessment of the complete manuscripts.Seven trials evaluating IE nutrition were included in the review, of which 6 were combined in a meta-analysis. These studies showed a low to moderate level of heterogeneity and significantly reduced total post-operative complications (risk ratio (RR) 0.67 CI 0.53 to 0.84). Three trials evaluating PN were included in a meta-analysis and a significant reduction in post-operative complications was demonstrated (RR 0.64 95% CI 0.46 to 0.87) with low heterogeneity, in predominantly malnourished participants. Two trials evaluating enteral nutrition (RR 0.79, 95% CI 0.56 to 1.10) and 3 trials evaluating standard oral supplements (RR 1.01 95% CI 0.56 to 1.10) were included, neither of which showed any difference in the primary outcomes. AUTHORS' CONCLUSIONS There have been significant benefits demonstrated with pre-operative administration of IE nutrition in some high quality trials. However, bias was identified which may limit the generalizability of these results to all GI surgical candidates and the data needs to be placed in context with other recent innovations in surgical management (eg-ERAS). Some unwanted effects have also been reported with components of IE nutrition in critical care patients and it is unknown whether there would be detrimental effects by administering IE nutrition to patients who could require critical care support after their surgery. The studies evaluating PN demonstrated that the provision of PN to predominantly malnourished surgical candidates reduced post-operative complications; however, these data may not be applicable to current clinical practice, not least because they have involved a high degree of 'hyperalimentation'. Trials evaluating enteral or oral nutrition were inconclusive and further studies are required to select GI surgical patients for these nutritional interventions.
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Affiliation(s)
- Sorrel Burden
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK.
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Boitano LT, Wang EC, Kibbe MR. Differential effect of nutritional status on vascular surgery outcomes in a Veterans Affairs versus private hospital setting. Am J Surg 2012; 204:e27-37. [DOI: 10.1016/j.amjsurg.2012.07.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Revised: 05/23/2012] [Accepted: 07/11/2012] [Indexed: 11/28/2022]
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Abstract
Esophageal cancer has traditionally been a disease with poor long term outcomes in terms of both survival and quality of life. In combination with surgical and pharmacologic therapy, nutrition support has been demonstrated to improve patient tolerance of treatment, quality of life, and longterm outcomes. An aggressive multi-disciplinary approach is warranted with nutrition support remaining a cornerstone in management. Historically, nutrition support has focused on adequate caloric provision to prevent weight loss and allow for tolerance of treatment regimens. Alterations in metabolism occur in these patients making their use of available calories inefficient and the future of nutritional support may lie in the ability to alter this deranged metabolism. The purpose of this article is to review the current literature surrounding the etiology, treatment, and role of nutrition support in improving outcomes in esophageal cancer.
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Janardhan V, Soundararajan P, Rani NV, Kannan G, Thennarasu P, Chacko RA, Reddy CUM. Prediction of Malnutrition Using Modified Subjective Global Assessment-dialysis Malnutrition Score in Patients on Hemodialysis. Indian J Pharm Sci 2012; 73:38-45. [PMID: 22131620 PMCID: PMC3224408 DOI: 10.4103/0250-474x.89755] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2010] [Revised: 02/14/2011] [Accepted: 02/15/2011] [Indexed: 01/30/2023] Open
Abstract
Malnutrition is widely prevalent among patients on hemodialysis. Malnutrition can be estimated using a fully quantitative scoring system Subjective Global Assessment-Dialysis Malnutrition Score which is simple, reliable and dynamic. The primary objective of the study was to assess the severity of malnutrition in patients with end stage renal disease and undergoing hemodialysis in a tertiary care teaching hospital in Chennai, using Subjective Global Asses sment-Dialysis Malnutrition Score and correlate it with standard indicators of malnutrition like anthropometric and biochemical parameters of the study population by Pearson's correlation. Anthropometric assessment included height, body weight, triceps skin fold thickness, mid arm circumference, mid arm muscle circumference % and biochemical parameters included serum albumin, transferrin, ferritin, total protein, total cholesterol, blood urea nitrogen and creatinine. Based on the scores, of the 66 patients, 91% were moderately malnourished. There was a significant negative correlation between modified Subjective Global Assessment-Dialysis Malnutrition Score and anthropometric measures such as triceps skin fold thickness, mid arm circumference, mid arm muscle circumference; biochemical markers such as albumin, transferrin and ferritin. The data obtained from this study confirm that a high degree of malnutrition was prevalent in patients on hemodialysis, as shown by anthropometric assessment, biochemical markers of malnutrition and Subjective Global Assessment-Dialysis Malnutrition Score. Nutritional status as determined by Subjective Global Assessment-Dialysis Malnutrition Score is a useful and reliable index for identifying patients at risk for malnutrition and it correlates well with anthropometric and biochemical assessment. may be integrated in regular assessment of malnutrition in patients on maintenance hemodialysis.
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Affiliation(s)
- Vasantha Janardhan
- Department of Pharmacy Practice, Faculty of Pharmacy, Department of Nephrology, Sri Ramachandra University, Porur, Chennai - 600 116, India
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108
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Haverkort EB, Binnekade JM, de Haan RJ, van Bokhorst - de van der Schueren MA. Handgrip strength by dynamometry does not identify malnutrition in individual preoperative outpatients. Clin Nutr 2012; 31:647-51. [DOI: 10.1016/j.clnu.2012.01.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Revised: 12/16/2011] [Accepted: 01/27/2012] [Indexed: 11/28/2022]
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Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, McNaught CE, MacFie J, Liberman AS, Soop M, Hill A, Kennedy RH, Lobo DN, Fearon K, Ljungqvist O. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr 2012; 31:783-800. [PMID: 23099039 DOI: 10.1016/j.clnu.2012.08.013] [Citation(s) in RCA: 445] [Impact Index Per Article: 37.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Accepted: 08/19/2012] [Indexed: 12/16/2022]
Abstract
BACKGROUND This review aims to present a consensus for optimal perioperative care in colonic surgery and to provide graded recommendations for items for an evidenced-based enhanced perioperative protocol. METHODS Studies were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts. For each item of the perioperative treatment pathway, available English-language literature was examined, reviewed and graded. A consensus recommendation was reached after critical appraisal of the literature by the group. RESULTS For most of the protocol items, recommendations are based on good-quality trials or meta-analyses of good-quality trials (quality of evidence and recommendations according to the GRADE system). CONCLUSIONS Based on the evidence available for each item of the multimodal perioperative-care pathway, the Enhanced Recovery After Surgery (ERAS) Society, International Association for Surgical Metabolism and Nutrition (IASMEN) and European Society for Clinical Nutrition and Metabolism (ESPEN) present a comprehensive evidence-based consensus review of perioperative care for colonic surgery.
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Affiliation(s)
- U O Gustafsson
- Department of Surgery, Ersta Hospital, Stockholm, Sweden.
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Nygren J, Thacker J, Carli F, Fearon KCH, Norderval S, Lobo DN, Ljungqvist O, Soop M, Ramirez J. Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr 2012; 31:801-16. [PMID: 23062720 DOI: 10.1016/j.clnu.2012.08.012] [Citation(s) in RCA: 254] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 08/19/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND This review aims to present a consensus for optimal perioperative care in rectal/pelvic surgery, and to provide graded recommendations for items for an evidenced-based enhanced recovery protocol. METHODS Studies were selected with particular attention paid to meta-analyses, randomized controlled trials and large prospective cohorts. For each item of the perioperative treatment pathway, available English-language literature was examined, reviewed and graded. A consensus recommendation was reached after critical appraisal of the literature by the group. RESULTS For most of the protocol items, recommendations are based on good-quality trials or meta-analyses of good-quality trials (evidence grade: high or moderate). CONCLUSIONS Based on the evidence available for each item of the multimodal perioperative care pathway, the Enhanced Recovery After Surgery (ERAS) Society, European Society for Clinical Nutrition and Metabolism (ESPEN) and International Association for Surgical Metabolism and Nutrition (IASMEN) present a comprehensive evidence-based consensus review of perioperative care for rectal surgery.
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Affiliation(s)
- J Nygren
- Department of Surgery, Ersta Hospital, Karolinska Institutet, Stockholm, Sweden.
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111
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Haverkort EB, de Haan RJ, Binnekade JM, van Bokhorst–de van der Schueren MA. Self-reporting of height and weight: valid and reliable identification of malnutrition in preoperative patients. Am J Surg 2012; 203:700-7. [DOI: 10.1016/j.amjsurg.2011.06.053] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2011] [Revised: 06/17/2011] [Accepted: 06/17/2011] [Indexed: 11/17/2022]
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Cawood AL, Elia M, Stratton RJ. Systematic review and meta-analysis of the effects of high protein oral nutritional supplements. Ageing Res Rev 2012; 11:278-96. [PMID: 22212388 DOI: 10.1016/j.arr.2011.12.008] [Citation(s) in RCA: 252] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Revised: 12/04/2011] [Accepted: 12/14/2011] [Indexed: 12/16/2022]
Abstract
Disease-related malnutrition is common, detrimentally affecting the patient and healthcare economy. Although use of high protein oral nutritional supplements (ONS) has been recommended to counteract the catabolic effects of disease and to facilitate recovery from illness, there is a lack of systematically obtained evidence to support these recommendations. This systematic review involving 36 randomised controlled trials (RCT) (n=3790) (mean age 74 years; 83% of trials in patients >65 years) and a series of meta-analyses of high protein ONS (>20% energy from protein) demonstrated a range of effects across settings and patient groups in favour of the high protein ONS group. These included reduced complications (odds ratio (OR) 0.68 (95%CI 0.55-0.83), p<0.001, 10 RCT, n=1830); reduced readmissions to hospital (OR 0.59 (95%CI 0.41-0.84), p=0.004, 2 RCT, n=546); improved grip strength (1.76 kg (95%CI 0.36-3.17), p<0.014, 4 RCT, n=219); increased intake of protein (p<0.001) and energy (p<0.001) with little reduction in normal food intake and improvements in weight (p<0.001). There was inadequate information to compare standard ONS (<20% energy from protein) with high protein ONS (>20% energy from protein). The systematic review and meta-analysis provides evidence that high protein supplements produce clinical benefits, with economic implications.
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Affiliation(s)
- A L Cawood
- Institute of Human Nutrition, University of Southampton, UK.
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114
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Health economic evaluation in complementary medicine. Complement Ther Med 2011; 19:289-302. [DOI: 10.1016/j.ctim.2011.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2010] [Revised: 08/12/2011] [Accepted: 09/12/2011] [Indexed: 12/18/2022] Open
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115
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Tsukamoto Y, Okabayashi T, Hanazaki K. Progressive artificial endocrine pancreas: The era of novel perioperative blood glucose control for surgery. Surg Today 2011; 41:1344-51. [PMID: 21922355 DOI: 10.1007/s00595-011-4537-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Accepted: 02/25/2011] [Indexed: 12/17/2022]
Abstract
Strict glycemic control needs to be maintained in critically ill surgical patients to reduce the mortality and morbidity due to hyperglycemia and associated infection. However, conventional intensive insulin therapy (IIT), which consists of intermittent blood glucose measurement and manually controlled infusions of insulin, tends to induce hypoglycemia and glucose variability. Many randomized clinical trials have been conducted to improve the efficacy of IIT, although some of these were stopped owing to frequent hypoglycemia. In pursuing safe and strict glycemic control for critically ill surgical patients, we found that a closed-loop glycemic control system was able to maintain appropriate blood glucose levels without hypoglycemia in more than 400 clinical cases. Considering the need for the perioperative and intensive care environment, a well-established artificial pancreas was modified into a new closed-loop glycemic control system, called the progressive artificial pancreas. The new device is slim in shape and shows clinical compatibility with the conventional artificial pancreas. We herein review this new closed-loop glycemic control system and the expectations for its future application in critically ill surgical patients.
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Affiliation(s)
- Yuuki Tsukamoto
- Department of Surgery, Kochi Medical School, Kochi University, Kohasu-Okocho, Nankoku, Kochi, 783-8505, Japan
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116
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Elia M. Oral nutritional support in patients with cancer of the gastrointestinal tract. J Hum Nutr Diet 2011; 24:417-20. [DOI: 10.1111/j.1365-277x.2011.01204.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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117
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Burden ST, Hill J, Shaffer JL, Campbell M, Todd C. An unblinded randomised controlled trial of preoperative oral supplements in colorectal cancer patients. J Hum Nutr Diet 2011; 24:441-8. [DOI: 10.1111/j.1365-277x.2011.01188.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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118
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Abstract
This article presents an overview of the current knowledge, status, and use of supplements by patients before surgical operations, together with the benefits expected of the supplements by the patients. The indications, potential advantages and disadvantages, and the relationships with various aspects of the preoperative preparation and postoperative management of surgical patients are discussed, with emphasis on the significant percentage of this population that is deficient in fundamental nutrients. Recent revisions and recommendations for some of the macronutrients are presented, together with a summary of federal regulations and an oversight of supplements.
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119
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Perioperative nutrition in abdominal surgery: recommendations and reality. Gastroenterol Res Pract 2011; 2011:739347. [PMID: 21687620 PMCID: PMC3113259 DOI: 10.1155/2011/739347] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2010] [Accepted: 03/20/2011] [Indexed: 12/14/2022] Open
Abstract
Introduction. Preoperative malnutrition is a major risk factor for increased postoperative morbidity and mortality. Definition and diagnosis of malnutrition and its treatment is still subject for controversy. Furthermore, practical implementation of nutrition-related guidelines is unknown.
Methods. A review of the available literature and of current guidelines on perioperative nutrition was conducted. We focused on nutritional screening and perioperative nutrition in patients undergoing digestive surgery, and we assessed translation of recent guidelines in clinical practice.
Results and Conclusions. Malnutrition is a well-recognized risk factor for poor postoperative outcome. The prevalence of malnutrition depends largely on its definition; about 40% of patients undergoing major surgery fulfil current diagnostic criteria of being at nutritional risk. The Nutritional Risk Score is a pragmatic and validated tool to identify patients who should benefit from nutritional support. Adequate nutritional intervention entails reduced (infectious) complications, hospital stay, and costs. Preoperative oral supplementation of a minimum of five days is preferable; depending on the patient and the type of surgery, immune-enhancing formulas are recommended. However, surgeons' compliance with evidence-based guidelines remains poor and efforts are necessary to implement routine nutritional screening and nutritional support.
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120
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Andrews EJ, McCourt M, O’Ríordáin MG. Enhanced recovery after elective colorectal surgery: now the standard of care. Ir J Med Sci 2011; 180:633-5. [DOI: 10.1007/s11845-011-0709-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2007] [Accepted: 03/24/2011] [Indexed: 12/15/2022]
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121
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Cost-effectiveness of a 3-month intervention with oral nutritional supplements in disease-related malnutrition: a randomised controlled pilot study. Eur J Clin Nutr 2011; 65:735-42. [DOI: 10.1038/ejcn.2011.31] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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122
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Gnagnarella P. Nutrition and cancer: from prevention to nutritional support, 8th October 2010, Milan. Ecancermedicalscience 2010; 4:205. [PMID: 22276046 PMCID: PMC3234016 DOI: 10.3332/ecancer.2010.205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Indexed: 12/19/2022] Open
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123
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Burden S, Todd C, Hill J, Lal S. Preoperative Nutrition in Patients Undergoing Gastrointestinal Surgery. Cochrane Database Syst Rev 2010. [DOI: 10.1002/14651858.cd008879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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124
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125
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Hendry PO, van Dam RM, Bukkems SFFW, McKeown DW, Parks RW, Preston T, Dejong CHC, Garden OJ, Fearon KCH. Randomized clinical trial of laxatives and oral nutritional supplements within an enhanced recovery after surgery protocol following liver resection. Br J Surg 2010; 97:1198-206. [PMID: 20602497 DOI: 10.1002/bjs.7120] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Routine laxatives may expedite gastrointestinal recovery and early tolerance of food within an enhanced recovery after surgery (ERAS) programme. Combined with carbohydrate loading and oral nutritional supplements (ONS), it may further enhance recovery of gastrointestinal function and promote earlier overall recovery. METHODS Seventy-four patients undergoing liver resection were randomized in a two-by-two factorial design to receive either postoperative magnesium hydroxide as a laxative, preoperative carbohydrate loading and postoperative ONS, their combination or a control group. Patients were managed within an ERAS programme of care. The primary outcome measure was time to first passage of stool. Secondary outcome measures were gastric emptying, postoperative oral calorie intake, time to functional recovery and length of hospital stay. RESULTS Sixty-eight patients completed the trial. The laxative group had a significantly reduced time to passage of stool: median (interquartile range) 4 (3-5) versus 5 (4-6) days (P = 0.034). The ONS group showed a trend towards a shorter time to passage of stool (P = 0.076) but there was no evidence of interaction in patients randomized to the combination regimen. Median length of hospital stay was 6 (4-7) days. There were no differences in secondary outcomes between groups. CONCLUSION Within an ERAS protocol for patients undergoing liver resection, routine postoperative laxatives result in an earlier first passage of stool but the overall rate of recovery is unaltered.
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Affiliation(s)
- P O Hendry
- Clinical and Surgical Sciences (Surgery), Royal Infirmary, Edinburgh, UK.
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126
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Pelletier KR, Herman PM, Metz RD, Nelson CF. Health and Medical Economics Applied to Integrative Medicine. Explore (NY) 2010; 6:86-99. [DOI: 10.1016/j.explore.2009.12.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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127
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Colorectal surgery patients prefer simple solid foods to clear fluids as the first postoperative meal. Dis Colon Rectum 2009; 52:1616-23. [PMID: 19690491 DOI: 10.1007/dcr.0b013e3181a90a2a] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Randomized controlled trials have established that there is no benefit to withholding oral food and fluids from colorectal surgery patients postoperatively. The aim of this survey was to determine food preferences for the first postoperative meal and compare these with a traditional clear-fluid diet. METHODS One hundred forty-five elective colorectal surgery patients were surveyed about their preferences for 35 common foods within 72 hours of surgery and their levels of nausea, hunger, and pain. Preferences were examined by postoperative day (one vs. two) and levels of nausea, hunger, and pain. RESULTS The survey showed that patients significantly preferred solid foods as early as the first postoperative day and their preferences had little congruency with the traditional clear-fluid diet. Foods highest in preference, such as eggs, regular broth soup (e.g., chicken noodle soup), toast, and potatoes, were significantly more preferred than common clear-fluid diet items such as gelatin, clear broth, and carbonated beverages (P < 0.01). Oral supplements were preferred by only 44%. Patients reported low levels of nausea, hunger, and pain. CONCLUSION Postoperative colorectal surgery patients prefer to receive simple solid foods rather than a clear-fluid diet as their first postoperative meal.
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128
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Lidder PG, Lewis S, Duxbury M, Thomas S. Systematic Review of Postdischarge Oral Nutritional Supplementation in Patients Undergoing GI Surgery. Nutr Clin Pract 2009; 24:388-94. [DOI: 10.1177/0884533609332175] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Paul G Lidder
- From Colorectal Surgery, Torbay Hospital, Torquay, UK; Derriford Hospital, Plymouth, UK; University of Edinburgh, UK; and Department of Oral & Dental Science, University of Bristol, UK
| | - Stephen Lewis
- From Colorectal Surgery, Torbay Hospital, Torquay, UK; Derriford Hospital, Plymouth, UK; University of Edinburgh, UK; and Department of Oral & Dental Science, University of Bristol, UK
| | - Mark Duxbury
- From Colorectal Surgery, Torbay Hospital, Torquay, UK; Derriford Hospital, Plymouth, UK; University of Edinburgh, UK; and Department of Oral & Dental Science, University of Bristol, UK
| | - Steven Thomas
- From Colorectal Surgery, Torbay Hospital, Torquay, UK; Derriford Hospital, Plymouth, UK; University of Edinburgh, UK; and Department of Oral & Dental Science, University of Bristol, UK
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129
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Affiliation(s)
- Ronald L. Koretz
- From the Department of Medicine, UCLA School of Medicine, Sylmar, California
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130
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Nygren J, Soop M, Thorell A, Hausel J, Ljungqvist O. An enhanced-recovery protocol improves outcome after colorectal resection already during the first year: a single-center experience in 168 consecutive patients. Dis Colon Rectum 2009; 52:978-85. [PMID: 19502866 DOI: 10.1007/dcr.0b013e31819f1416] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE This study was designed to investigate the clinical outcome and recovery before and immediately after implementation of the enhanced recovery after surgery enhanced recovery after surgery protocol in colonic and rectal resection. METHODS One hundred and sixty-eight consecutive patients in a single center underwent colorectal surgery before (traditional, n = 69) and immediately after implementing enhanced recovery after surgery (n = 99). Rectal surgery was performed in 77 patients. Postoperative food and fluid intake, mobilization, physiologic function, and clinical outcome were measured prospectively. RESULTS Resumption of oral diet was achieved on postoperative day postoperative day 1 in the enhanced recovery after surgery group. In the enhanced recovery after surgery group, mobilization more than 6 hours daily was achieved on postoperative day 2 to 3 and passage of stool occurred on postoperative day 2 vs. postoperative day 5 in the traditional group (P < 0.0001). Muscle strength and lung function were less reduced in the enhanced recovery after surgery group (P < 0.05). Median hospital stay was reduced by 2 days (P < 0.01). Readmission rates increased (4 percent vs. 15 percent, P < 0.01) but total hospital stay was still lower in the enhanced recovery after surgery group (P < 0.01). After colonic resection, postoperative complications decreased in enhanced recovery after surgery (37 percent vs. 18 percent, P < 0.05), whereas no change was found after rectal resection. CONCLUSION Immediately after implementing enhanced recovery after surgery, recovery was improved and length of hospital stay was reduced. Notably, postoperative morbidity decreased only in patients undergoing colonic resection.
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Affiliation(s)
- Jonas Nygren
- Center of Gastrointestinal Disease, Ersta Hospital and Karolinska Institutet, Institution of Clinical Sciences at Danderyds Hospital, Stockholm, Sweden.
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131
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Bower MR, Martin RC. Nutritional management during neoadjuvant therapy for esophageal cancer. J Surg Oncol 2009; 100:82-7. [DOI: 10.1002/jso.21289] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Milne AC, Potter J, Vivanti A, Avenell A. Protein and energy supplementation in elderly people at risk from malnutrition. Cochrane Database Syst Rev 2009; 2009:CD003288. [PMID: 19370584 PMCID: PMC7144819 DOI: 10.1002/14651858.cd003288.pub3] [Citation(s) in RCA: 264] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Evidence for the effectiveness of nutritional supplements containing protein and energy, often prescribed for older people, is limited. Malnutrition is more common in this age group and deterioration of nutritional status can occur during illness. It is important to establish whether supplementing the diet is an effective way of improving outcomes for older people at risk from malnutrition. OBJECTIVES This review examined trials for improvement in nutritional status and clinical outcomes when extra protein and energy were provided, usually as commercial 'sip-feeds'. SEARCH STRATEGY We searched The Cochrane Library, MEDLINE, EMBASE, Healthstar, CINAHL, BIOSIS, CAB abstracts. We also hand searched nutrition journals and reference lists and contacted 'sip-feed' manufacturers. SELECTION CRITERIA Randomised and quasi-randomised controlled trials of oral protein and energy supplementation in older people, with the exception of groups recovering from cancer treatment or in critical care. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed trials prior to inclusion and independently extracted data and assessed trial quality. Authors of trials were contacted for further information as necessary. MAIN RESULTS Sixty-two trials with 10,187 randomised participants have been included in the review. Maximum duration of intervention was 18 months. Most included trials had poor study quality. The pooled weighted mean difference (WMD) for percentage weight change showed a benefit of supplementation of 2.2% (95% confidence interval (CI) 1.8 to 2.5) from 42 trials. There was no significant reduction in mortality in the supplemented compared with control groups (relative risk (RR) 0.92, CI 0.81 to 1.04) from 42 trials. Mortality results were statistically significant when limited to trials in which participants (N = 2461) were defined as undernourished (RR 0.79, 95% CI 0.64 to 0.97).The risk of complications was reduced in 24 trials (RR 0.86, 95% CI 0.75 to 0.99). Few trials were able to suggest any functional benefit from supplementation. The WMD for length of stay from 12 trials also showed no statistically significant effect (-0.8 days, 95% CI -2.8 to 1.3). Adverse effects included nausea or diarrhoea. AUTHORS' CONCLUSIONS Supplementation produces a small but consistent weight gain in older people. Mortality may be reduced in older people who are undernourished. There may also be a beneficial effect on complications which needs to be confirmed. However, this updated review found no evidence of improvement in functional benefit or reduction in length of hospital stay with supplements. Additional data from large-scale multi-centre trials are still required.
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Affiliation(s)
- Anne C Milne
- Stonelea, Prospect Terrace, Port Elphinstone, InverurieAberdeenAberdeenshire, ScotlandUKAB51 3UN
| | - Jan Potter
- South East Sydney and Illawarra Area Health ServiceAged Care Southern Hospital NetworkLMB 8808South Coast Mail Centre WollongongNew South WalesAustralia2521
| | - Angela Vivanti
- Princess Alexandra HospitalDepartment of Nutrition and DieteticsIpswich RoadWoolloongabbaQueenslandAustralia4103
| | - Alison Avenell
- University of AberdeenHealth Services Research UnitForesterhillAberdeenUKAB25 2ZD
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Lewis SJ, Andersen HK, Thomas S. Early enteral nutrition within 24 h of intestinal surgery versus later commencement of feeding: a systematic review and meta-analysis. J Gastrointest Surg 2009; 13:569-75. [PMID: 18629592 DOI: 10.1007/s11605-008-0592-x] [Citation(s) in RCA: 318] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2008] [Accepted: 06/25/2008] [Indexed: 01/31/2023]
Abstract
BACKGROUND We set out to evaluate early commencement of post-operative enteral nutrition versus traditional management in patients undergoing gastrointestinal surgery. METHODS Electronic databases were searched, references lists were scanned and authors contacted for additional information. We looked for randomised controlled trials comparing early commencement of feeding (within 24 h) with no feeding in patients undergoing gastrointestinal surgery. Primary endpoints were wound infections, intra-abdominal abscesses, pneumonia, anastomotic leakage, mortality, length of hospital stay and complications of feeding. Data were combined to estimate the common relative risk of post-operative complications and associated 95% confidence intervals. RESULTS Thirteen trials, with a total of 1,173 patients, fulfilled our inclusion criteria. Mortality was reduced with early post-operative feeding. Early post-operative feeding increased vomiting. The direction of effect is suggestive of a reduction of risk of post-surgical complications and reduced length of hospital stay. CONCLUSION There is no obvious advantage in keeping patients 'nil by mouth' following gastrointestinal surgery. Early enteral nutrition is associated with reduced mortality, though the mechanism is not clear. This review supports the notion that early commencement of enteral feeding may be of benefit.
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Affiliation(s)
- Stephen J Lewis
- Department of Gastroenterology, Derriford Hospital, Plymouth, Devon PL6 8DH, UK.
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Yukawa M, Weigle DS, Davis CD, Marck BT, Wolden-Hanson T. Peripheral ghrelin treatment stabilizes body weights of senescent male Brown Norway rats at baseline and after surgery. Am J Physiol Regul Integr Comp Physiol 2008; 294:R1453-60. [DOI: 10.1152/ajpregu.00035.2008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Unintentional weight loss may occur spontaneously in older humans and animals. Further weight losses after surgery or illness in the older patients result in increased morbidity, mortality, and hospital readmission rate. A growing body of work has shown increased appetite and weight gain in response to administration of ghrelin, the “hunger hormone.” We conducted two studies in senescent male Brown Norway rats to assess the ability of peripheral administration of ghrelin to increase body weight and food intake. One study assessed the effect of 2 wk of daily subcutaneous ghrelin administration (1 mg·kg−1·day−1) to senescent rats in a baseline condition; a second study used the same administration protocol in an interventional experiment with aged rats subjected to a surgery with 10–15% blood loss as a model of elective surgery. In both studies, animals receiving ghrelin maintained their body weights, whereas control animals lost weight. Body weight stability was achieved in ghrelin-treated animals despite a lack of increase in daily or cumulative food intake in both experiments. Hormone and proinflammatory cytokine levels were measured before surgery and after 14 days of treatment. Ghrelin treatment appeared to blunt declining ghrelin levels and also to blunt cytokine increases seen in the surgical control group. The ability of peripheral ghrelin treatment to maintain body weights of senescent rats without concomitant increases in food intake may be due to its known ability to decrease sympathetic activity and metabolic rate, perhaps by limiting cytokine-driven inflammation.
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135
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Are there any benefits from minimizing fasting and optimization of nutrition and fluid management for patients undergoing day surgery? Curr Opin Anaesthesiol 2008; 20:540-4. [PMID: 17989547 DOI: 10.1097/aco.0b013e3282f15493] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE OF REVIEW As a result of advances in anaesthesia and surgery, an increasing number of surgical procedures are currently possible in the ambulatory setting. Nausea/vomiting and sedation/drowsiness are often associated with delayed discharge and readmission. These symptoms are also related to pharmacological treatment as well as dehydration and fasting. The evidence that preoperative fasting and dehydration not only reduces preoperative well being, but may also affect postoperative recovery is currently being reviewed. RECENT FINDINGS In association with minor surgical procedures, rehydration with approximately 1 l fluid, and in cases with a moderate degree of surgery, such as laparoscopic surgery, 1-3 l fluid, given perioperatively will improve postoperative well being and recovery. Administration of a carbohydrate-rich beverage not only provides fluid but also counteracts the negative effects of preoperative fasting, which in turn reduces preoperative hunger and improves well being. Postoperatively, this treatment reduces insulin resistance, which may be relevant in surgery with significant postoperative stress response. Two studies on laparoscopic cholecystectomy demonstrate different results regarding effects on postoperative outcome and nausea/vomiting and further evaluation is required. SUMMARY When preoperative dehydration is corrected, postoperative well being and clinical outcome improves. Avoiding preoperative fasting by administration of carbohydrate-rich beverages improves preoperative well being while effects on postoperative recovery in patients undergoing ambulatory surgery need to be further evaluated.
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136
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Abstract
Malnutrition remains a common problem in surgical patients and is associated with significant morbidity and mortality. It is imperative that all surgical patients undergo nutritional screening on admission to highlight malnourished or at risk patients and implement a nutritional plan. Nutrition can be delivered by oral supplements, enteral or parenteral feeding, the route depending on an individual's requirements and surgical condition. Enteral feeding has largely been regarded as superior to parenteral feeding, as it is cheaper, safer and “more physiological” but studies show this is not always the case. This article reviews the basics of surgical nutrition and assesses the evidence supporting enteral versus parenteral nutrition.
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Affiliation(s)
- LH Moyes
- Department of Colorectal Surgery, Glasgow Royal Infirmary, 84 Castle Street, Glasgow G4 0SF
| | - RF Mckee
- Department of Colorectal Surgery, Glasgow Royal Infirmary, 84 Castle Street, Glasgow G4 0SF
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Kennedy DA, Hart J, Seely D. Cost effectiveness of natural health products: a systematic review of randomized clinical trials. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2007; 6:297-304. [PMID: 18955290 PMCID: PMC2722206 DOI: 10.1093/ecam/nem167] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Health care spending in North America is consuming an ever-increasing share of Gross Domestic Product (GDP). A large proportion of alternative health care is consumed in the form of natural health products (NHPs). The question of whether or not NHPs may provide a cost-effective choice in the treatment of disease is important for patients, physicians and policy makers. The objective of this study was to conduct a systematic review of the literature in order to find, appraise and summarize high-quality studies that explore the cost effectiveness of NHPs as compared to conventional medicine. The following databases were searched independently in duplicate from inception to January 1, 2006: EMBASE, MEDLINE, CINAHL, BioethicsLine, Wilson General Science abstracts, EconLit, Cochrane Library, ABI/Inform and SciSearch. To be included in the review, trials had to be randomized, assessed for some measure of cost effectiveness and include the use of NHPs as defined by the Natural Health Products Directorate. Studies dealing with diseases due to malnutrition were excluded from appraisal. The pooled searches unveiled nine articles that fit the inclusion/exclusion criteria. The conditions assessed by the studies included three on postoperative complications, two on cardiovascular disease, two on gastrointestinal disorders, one on critically ill patients and one on urinary tract infections. Heterogeneity between the studies was too great to allow for meta-analysis of the results. The use of NHPs shows evidence of cost effectiveness in relation to postoperative surgery but not with respect to the other conditions assessed. In conclusion, NHPs may be of use in preventing complications associated with surgery. The cost effectiveness of some NHPs is encouraging in certain areas but needs confirmation from further research.
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Affiliation(s)
- Deborah A Kennedy
- ND, Director, Department of Research and Clinical Epidemiology, The Canadian College of Naturopathic Medicine, 1255 Sheppard Ave East, Toronto, ON M2K 1E2,
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138
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Malnutrition in acute care patients: A narrative review. Int J Nurs Stud 2007; 44:1036-54. [DOI: 10.1016/j.ijnurstu.2006.07.015] [Citation(s) in RCA: 116] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2006] [Revised: 07/12/2006] [Accepted: 07/13/2006] [Indexed: 01/15/2023]
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139
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Abstract
Nutritional support, including oral nutritional supplements, enteral tube feeding and parenteral nutrition, can be an important part of the management of any patient. Malnutrition is common and costly, clinically and financially, if left untreated. In patients with, or at risk of, malnutrition, the appropriate use of nutritional support can prevent complications arising, produce other clinical, functional and financial benefits, and can be life saving in some situations. This article discusses the evidence from systematic reviews and meta-analyses of the effectiveness of nutritional support.
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Affiliation(s)
- Rebecca J Stratton
- Institute of Human Nutrition, School of Medicine, University of Southampton, Southampton General Hospital, Southampton, UK.
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140
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López Hellín J, Baena-Fustegueras JA, Sabín-Urkía P, Schwartz-Riera S, García-Arumí E. Nutritional modulation of protein metabolism after gastrointestinal surgery. Eur J Clin Nutr 2007; 62:254-62. [PMID: 17375114 DOI: 10.1038/sj.ejcn.1602732] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The metabolic response to surgery includes alterations in protein metabolism, resulting in a net loss of proteins. Protein hypercatabolism is considered an unavoidable consequence of injury, and an important source of morbidity and mortality. Our purpose was to determine the effect of nutrition on protein metabolism following gastrointestinal surgery, and to elucidate whether postoperative protein loss can be prevented with adequate nutritional support. METHODS Patients who had undergone gastrointestinal surgery were given four different parenteral nutritions with increasing glucose, lipid and amino acid content during the 7 days following surgery. Nitrogen balance, protein synthesis and protein breakdown were determined using in vivo stable isotope labelling. Other metabolites (3-methylhistidine, creatinine, urea, cortisol, glucose, insulin, amino acids and C-reactive protein) were measured. RESULTS A nutrition-dependent alteration of protein metabolism was found in response to surgical injury. Nutrition modified nitrogen balance, whole-body protein breakdown and, to a lesser extent, whole-body protein synthesis and muscle protein breakdown. The low-energy parenteral nutrition without amino acids produced a negative nitrogen balance (postoperative day 7=-0.381 g protein kg(-1)day(-1)) and important alterations in postoperative protein metabolism that did not normalize during the study period (day 7 protein synthesis=239% and protein breakdown 217% vs preoperative). Patients receiving the two low energy parenteral nutritions containing amino acids had a less negative nitrogen balance (day 7=-0.011 and -0.133 g protein kg(-1)day(-1)) and a transient increase in protein metabolism. The complete parenteral nutrition maintained, during all studied days, protein metabolism parameters within the preoperative reference range (synthesis day 2=92%, day 4=110% day 7=79%; breakdown day 2=85%, day 4=80%, day 7=76% vs preoperative) and a positive nitrogen balance (day 2=+0.0387, day 4=+0.578 and day 7=+0.227 g protein kg(-1)day(-1)). CONCLUSION Complete nutritional support can prevent protein loss after gastrointestinal surgery and maintain protein metabolism without alterations.
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Affiliation(s)
- J López Hellín
- IBBIM-Institut de Recerca, Hospital Vall d'Hebron, Barcelona, Spain.
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141
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LJUNGQVIST OLLE, HAUSEL JONATAN, NYGREN JONAS, THORELL ANDERS, SOOP MATTIAS. Preoperative patient preparation for enhanced recovery after surgery. ACTA ACUST UNITED AC 2007. [DOI: 10.1111/j.1778-428x.2007.00045.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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142
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JUNGER MARC, SCHOENBERG MICHAELHERMANN. Postoperative care in fast-track rehabilitation for elective colonic surgery. ACTA ACUST UNITED AC 2007. [DOI: 10.1111/j.1778-428x.2007.00047.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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143
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Koretz RL, Avenell A, Lipman TO, Braunschweig CL, Milne AC. Does enteral nutrition affect clinical outcome? A systematic review of the randomized trials. Am J Gastroenterol 2007; 102:412-29; quiz 468. [PMID: 17311654 DOI: 10.1111/j.1572-0241.2006.01024.x] [Citation(s) in RCA: 160] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Both parenteral nutrition (PN) and enteral nutrition (EN) are widely advocated as adjunctive care in patients with various diseases. A systematic review of 82 randomized controlled trials (RCTs) of PN published in 2001 found little, if any, effect on mortality, morbidity, or duration of hospital stay; in some situations, PN increased infectious complication rates. OBJECTIVE The objective was to assess the effect of EN or volitional nutrition support (VNS) in individual disease states from available RCTs. DESIGN We conducted a systematic review. RCTs comparing EN or VNS with untreated controls, or comparing EN with PN, were identified and separated according to the underlying disease state. Meta-analysis was performed when at least three RCTs provided data. The evidence from the RCTs was summarized into one of five grades. A or B, respectively, indicated the presence of strong or weak (low-quality RCTs) evidence supporting the use of the intervention. C indicated a lack of adequate evidence to make any decision about efficacy. D indicated that limited data could not support the intervention. E indicated either that strong data found no effect, or that either strong or weak data suggested that the intervention caused harm. PATIENTS AND SETTINGS RCTs could include either hospitalized or nonhospitalized patients. The EN or VNS had to be provided as part of a treatment plan for an underlying disease process. INTERVENTIONS The RCT had to compare recipients of either EN or VNS with controls not receiving any type of artificial nutrition or had to compare recipients of EN with recipients of PN. OUTCOME MEASURES These were mortality, morbidity (disease specific), duration of hospitalization, cost, or interventional complications. SUMMARY OF GRADING: A: No indication was identified. B: EN or VNS in the perioperative patient or in patients with chronic liver disease; EN in critically ill patients or low birth weight infants (trophic feeding); VNS in malnourished geriatric patients. (The low-quality trials found a significant difference in survival favoring the VNS recipients in the malnourished geriatric patient trials; two high-quality trials found nonsignificant differences that favored VNS as well.) C: EN or VNS in liver transplantation, cystic fibrosis, renal failure, pediatric conditions other than low birth weight infants, well-nourished geriatric patients, nonstroke neurologic conditions, AIDS; EN in acute pancreatitis, chronic obstructive pulmonary disease, nonmalnourished geriatric patients; VNS in inflammatory bowel disease, arthritis, cardiac disease, pregnancy, allergic patients, preoperative bowel preparation. D: EN or VNS in patients receiving nonsurgical cancer treatment or in patients with hip fractures; EN in patients with inflammatory bowel disease; VNS in patients with chronic obstructive pulmonary disease. E: EN in the first week in dysphagic, or VNS at any time in nondysphagic, stroke patients who are not malnourished; dysphagia persisting for weeks will presumably ultimately require EN. CONCLUSIONS There is strong evidence for not using EN in the first week in dysphagic, and not using VNS at all in nondysphagic, stroke patients who are not malnourished. There is reasonable evidence for using VNS in malnourished geriatric patients. The recommendations to consider EN/VNS in perioperative/liver/critically ill/low birth weight patients are limited by the low quality of the RCTs. No evidence could be identified to justify the use of EN/VNS in other disease states.
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Affiliation(s)
- Ronald L Koretz
- Department of Medicine, Olive View-UCLA Medical Center, Sylmar, California 91342, USA
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144
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The impact of malnutrition on healthcare costs and economic considerations for the use of oral nutritional supplements. ACTA ACUST UNITED AC 2007. [DOI: 10.1016/j.clnu.2007.04.002] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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145
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Andersen HK, Lewis SJ, Thomas S. Early enteral nutrition within 24h of colorectal surgery versus later commencement of feeding for postoperative complications. Cochrane Database Syst Rev 2006:CD004080. [PMID: 17054196 DOI: 10.1002/14651858.cd004080.pub2] [Citation(s) in RCA: 132] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The role of early postoperative enteral nutrition after gastrointestinal surgery is controversial. Traditional management consist of 'nil by mouth', where patients receive fluids followed by solids when tolerated. Although several trials have implicated lower incidence of septic complications and faster wound healing upon early enteral feeding, other trials have shown opposite results. The immediate advantage of caloric intake could be a faster recovery with fewer complications, to be evaluated systematically. OBJECTIVES To evaluate whether early commencement of postoperative enteral nutrition compared to traditional management (no nutritional supply) is associated with fewer complications in patients undergoing gastrointestinal surgery SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials, PUBMED, EMBASE, and LILACS from 1979 (first RCT published) to March 2006. We manually scanned the references from the relevant articles, and consulted primary authors for additional information. SELECTION CRITERIA We looked for randomised controlled trials (RCT's) comparing early commencement of feeding (within 24 hours) with no feeding in patients undergoing gastrointestinal surgery. Early enteral nutrition is defined as all oral intakes (i.e. registered oral intake, supplemented oral feeding) and any kind of tube feeding (gastric, duodenal or jejunal) containing caloric content. No feeding is traditional management, defined as none caloric oral intake or any kind of tube feeding before bowel function. The definition 'no nutrition' includes non caloric placebo and water. DATA COLLECTION AND ANALYSIS The three authors independently assessed the identified trials, and extracted the relevant data using a specifically developed data extraction sheet. Primary end points of interest were: Wound infections and intraabdominal abscesses, postoperative complications such as acute myocardial infarction, postoperative thrombosis or pneumonia, anastomotic leakages, mortality, length of hospital stay, and significant adverse effects. We combined data to estimate the common relative risk of postoperative complications, and calculated the associated 95% confidence intervals. For analysis, we used fixed effects model (risk ratios to summarise the treatment effect) whenever feasible. The treatment effect on length of stay was estimated using effect size (presented as mean +/- SD). Some outcomes were not analysed but presented in a descriptive way. We used a random effects model to estimate overall risk ratio and effect size. MAIN RESULTS We identified thirteen randomised controlled trials, with a total of 1173 patients, all undergoing gastrointestinal surgery. Individual clinical complications failed to reach statistical significance, but the direction of effect indicates that earlier feeding may reduce the risk of post surgical complications. Mortality was the only outcome showing a significant benefit, but not necessarily associated with early commencement of feeding, as the reported cause of death was anastomotic leakage, reoperation, and acute myocardial infarction. AUTHORS' CONCLUSIONS Although non-significant results, there is no obvious advantage in keeping patients 'nil by mouth' following gastrointestinal surgery, and this review support the notion on early commencement of enteral feeding.
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146
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Abstract
This review discusses the metabolic changes that occur during fasting, especially in relation to surgical stress. Currently available evidence on the relevance of different aspects of perioperative nutritional support are presented. Attenuation of surgical stress and insulin treatment in insulin-resistant patients after surgery and trauma have been shown to markedly affect stress metabolism as well as patient morbidity and mortality. Avoiding preoperative fasting has been shown to be related to a substantial reduction in postoperative stress and insulin resistance. Implementation of a standardized programme with a multimodal approach using evidence-based perioperative routines has been shown to further reduce surgical stress and to markedly enhance functional recovery also after major surgical procedures.
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Affiliation(s)
- Jonas Nygren
- Centre of Gastrointestinal Disease, Ersta Hospital and Karolinska Institutet, P.O. Box 4622, 116 91 Stockholm, Sweden.
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147
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Weimann A, Braga M, Harsanyi L, Laviano A, Ljungqvist O, Soeters P, Jauch KW, Kemen M, Hiesmayr JM, Horbach T, Kuse ER, Vestweber KH. ESPEN Guidelines on Enteral Nutrition: Surgery including organ transplantation. Clin Nutr 2006; 25:224-44. [PMID: 16698152 DOI: 10.1016/j.clnu.2006.01.015] [Citation(s) in RCA: 645] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2006] [Accepted: 01/20/2006] [Indexed: 02/07/2023]
Abstract
Enhanced recovery of patients after surgery ("ERAS") has become an important focus of perioperative management. From a metabolic and nutritional point of view, the key aspects of perioperative care include: Enteral nutrition (EN) by means of oral nutritional supplements (ONS) and if necessary tube feeding (TF) offers the possibility of increasing or ensuring nutrient intake in cases where food intake is inadequate. These guidelines are intended to give evidence-based recommendations for the use of ONS and TF in surgical patients. They were developed by an interdisciplinary expert group in accordance with officially accepted standards and are based on all relevant publications since 1980. The guideline was discussed and accepted in a consensus conference. EN is indicated even in patients without obvious undernutrition, if it is anticipated that the patient will be unable to eat for more than 7 days perioperatively. It is also indicated in patients who cannot maintain oral intake above 60% of recommended intake for more than 10 days. In these situations nutritional support should be initiated without delay. Delay of surgery for preoperative EN is recommended for patients at severe nutritional risk, defined by the presence of at least one of the following criteria: weight loss >10-15% within 6 months, BMI<18.5 kg/m(2), Subjective Global Assessment Grade C, serum albumin <30 g/l (with no evidence of hepatic or renal dysfunction). Altogether, it is strongly recommended not to wait until severe undernutrition has developed, but to start EN therapy early, as soon as a nutritional risk becomes apparent.
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Affiliation(s)
- A Weimann
- Klinik f. Allgemein- und Visceralchirurgie, Klinikum "St. Georg", Leipzig, Germany.
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148
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Davenport DL, Henderson WG, Khuri SF, Mentzer RM. Preoperative risk factors and surgical complexity are more predictive of costs than postoperative complications: a case study using the National Surgical Quality Improvement Program (NSQIP) database. Ann Surg 2005; 242:463-8; discussion 468-71. [PMID: 16192806 PMCID: PMC1402344 DOI: 10.1097/01.sla.0000183348.15117.ab] [Citation(s) in RCA: 147] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This single-center study tested the hypothesis that preoperative risk factors and surgical complexity predict more variation in hospital costs than complications. BACKGROUND Complications after surgical operations have been shown to significantly increase hospital cost. The impact on complication-related costs of preoperative risk factors is less well known. METHODS The National Surgical Quality Improvement Program (NSQIP) preoperative risk factors, surgical complexity, and outcomes, along with hospital costs, were analyzed for a random sample of 5875 patients on 6 surgical services. Operation complexity was assessed by work RVUs (Centers for Medicare and Medicaid Services Resource Based Relative Value Scale). The difference in mean hospital costs associated with all variables was analyzed. Multiple linear regression was used to determine the cost variation associated with all variables separately and combined. RESULTS Fifty-one of 60 preoperative risk factors, work RVUs, and 22 of 29 postoperative complications were associated with higher variable direct costs (P < 0.05). Linear regressions showed that risk factors predicted 33% (P < 0.001) of cost variation, work RVUs predicted 23% (P < 0.001), and complications predicted 20% (P < 0.001). Risk factors and work RVUs together predicted 49% of cost variation (P < 0.001) or 16% more than risk factors alone. Adding complications to this combined model modestly increased prediction of costs by 4% for a total of 53% (P < 0.001). CONCLUSION Preoperative risk factors and surgical complexity are more effective predictors of hospital costs than complications. Preoperative intervention to reduce risk could lead to significant cost savings. Payers and regulatory agencies should risk-adjust hospital cost assessments using clinical information that integrates costs, preoperative risk, complexity of operation, and outcomes.
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Affiliation(s)
- Daniel L Davenport
- University of Kentucky, Department of Surgery, Lexington, Kentucky 40536, USA.
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149
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Abstract
In patients with gastrointestinal malignancies, i.e. cancers of the stomach, colon, liver, biliary tract or pancreas, progressive undernutrition can be regularly observed during the course of illness. Undernutrition significantly affects the patients' quality of life, morbidity and survival. Pathogenetically, two different causes are relevant in the development of undernutrition in patients with gastrointestinal cancer. One cause is reduced nutritional intake. This condition is referred to as anorexia and can be worsened by the side effects of cancer therapy. The other cause is the release of endogenous transmitters and/or other products of the tumour leading to the cachexia syndrome, which is characterized by loss of body weight, negative nitrogen balance and fatigue. Cancer anorexia and cancer cachexia may have synergistic negative effects in affecting the patients' status. In this review, current nutritional support strategies with respect to different clinically relevant situations are described. An algorithm of the treatment strategies, including dietetic counselling, oral supplements, enteral and parenteral nutritional support is given. One focus is the approach of nutrition-focused patient care, which shows promising results. In addition, the possibilities of pharmacological intervention are discussed.
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Affiliation(s)
- J Ockenga
- Department of Gastroenterology, Hepatology and Endocrinology, Charité-University Medicine Berlin, Berlin, Germany.
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Herman PM, Craig BM, Caspi O. Is complementary and alternative medicine (CAM) cost-effective? A systematic review. Altern Ther Health Med 2005; 5:11. [PMID: 15932647 PMCID: PMC1182346 DOI: 10.1186/1472-6882-5-11] [Citation(s) in RCA: 113] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2004] [Accepted: 06/02/2005] [Indexed: 11/10/2022]
Abstract
BACKGROUND Out-of-pocket expenditures of over 34 billion dollars per year in the US are an apparent testament to a widely held belief that complementary and alternative medicine (CAM) therapies have benefits that outweigh their costs. However, regardless of public opinion, there is often little more than anecdotal evidence on the health and economic implications of CAM therapies. The objectives of this study are to present an overview of economic evaluation and to expand upon a previous review to examine the current scope and quality of CAM economic evaluations. METHODS The data sources used were Medline, AMED, Alt-HealthWatch, and the Complementary and Alternative Medicine Citation Index; January 1999 to October 2004. Papers that reported original data on specific CAM therapies from any form of standard economic analysis were included. Full economic evaluations were subjected to two types of quality review. The first was a 35-item checklist for reporting quality, and the second was a set of four criteria for study quality (randomization, prospective collection of economic data, comparison to usual care, and no blinding). RESULTS A total of 56 economic evaluations (39 full evaluations) of CAM were found covering a range of therapies applied to a variety of conditions. The reporting quality of the full evaluations was poor for certain items, but was comparable to the quality found by systematic reviews of economic evaluations in conventional medicine. Regarding study quality, 14 (36%) studies were found to meet all four criteria. These exemplary studies indicate CAM therapies that may be considered cost-effective compared to usual care for various conditions: acupuncture for migraine, manual therapy for neck pain, spa therapy for Parkinson's, self-administered stress management for cancer patients undergoing chemotherapy, pre- and post-operative oral nutritional supplementation for lower gastrointestinal tract surgery, biofeedback for patients with "functional" disorders (eg, irritable bowel syndrome), and guided imagery, relaxation therapy, and potassium-rich diet for cardiac patients. CONCLUSION Whereas the number and quality of economic evaluations of CAM have increased in recent years and more CAM therapies have been shown to be of good value, the majority of CAM therapies still remain to be evaluated.
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Affiliation(s)
- Patricia M Herman
- Program in Integrative Medicine, University of Arizona, Tucson, Arizona, USA
| | - Benjamin M Craig
- Department of Pharmacy, University of Arizona, Tucson, Arizona, USA
| | - Opher Caspi
- Recanati Center for Internal Medicine and Research, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel
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