Implementation of an evidenced based nutrition support pathway for haematopoietic progenitor cell transplant patients

Proactive enteral nutrition for patients undergoing allogeneic stem cell transplantation- implementation and clinical outcomes

BACKGROUND/ OBJECTIVES

Nutrition support is frequently required post allogeneic haematopoietic progenitor cell transplantation (HPCT) however the tolerance of enteral nutrition (EN) can vary. This mixed methods study aimed to explore staff perceptions, barriers and enablers to the use of EN post HPCT and report the implementation and outcomes of a nutrition protocol.

SUBJECT/ METHODS

A survey on barriers and enablers to the use of EN was developed and distributed to medical and nursing staff. Data on nutrition and clinical outcomes was collected for 12 months post implementation of a new nutrition protocol.

RESULTS

Thirty staff completed the survey, key barriers identified included uncertain EN tolerance, lack of confidence in nasogastric tube placement and insufficient training and resources. Eighty-four patients commenced EN, 23 changed to PN (27%) and 61 received EN only (73%). In total 36 patients received PN and eight patients oral nutrition support only. There was a difference in type of conditioning (p = 0.025) and nutritional status (p = 0.016) between patients who received PN vs EN only, with a higher proportion of malnourished patients receiving PN (23% vs 5%). Patients who received PN had a longer length of hospital stay (median 22 vs 19 days, p = 0.012) and lower rate of survival to day 100 (81% vs 95%, p = 0.036) than patients who received EN.

CONCLUSION

The use of EN may lead to improved clinical outcomes compared to PN therefore should be implemented as first line nutrition support.

Changes in Nutritional Intake, Body Composition, and Handgrip Strength in Patients Undergoing Autologous Hematopoietic Stem Cell Transplantation: A Retrospective Study

Patients who undergo autologous hematopoietic stem cell transplantation (autoHSCT) often experience reduced oral intake and wasting. We examined their daily nutritional intake, assessed alterations in body composition and muscle strength, and explored associations between decreased nutritional intake and treatment outcomes. This retrospective study included 64 patients. Their food record charts and parenteral nutrition (PN) prescriptions from medical records were used to assess nutritional intake. Body composition and handgrip strength data were obtained from dietitian records. Patients consumed >75% of their nutritional requirements through an oral diet in 6.7 days, 50-75% in 4.8 days, 25-50% in 5.0 days, and <25% in 3.1 days. The average oral intake was 62% of the requirement and was partially supplemented with PN. Patients experienced a mean decrease in body weight of 2.9 ± 3.0 kg, with 2.3 ± 3.4 kg of lean mass, and a mean reduction in handgrip strength of 3.5 ± 3.6 kg. We found a positive correlation of caloric deficits with weight loss and handgrip strength reduction and negative correlation with time to neutrophil engraftment and duration of hospitalization. This study highlighted a notable reduction in oral nutritional intake following autoHSCT. While caloric deficits might affect outcomes, further investigation is warranted to explore this observation.

Enteral nutrition optimization program for children undergoing blood & marrow transplantation: A quality improvement project

BACKGROUND

Malnutrition in children and young adults undergoing blood and marrow transplantation (BMT) increases morbidity and mortality. Addressing this via optimization of enteral nutrition can potentially improve outcomes.

METHODS

This Quality Improvement project utilized pre-post-intervention design and post-intervention survey to evaluate a novel program optimizing enteral nutrition support in children undergoing BMT. All patients aged 0-18 who were admitted during the 16-week implementation period followed the Enteral Nutrition Optimization Program from pre-BMT through discharge. Data on biometric indicators, complications, and post-transplant milestone time markers were evaluated via Mann-Whitney U, Fisher's exact, and Chi-square tests as indicated using SPSS™ Version 27. A separate sample of clinical providers completed a post-intervention survey to evaluate the feasibility and acceptance of the intervention.

FINDINGS

Six patients received the intervention, with 12 patients evaluated. There were no statistical differences between groups on measured evaluations of weight loss (0.15 kg vs +0.4 kg, p = 0.39), malnutrition (2 vs 3, p = 0.545), graft-versus-host-disease (2 vs 2, p = 1), time to engraftment (platelets day 22 vs 20.5, p = 0.589), infections (p = 0.368), and length of stay (32.5 days vs 31 days, p = 1). The provider sample of 45 participants showed overall feasibility and acceptance of the intervention (88.9% agreed or strongly agreed).

DISCUSSION

Feasibility and acceptance were high, resulting in increased use of nasogastric and gastrostomy tubes. Though no clinical significance, interpretation is limited due to the small sample size.

PRACTICE IMPLICATIONS

Implementing a novel nutritional support program resulted in a culture shift towards enteral nutrition optimization. Further studies are needed to determine clinical impacts.

Medical nutrition therapy during intensive remission-induction treatment and hematopoietic stem cell transplantation in acute myeloid leukemia patients: Hematologists' experiences and perspectives

BACKGROUND & AIMS

The European Societies for Clinical Nutrition and Metabolism (ESPEN) and Blood and Marrow Transplantation (EBMT) recommend enteral nutrition (EN) as the first-choice medical nutrition therapy in acute myeloid leukemia (AML) patients undergoing intensive treatments, including high-dose remission-induction chemotherapy and hematopoietic stem cell transplantation (HSCT). However, parenteral nutrition (PN) remains the preferred method of nutrition support in current clinical practice. The aim of this qualitative study was to gain insight into hematologists' experiences and perspectives regarding the choice and ESPEN/EBMT recommendations on EN versus PN.

METHODS

Online semi-structured interviews were conducted with one hematologist from each of the 21 hospitals offering intensive AML treatments in the Netherlands, using Microsoft Teams. Interviews were audio-recorded, transcribed verbatim and thematically analyzed using Atlas. ti. One hundred nineteen hematologists working in the same hospitals were invited to complete a short online questionnaire survey (SurveyMonkey®) regarding their knowledge and opinion on the ESPEN/EBMT guidelines recommending EN over PN during intensive AML treatments. The results of this survey are presented in a descriptive way.

RESULTS

Fifty-nine hematologists participated in this study (42% overall response rate), of which 21 in the semi-structured interviews (response rate 100%) and 38 in the online survey (response rate 32%). Hematologists considered medical nutrition therapy important for prevention and treatment of malnutrition and associated adverse outcomes in AML patients undergoing intensive remission-induction treatment and HSCT. However, opposed to the ESPEN/EBMT guidelines, the vast majority of hematologists were hesitant or reluctant to use EN instead of PN as the first-choice medical nutrition therapy in these patients. The most frequently cited barriers to use EN were the expected low feasibility and tolerance of EN, feeding tube-related discomfort and bleeding risk, and patient refusal. Other barriers to follow the guidelines on EN were related to personal factors, including hematologists' knowledge (lack of awareness and familiarity) and attitude (lack of agreement, outcome expectancy, experience, success, motivation, and learning culture), guideline-related factors (lack of evidence and applicability), and external factors (lack of collaboration and resources). Facilitators included strategies for nutrition education and dissemination of nutritional guidelines, interprofessional and patient collaboration, availability of feeding tubes that can be inserted without endoscopy and stronger scientific evidence.

CONCLUSIONS

Hematologists recognized the importance of medical nutrition therapy for reducing malnutrition and related negative outcomes during intensive AML treatments. However, contrary to the ESPEN/EBMT guidelines, they preferred PN instead of EN as the medical nutrition therapy of first choice. To reduce compliance barriers, interventions should focus on improving hematologists' knowledge of medical nutrition therapy and dietary guidelines, enhancing success rates of EN by adequately triaging patients eligible for EN and inserting duodenal feeding tubes using an electromagnetic sensing device without endoscopy, developing decision aids and multidisciplinary guidelines and care pathways. Furthermore, future trials should focus on the feasibility and benefits of EN versus PN both during remission-induction treatment and HSCT.

From support to therapy: rethinking the role of nutrition in acute graft-versus-host disease

Allogeneic Hematopoietic stem cell transplantation (HSCT) offers a potential cure for patients with hematologic malignancies. Unfortunately, graft-versus-host disease (GVHD) remains a major obstacle to the greater success of this treatment. Despite intensive research efforts over the past several decades, GVHD is still a major cause of morbidity and mortality in patients receiving allogeneic HSCT. The genetic disparity between donor and recipient is the primary factor that dictates the extent of alloimmune response and the severity of acute GVHD (aGVHD). However, some nongenetic factors are also actively involved in GVHD pathogenesis. Thus, identifying host factors that can be readily modified to reduce GVHD risk is of important clinical significance. We are particularly interested in the potential role of nutrition, as a nongenetic factor, in the etiology and management of aGVHD. In this article, we summarize recent findings regarding how different routes of nutritional support and various dietary factors affect aGVHD. Since diet is one of the most important factors that shape gut microbiota, we also provide evidence for a potential link between certain nutrients and gut microbiota in recipients of allogeneic HSCT. We propose a shifting role of nutrition from support to therapy in GVHD by targeting gut microbiota.

Examination of a nutritional treatment pathway according to pretreatment health status and stress levels of patients undergoing hematopoietic stem cell transplantation

Introduction

This study aimed to validate hematopoietic stem cell transplantation (HSCT) treatment via a tailored nutritional pathway in myeloablative conditioning (MAC), determine its efficacy in terms of remission, and explore associations between clinical outcomes and nutritional indicators.

Methods

We included patients who underwent MAC for HSCT at the Shizuoka Cancer Center Stem Cell Transplantation between 2015 and 2019. We evaluated outcomes from the day before treatment initiation (transplant date: day 0) to day 42.

Results

Among the 40 MAC cases (participant characteristics: 20/40 males, mean age of 52 years, and mean body mass index of 21.9 kg/m²), we found that the percent loss of body weight and loss of skeletal muscle mass were correlated with the basal energy expenditure rate (BEE rate; r = 0.70, p<0.001 and r = 0.49, p<0.01, respectively). Based on the receiver operating characteristics curves, the cutoff value for the BEE rate in terms of weight loss was 1.1. Salivary amylase levels did not significantly change during the treatment course. Continuous variables, including oral caloric intake and performance status, showed statistically significant correlations with nutrition-related adverse events during treatment (r = −0.93, p<0.01 and r = 0.91, p<0.01, respectively). Skeletal muscle mass before treatment initiation was an independent predictive variable for reduced 2-year survival (p = 0.04).

Conclusion

Our results support the validity of a safe nutritional pathway with a BEE rate of 1.1 for HSCT patients pretreated with MAC. Specifically, we found that this pathway could prevent weight loss in response to nutrition-related adverse events. Skeletal muscle mass before treatment was identified as an independent risk factor for reduced 2-year survival.

Implementation of a standardised perioperative nutrition care pathway in upper gastrointestinal cancer surgery: a multi-site pilot study

BACKGROUND

Perioperative nutrition support is recommended for patients undergoing upper gastrointestinal (UGI) cancer surgery; however, limited evidence exists regarding implementation of a nutrition care pathway in clinical practice. The aims of this pilot study were to determine if implementation of a standardised perioperative nutrition pathway for patients undergoing UGI cancer surgery improves access to dietetics care, and to evaluate study feasibility, fidelity, resource requirements and effect on clinical outcomes.

METHODS

Patients with newly diagnosed UGI cancer from four major metropolitan hospitals in Melbourne, planned for curative intent surgery, were included in the prospective pilot study (n=35), with historical controls (n=35) as standard care. Outcomes were dietetics care (dietetics contacts) nutritional status; hand grip strength; weight change; preoperative hospital admissions; complications and length of stay; recruitment feasibility; fidelity and adherence; and, resource requirements. Continuous data were analysed using independent samples t-test accounting for unequal variances or Mann-Whitney U test. Dichotomous data were analysed using Fisher's exact test.

RESULTS

The percentage of participants receiving preoperative dietetic intervention increased from 55% to 100% (p<0.001). Mean and standard deviation (SD) dietetics contacts increased from 2.2 (3.7) to 5.9 (3.9) (p<0.001). Non-statistically significant decreases in preoperative nutrition-related hospital admissions, and surgical complications were demonstrated in patients who underwent neoadjuvant therapy. Recruitment rate was 81%, and adherence to the nutrition pathway was high (>70% for all stages of the pathway). The mean estimated resource requirement for the preoperative period was 3.7 (2.8) hours per patient.

CONCLUSION

Implementation of this standardised nutrition pathway resulted in improved access to dietetics care. Recruitment feasibility and high fidelity to the intervention suggest that a larger study would be viable. This article is protected by copyright. All rights reserved.

Implementing a standardised perioperative nutrition care pathway in upper gastrointestinal cancer surgery: a mixed-methods analysis of implementation using the Consolidated Framework for Implementation Research

Background

Implementation studies of complex interventions such as nutrition care pathways are important to health services research, as they support translation of research into practice. There is limited research regarding implementation of a nutrition care pathway in an upper gastrointestinal (UGI) cancer population. The aim of this study was to comprehensively evaluate the implementation process of a perioperative nutrition care pathway in UGI cancer surgery using The Consolidated Framework for Implementation Research (CFIR).

Methods

This was a mixed methods implementation study conducted during a pilot study of a standardised nutrition care pathway across four major hospitals between September 2018 to August 2019. Outcome measures included five focus groups among study dietitians (n = 4–8 per group), and quantitative satisfaction surveys from multi-disciplinary team (MDT) members (n = 14) and patients (n = 18). Focus group responses were analysed thematically using the CFIR constructs, which were used as a priori codes. Survey responses were summarised using means and standard deviations. A convergent parallel mixed methods approach according to CFIR domains and constructs was used to integrate qualitative and quantitative data.

Results

Qualitative data demonstrated that dietitian perceptions primarily aligned with five CFIR constructs (networks and communications, structural characteristics, adaptability, compatibility and patient needs/resources), indicating a complex clinical and implementation environment. Challenges to implementation mostly related to adapting the pathway, and the compatibility of nutrition coordination to existing aspects of care within each setting. Identified benefits from dietitian qualitative data and MDT survey responses included increased engagement between the dietitian and MDT, and a more proactive approach to nutrition care. Patients were highly satisfied with the service, with the majority of survey items being rated highly (≥4 of a possible 5 points).

Conclusions

The nutrition care pathway was perceived to be beneficial by key stakeholders. Based on the findings, sustainability and compliance to this model of care may be achieved with improved systems level coordination and communication.

Effect of an Evidence-Based Nutrition Care Pathway for Cancer Patients Undergoing Gastrointestinal and Pelvic Surgery

Malnutrition in gastrointestinal surgery is associated with poorer post-operative outcomes which may be mitigated by delivery of evidence-based nutrition care. This study reports on the development, implementation and evaluation of an evidence-based nutrition care pathway for lower gastrointestinal and pelvic cancer patients. A retrospective cohort study of 40 surgical lower gastrointestinal and pelvic cancer patients pre- and post-implementation of the pathway was conducted. Outcomes assessed were, care pathway adherence, weight change, time to post-operative commencement of nutrition, and post-operative length of stay. Post-implementation of the pathway there were significant improvements in the proportion of patients who received dietetic assessment and education pre-surgery (0% vs 55%, P < .001) at regular intervals during admission (35% vs. 90%, P < .001) and post-discharge (22.5% vs. 81.8%, P < .001). Mean weight change between admission and discharge reduced post-implementation (-3.5%, SD 4.7 vs, -5.6%, SD 4.7; P = 0.08). Post-operative length of stay remained similar (16 day, IQR 11-34.7 vs. 17.5 day, IQR 11.2-25; P = 0.71). Post-implementation a greater proportion of patients commenced oral or enteral nutrition within 24 h, post-operatively (75% vs. 57.5%, P = 0.1). The nutrition care pathway was an effective method for delivering evidence-based nutrition care, resulting in clinically but not statistically significant improvements in outcomes.

Optimization of nutrition support practices early after hematopoietic cell transplantation

Nutrition support is often required during hematopoietic cell transplant (HCT) given the gastrointestinal toxicity that frequently precludes adequate protein-calorie intake. This article reviews the latest evidence for enteral versus parenteral nutrition in the adult and pediatric HCT population and addresses key considerations as well as barriers to implement this in practice. Registered Dietitian Nutritionists are key members of the interdisciplinary team to proactively manage enteral nutrition support to provide timely, adequate protein and calories to help prevent malnutrition, loss of lean body mass, and functional decline as well as provide evidence-based diet recommendations. This article also reviews emerging research supporting the role of luminal nutrients to maintain microbiotal diversity.

Nutrition Support Practices of Hematopoietic Stem Cell Transplantation Centers in Mainland China

It has been identified that malnutrition can influence the immune system and time of engraftment, and it's also associated with increased incidence of complications, prolonged length of hospital stays, and transplant mortality and morbidity in patients undergoing hematopoietic stem cell transplantation (HSCT), so dynamic nutrition care is highly important. The aim of this study was to better understand the differences between clinical nutrition practices and international recommendations as well as possible barriers to the use of nutrition support in HSCT patients. An evidence-based nutrition support pathway was constructed through a systematic literature review to identify evidence and recommendations relating to the relevant issues. Then, a questionnaire consisting of 28 questions that focused on the 4 topics, namely, assessment and screening for malnutrition, nutrition support interventions, nutrition support in gastrointestinal graft-versus-host disease (GVHD) and neutropenic diet was developed by the study authors and used for data collection. Responses of 18 HSCT centers from 17 provinces were received. General assessment for malnutrition was performed at 72% (13/18) centers. Parenteral nutrition (PN) was given as the first option to HSCT patients in the majority of centers, despite the fact that current guidelines recommend enteral nutrition (EN) over PN. As many as 72% (13/18) of the centers considered a neutropenic diet in the management of HSCT patients, but only one center had a formal neutropenic diet protocol in place for transplant recipients. Criteria for initiating nutrition support in patients with gastrointestinal GVHD were heterogeneous among the centers, and PN was the most widely used technique. The survey results revealed significant heterogeneity with regard to nutrition support practices among the centers, as well as between the practices and the guidelines. Standard nutrition support guidelines or protocols for nutrition support practices were absent in most of the centers.

Adherence to guidelines on nutrition support during intensive treatment of acute myeloid leukemia patients: A nationwide comparison

BACKGROUND & AIMS

The level of adherence to the updated guidelines of The European Societies for Clinical Nutrition and Metabolism (ESPEN) and for Blood and Marrow Transplantation (EBMT) on nutrition in intensively treated adult acute myeloid leukemia (AML) patients in clinical practice is unknown. The aim of this nationwide survey was to investigate ESPEN/EBMT nutritional guideline adherence during intensive AML treatment, variation in nutrition support practices among hospitals and whether these practices changed after guideline publication.

METHODS

All 22 Dutch hospitals providing (aftercare following) high-dose chemotherapy and/or hematopoietic stem cell transplantation for adult AML patients were surveyed on nutrition support practices during these intensive AML treatments. We used an online questionnaire in 2015 and semi-structured telephone interviews in 2018-2019. Both surveys were completed by registered dieticians and addressed the use of enteral (EN) and parenteral (PN) nutrition. The ESPEN/EBMT nutritional guideline adherence was investigated through the telephone interviews.

RESULTS

High-level ESPEN/EBMT guideline adherence and/or uniformity among hospitals regarding nutrition support practices during intensive AML treatment were observed for nutritional screening, -aims, safe food handling and exercise training. Adherence to ESPEN/EBMT recommendations that were not implemented into national guidelines, including nutritional assessment and use of medical nutrition, was poor. All hospitals assessed nutritional intake, -impact symptoms and body weight, but muscle mass, physical performance and degree of systemic inflammation were rarely and variably monitored. Although the number of hospitals using EN as first-choice nutritional intervention increased from 3 hospitals in 2015 to 8 in 2019, PN remained the preferred method of nutrition support. Furthermore, the timing of medical nutrition varied.

CONCLUSIONS

Although the use of EN increased after publication of the updated ESPEN/EBMT nutritional guidelines, adherence to these standards was limited and there was heterogeneity in nutrition support practices during intensive AML treatment among hospitals. Incorporating international nutritional standards into national guidelines by nutrition expert groups immediately upon publication may improve adherence.

Brazilian Nutritional Consensus in Hematopoietic Stem Cell Transplantation: Adults

The nutritional status of patients submitted to hematopoietic stem cell transplant is considered an independent risk factor, which may influence on quality of life and tolerance to the proposed treatment. The impairment of nutritional status during hematopoietic stem cell transplant occurs mainly due to the adverse effects resulting from conditioning to which the patient is subjected. Therefore, adequate nutritional evaluation and follow-up during hematopoietic stem cell transplant are essential. To emphasize the importance of nutritional status and body composition during treatment, as well as the main characteristics related to the nutritional assessment of the patient, the Brazilian Consensus on Nutrition in Hematopoietic Stem Cell Transplant: Adults was prepared, aiming to standardize and update Nutritional Therapy in this area. Dietitians, nutrition physicians and hematologists from 15 Brazilian centers thar are references in hematopoietic stem cell transplant took part.

Benefit of Reducing Body Weight Loss with A Nutritional Support Pathway in Patients Undergoing Allogeneic Hematopoietic Stem Cell Transplantation

BACKGROUND

This retrospective, historically controlled investigative study examined the benefit of a nutritional support pathway that included nutritional education before the start of conditioning and emphasized oral nutrition in response to nutrition-related adverse events in patients undergoing hematopoietic stem cell transplantation (HSCT).

MATERIAL AND METHODS

Participants were patients undergoing allogeneic HSCT; 46 were in the control group (i.e., did not follow our nutritional pathway) and 36 were in the group that underwent nutritional intervention (enhanced nutrition group). We compared the following parameters between groups from the day before the start of conditioning to the day after completion of parenteral nutrition (PN): percent loss of body weight (%LBW), percent loss of skeletal muscle mass (%LSMM), and estimated basal energy expenditure (EBEE) sufficiency rate. The relationship between each parameter and %LBW was also examined. We also compared nutritional indices, gastrointestinal graft versus host disease (GvHD) grade, oral energy intake, and %LBW between groups.

RESULTS

There was a relationship between %LBW, %LSMM, and EBEE sufficiency rate in both groups. Compared with the control group, the enhanced nutrition group had significantly improved energy intake amount, EBEE sufficiency rate, PN duration, and oral energy intake over time. The enhanced nutrition group also had increased oral energy intake, no difference in gastrointestinal GvHD grade, and improved %LBW compared with the control group.

CONCLUSIONS

Use of our nutritional support pathway in patients undergoing HSCT may be beneficial for %LBW and gastrointestinal GvHD grade, enabling early enhanced nutritional intervention after HSCT.

Brazilian Nutritional Consensus in Hematopoietic Stem Cell Transplantation: Elderly

The Brazilian Nutritional Consensus in Hematopoietic Stem Cell Transplantation: Elderly was elaborated by nutritionists, nutrologists and hematologists physicians from 15 Brazilians reference centers in hematopoietic stem cell transplantation, in order to emphasize the importancy of nutritional status and the body composition during the treatment, as well as the main characteristics related to patient's nutritional assessment. Establishing the consensus, we intended to improve and standardize the nutritional therapy during the hematopoietic stem cell transplantation. The Consensus was approved by the Brazilian Society of Bone Marrow Transplantation.

Caloric and protein intake in different periods of hospitalization of patients undergoing hematopoietic stem cell transplantation

OBJECTIVE

To evaluate the nutritional status and caloric and protein intake during the hospitalization of patients undergoing hematopoietic stem cell transplantation.

METHODS

A retrospective study was performed based on clinical and nutritional data of patients undergoing autologous and allogeneic hematopoietic stem cell transplantation from March 2015 to March 2017. The mean caloric and protein intake were evaluated in three different intervals (P1: from admission to the day before transplantation, P2: from the transplantation day to the day before engraftment, P3: from the engraftment day to the day of hospital discharge). Body mass index, weight loss, gastrointestinal symptoms and use of nutritional therapy were also evaluated.

RESULTS

Thirty-five patients were included in this study (25 autologous and ten allogeneic). The majority (62.6%) were overweight at admission. The median and percentage weight loss were 3.2 kg and 4.6%, respectively. A nutritional supplement was provided to 33 patients for a median of nine days. The most prevalent gastrointestinal symptoms were nausea (91.4%), vomiting (88.6%) and diarrhea (80%). The mean caloric and protein intake and adequacy of patients were 1569.0 ± 443.3 Kcal (73.6 ± 22.1%) and 66 ± 22.8 g (61.9 ± 20%), respectively. The allogeneic group presented lower intake and caloric and protein adequacy throughout hospitalization, in particular in P2, compared to the autologous patients.

CONCLUSION

The patients presented deterioration of nutritional status during hospitalization with the reduction in food intake being greater in patients submitted to allogeneic transplantation.

Implementing and sustaining an evidence-based nutrition service in a haematology unit for autologous stem cell transplant patients

PURPOSE

Effective, timely and evidence-based nutritional management is important in patients receiving autologous haematopoietic stem cell transplant (HSCT) to prevent the negative consequences of developing malnutrition. This study describes a robust process for development and implementation of an evidence-based nutrition care pathway for HSCT patients in a tertiary cancer centre.

METHODS

A comprehensive review of the literature was completed to identify relevant articles and evidence-based guidelines to inform the development of the pathway. Evidence from the literature review was assessed and utilised to underpin the development of pathway. The pathway was implemented in the haematology service in collaboration with the multidisciplinary haematology team. Dietetic resource requirements for implementation of the pathway were determined and clinician compliance with the care pathway was assessed to evaluate the feasibility of the pathway in supporting delivery of evidence-based care.

RESULTS

The evidence-based care pathway was implemented in 2011 with the final care pathway based on recommendations from five international evidence-based guidelines. Overall clinician compliance with delivering nutrition management described in the care pathway was high at 84%. The dietetic resource requirement for implementation of the care pathway was 300 to 400 h per 100 patients depending on conditioning chemotherapy regimen.

CONCLUSION

A robust process for developing and implementing a nutrition care pathway for HSCT patients was effective in supporting the delivery of evidence-based nutritional management for patients treated with HSCT.

Optimization of nutrition during allogeneic hematologic stem cell transplantation

PURPOSE OF REVIEW

Malnutrition before and during hematopoietic stem cell transplantation (HSCT) is an independent risk factor for mortality in patients undergoing hematopoietic stem cell transplantation. Yet, optimal use of nutritional support to improve outcomes remains controversial. Our aim was to do an up-to-date literature review regarding nutritional therapy in allogeneic HSCT, the neutropenic diet and the use of immunonutrients.

RECENT FINDINGS

Several observational studies find malnutrition to be associated with poor outcome, increased complications and lower overall survival. There are, however, few interventional trials proving the benefits of nutritional therapy in this population compared with no nutritional treatment. Regarding routes of treatment, studies suggested that parenteral nutrition is associated with higher risk for complications compared with enteral nutrition. Whether the use of specific formulas, such as immunonutrition, has a beneficial effect on clinical outcome is not established yet. Strict use of neutropenic diets did not show a reduction in infection risk and clinical outcome, and can no longer be recommended.

SUMMARY

Our updated search confirms that malnutrition is a strong negative predictor for outcome, yet optimal use of nutritional interventions to prevent or treat malnutrition remains ill-defined. There is need for larger randomized trials to better address these issues in the future.

The Effect of Evidence-Based Nutrition Clinical Care Pathways on Nutrition Outcomes in Adult Patients Receiving Non-Surgical Cancer Treatment: A Systematic Review

Nutritional decline associated with non-surgical cancer treatment has been well documented. The implementation of an evidence-based nutrition care pathway is one approach suggested to improve the nutrition outcomes of this group of patients. We aimed to systematically review published original research to determine whether evidence-based nutrition clinical care pathways, as compared with usual care, improve outcomes for patients receiving non-surgical cancer treatment. The review was registered with PROSPERO (CRD42017048816) and followed PRISMA guidelines. The search strategy was conducted in four databases, and supplemented by an internet search, from inception to October 2016. Study quality was assessed using the Quality Criteria Checklist for Primary Research. Results were synthesized descriptively. Six reports of five studies formed the final library with a range of interventions and control practices investigated across several diagnostic groups. Nutrition outcomes were reported using multiple approaches with either no effect, or in favor of the clinical pathway intervention. Risk of bias was low in two studies with some risk in the remaining three studies. It was not possible to determine whether the effect on nutritional outcomes was attributable to care pathway implementation. The need to extend the evidence base through high-quality clinical trials was evident.

Revisiting nutritional support for allogeneic hematologic stem cell transplantation-a systematic review

In 2009, the American Society of Parenteral and Enteral Nutrition and its European counterpart (Euopean Society for Parenteral and Enteral Nutrition) published guidelines regarding nutritional support of patients with hematologic stem cell transplantation. Our aim was to do an up-to-date literature review regarding benefit of nutritional interventions and treatment recommendations. We searched MEDLINE, EMBASE and Cochrane Library for interventional and observational clinical studies. We extracted data based on a predefined case report form and assessed bias. Out of 459 potential abstracts, 13 studies of mostly moderate quality with a total of 18 167 patients were included. Two very large trials reported negative associations of malnutrition and survival, transplant-related mortality and relapse risk. Some trials found enteral nutrition (EN) to be as effective as parenteral nutrition (PN) with lower complication rates. In addition, EN was associated with better survival, less acute GvHD and faster neutrophil recovery. A neutropenic diet was not superior regarding overall survival, but in contrast resulted in higher infection risk. Current moderate quality studies show negative associations of malnutrition and clinical outcomes, with EN being superior to PN. There was no benefit of neutropenic diets. Large, randomized controlled studies are needed to better understand optimal nutritional support in this patient population.