Faculty Bibliography

The dual burden of undernutrition and overnutrition requires a greater understanding and commitment to physician training and specialization in nutrition support. Despite the significant healthcare need and existence of organizations focused on nutrition support such as the American Society for Parenteral and Enteral Nutrition (ASPEN), physician involvement in the nutrition care of high-risk patients remains low. In an ASPEN survey of members, inadequate training among physicians was reported along with significant barriers to involvement in nutrition support, such as insufficient protected time, reduced reimbursement and financial support, inadequate support from administrators or supervisors, as well as a nationwide reduction in number of nutrition support teams. These changes in the healthcare landscape prompted the ASPEN Physician Engagement Committee to develop a critical review focused on domains of nutrition risk assessment, enteral and parenteral access and support, scholarly activities, board certification, administrative responsibilities, education and training opportunities, coding, and reimbursement. The aim of this critical review is to capacitate physicians to engage in nutrition support and enhance their acumen in clinical nutrition to improve patient care and enrich personal and professional development.

PURPOSE OF REVIEW/OBJECTIVE:The purpose of this review is to explore the role of specialized pro-resolving mediators (SPMs) in the resolution of inflammation in inflammatory bowel disease (IBD) focusing on their potential therapeutic benefits in these conditions. RECENT FINDINGS/RESULTS:IBD is characterized by chronic inflammation and mucosal barrier dysfunction, driven by a dysregulated immune response. SPMs, which are derived from polyunsaturated fatty acids, have been identified as active agents in resolving inflammation without impairing immune function. Preclinical studies indicate that SPMs can reduce intestinal inflammation, but clinical data are still limited. Moreover, SPMs may influence colorectal cancer (CRC) by modulating tumor-promoting inflammation and enhancing chemotherapy response. SPMs offer a promising approach to inflammation resolution and mucosal healing in IBD and CRC. However, further research is necessary to better understand their therapeutic potential and to establish their clinical applicability in these diseases.

PURPOSE OF REVIEW/OBJECTIVE:Fiber restriction has been a long-standing strategy for patients with inflammatory bowel disease (IBD), ostensibly to improve symptoms and reduce complications. Fiber though has a well-documented trophic effect on gut barrier defenses and the intestinal microbiome. This report discusses how texture modification may allow the safe and effective provision of much needed fiber to this patient population. RECENT FINDINGS/RESULTS:The effect of dietary fiber is characterized by maintenance of gut integrity, support of the microbiome, and immune modulation. Low-fiber diets in patients with IBD result in greater dysbiosis, intestinal permeability, and mucosal inflammation. New recommendations from international IBD guidelines now promote texture modification to allow for inclusion of fiber in certain conditions of IBD. For patients flaring with acute inflammation, or those with ileostomy, intestinal stricture, or ileal pouch anastomosis, continued fiber intake with softer textures and mechanical modification should be prioritized when feasible. For patients recovering from surgery, diet advancement should include reintroduction of soluble and insoluble fibers, while those in remission should have little or no dietary restrictions. Texture modification of high fiber foods may be accomplished by a variety of strategies involved in the selection, preparation, and cooking of fruits and vegetables. Greater effort to include dietary soluble and insoluble fiber should result in clinical benefit to the IBD patient, avoiding the adverse consequences of a low-fiber diet.

BACKGROUND/AIMS/UNASSIGNED:Percutaneous endoscopic gastrostomy (PEG) tube placement is a common procedure used to initiate enteral feeding. To our knowledge, there are no previous studies that analyze predictors of PEG failure. This study aims to identify risk factors for failure of inpatient PEG placement. METHODS/UNASSIGNED:A retrospective chart review was conducted of inpatients in the Montefiore Health System who were scheduled to undergo PEG placement from 2016 to 2020 (n=1,138). Patient, endoscopist, and procedural characteristics were summarized using descriptive statistics, both overall and stratified by whether the PEG was successfully placed. RESULTS/UNASSIGNED:The overall success rate of PEG placement was 89%. The most common indications included stroke (31%), dementia (27%), and ventilator use (24%). Patient characteristics, including body mass index (BMI) (p=0.16) and indication for PEG placement (p=0.06), were not significantly associated with PEG failure. Instead, endoscopist and procedural characteristics were found to be significant, including type of attending (p<0.001), location of case (p=0.02), and category of anesthesia (p<0.001). CONCLUSIONS/UNASSIGNED:PEG placement remains a highly successful procedure. Endoscopist and procedural characteristics, not patient characteristics, were associated with PEG placement success. Notably, patient BMI and indication for PEG placement could not be used to risk stratify candidates for PEG placement.

Patients requiring complex or extensive surgery are often at high risk for perioperative and postoperative nutrition risk. Despite published guidelines, providing adequate nutrition to these patients continues to remain a clinical challenge. Using the case of a patient with preoperative nutrition risk who will need to undergo timely cancer resectional surgery, speakers presenting at the American Society for Parenteral and Enteral Nutrition 2022 Preconference discussed novel strategies to assess for nutrition risk, enhanced recovery after surgery, and preoperative and postoperative nutrition management in these often complex surgical patients.

There is evidence that significant quality problems arise as patients transitions in care from one setting to another. Attention to nutrition during transitions of care is important to avoid complication. During the American Society for Parenteral and Enteral Nutrition 2022 preconference course, nutrition during transition of care from pediatric to adult care, from the intensive care unit to the hospital floors and from the hospital to home was addressed.

BACKGROUND:Malnutrition is underrecognized and underdiagnosed, despite high prevalence rates and associated poor clinical outcomes. The involvement of clinical nutrition experts, especially physicians, in the care of high-risk patients with malnutrition remains low despite evidence demonstrating lower complication rates with nutrition support team (NST) management. To facilitate solutions, a survey was designed to elucidate the nature of NSTs and physician involvement and identify needs for novel nutrition support care models. METHODS:This survey assessed demographics of NSTs, factors contributing to the success of NSTs, elements of nutrition education, and other barriers to professional growth. RESULTS:Of 255 respondents, 235 complete surveys were analyzed. The geographic distribution of respondents correlated with population concentrations of the United States (r = 90.8%, p < .0001). Most responding physicians (46/57; 80.7%) reported being a member of NSTs, compared with 56.5% (88/156) of dietitians. Of those not practicing in NSTs (N = 81/235, 34.4%), 12.3% (10/81) reported an NST was previously present at their institution but had been disbanded. Regarding NSTs, financial concerns were common (115/235; 48.9%), followed by leadership (72/235; 30.6%), and healthcare professional (HCP) interest (55/235; 23.4%). A majority (173/235; 73.6%) of all respondents wanted additional training in nutrition but reported insufficient protected time, ability to travel, or support from administrators or other HCPs. CONCLUSION/CONCLUSIONS:Core actions resulting from this survey focused on formalizing physician roles, increasing interdisciplinary nutrition support expertise, utilizing cost-effective screening for malnutrition, and implementing intervention protocols. Additional actions included increasing funding for clinical practice, education, and research, all within an expanded portfolio of pragmatic nutrition support care models.

Pharmacologic management for ulcerative colitis (UC) has recently been expanded to include anti- tumor necrosis factor (TNF) therapy for severe disease. Infliximab, a chimeric monoclonal antibody directed again TNF alpha was first tested in patients with Crohn's disease. In addition to serious infections, malignancy, drug induced lupus and other autoimmune diseases, serum sickness-like reactions, neurological disease, and infusion reactions further complicate the use of Infliximab. We report a case of prolonged fever after Infliximab infusion to treat steroid refractory UC.