An electronic decision tree to guide physicians in prescribing parenteral nutrition in hospitalised patients: development, validation and proof of concept

AbstractVegetable lipid emulsions (LE) contain non-declared phytosterols (PS). We aimed to determine PS content depending on the brand and LE batch, and in adult hospitalised patients treated with parenteral nutrition (PN), to establish the association between plasma and administered PS. Part I was the LE study: totals and fractions of PS in three to four non-consecutive batches from six LE were analysed. Part II was the patient study: patients with at least 7 previous days of PN with 0·8 g/kg per d of an olive/soyabean (O/S) LE were randomised (day 0) 1:1 to O/S or 100 % fish oil (FO) at a dose of 0·4 g/kg per d for 7 d (day 7). Plasma PS, its fractions, total cholesterol on days 0 and 7, their clearance and their association with PS administered by LE were studied. In part I, LE study: differences were found in the total PS, their fractions and cholesterol among different LE brands and batches. Exclusive soyabean LE had the highest content of PS (422·36 (sd 130·46) μg/ml). In part II, patient study: nineteen patients were included. In the O/S group, PS levels were maintained (1·11 (sd 6·98) μg/ml) from day 0 to 7, while in the FO group, significant decreases were seen in total PS (−6·21 (sd 4·73) μg/ml) and their fractions, except for campesterol and stigmasterol. Plasma PS on day 7 were significantly associated with PS administered (R2 0·443). PS content in different LE brands had great variability. PS administered during PN resulted in accumulation and could be prevented with the exclusive administration of FO LE.

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Namilumab or infliximab compared with standard of care in hospitalised patients with COVID-19 (CATALYST): a randomised, multicentre, multi-arm, multistage, open-label, adaptive, phase 2, proof-of-concept trial

The Lancet Respiratory Medicine ◽

10.1016/s2213-2600(21)00460-4 ◽

2021 ◽

Author(s):

Benjamin A Fisher ◽

Tonny Veenith ◽

Daniel Slade ◽

Charlotte Gaskell ◽

Matthew Rowland ◽

...

Keyword(s):

Standard Of Care ◽

Phase 2 ◽

Proof Of Concept ◽

Open Label ◽

Hospitalised Patients

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Detecting explosives by PGNAA using KNN Regressors and decision tree classifier: A proof of concept

Progress in Nuclear Energy ◽

10.1016/j.pnucene.2020.103332 ◽

2020 ◽

Vol 124 ◽

pp. 103332 ◽

Cited By ~ 1

Author(s):

K. Hossny ◽

S. Magdi ◽

Abdelfattah Y. Soliman ◽

Ahmad Hany Hossny

Keyword(s):

Decision Tree ◽

Proof Of Concept ◽

Decision Tree Classifier ◽

Tree Classifier

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Macrolide combination therapy for patients hospitalised with community-acquired pneumonia? An individualised approach supported by machine learning

European Respiratory Journal ◽

10.1183/13993003.00824-2019 ◽

2019 ◽

Vol 54 (6) ◽

pp. 1900824 ◽

Cited By ~ 3

Author(s):

Rainer König ◽

Xueqi Cao ◽

Marcus Oswald ◽

Christina Forstner ◽

Gernot Rohde ◽

...

Keyword(s):

Machine Learning ◽

Combination Therapy ◽

Decision Tree ◽

Controlled Trial ◽

Community Acquired Pneumonia ◽

Moderate Severity ◽

Respiratory Secretion ◽

Hospitalised Patients ◽

Atypical Pathogens ◽

Leukocyte Counts

BackgroundThe role of macrolide/β-lactam combination therapy in community-acquired pneumonia (CAP) of moderate severity is a matter of debate. Macrolides expand the coverage to atypical pathogens and attenuate pulmonary inflammation, but have been associated with cardiovascular toxicity and drug interactions. We developed a decision tree based on aetiological and clinical parameters, which are available ex ante to support a personalised decision for or against macrolides for the best clinical outcome of the individual patient.MethodsWe employed machine learning in a cross-validation scheme based on a well-balanced selection of 4898 patients after propensity score matching to data available on admission of 6440 hospitalised patients with moderate severity (non-intensive care unit patients) from the observational, prospective, multinational CAPNETZ study. We aimed to improve the primary outcome of 180-day survival.ResultsWe found a simple decision tree of patient characteristics comprising chronic cardiovascular and chronic respiratory comorbidities as well as leukocyte counts in the respiratory secretion at enrolment. Specifically, we found that patients without cardiovascular or patients with respiratory comorbidities and high leukocyte counts in the respiratory secretion benefit from macrolide treatment. Patients identified to be treated in compliance with our treatment suggestion had a lower mortality of 27% (OR 1.83, 95% CI 1.48–2.27; p<0.001) compared to the observed standard of care.ConclusionStratifying macrolide treatment in patients following a simple treatment rule may lead to considerably reduced mortality in CAP. A future randomised controlled trial confirming our result is necessary before implementing this rule into the clinical routine.

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Parenteral nutrition line sepsis: the difficulty in diagnosis

Proceedings of The Nutrition Society ◽

10.1017/s0029665110001540 ◽

2010 ◽

Vol 69 (4) ◽

pp. 508-510 ◽

Cited By ~ 1

Author(s):

Derek McWhirter

Keyword(s):

Parenteral Nutrition ◽

Standard Technique ◽

Exact Science ◽

True Number ◽

Hospitalised Patients ◽

Microbiological Techniques ◽

Modern Medical Practice ◽

Definition Of ◽

Line Infection ◽

Line Sepsis

Parenteral nutrition (PN) line sepsis is a common and yet poorly managed complication in hospitalised patients receiving PN. Making a clinical diagnosis is difficult as the clinical picture can be very non-specific and definitions of what constitutes line infection can vary. Once there is clinical suspicion, proving it with microbiological techniques is not an exact science. Traditional techniques have required the removal of the PN line to allow microbiologists to perform analysis of it for infection. This has obvious drawbacks as it is often not easy to replace the line in these patients and the line is often later proven not to be the source of the sepsis. Although the gold-standard technique still requires removal of the line, there has been development in the field of diagnosis line infection while conserving the line. These include intra-luminal brushings of the line, differential blood cultures and simple swabs of the line hub. These techniques are not as sensitive but reduce the problems caused by removing and re-inserting the line in these patients. The definition of PN line sepsis varies between institutions. Rates can be expressed as a true number of cases, or can be expressed correctly as a number of cases per 1000 line days to standardise rates between units of differing sizes. Rates can also be altered if the diagnostic criteria are too strict or too lax. Accurate diagnosis of PN line sepsis remains difficult in modern medical practice.

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Namilumab or infliximab compared to standard of care in hospitalised patients with COVID-19 (CATALYST): a phase 2 randomised adaptive trial

10.1101/2021.06.02.21258204 ◽

2021 ◽

Author(s):

Benjamin A Fisher ◽

Tonny Veenith ◽

Daniel Slade ◽

Charlotte Gaskell ◽

Matthew Rowland ◽

...

Keyword(s):

Usual Care ◽

Clinical Outcomes ◽

Standard Of Care ◽

Phase 2 ◽

Proof Of Concept ◽

Open Label ◽

Hospitalised Patients ◽

Factor Inhibitor ◽

Poor Outcomes ◽

Over Time

Background Dysregulated inflammation is associated with poor outcomes in Coronavirus disease 2019 (COVID-19). We assessed the efficacy of namilumab, a granulocyte-macrophage colony-stimulating factor inhibitor and infliximab, a tumour necrosis factor inhibitor in hospitalised patients with COVID-19 in order to prioritise agents for phase 3 trials. Methods In this randomised, multi-arm, parallel group, open label, adaptive phase 2 proof-of-concept trial (CATALYST) we recruited hospitalised patients ≥16 years with COVID-19 pneumonia and C-reactive protein (CRP) ≥40mg/L in nine UK hospitals. Participants were randomly allocated with equal probability to usual care, or usual care plus a single 150mg intravenous dose of namilumab (150mg) or infliximab (5mg/kg). Randomisation was stratified for ward versus ICU. The primary endpoint was improvement in inflammation in intervention arms compared to control as measured by CRP over time, analysed using Bayesian multi-level models. ISRCTN registry number 40580903. Findings Between 15th June 2020 and 18th February 2021 we randomised 146 participants: 54 to usual care, 57 to namilumab and 35 to infliximab. The probabilities that namilumab and infliximab were superior to usual care in reducing CRP over time were 97% and 15% respectively. Consistent effects were seen in ward and ICU patients and aligned with clinical outcomes, such that the probability of discharge (WHO levels 1-3) at day 28 was 47% and 64% for ICU and ward patients on usual care, versus 66% and 77% for patients treated with namilumab. 134 adverse events occurred in 30/55 (54.5%) namilumab patients compared to 145 in 29/54 (53.7%) usual care patients. 102 events occurred in 20/29 (69.0%) infliximab patients versus 112 events in 17/34 (50.0%) usual care patients. Interpretation Namilumab, but not infliximab, demonstrated proof-of-concept evidence for reduction in inflammation in hospitalised patients with COVID-19 pneumonia which was consistent with secondary clinical outcomes. Namilumab should be prioritised for further investigation in COVID-19. Funding Medical Research Council.

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Caloric adequacy of parenteral nutrition and its influence on the clinical outcome of hospitalised patients

Nutrition and Health ◽

10.1177/02601060211070108 ◽

2022 ◽

pp. 026010602110701

Author(s):

Carmen de Cáceres ◽

Teresa Rico ◽

Cristina Abreu ◽

Ana Isabel Velasco ◽

Rafael Lozano ◽

...

Keyword(s):

Parenteral Nutrition ◽

Clinical Outcomes ◽

Nutrient Intake ◽

Prospective Observational Study ◽

Positive Impact ◽

Length Of Hospital Stay ◽

Infectious Complications ◽

Anthropometric Parameters ◽

Predictive Equations ◽

Hospitalised Patients

Background: The adaptation of Parenteral Nutrition (PN) to actual energy requirements of hospitalised patients is essential, since excessive and insufficient nutritional intake have been associated with poor clinical outcomes. Aim: To evaluate the adaptation of prescribed PN to the estimated nutritional requirements using three predictive equations and the influence of excessive/insufficient nutrient intake on patient clinical outcomes (nutritional parameters, metabolic and infectious complications). Methods: Prospective, observational study in hospitalised patients nutritionally assessed. Data was collected the first and fifth/sixth day of PN with clinical (infection, length of hospital stay), biochemical (visceral proteins, cholesterol, glucose, triglycerides, lymphocytes, CRP) and anthropometric parameters (skin folds, height, weight). Theoretical requirements were calculated using Harris-Benedict (HB), Mifflin-St Jeor (MF) and 25 Kcal/Kg/day formulas. The HB formula was used to compare estimated and provided requirements. Results: A total of 94 patients (mean: 72 ± 13.7 years old) were included with initial mean weight and height of 69.2 Kg and 162.8 cm, respectively (mean BMI: 26.1 Kg/m2). No statistically significant differences were found between the actual (1620 Kcal/day) and estimated caloric mean calculated with HB (1643 Kcal/day) and MF (1628 Kcal/day). When comparing with the caloric estimation, 31.9% of patients were underfed, while 14.9% were overfed. Intergroup analysis demonstrated significant variations in albumin, prealbumin, glucose, cholesterol, triglycerides and MUAC, with a significant increase of hyperglycaemia (+37.86; p < 0.05) and hypertriglyceridemia (+63.10; p < 0.05), being higher in overfed patients. Conclusion: In our study, inadequate nutrient intake was associated with a higher degree of hyperglycaemia and hypertriglyceridemia, without positive impact on anthropometric parameters.

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