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Guideline for developing clinical guidelines

Chinese Journal of Clinical Nutrition.2013;(3):140-142. doi:10.3760/cma.j.issn.1674-635X.2013.03.002

Clinical practice guidelines have been widely applied worldwide.Compared with the developed countries,however,the development of guidelines still has many limitations in China,which is mainly due to the lack of a guideline for guiding this process.Such a guideline,defined as “a structured and coordinated programme designed with the specific aim of producing several clinical practice guidelines should be able to specify the development,dissemination,implementation,evaluation,and update of each clinical practice guideline.Furthermore,the lack of high-quality randomized controlled trials and cohort studies also restricts the development of high-level guidelines.After the development of such a guideline for developing guidelines,we can expect the faster development of Chinese clinical practice guidelines that are more carefully designed,more reliable,and more practical.

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Change of dietary intake before and after hematopoietic stem cell transplantation in pediatric patients

Jun FEI ; Liya PAN ; Chenlin ZHU ; Yi FENG ; Zhuoqi ZHAO ; Li HONG

Chinese Journal of Clinical Nutrition.2014;22(2):67-73. doi:10.3760/cma.j.issn.1674-635X.2014.02.001

Objective To explore the change of dietary intake and nutritional status before and after hematopoietic stem cell transplantation (HSCT) in pediatric patients to assess the importance of nutritional interventions.Methods In this observational cohort study,65 children undergoing HSCT between January 2012 and November 2012 in the Department of Hematology and Oncology,Shanghai Children's Medical Center were enrolled.The data collected before preconditioning were considered as the baseline data.We also collected data twice a week between preconditioning and 30 days after HSCT,and once a week from 30 days to 100 days after HSCT.Dietary analysis and urea nitrogen analysis were conducted in parallel.Results The baseline level of energy intake was (5 844.9 ±2 490.4) kJ/d,protein intake was (56.4 ±28.6) g/d,fat intake was (49.7 ±38.9) g/d,and carbohydrate intake was (190.9 ± 91.1) g/d.With the hematopoietic reconstruction,the oral nutrients intake significantly decreased compared with the baseline levels (all P =0.000).During the recovery period after HSCT,the energy intake showed no significant difference when compared with the baseline level in the 6th postoperative week,protein in the 13th week,carbohydrate in the 4th week,and fat in the 6th week.The urine nitrogen was (3.9 ± 2.4) g/d before HSCT,which increased to (16.7 ± 11.0) g/d after preconditioning (P=0.000).In the 1st postoperative week,the weight (P =0.000),triceps skin fold thickness (P =0.003),mid-upper arm circumference (P =0.000),serum albumin (P =0.000) and prealbumin (P =0.000) of the patients all significantly decreased compared with the baseline levels.In the 9th postoperative week,the fat-free body weight percentage (P =0.010),muscle percentage (P =0.001) and protein percentage (P =0.000) were significantly lower than the baseline levels,while the body fat percentage was higher than the baseline level (P =0.002).Conclusions Children undergoing HSCT exhibit a marked reduction in nutrient intakes at the early stage of HSCT,which may gradually return normal during the recovery period.This process may be slow,especially for the protein,and therefore may affect the serum protein level in these pediatric patients.Thus,more careful nutrition guidance is necessary during HSCT for pediatric patients,emphasizing oral nutrients intakes,and high protein dietary or formula may be helpful.

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Level of serum palmitic acid in patients with non-alcoholic fatty liver disease

Kenan PENG ; Zhipeng TANG ; Bo LIU ; Haili ZHAO ; Guojing CHAI ; Xiaoyun ZHAO

Chinese Journal of Clinical Nutrition.2014;22(2):92-96. doi:10.3760/cma.j.issn.1674-635X.2014.02.005

Objective To analyze the serum levels of medium-and long-chain free fatty acids (FFAs)in patients with hyperlipidemic non-alcoholic fatty liver disease (NAFLD) in order to shed some light on prevention and treatment of NAFLD.Methods The clinical data of 125 patients with high triglyceride (TG)levels who were treated in Hebei General Hospital from January 2011 to May 2011 were analyzed in this study.They were further divided into HF group (n =64) and H group (n =61) based on the presence of NAFLD or not.In addition,63 healthy individuals were recruited from the Central Hospital of Handan during the same period as the control group (N group).Serum medium-and long-chain FFAs were detected by gas chromatography.The body mass index (BMI),abdominal circumference,blood pressure,fasting blood glucose (FBG),and serum lipids including TG,total cholesterol (TC),high-density lipoprotein cholesterol (HDL-C),and low-density lipoprotein cholesterol (LDL-C) were measured.Results Compared with the N group,the H group had significantly higher BMI [(25.24 ± 1.41) kg/m2 vs.(24.32 ± 1.12) kg/m2,P =0.004],abdominal circumference [(84.72 ± 1.34) cm vs.(77.33 ±0.89) cm,P =0.010],and diastolic blood pressure [(77.35±1.21) mmHgvs.(75.21 ±1.61) mmHg,P=0.014]; also,the serum TG [(2.86±0.55) mmol/Lvs.(0.93±0.27) mmol/L,P=0.000] andTC levels [(4.56±0.66) mmol/Lvs.(4.36±0.47) mmol/L,P=0.000],serum myristic acid (C14∶0) [(0.49±0.04)％ vs.(0.36±0.01)％,P=0.011],palmitic acid (C16 ∶ 0) [(18.36 ± 0.47) ％ vs.(15.97 ± 0.30) ％,P =0.000],palmitoleic acid (C16∶ 1) [(1.00±0.12)％ vs.(0.58±0.02)％,P=0.001],and oleic acid (C18 ∶ 1) [(18.20±0.70) ％ vs.(12.23 ± 0.37) ％,P =0.000] all significantly increased,while stearic acid (C18 ∶ 0) [(7.52 ±0.22)％ vs.(8.15 ±0.28)％,P=0.012],eicosadienoic acid (C20 ∶ 2) [(0.61 ±0.07)％ vs.(1.03 ±0.17) ％,P =0.000],eicosatrienoic acid (C20 ∶ 3) [(1.77 ± 0.15) ％ vs.(2.49 ± 0.18) ％,P =0.002],and docosahexenoic acid (C22 ∶ 6) [(1.44 ± 0.08) ％ vs.(1.67 ± 0.09) ％,P =0.014] significantly decreased.Compared with the H group,the HF group had significantly higher weight [(85.76 ± 3.10) kg vs.(71.45 ±2.88) kg,P =0.003],abdominal circumference [(96.30 ±2.05) cm vs.(84.72 ± 1.34) cm,P=0.000],systolic blood pressure [(117.12 ±1.15) mmHg vs.(113.23 ±1.25) mmHg,P=0.009],and diastolic blood pressure [(79.54 ± 1.42) mmHg vs.(77.35 ± 1.21) mmHg,P =0.016],whereas the sreum FGB,TG,TC,HDL-C,and LDL-C showed no significant differentces; serum palmitic acid (C16 ∶ 0)[(19.54 ± 0.30) ％ vs.(18.36 ± 0.47) ％,P =0.000] also significantly increased.The serum level of eicosadienoic acid (C20 ∶ 2) in HF group was between that in N group and H group [(0.78 ± 0.09) ％ vs.(1.03 ±0.17)％,(0.78±0.09)％ vs.(0.61 ±0.07)％,both P=0.000].Conclusions The increased serum level of palmitic acid may be a risk factor for NAFLD.Reducing saturated fatty acids and increasing unsaturated acids in diets may be helpful for preventing NAFLD.

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Application and tolerance analysis of postoperative enteral nutrition in patients with gastric cancer

Qinmeng HOU ; Lianan DING ; Dongguang NIU ; Guojian QU ; Luguang LIU

Chinese Journal of Clinical Nutrition.2014;22(2):97-100. doi:10.3760/cma.j.issn.1674-635X.2014.02.006

Objective To explore the factors related to the tolerance to enteral nutrition (EN) in gastric carcinoma patients undergoing surgical treatment and the implementation strategy of EN.Methods Fifty-four patients with gastric carcinoma undergoing surgery from November 2011 to September 2012 in the Affiliated Hospital of Medical College of Qingdao University were enrolled.EN were applied with sequential and gradual strategies.The tolerance status to EN was recorded.Factors related to the patient tolerance to EN were analyzed using single-factor and multiple-factor Logistic regression analysis.The incidences of gastrointestinal symptoms during EN application were recorded.Results Among the 54 patients,49 (90.74％) patients could tolerate EN.Single-factor analysis and multiple-factor Logistic regression analysis both showed that tumor staging (single-factor analysis:x2 =7.287,P =0.007 ; multiple-factor analysis:t =2.559,P =0.014) and surgical approach (singlefactor analysis:x2 =7.825,P =0.005 ; multiple-factor analysis:t =2.254,P =0.043) were major factors affecting patient tolerance to EN.Among the patients tolerant to EN,abdominal distension (19/49,38.8％) was the major gastrointestinal symptom of EN.Conclusion The sequential and gradual EN application strategy is suitable for the patients with gastric cancinoma after surgery,and can be widely used in clinical practice.

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Effects of perioperative probiotics administration on patients with colorectal cancer

Hongqi CHEN ; Yang XIA ; Chenzhang SHI ; Yong LIANG ; Yongzhi YANG ; Huanlong QIN

Chinese Journal of Clinical Nutrition.2014;22(2):74-81. doi:10.3760/cma.j.issn.1674-635X.2014.02.002

Objective To evaluate the effects of perioperative probiotics administration on patients with colorectal cancer and to explore its possible mechanism.Methods Seventy patients with colorectal cancer who were scheduled to undergo radical colorectomy at Shanghai Sixth People's Hospital between May 2011 and July 2011 were randomly divided with random number table into the control group (n =35) and the treatment group (n =35).The two groups in 5 days preoperatively and 7 days postoperatively were given daily doses of probiotics preparation consisting of two combined live bacteria and placebo,respectively.The structure of intestinal epithelial tight junction was observed by electron microscopy in colorectal tissue specimens collected during the operation.The expression of tight junctional protein was detected using Western blot and real-time RT-PCR technology.Intestinal epithelial permeability was evaluated by Ussing Chamber system.Stool samples and blood samples were collected on the 7th day after operation.The diversity of faecal flora was analyzed by terminal restriction fragment length polymorphism (T-RFLP) technique,and the quantitative detection of specific bacteria was conducted by bacterial culture.Clinical parameters including the first exhaust and defecate time,distension and diarrhea incidence,systemic inflammatory response,and postoperative infective complications were recorded.Results Compared with the control group,the treatment group showed better intestinal epithelial tight junction ultrastructure.The expression of tight junction proteins occludin,claudin-1,and ZO-1 (protein:all P ＜ 0.001 ; mRNA:P =0.005,0.001,0.006) and the transepithelial electrical resistance [(28.3 ±5.2) Ω · cm2 vs.(22.1 ± 4.7) Ω · cm2,P =0.002] were significantly increased,the large molecule permeability [(0.91 ± 0.17) ％ vs.(1.65 ± 0.33) ％,P ＜ 0.001] reduced,the diversity of intestinal flora (P=0.006) increased,the growth of intestinal Bifidobacteria [(143.4 ±35.9) vs.(100.0 ±0.0),P=0.002] and Lactobacilli [(111.3 ± 52.9) vs.(100.0 ± 0.0),P ＜ 0.001] promoted,and the growth of Clostridium perfringens [(66.2 ±23.7) vs.(100.0 ±0.0),P ＜0.001] inhibited in the treatment group.The treatment group also showed shorter postoperative exhaust [(2.5 ± 1.7) d vs.(4.5 ±2.0) d,P ＜0.001] and defecate time [(5.0 ± 1.3) d vs.(6.3 ± 1.1) d,P =0.002],lower incidence of diarrhea (20％ vs.40％,P =0.005) and abdominal distension (35 ％ vs.60％,P =0.021).Conclusion Probiotics used perioperatively in patients with colorectal cancer can effectively enhance the intestinal epithelia barrier function,maintain the homeostasis of gut flora,shorten the postoperative first exhaust and defecate time,reduce the incidence of diarrhea and abdominal distension,and promote the recovery of intestinal function.

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Correlation of the nutritional status with liver function and clinical outcomes in surgically treated liver cancer patients

Hongyuan CUI ; Zhao LI ; Jiye ZHU

Chinese Journal of Clinical Nutrition.2014;22(2):82-86. doi:10.3760/cma.j.issn.1674-635X.2014.02.003

Objective To investigate the relationship of the nutritional status with liver function and clinical outcomes of liver cancer patients treated with surgery.Methods Altogether 112 hospitalized patients undergoing surgical treatments for liver cancer were enrolled from October 2011 to October 2013.Their general clinical data were collected,including creatinine-height index (CHI),arm circumference,grip strenghth,albumin,prealbumin,and transferrin.The nutritional status was assessed using Patient-Generated Subjective Global Assessment (PG-SGA).The liver function was assessed with Child-Pugh classification.Postoperative infectious complications and the hospital stays were recorded to assess the clinical outcomes.The correlation between nutritional status and liver function,and that between nutritional status and clinical outcomes were analyzed.Results Among the 112 patients,70 (62.5％) were in normal nutritional status,34 (30.4％) were with moderate malnutrition,and 8 (7.1％) were with severe malnutrition according to PG-SGA scores.PG-SGA assessment showed strong consistence with CHI nutritional assessment (κ =0.760,P =0.000),and moderate consistence with arm circumference assessment (κ =0.564,P =0.000),and grip strength assessment (κ =0.523,P =0.000).The live function classified by Child-Pugh was found highly correlated with PG-SGA assessment (rs =0.829,P =0.000).Postoperative infectious complications and hospital stays were both positively correlated with PG-SGA assessment (r =0.349,P =0.000 ; r =0.624,P =0.000).Conclusions PD-SGA combining with CHI can be used for the nutritional status assessment of liver cancer patients undergoing surgical treatments.The nutritional status of the patients has positive correlation with live function,infectious complications,and postoperative hospital stays.

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Staphylococcus aureus DNA in human venous blood detected by real-time quantitative PCR assay

Junren KANG ; Enling MA ; Jiabin FANG ; Xizeng CUI

Chinese Journal of Clinical Nutrition.2014;22(2):101-105. doi:10.3760/cma.j.issn.1674-635X.2014.02.007

Objective To establish a rapid real-time quantitative polymerase chain reaction (RQ-PCR)assay in quantifying and detecting Staphylococcus aureus DNA from human venous blood samples,so as to quantificationally evaluate the systemic infection caused or deteriorated by intestinal bacteria translocation.Methods Totally 26 clinical blood samples and 15 simulation blood samples were detected.The primers and TaqMan probe were designed targeting the highly conserved house-keeping femA gene of Staphylococcus aureus,and a 20 μl RQ-PCR amplification reaction system was established.The standard curve was built based on the recombinant plasmid DNA containing the amplicon of the target gene,and genomic DNA was extracted using QIAamp DNA Blood Mini Kit.Results The specificity of primers and probe was excellent,the detecting limit was 100 copies/μl (103 CFU/ml),the sensitivity was 99.7％,and the specificity was 94.6％.The correlation coefficient of the standard curve was between 0.9918 and 0.9997.For samples with different Staphylococcus anreus concentrations,the average accuracy of the RQ-PCR assay was (96.25 ± 2.26) ％ ; the intra-and interassay coefficients of variation were (8.06 ±0.07)％ and (10.01 ±4.40)％,respectively.The average recovery rate of Staphylococcus aureus DNA in blood samples was (111.72 ± 20.72) ％.In clinical blood samples,the positive rate of Staphylococcus aureus DNA was 15.4％ (4/26),while the blood culture of these samples all produced negative result for Staphylococcus aureus.Conclusion RQ-PCR assays is a rapid,sensitive,and specific method with good repetitiveness and can be used in the quantitative detection of Staphylococcus aureus in whole blood samples.

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Advances in nutrition screening and nutritional assessment among critically ill children

Jingjing LI ; Ying WANG

Chinese Journal of Clinical Nutrition.2014;22(2):106-111. doi:10.3760/cma.j.issn.1674-635X.2014.02.008

Malnutrition is common in critically ill children.Nutrition prescription is hampered by various factors,and the nutritional status of these children often deteriorates during hospitalization.Nutrition therapy for critically ill children must be based on proper nutrition screening and nutritional assessment.Adopting dynamic nutritional assessment is an effective method to monitor patients under nutrition therapy and inform the prescription and administration of nutrition therapy.This article reviews the recent advances in nutrition screening and nutritional assessment in critically ill children.

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Vascular ultrasound combined with Seldinger technology improves the success rate of peripherally inserted central catheter and reduces potential complications

Hui TANG ; Qiufen XIANG ; Chunhua YU ; Yan FU ; Junying LI

Chinese Journal of Clinical Nutrition.2012;20(3):178-181. doi:10.3760/cma.j.issn.1674-635X.2012.03.011

ObjectiveTo investigate the applicability and superiority of modified Seldinger technique (MST).MethodsTotally 108 patients receiving peripherally inserted central catheter (PICC) through vascular ultrasound combined with MST technology were enrolled as MST group and another 108 patients receiving PICC using traditional direct vision method as control group.The first puncture success rate,PICC succesa rate,catheterization time required,and early complication rate were compared between these two groups.ResultsThe first puncture success rate was 88.89％ in MST group and 72.22％ in control group (P=0.002) ; the catheterization success rate was 82.41％ in MST group and 57.41％ in control group ( P =0.000).In the MST group,there were two cases where the catheter within neck was ectopic ( P =0.003 ),two cases experienced bleeding at the puncture sites (P =0.017),three cases had phlebitis (P =0.001 ),and one case suffered from catheter blockage (P=0.010).In the eontrol group,the corresponding numbers were 13,10,18,and 9.However,the time required for PICC showed no significant difference between these two groups (P=0.685).In the MST group,15 cases were catheterized in less than 15 minutes,72 cases between 15 and 25 minutes,and 21 cases for more than 25 minutes.In the control group,12 cases were catheterized in less than 15 minutes,70 cases between 15 and 25 minutes,and 26 cases for more than 25 minutes.ConclusionPICC through MST can be more effective in positioning the targeting blood vessels,increasing the success rate of catheter insertion,reducing various tissue damages,and lowering potential complications.

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"Effect of perioperative use of fish oil on ""post-operative fatigue"" of rat"

Qiang WANG ; Ludi DU ; Bicheng CHEN ; Feng ZHOU ; Jingyi YAN ; Zhen YU

Chinese Journal of Clinical Nutrition.2012;20(3):153-157. doi:10.3760/cma.j.issn.1674-635X.2012.03.005

ObjectiveTo investigate the effect of perioperative use of fish oil on post-operative fatigue(POF) of rat.MethodsAfter one week's preoperative behavior training,12 rats presented poor behavior were excluded from 60 healthy adult male SD rats as the normal controls of serum parameters.The remaining 48 rats were randomly divided into model group and fish oil treatment group by random number table.The fish oil treatment group received 10 days' (3 days before surgery and 7 days after surgery) intraperitoneal injection of fish oil [2 ml/( kg · d) ],and the model group with saline.On the 1st,3rd,5th,and 7th post-operative day,rats were assessed by Morris water-maze and tail suspension test.Serum levels of interleukin ( IL)-1β,IL-6,tumor necrosis factor-α (TNF-α),superoxide dismutase (SOD),and glutathione peroxidase (GSH-PX) were measured.ResultsSerum parameters:on the 1st and 3rd post-operative day,the IL-6 level in the fish oil treatment group [ (66.22 ±8.80),(56.03 ± 1.19) pg/ml] was significantly lower than in model group [ (83.30 ± 10.69),(82.72 ± 24.27) pg/ml ] (P =0.034,P =0.038 ) ; on the 1 st,3rd,5th,and 7th post-operative day,the TNF-α level in the fish oil treatment group [ ( 104.36 ±5.02),(84.49 ±7.81 ),(64.47 ±2.89),(39.29 ±2.52)pg/ml ] was significantly lower than in model group [ ( 120.01 ± 14.99 ),( 119.68 ± 8.84),(75.29 ± 2.58 ),(41.96±1.65) pg/ml] (P=0.014,P=0.003,P=0.000,P=0.004); onthe1st,3rd,5th,and 7th postoperative day,the IL-1β level [(155.11 ±9.08),(79.39±5.86),(57.26±16.07),(35.42±1.53) pg/ml]was significantly lower than model group [ (204.87±30.61),(198.82±54.83),(152.12±29.06),(64.35 ± 2.70) pg/ml ] ( P =0.024,P =0.002,P =0.000,P =0.000) ; on the 5th postoperative day,SOD ( 1.08±0.08) μmol/L was significantly higher than model group (0.71±0.06) μmoL/L (P=0.000) ; on the 5th and 7th postoperative day,GSH-PX [ (31.21 ± 1.30), (30.78 ± 1.83) μmol/L] was significantly higher than model group [ (25.03 ±1.74),(27.57±3.57) μ mol/L](P=0.000,P=0.036).Behavior:in tail suspension test,on the 1st and 3rd postoperative day,value of struggle in fish oil treatment group [ (6620 ± 1390),(7011 ± 1472) mv · s] was significantly higher than in model group [ (4739 ± 1040),(4344 ± 1130) mv · s](P=0.048,P=0.043); cumulative fixed time [ (118.42±10.05), (101.02±8.68) s] and single rest time [ (55.39±7.70),(56.60±5.88) s] was lower thanin modelgroup [ (135.08+12.44),(131.02±9.24) s; (65.73±3.78),(64.93±3.25) s] (P=0.042,P=0.012,P=0.043,and P=0.042).In Morris water-maze,on the 3rd and 5th postoperative day,escape latent period of fish oil treatment group [ (48.263 ±1.815),(44.955±2.567) s] was lower than model group [ (51.543±1.990),(49.956±2.888) s] (P=0.035,P=0.035) ; on the 1st,3rd,5th,and 7th postoperative day,the cross platform number (1.04±0.25,1.95±0.49,2.42 ±0.41,3.21 ±0.53) was significantly higher than in model group (0.58 ±0.26,1.20±0.33,1.50±0.39,2.17±0.68) (P=0.002,P=0.003,P=0.018,P=0.035).ConclusionPerioperative use of fish oil can reduce postoperative inflammatory response,enhance antioxidant defense capability,and mitigate post-operative fatigue.

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