Global PN Fellowship

Abstract Title: Examining Outcomes in Pediatric Sepsis and Septic Shock Patients at Risk for Malnutrition

Authors: Elias A. Wojahn, BS; Liyun Zhang, MS; Amy Pan, PhD; Theresa Mikhailov, MD, PhD

Summary/Review

Nutrition plays a critical role in the management of children recovering from severe illness including sepsis and septic shock which are life threatening conditions. This study examined the clinical outcomes of pediatric patients with sepsis and septic shock in relation to their nutritional status. Clinical outcomes of interest included mortality and pediatric intensive care unit (PICU) length of stay and hospital length of stay. Malnutrition was significantly associated with prolonged PICU (p < 0.0001) and hospital length of stay (p< 0.0001).

In clinical practice, the association between prolonged PICU and hospital stay in children with malnutrition highlights the importance of early nutritional assessment and intervention. Healthcare providers should therefore incorporate nutritional screening upon admission to the PICU to promptly identify children at risk. Early initiation of nutritional support may be considered in malnourished patients admitted to the PICU considering they are at high risk.

Based on these findings, I propose implementing a protocol whereby all children admitted to the PICU with sepsis or septic shock undergo a formal nutritional assessment within 24 hours of admission. Patients identified as malnourished, would be flagged in the electronic medical record or documented in the nutrition support service attending’s note, ensuring they are clearly identified for the care team. This would prompt daily discussion on nutrition support rounds. Additionally tracking metrics such as PICU length of stay, as well as changes in nutritional status would allow to monitor the impact of this intervention. This data could further support the integration of nutritional assessment and, management in the sepsis care protocols.

Abstract Title: The OPPortuNity Study: Outpatient Preoperative Parenteral Nutrition in Malnourished Surgical Patients: A Feasibility Study

Authors: Narisorn Lakananurak, MD; Leah Gramlich, MD

Summary/Review

This study evaluated the outcomes and feasibility of administering supplemental parenteral nutrition (PN) to malnourished patients prior to undergoing surgery in an outpatient clinic setting. This study enrolled patients scheduled for major surgery who were either malnourished or at risk of malnutrition. Participants received supplemental PN for 5-10 days prior to surgery. The PN was administered over 4–5 hours at an infusion clinic. The PN formulation used was Olimel N12 (1000 mL). Safety parameters were monitored. A total of eight patients were included in the study. Nutritional assessment using the PG-SGA revealed that 75% of patients had moderate malnutrition, while 25% had severe malnutrition. Following PN administration, all nutritional parameters—including body weight, body mass index, nutritional status score (PG-SGA), handgrip strength, and quality of life scores—showed improvement. In terms of feasibility, both patients and healthcare staff reported high feasibility ratings across domains of acceptability, appropriateness, and feasibility. No complications were observed in any of the participants.

This research highlights the value of nutritional support in perioperative care. It demonstrates that preoperative supplemental PN can be safely and effectively administered in an outpatient setting, leading to enhanced nutritional status and decreased healthcare cost. In the future, outpatient PN may be extended to a broader population beyond those undergoing surgery. Moreover, the development and implementation of standardized protocols will be essential to ensure consistency, safety, and efficacy in clinical practice.

In Thailand, the availability of inpatient beds remains limited. The implementation of outpatient PN would provide a practical and cost-effective solution. However, to adopt this model, it would be essential to establish clear patient selection criteria, safety monitoring protocol and standardized PN formulations suitable for outpatient administration. Lastly, healthcare professionals should receive appropriate training to recognize and manage potential complications in an outpatient setting.

Abstract Title: Plasma Sphingolipids Strongly Correlate With Cholesterol Metabolism but Fairly With Glucose Metabolism and Body Composition Following Roux-en-Y Gastric Bypass

Authors: Gabriela de Oliveira Lemos, MD; Natasha Mendonça Machado, PhD; Raquel Torrinhas, PhD; Dan Linetzky Waitzberg, PhD

Summary/Review

This study examines the association between plasmatic sphingolipids (SLs) and metabolic changes following bariatric surgery, specifically Roux-en-Y gastric bypass (RYGB) in women with obesity and type 2 diabetes. Utilizing untargeted metabolomics and detailed body composition assessments, the research found that SL levels, especially certain ceramides and sphingomyelins, significantly changed after the mentioned surgery. While SLs have shown a weak correlation with glucose metabolism, they showed a significant and consistent correlation with cholesterol metabolism, particularly pro-atherogenic lipoproteins like LDL-c and VLDL-c. on the other hand, specific ceramides had a moderate inverse correlation with body fat and a positive correlation with lean mass while there were a few sphingomyelins behaved differently. These attained results emphasize the lipid remodeling that occurs following bariatrics surgery, namely RYGB, and suggest a potential mechanistic association between SLs and cholesterol homeostasis in individuals’ post-surgery.

The results and findings are of clinical significance because they imply SLs could serve as and function as future biomarkers or even therapeutic targets for indicating lipid metabolism improvements following bariatric surgery in clinical settings. This may also open up novel and clinical strategies in nutritional and metabolic management, particularly for patients with dyslipidemia or high cardiovascular risk post-bariatric surgeries.

In an interview with the authors, they reflected on their growing interest in the role of lipidomics in personalized medicine. They emphasized that glucose markers respond quickly to RYGB, the glycemic response is currently anticipated. On the other hand, lipidemic and lipidomic responses are still unpredictable, especially SLs, which undergo distinct changes that may influence long-term cardiometabolic health and be a prospective diagnostic or therapeutic target in this issue.
In my clinical practice working in the field, these insights have inspired me and encourages me to look beyond traditional and current markers and investigations and consider lipidomic profiles when studying post-bariatric patients, even though these biomarkers are not usually used or available in a clinical setting yet, but they could be a valuable tool in precision medicine. Also, once its importance is highlighted in protocols like that, these tools can be broadly acknowledged and become more accessible for precision medicine in the future.

The study is well-structured and makes a compelling case for further research into SLs as post-operative biomarkers. Incorporating lipidomics into clinical trials following metabolic and bariatric surgery could reframe the metabolic improvements beyond glycemic control.

Abstract Title: Impact of Sarcopenia and Frailty on Post-Operative Outcomes Following Pancreaticoduodenectomy

Authors: Radha Chada, PhD, RD; Jaini Paresh Gala, MS; Ashwini Chandrasekaran, MSc; Monish Karunakaran, MS, DrNB; G V Rao, MS, MAMS, FRCS; Pradeep Rebala, MS; Balakrishna Nagalla, PhD

Summary/Review

This study investigated the impact of sarcopenia—characterized by low skeletal muscle mass and handgrip strength—on post-operative outcomes in patients undergoing pancreaticoduodenectomy for pancreatic cancer. Using CT scans and handgrip strength measurements aligned with Asian-specific criteria, researchers found that 18.9% of patients had sarcopenia, with significantly higher rates in older adults and females. Sarcopenia was associated with increased post-surgical mortality. Although most patients had reduced 6-minute walk distances — a measure of frailty — this measure did not correlate with mortality or length of stay.

There are multiple meta-analyses suggesting adverse events and increasing mortality for cancer patients receiving chemotherapy or radiation and for those undergoing surgery.[1,2] This study assessed frailty, nutrition status, and sarcopenia using validated assessments for each. Malnutrition may lead to frailty and sarcopenia and the interrelated nature highlights the importance of screening for each. As malnutrition plays a major role in the development of frailty and sarcopenia, nutritional interventions are key to improving clinical outcomes.[3]

In discussion with the first author, Dr. Reddy – her team wanted to understand whether a pre-habilitation program might be justified. She pointed out in her presentation that many of the patients (79%) returned to being functionally active after the surgery. Despite the lack of a structured program, her team, per their usual protocol, provided dietary counseling to the patients 4 weeks before surgery. Though the disease certainly impacted muscle mass for these patients, Dr. Chada was clear about the importance of diet and exercise.

At my institution – a standalone cancer center – my current goal is to create a multidisciplinary nutrition support clinic to improve clinical outcomes for patients undergoing cancer treatment. As we have many patients undergoing pancreaticoduodenectomy, Dr. Chada’s research will help to guide the sorts of screening and interventions we consider for these patients.

1. Su H, Ruan J, Chen T, Lin E, Shi L. CT-assessed sarcopenia is a predictive factor for both long-term and short-term outcomes in gastrointestinal oncology patients: a systematic review and meta-analysis. Cancer Imaging. 2019;19. doi:10.1186/s40644-019-0270-0
2. Zhang Y, Zhang J, Zhan Y, Pan Z, Liu Q, Yuan W. Sarcopenia Is a Prognostic Factor of Adverse Effects and Mortality in Patients With Tumour: A Systematic Review and Meta‐Analysis. J Cachexia Sarcopenia Muscle. 2024;15(6):2295-2310. doi:10.1002/jcsm.13629
3. Cruz-Jentoft AJ, Kiesswetter E, Drey M, Sieber CC. Nutrition, frailty, and sarcopenia. Aging Clin Exp Res. 2017;29(1):43-48. doi:10.1007/s40520-016-0709-0

Abstract Title: The Utility of Artificial Intelligence in the Creation of Meal Plans in an Outpatient Dietetics Setting: A Proof-of-Concept and Feasibility Study

Authors: Manpreet Mundi, MD; Osman Mohamed Elfadil, MBBS; Danielle Johnson, MS, RDN; Christopher Schafer, MS, RDN; Jami Theiler, RDN; Jason Ewoldt, MD, RDN; Madelynn Strong, MS, RDN; Katherine Zeratsky, RDN; Angie Clinton, MS, RDN; Sara Wolf, RDN; Ryan Hurt, MD, PhD

Summary/Review

A well-crafted meal plan that incorporates expertise in nutritional requirements, health conditions, and patient preferences is time-consuming. Dr. Mundi et al. embraced Artificial Intelligence (AI) in nutrition care and examined the effectiveness of AI in creating meal plans compared to registered dietitians (RDNs) in five scenarios. While RDNs were confident in their meal plans (mean score: 3.8–4.8), they spent significantly more time compared to AI (RDNs: 56.4-61.8 minutes/case vs. AI: <1 minute/case).

Although AI models were efficient, they lacked consistency in meeting caloric goals and protein targets when presented with specific dietary restrictions, such as chronic kidney disease. As Dr. Mundi notes, AI in its current state would not replace the clinician. Instead, it serves as an “augmentation tool” where AI can rapidly generate a preliminary meal plan that is modified by the clinician to ensure nutritional accuracy.
Dr. Mundi emphasized: “AI models are not as good as we need them to be used in clinical practice without verification,” but they represent an “incredible tool” that is extremely efficient, and capable of learning and evolving. Our healthcare systems are increasingly complex and demanding, and a hybrid model of AI-support with clinical expertise can increase productivity without compromising patient care.

Future studies of AI compared to RD-generated TPN prescriptions will be valuable due its inherent complexity. In our nutrition programs, I hope to incorporate AI as a clinical tool for patients on oral diets or weaning off TPN, enabling more time to refine complex EN/PN prescriptions and provide patient-centered counseling.