NCPXXX10.1177/0884533614566043Nutrition in Clinical Practice

Nutrition in Clinical Practice Volume 30 Number 1 February 2015 11­–13 © 2015 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0884533614566043 ncp.sagepub.com hosted at online.sagepub.com

Editor’s Note

With this first issue of Nutrition in Clinical Practice (NCP) for 2015, we bring you several A.S.P.E.N. feature papers. The “A.S.P.E.N. Standards of Practice for Nutrition Support Pharmacists” is included in this issue. This document outlines minimum requirements for nutrition support pharmacists and provides guidelines for competency and skills in nutrition support. The “Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: Indicators Recommended for the Identification and Documentation of Pediatric Malnutrition (Undernutrition)” is also included. This document, jointly published by A.S.P.E.N. and The Academy of Nutrition and Dietetics, aims to identify a set of indicators that can be used to diagnose and document undernutrition across the continuum of care in individuals aged 1 month to 18 years. This Consensus Statement defines pediatric malnutrition, characterizes the difference between acute and chronic undernutrition, and details indicators of pediatric undernutrition. This issue also marks the reintroduction of continuing education (CE) articles for NCP readers. Readers can apply for CE credit by reading a specified article in each issue and completing an online evaluation and activity evaluation. The CE article in this issue, authored by Ayers, Dixon, and Mayes, gives a detailed overview of acid-base disorders. The authors define acids and bases and then explain the difference between metabolic acidosis and alkalosis as well as respiratory acidosis and alkalosis. The authors use case studies to convey concepts of nutrition support and acid-base disorders. The overall theme for this issue is micronutrients. The first article on micronutrients is by Michael Kraft, who focuses on phosphorus and calcium homeostasis. Kraft discusses the specific considerations for phosphorus and calcium requirements in patients receiving nutrition support. The paper describes specific considerations for calcium and phosphorus in disease states such as chronic kidney disease and intestinal failure as well as in the presence of long-term parenteral nutrition (PN) therapy. Phosphorus and calcium compatibility in PN is reviewed as well as abnormalities of phosphorus and calcium and how they can be prevented and treated. The paper by Manzanares, Langlois, and Heyland addresses selenium requirements in critically ill patients. Recommendations for selenium intake for both healthy and critically ill patients are included. The anti-inflammatory properties of selenium as well

as the mechanisms of action are discussed, and trials with selenium supplementation in patients with sepsis are summarized. Also in this issue, Finch addresses micronutrient (copper, selenium, zinc, manganese, chromium, molybdenum, and iodine) needs of the premature infant. The purpose of this paper is 3-fold: (1) to summarize the role of trace minerals in preterm infants, (2) to discuss the clinical signs of deficiency and toxicity, and (3) to provide recommendations for micronutrient intake in preterm infants. As most readers are aware, there have been significant shortages of parenteral micronutrients over the last few years. Jay Mirtallo, in his article, gives a perspective on the shortages by exploring the critical role of micronutrients, addressing the inadequacy of commercial micronutrient products, and highlighting some of the deficiencies reported as a result of inadequate supplementation in patients receiving PN. This issue also contains several Clinical Observation papers in which authors report consequences of vitamin and mineral deficiencies. The paper by Hutcheon describes the development of Wernicke’s encephalopathy (thiamine deficiency) in a woman who fasted for 40 days. The paper by Baird and Ravindranath describes vitamin B deficiencies that developed in an 11-year-old boy with autism. The nutrient deficiencies seemed to stem from the patient’s limited food selections. Giacalone and colleagues describe lactic acid deficiency in 3 critically ill adults. In all 3 cases, vitamin supplementation was withheld from PN solution due to a shortage. There are 3 research papers addressing micronutrients. In a brief research paper, Norton et al define the prevalence of vitamin D deficiency in pediatric patients with cystic fibrosis. Despite vitamin D supplementation in these patients, 25% of the population did meet an optimal serum level of vitamin D. MacKay and colleagues conducted a retrospective study of pediatric patients receiving PN; 751 received copper supplementation and 90 patients did not receive copper supplementation. Contrary to what might be expected, the researchers did not find a correlation between serum copper levels and levels of conjugated bilirubin. The researchers’ recommendation was to assess copper levels in patients 14 days after the initiation of PN therapy. The next paper evaluated serum vitamin B12 levels in patients in a rehabilitation unit. Earl, Wong, and Payne determined that patients with an amputation tended to have a higher prevalence of low blood vitamin B12 levels compared

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Nutrition in Clinical Practice 30(1)

with the general population. Because of the these results, the authors recommend screening and treating for vitamin B12 deficiency, as deficiency can contribute to anemia, cognitive decline, and neuropathy. There are a few additional articles in this issue to point out. I invite you to read the paper and listen to the podcast recorded with Elke on the controversial subject of measuring gastric residual volumes in enterally fed patients. Readers will also find interest in the Clinical Controversy paper by Brown regarding standard vs specialty enteral nutrition formulas as well as the research study by Perry, Stankorb, and Salgueiro in which the researchers evaluated the bacterial growth and contamination in enteral feeding formula in the intensive care unit.

The final research article included this issue is by Declercq, Van Biervliet, and Robberecht, who evaluated the use of pancreatic enzyme replacement therapy in patients with cystic fibrosis who developed distal intestinal obstruction syndrome. We are off to a good start in 2015. If your new year’s resolution is to increase your knowledge of nutrition support, NCP can be a valuable tool in achieving your goal.

Jeanette M. Hasse, PhD, RD, LD, FADA, CNSC NCP Editor-in-Chief

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A.S.P.E.N Journal-based Continuing Education (CE) Activity Journal Article Title and Citation: Acid-Base Disorders: Learning the Basics, NCP February 2015 Journal-based CE Activity Overall Goal: The NCP Editor, in concurrence with A.S.P.E.N.’s Education and Professional Development Committee, selected this article to be offered for CE credit to fill an observed learning need in the arena of clinical nutrition and metabolism. This CE activity serves to promote the process of life-long learning for physicians, dietitians, pharmacists, and nurses by providing peer-reviewed journal articles that fully qualify for continuing education credits. Goal and Target Audience: This educational activity is directed toward clinical nutrition and metabolism professionals and others who wish to update their knowledge of clinical nutrition and metabolism. By participating in this educational activity, the reader may expect to: • Acquire knowledge in the area of clinical nutrition and metabolism research • Update or confirm your understanding of appropriate clinical nutrition and metabolism practices. • Identify further learning needs as they relate to the subject matter. Learning Objectives: 1. Discuss the role of the kidneys and lungs in acid-base homeostasis. 2. Summarize common causes of metabolic and respiratory acidosis and alkalosis. 3. Explain the roles of the kidneys and lungs in the principles of compensation. Successful Completion: To obtain CE credit for this activity, attendees must read the journal article in its entirety, complete an online assessment for each article and achieve a score of 100%, and complete an online activity evaluation. All are located in A.S.P.E.N.’s eLearning Center – www.nutritioncare.org/elearning. Accreditation Statements/Continuing Education Credit: Nurses, Pharmacists and Physicians The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) is accredited by the American Nurses Credentialing Center (ANCC), the Accreditation Council for Pharmacy Education (ACPE), and the Accreditation Council for Continuing Medical Education (ACCME), to provide continuing education for the healthcare team. This activity is for a maximum of 1 contact hour (0.1 CEU) per journal article and is a knowledge activity.


A.S.P.E.N., Provider Number AM005, is a Continuing Professional Education (CPE) Accredited Provider with the Commission on Dietetic Registration (CDR). Registered dietitians (RDs) and dietetic technicians, registered (DTRs) will receive a maximum of 1 continuing professional education units (CPEU) for completion of each journal article. CDR level 2. Dietitians may post comments on this program on www.cdrnet.org.

Policies/Information: • Release and Expiration: Release date: February 1, 2015. Expiration date: February 28, 2016. All CE credit must be claimed by the expiration date in A.S.P.E.N.’s eLearning Center – www.nutritioncare.org/elearning. • Non-Commercialism: A.S.P.E.N. subscribes to the ACCME Standards for Commercial Support. A.S.P.E.N. does not provide programs that constitute advertisement or include promotional materials. A.S.P.E.N. does not endorse any products. • Computer Requirements and Technical Support: Participants will need a computer with internet connection to access the online assessment and evaluation for each journal article. If the journal article is read electronically, then the ability to read a PDF document is also necessary. Users should enable pop-ups if attempting to read article electronically. For technical difficulties please contact Digitell Inc. Customer Support at: 1-800-679-3646. Office hours are between 9AM to 5PM ET, Monday through Friday • Privacy and Confidentiality: A.S.P.E.N. respects the privacy of its members and website visitors. Companies that receive personal information from A.S.P.E.N. in order to execute the business of A.S.P.E.N. may use personal information only for that purpose. • Refund Policy: Refunds are not available. • Grievances: Grievances must be submitted in writing to Director of Education and Research at A.S.P.E.N. 8630 Fenton Street. Suite 412. Silver Spring, MD 20910. Commercial Support and Sponsorship: No commercial support or sponsorship has been received for this continuing education activity. Commercial Relationships Disclosures and Conflicts of Interest (COI) of Authors and Journal Editors The following authors have nothing to disclose: Phil Ayers, Carman Dixon, Andrew Mays

A.S.P.E.N. is approved by the California Board of Registered Nursing, Provider CEP 3970.

NCP Associate Editors, Elizabeth Krzywda, Mary Marian, and Gerard Mullin have nothing to disclose. Todd Canada has served in a consultant role for Baxter Healthcare and NPS Pharmaceuticals and has received honoraria. John DiBaise has served as a principal investigator on a research grant from GI Dynamics, Inc and has served as a book editor for McGraw-Hill and received royalties.

ACPE UAN: 0216-0000-15-061-H04-P.

NCP Editor-in-Chief Jeanette Hasse has nothing to disclose.

A.S.P.E.N. designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credits TM per article. Physicians should only claim credit commensurate with the extent of their participation in the activity.

No conflicts related to disclosure information present and subsequently no need for resolution. Standard journal peer review process also in place as another layer of review to ensure no conflicts to resolve.

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Requirements for nutrition support pharmacists.

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