American Society for Parenteral and Enteral Nutrition Clinical Nutrition Week 2014 Abstract Presentations Table of Contents Oral Paper Sessions Paper Session Oral Page Numbers Premier Paper Session Oral pages 2-12 Parenteral Nutrition Oral pages 12-17 Enteral Nutrition Oral pages 17-23 Malnutrition, Obesity, Practice Issues Oral pages 23-34 Critical Care Oral pages 34-43 GI & Metabolic Oral pages 43-48 Pediatrics & Neonatal Oral pages 48-59 Poster Presentations Poster Session Abstract Number Poster Page Number Parenteral Nutrition Abstracts # 1-31 Page 60-86 Enteral Nutrition Abstracts # 32-43 Page 86-95 Malnutrition / Obesity / Abstracts # 44-69 Page 95-118 Practice Critical Care /Critical Health Abstracts # 70-91 Page 118-145 GI / Metabolic Abstracts # 92-108 Page 145-157 Pediatric / Neonatal Abstracts # 109-126 Page 157-175 International Posters by Continent Canada (North America) Abstracts # I-1 to I-17 Page 176-201 South America Abstracts # I-18 to I-20 Page 202-205 Asia Abstracts # I-21 to I-35 Page 205-223 United Kingdom Abstract #I-36 Page 223 Europe Abstracts # I-37 to I-42 Page 223-233 Asia Abstract # I-43 Page 233-234 ORAL ABSTRACT PRESENTATIONS PREMIER PAPER SESSION AND VARS AWARD COMPETITION The Harry M. Vars award is annually given to the person presenting the highest-scoring qualified abstract for CNW. The candidates are also evaluated on a manuscript based on their abstract, as well as on their expertise and knowledge of the science as demonstrated during their oral presentation at the Premier Paper Session. Vars Candidate and Abstract of Distinction 1792860 - Reasons for Enteral Nutrition Cessation in Surgical Intensive Care Unit Patients Daniel D. Yeh, MD1; Miroslav Peev, MD2,1; Polina Osler, MS1; Yuchiao Chang, PhD1; Erin Gillis, RD1; Caitlin Mackay, MS, RD, LDN1; Sharon Darak, RD, CNSC, LDN1; George Velmahos, MD, PhD1 1Surgery, Massachusetts General Hospital, Boston, MA; 2Surgery, Tufts Medical Center, Boston, MA. Purpose: Enteral nutrition (EN) is the preferred route of nutrient delivery in the intensive care unit (ICU). However, actual delivery is only about 50% of prescribed calories. Previous studies in mostly medical ICU patients report that the majority of interruptions are avoidable. The purpose of this study was to investigate and categorize reasons for EN interruption in surgical ICU (SICU) patients and determine if they were avoidable. Methods: This prospective observational cohort study was conducted over 9 months in two SICUs. All patients age>18 years who received EN for more than 72 hours were eligible for inclusion. Exclusion criteria were: ICU stay less than 72 hours, previous ICU stay within the same hospitalization, received EN prior to ICU admission, admission diagnosis of intestinal obstruction (mechanical or paralytic ileus), death within 72 hours after ICU admission. Data collected included ICU admission diagnosis, age, gender, acute physiology and chronic health evaluation (APACHE II) score and Charlson Comorbidity Index (CCI). Data on calorie and protein intake from enteral and parenteral feeding were recorded by the investigators daily during the SICU admission for a maximum of 14 days until initiation of oral intake, ICU discharge, or death, whichever occurred first. All instances of and reasons for EN interruption were recorded. Each episode was categorized as avoidable or unavoidable based on predefined criteria. Outcome variables were defined as hospital and ICU length of stay (LOS), ventilator-free days (VFD), in-hospital and 30 days after ICU admission mortality and complications. Descriptive data were reported as means and standard deviations (SD), medians and inter-quartile ranges (IQR) or as frequencies (%) as appropriate. Patients were dichotomized into NO CESSATION and CESSATION groups based on whether any EN interruption occurred during SICU course. Outcomes between the two groups were compared using two-sample t-tests, Wilcoxon rank sum tests, or Fisher's exact tests as appropriate. Two-sided P values < 0.05 were considered statistically significant. Results: Among 94 SICU patients, there were a total of 106 EN interruptions. Reasons interruption were: extubation (n=29), bedside tracheostomy/percutaneous endoscopic gastrostomy (n=23), imaging study (n=16), orthopedic operation (n=12), high gastric residual volume (n=10), interventional radiology procedure (n=6), other operation (n=6), gastrointestinal operation (n=4). A total of 28 (26.4%) of interruptions were considered avoidable. (TABLE 1) There were no differences in baseline demographics. The CESSATION group had significantly greater daily caloric deficit (608 vs. 346 cal, p=0.001) and had significantly greater cumulative caloric deficit (5834 vs. 3066 cal, p=0.001) and longer hospital length of stay (LOS) (33 d vs. 25 d, p=0.01). (FIGURE 1) Ventilator-free days were fewer, and ICU LOS was longer, but this did not achieve statistical significance. Conclusions: In SICU patients receiving EN, only 26.4% of EN interruptions were potentially avoidable. Patients who experienced any interruption of EN accumulated greater caloric deficit and had worse clinical outcomes. In this patient population, most interruptions cannot be avoided and efforts should be focused on maximizing calorie delivery before or after interruptions, rather than decreasing the frequency of interruption. Clinical Nutrition Week 2014 2 Clinical Nutrition Week 2014 3 Vars Candidate and Abstract of Distinction 1834609 - Long-Term Neurodevelopmental Outcomes of Infants Treated With Intravenous Fat Emulsion Reduction for the Management of Parenteral Nutrition-Associated Cholestasis Allison B. Blackmer, PharmD, BCPS1; Seth Warschausky, PhD3; Sabina Siddiqui, MD2; Kathleen Welch, MS4; Karolyn Horn, PharmD Candidate 20141; Ashely Wester, PharmD Candidate 20141; Micah Warschausky, Research Assistant/ Undergraduate Student5; Daniel Tietelbaum, MD2 1College of Pharmacy, University of Michigan, Ann Arbor, MI; 2Department of Pediatric Surgery, University of Michigan, Ann Arbor, MI; 3Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI; 4Center for Statistical Consultation and Research, University of Michigan, Ann Arbor, MI; 5University of Michigan Health System, University of Michigan, Ann Arbor, MI. Purpose: A strong association exists between dosage of intravenous fat emulsion (IVFE) and development of parenteral nutrition (PN)-associated cholestasis (PNAC). Intravenous fat emulsion reduction (IFER) is an effective management strategy for PNAC; however, IFER during infancy may lead to reduction of essential nutrients during an important developmental period. Neurodevelopmental outcomes (NDOs) associated with IFER have not previously been reported. Yet, neurodevelopment is greatest during infancy, and thus this remains a critical question. This single-institution, prospective study examined the risk for cognitive and adaptive delays and behavioral concerns, as well as key predictors of NDOs, in pediatric patients previously treated with IFER. Methods: Patients between 2—5 years of age at the time of study enrollment previously treated with IFER were included. Patients with major congenital or chromosomal anomaly, metabolic disorder, hypoxic ischemic encephalopathy, seizure disorder or cerebral palsy were excluded. NDOs were evaluated by the Ages and Stages Questionnaires-3 (ASQ-3), Parents' Evaluations of Developmental Status (PEDS), and Behavior Assessment System for Children, 2nd Ed. Preschool, Parent (BASC-2). Primary outcome measure was the dichotomized risk categorization on the ASQ-3. Secondary outcome measures included overall and dichotomized risk categorization on the PEDS tool, composite t-scores, trichotomized and dichotomized risk categorization on the BASC-2 tool. A combined overall risk categorization for patients deemed at risk on either PEDS or ASQ-3 was also evaluated. Statistical analysis used Student's t-test and Wilcoxon rank sums tests for continuous variables, and Chi-square and Fisher's exact tests for categorical variables. Linear and logistical regression evaluated the relationship between NDOs and predictive variables. IFER related variables included mean duration of PN and IFER, mean lipid dose (g/kg/day) and documentation of essential fatty acid deficiency (EFAD). Results: Parental consent was obtained in 25 of 62 patients. Demographics (Table 1) were similar in consented vs. non-consented, except that consented had greater gestational age, p=0.05, and lower incidence of hypoxia, p=0.04. All consented patients had completed PEDS tool, and 72% (n=18) completed ASQ-3 and BASC-2 tools. Figures 1 and 2 summarize dichotomized risk categorization for ASQ-3 and PEDS, respectively. Mean t-scores, trichotomized and risk categorization on the BASC-2 are outlined in Table 2. All 4 composite domains fell within the average, normative developmental range (41-59). A majority of patients were observed to be "typically developing" (67- 89%). The combined overall risk categorization revealed that of the 18 children completing all 3 tools, 61.1% were found to be at "no risk". Regression analyses revealed younger gestational age to be a predictor of poor NDO in gross motor (p=0.024) and personal-social (p=0.0441) on the ASQ-3, and on adaptive skills (p=0.032) on the BASC-2. Older age at study enrollment predicted negative NDO on the PEDS tool, p=0.0064. Importantly, IFER- related variables were not found to be predictors of negative NDOs. Surprisingly, higher mean lipid dose predicted both score and risk categorization of externalizing problems on the BASC-2, p=0.031 and p=0.043, respectively. Conclusions: This study represents the first report of NDOs in pediatric patients treated with IFER during infancy. While limited by small sample size, IFER related variables were not found to be significant predictors of negative NDOs, and IFER treated patients score within the normative range the vast majority of the time. The results set the stage for a larger, multi-center, prospective study. Clinical Nutrition Week 2014 4 Clinical Nutrition Week 2014 5 Clinical Nutrition Week 2014 6 Clinical Nutrition Week 2014 7 Vars Candidate and Abstract of Distinction 1835138 - Association Between Prehospital Vitamin D Status and Hospital-Acquired Clostridium difficile Infections Sadeq A. Quraishi, MD, MMSc2; Augusto A. Litonjua, MD, MPH3; Takuhiro Moromizato, MD4; Fiona Gibbons, MD5; Carlos A. Camargo, Jr, MD, DrPH6; Edward Giovannucci, MD, ScD7; Kenneth B. Christopher, MD1 1Renal Division, Brigham and Women's Hospital, Boston, MA; 2Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA; 3Pulmonary and Critical Care Division, Brigham and Women's Hospital, Boston, MA; 4Department of Medicine, Okinawa Hokubu Prefectural Hospital, Nago City, Japan; 5Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA; 6Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA; 7Departments of Nutrition and Epidemiology, Harvard School of Public Health, Boston, MA. Purpose: Recent evidence suggests that vitamin D is a key regulator of the immune system, and as such, it may play an important role in patient susceptibility to hospital-acquired infections, including hospital-acquired Clostridium difficile infections (HACDIs). The purpose of this study was to investigate whether pre-admission 25- hydroxyvitamin D [25(OH)D] levels are associated with the risk of HACDI. We hypothesized that vitamin D status before hospital admission is associated with the risk of developing HACDI. Methods: Our retrospective cohort study focused on 568 adult patients from two Boston teaching hospitals between August 1993 and November 2006. We excluded 44 patients who received high-dose vitamin D supplementation (Ergocalciferol 50,000 IU) between the 25(OH)D level draw and hospital admission. The exposure of interest was pre-admission serum 25(OH)D level obtained 7 to 365 days prior to the date of hospitalization. 25(OH)D levels were categorized a priori as <10 ng/mL, 10-19.9 ng/mL, 20-29.9 ng/mL, and ≥30 ng/mL. All cut points were adapted from existing national clinical guidelines. Serum 25(OH)D in all cohort subjects was determined by radioimmunoassay (RIA). The primary end point was incident HACDI. Microbiology reports on stool samples for the study cohort were obtained from the computerized registry at the hospitals under study. All cohort patients had stool sample testing for Clostridium difficile toxin A and B by enzyme-linked immunosorbent assay (ELISA). A positive result was defined as the presence of toxin A or B in at least one stool sample. In order to be considered a HACDI, the first positive toxin result must have been on a stool sample obtained >48 hours after hospital admission in patients with no known history of Clostridium difficile infection. Unadjusted associations between 25(OH)D Clinical Nutrition Week 2014 8 levels and HACDI were estimated by bivariable logistic regression models. Adjusted odds ratios were estimated by multivariable logistic regression models with a priori inclusion of covariates thought to be linked with both 25(OH)D level and HACDI. Locally weighted scatter plot smoothing (LOWESS) was used to graphically represent the relationship between pre-hospital 25(OH)D level and risk of HACDI. Results: The mean age at hospital admission was 63±18 years. Most patients were female, white, and had a medically-related DRG. The mean 25(OH)D level was 19±12 ng/mL. Approximately half (53%) of the 25(OH)D measurements occurred in the 3 months before hospital admission. Over the hospital stay, 11% (95%CI, 9-14) of the cohort met criteria for incident HACDI. Following adjustment for age, sex, race (non-white vs. white), patient type (medical vs. surgical), and Deyo-Charlson index, patients with 25(OH)D levels <10 ng/mL had higher odds of HACDI (OR 2.90; 95%CI, 1.01-8.34), compared to patients with 25(OH)D levels of ≥30 ng/ml. When patients with HACDI were analyzed relative to a larger patient cohort without HACDI or without Clostridium difficile toxin A and B measured (n=5,047), those with 25(OH)D levels <10 ng/mL (OR 4.96; 95%CI, 1.84-13.38) and 10-19.9 ng/mL (OR 3.36; 95%CI, 1.28-8.85) had higher adjusted odds of HACDI compared to patients with 25(OH)D levels ≥30 ng/ml. LOWESS plot (Figure 1) demonstrated a near inverse linear association between 25(OH)D level and risk of HACDI up to 25(OH)D levels near 30 ng/mL. Beyond serum 25(OH)D levels of 50 ng/mL, the curve appears flat. Conclusions: In our cohort of adult patients, vitamin D status before hospital admission was inversely associated with the risk of developing HACDI. These data support the need for randomized, controlled trials to test the role of vitamin D supplementation to prevent HACDI. Figure 1. Vitamin D status versus risk of hospital-acquired Clostridium difficile infection. 25(OH)D = 25- hydroxyvitamin D; HACDI = hospital-acquired Clostridium difficile infection. Locally weighted scatter plot smoothing utilized to represent the near inverse linear association between pre-hospital 25(OH)D level and risk of HACDI. Plot constructed with data from inpatients with pre-hospital vitamin D status and toxin A or B measured in stool samples (n=568). Clinical Nutrition Week 2014 9 Vars Candidate and Abstract of Distinction 1835359 - Use of Three Nutrition Screening Tools to Assess Nutrition Risk in the Intensive Care Unit Anne Coltman, MS, RD, CNSC; Sarah Peterson, MS, RD, CNSC; Kelly Roehl, MS, RD, CNSC; Hannah Roosevelt, MS, RD, CNSC; Diane Sowa, MBA, RD Clinical Nutrition, Rush University Medical Center, Chicago, IL. Purpose: Identifying patients at nutrition risk proves especially difficult in the intensive care unit (ICU) due to the nature of critical illness. Unfortunately, no consensus exists on the most appropriate method to identify these patients. Accurate identification of patients at risk using traditional nutrition screens is limited, as weight loss and BMI may be reflective of fluid status, rather than actual body habitus in critical illness. Furthermore, a nutrition and weight history may be difficult to obtain due to alterations in mental status, hemodynamic instability and need for mechanical ventilation impeding a clinician's ability to obtain vital information. The inclusion of physical assessment in Subjective Global Assessment (SGA) is useful, as it does not require patient interaction; however, this tool, also, requires a detailed patient history. The Nutrition Risk in the Critically Ill (NUTRIC) score is unique in its inclusion of assessment of inflammation and severity of illness. Recent randomized controlled trials have demonstrated that provision of adequate calories and protein in critical illness may have deleterious effects on outcomes; identifying patients with the highest potential to benefit from nutrition support is essential. The objective of this quality improvement project was to apply different nutrition screening tools to a sample of patients admitted to the ICU Methods: A convenience sample of 302 patients admitted to the medical, surgical, and neuroscience ICU was used. All patients were screened within 24 hours of admission. Routine nutrition screening included the following variables: significant weight loss, BMI<18.5 or >40, presence of dysphagia, or use of enteral/parenteral nutrition prior to admission. Subjective Global Assessment (SGA), composed on intake prior to admission, presence of GI symptoms, weight loss, functional assessment, and physical assessment, was also performed. A NUTRIC score was calculated for each patient using age, APACHE II, SOFA, number of comorbidities, and days from hospital to ICU admission. NUTRIC scores were calculated without using IL-6 values; therefore, patients were classified as having a high score if the sum was 5 or greater. Additional information was collected on demographics, severity of illness, hospital and ICU length of stay (LOS) and disposition. Descriptive statistics were utilized to examine counts/proportions and means +SD Results: Large differences were seen between screening tools, as 29% (n=89) of patients were screened at risk using routine screening, 38% (n=114) using SGA, and only 13% (n=38) using the NUTRIC score. Only 10 patients met criteria for all three tools (Figure 1). Similar mortality rates were seen between groups (11% routine screening, 12% SGA, 13% NUTRIC). ICU and hospital LOS was longest in patients deemed at risk using the NUTRIC score, compared to both routine screening and SGA (Table 1). Similar demographic data and dispositions were seen between risk groups Conclusions: Traditional screening tools are likely inappropriate for use in the ICU, as they require patient interviews. Inclusion of both physical assessment and severity of illness may be useful in predicting nutrition risk. Additional research is needed to determine if changes in the nutrition screening process affect outcomes in the critically ill. Table 1: Hospital and ICU LOS and hospital disposition using Routine Screening, Subjective Global Assessment (SGA), and NUTRIC Risk with Routine Screening Risk with SGA Risk with NUTRIC Score (n=89) (n=114) (n=38) Age (mean years ± SD) 61.0±15.4 61.7±15 69.7±12.1 BMI (mean kg/m2 ± SD) 26.5±7.7 27.0±8.1 26.8±8.1 Hospital LOS (mean 10.6±8.9 9.8±8.5 11.9±10.5 days±SD) ICU LOS (mean days ± SD) 4.5±4.2 5.4±5.3 6.4±7.1 Expired (n(%)) 10 (11%) 14 (12%) 5 (13%) Discharged to Rehab (n(%)) 14 (15%) 19 (17%) 6 (16%) Clinical Nutrition Week 2014 10