がん患者では骨格筋量が重度嚥下障害と関連する

がん患者では骨格筋量が重度嚥下障害と関連するという論文が、J Cachexia Sarcopenia Muscleに掲載されました。以下のHPで全文読めます。

http://onlinelibrary.wiley.com/doi/10.1002/jcsm.12052/full

サルコペニアの嚥下障害とリハ栄養に関心のある多くの方に読んでほしいですね。よろしくお願い申し上げます。

Background

The purpose of this study was to assess the association between skeletal muscle mass, activities of daily living (ADLs) and severe dysphagia in cancer patients.

Methods

A nested case-control study was performed in 111 consecutive cancer patients with dysphagia who were prescribed speech therapy. Skeletal muscle mass comprising the cross-sectional area of the left and right psoas muscles was assessed via abdominal computed tomography at the third lumbar vertebral level. ADLs were evaluated by the Barthel Index. The severity of dysphagia was assessed by the Food Intake Level Scale and was characterized by non-oral feeding or oral food intake at discharge. Univariate and logistic regression analyses were applied to examine the associations between dysphagia, skeletal muscle index (SMI) and ADLs.

Results

There were 86 men and 25 women (mean age, 70 years). The mean SMI was 5.68 ± 1.74 cm²/m² in men and 4.43 ± 1.21 cm²/m² in women. The median Barthel Index score was 20. Thirty-three patients were on non-oral feeding at discharge. The mean SMI did not differ significantly between non-oral feeding and oral food intake groups in t-test. The median Barthel Index score was lower in the non-oral feeding group in Mann–Whitney U test. Logistic regression analysis of the severity of dysphagia adjusted for age, sex, SMI, Barthel Index score, serum albumin, cancer type and stage, and vocal cord paralysis showed that SMI was associated independently with oral food intake at discharge. Barthel Index score showed a tendency to be associated with oral food intake.

Conclusions

Skeletal muscle mass is associated with severe dysphagia in cancer patients. ADLs show a tendency to be associated with severe dysphagia in cancer patients.

リハ関連雑誌のガイドライン使用義務化

ご存知の方も多いと思いますが、2015年1月1日からリハ関連28雑誌では、研究デザイン別のガイドライン（CONSORT、STROBE、CAREなど）使用が投稿論文に義務化されます。下記HPで全文読めます。必ずガイドラインを使用して研究計画立案と執筆をしましょう。

http://ptjournal.apta.org/content/94/4/446.long

Dysphagia assessed by the 10-item Eating Assessment Tool is associated with nutritional status and activities of daily living in elderly individuals requiring long-term care

Dysphagia assessed by the 10-item Eating Assessment Tool is associated with nutritional status and activities of daily living in elderly individuals requiring long-term careという論文が、The
Journal of Nutrition, Health and Agingという雑誌にアクセプトされました。

http://www.springer.com/medicine/family/journal/12603

リハ栄養の原著論文をアクセプトさせることができてよかったです。抄録だけ掲載しておきます。

Objectives: The 10-item Eating Assessment Tool (EAT-10) is a self-administered questionnaire for dysphagia screening, with each item scored from 0 to 4. We assessed the associations among the EAT-10 score, nutritional status and activities of daily living (ADL) in elderly individuals requiring long-term care.
Design: Cross-sectional study.
Setting: Geriatric health services facilities, acute hospitals, and the community.
Participants: Elderly individuals ≥65 years of age with dysphagia or possible dysphagia (N=237).
Measurements: The EAT-10, the Mini Nutritional Assessment Short Form (MNA-SF) and the Barthel Index.
Results: There were 90 males and 147 females. Mean age was 82 ± 8 years. Eighty-nine were in geriatric health services facilities, 28 were in acute hospitals, and 120 were community-dwelling. The median Barthel Index score was 55 (interquartile range: 25, 80). The median EAT-10 score was 1 (interquartile range: 0, 9), and 101 respondents a score more than 3, indicating the presence of dysphagia. The MNA-SF revealed that 81 were malnourished, 117 were at risk of malnutrition, and 39
had a normal nutritional status. The Barthel Index score and MNA-SF score were significantly lower in those with an EAT-10 score between 3 and 40, compared to those with an EAT-10 score between 0 and 2. The EAT-10 has an independent effect on the Barthel Index and the MNA-SF by adjusting for covariates such as age, gender, and setting in multiple regression analysis.
Conclusions: Dysphagia assessed by the EAT-10 is associated with nutritional status and ADL in elderly individuals requiring long-term care.

NUTRITIONレター論文

早期栄養サポートと理学療法は急性疾患高齢患者の長期ADL自立度を改善する、というNUTRITION論文へのレター論文が掲載されました。

Hidetaka Wakabayashi. Comment on “Early nutritional support and physiotherapy improved long-term self-sufficiency in acutely ill older patients” NUTRITION, DOI: 10.1016/j.nut.2014.09.014

私のレター論文は以下のHPで全文読めます。

http://www.sciencedirect.com/science/article/pii/S0899900714004365

リハ栄養では重要な論文ですが気になる点がいくつかありましたので、初めてレター論文を書いてみました。インパクトファクター3点台の雑誌ですので、レター論文でも掲載されるとやはり嬉しいですね。

もとの論文は以下のHPで抄録だけ読むことができます。

http://www.nutritionjrnl.com/article/S0899-9007(14)00349-9/abstract

リハ栄養の論文はまだまだ少ないので、気になる点があるリハ栄養の論文が掲載された場合には、今後もレター論文を投稿しようと考えています。この領域を盛り上げていきたいです。

J Cachexia Sarcopenia Muscleリハ栄養論文

障害のあるサルコペニアに対するリハ栄養のレビュー論文が、J Cachexia Sarcopenia Muscleにアクセプトされました。

Wakabayashi H, Sakuma K.Rehabilitation nutrition for sarcopenia with disability: a combination of both rehabilitation and nutrition care management. J Cachexia Sarcopenia Muscle. 2014 Sep 16. [Epub ahead of print]

リハ栄養というコンセプトを世界に発信した最初の論文になりますし、J Cachexia Sarcopenia MuscleのImpact Factorは7.4と高いので、インパクトの大きい論文だと自分では思います。

下記HPから全文ダウンロード可能です。多くの方に読んでいただけると嬉しいです。よろしくお願い申し上げます。

http://download.springer.com/static/pdf/564/art%253A10.1007%252Fs13539-014-0162-x.pdf?auth66=1411135474_32da4b46105dddc16652e0e4fb82e057&ext=.pdf

Abstract
Malnutrition and sarcopenia often occur in rehabilitation settings. The prevalence of malnutrition and sarcopenia in older patients undergoing rehabilitation is 49-67 % and 40-46.5 %, respectively. Malnutrition and sarcopenia are associated with poorer rehabilitation outcome and physical function. Therefore, a combination of both rehabilitation and nutrition care management may improve outcome in disabled elderly with malnutrition and sarcopenia. The concept of rehabilitation nutrition as a combination of both rehabilitation and nutrition care management and the International Classification of Functioning, Disability and Health guidelines are used to evaluate nutrition status and to maximize functionality in the elderly and other people with disability. Assessment of the multifactorial causes of primary and secondary sarcopenia is important because rehabilitation nutrition for sarcopenia differs depending on its etiology. Treatment of age-related sarcopenia should include resistance training and dietary supplements of amino acids. Therapy for activity-related sarcopenia includes reduced bed rest time and early mobilization and physical activity. Treatment for disease-related sarcopenia requires therapies for advanced organ failure, inflammatory disease, malignancy, or endocrine disease, while therapy for nutrition-related sarcopenia involves appropriate nutrition management to increase muscle mass. Because primary and secondary sarcopenia often coexist in people with disability, the concept of rehabilitation nutrition is useful for their treatment. Stroke, hip fracture, and hospital-associated deconditioning are major causes of disability, and inpatients of rehabilitation facilities often have malnutrition and sarcopenia. We review the concept of rehabilitation nutrition, the rehabilitation nutrition options for stroke, hip fracture, hospital-associated deconditioning, sarcopenic dysphagia, and then evaluate the amount of research interest in rehabilitation nutrition.

入院リハ患者の低栄養に対する経口栄養介入：メタ解析

入院リハ患者の低栄養に対する経口摂取での栄養介入の予防と治療効果をみた系統的レビューとメタ解析の論文を紹介します。

http://www.ncbi.nlm.nih.gov/pubmed/24811842

10論文が系統的レビューの対象となっていますが、メタ解析は経口栄養剤によるエネルギーとたんぱく質の摂取量のみ行われました。エネルギーとたんぱく質の摂取量は、どちらも有意に増加しました。

でもエネルギーとたんぱく質の摂取量は、リハ栄養の一次アウトカムではないですよね。少なくとも低栄養改善、できればADLやQOL改善、入院期間短縮などがアウトカムでないと…。リハ栄養のエビデンスが少ないことがよくわかります。 何とかしないとですね。

Collins J1, Porter J.　The effect of interventions to prevent and treat malnutrition in patients admitted for rehabilitation: a systematic review with meta-analysis.　J Hum Nutr Diet. 2014 May 9. doi: 10.1111/jhn.12230. [Epub ahead of print]

Abstract
BACKGROUND: Malnutrition occurs frequently among patients in rehabilitation, leading to poorer outcomes. Evidence of the effects of interventions to prevent or treat malnutrition is required to guide clinical practice in this setting. This systematic review aimed to determine the effect of oral nutrition interventions implemented in rehabilitation on nutritional and functional outcomes.

METHODS: Five databases were searched to identify relevant publications; intervention trials of oral nutrition interventions (such as oral nutrition supplements, foodservice interventions, clinical care processes, enhanced eating environments) conducted with patients admitted for rehabilitation, reporting dietary intake, anthropometric, biochemical or functional outcomes. The reviewers determined study eligibility and assessed the included studies for risk of bias. Outcome data were combined narratively and by meta-analyses.

RESULTS: From 1765 publications, 10 studies trialling oral nutrition supplements, foodservice interventions and clinical care processes (of neutral or positive quality) were identified. Compared to meals alone, oral nutritional supplements significantly improved energy and protein intake, with some evidence for improvements in anthropometry and length of stay. There was little evidence that speciality supplements were beneficial compared to standard versions. Meta-analyses demonstrated significantly greater energy [weighted mean difference (WMD) = 324 kcal, 212-436 kcal 95% confidence interval (CI)] and protein (WMD = 9.1 g, 0.2-17.9 g 95% CI) intake with energy dense meals. Opposing results were reported in studies investigating enhanced clinical care processes.

CONCLUSIONS: The provision of oral nutrition supplements and energy dense meals improved energy and protein intake and therefore may comprise effective strategies for addressing malnutrition in rehabilitation. The effect of these strategies on other nutritional and functional outcomes should be explored further.

頭部挙上筋力は嚥下障害と栄養障害と関連する

虚弱・フレイルの高齢者で頭部挙上筋力は嚥下障害と栄養障害と関連するという論文がGeriatrics & Gerontology InternationalのHPに掲載されました。

 

Wakabayashi H, et al. Head lifting strength is associated with dysphagia and malnutrition in frail older adults. Geriatrics & Gerontology International, DOI: 10.1111/ggi.12283

 

http://onlinelibrary.wiley.com/doi/10.1111/ggi.12283/abstract

 

タイトルどおりですが、頭部挙上筋力が弱い方や自力で頭部挙上をできない方は、嚥下機能や栄養状態が悪いことが多いという研究です。限界は多いですが、リハ栄養やサルコペニアの嚥下障害のエビデンスに少しはなると思っています。

 

リサーチクエスチョンは以下のとおりです。
P：摂食嚥下障害もしくは摂食嚥下障害疑いの65歳以上の要支援・要介護高齢者は
E：頭部挙上筋力が強いと（仰臥位で自分の力で頭を持ち上げることができると）
C：頭部挙上筋力が弱い場合と比較して（仰臥位で自分の力で頭を持ち上げることができない場合と比較して）
O：摂食嚥下障害・栄養障害を認めないことが多い
D：横断研究

386人を対象に、頭部挙上筋力は徒手筋力テスト、摂食嚥下障害の程度は臨床的重症度分類（DSS）、栄養状態は簡易栄養状態評価（MNA-SF）で評価しました。頭部挙上筋力と摂食嚥下障害・栄養障害の関連を、調査しました。男性129人、女性257人。平均年齢83歳。

結果ですが、386人中189人（49％）が仰臥位で自分の力で頭を持ち上げることができました。摂食嚥下機能は、79人が正常、138人が誤嚥のない摂食嚥下障害、169人が誤嚥のある摂食嚥下障害でした。栄養状態は、40人が栄養状態良好、171人が低栄養のおそれあり、175人が低栄養でした。

スペアマン順位相関係数では、頭部挙上筋力と摂食嚥下機能(r=0.458)、栄養状態(r=0.331)、年齢(r=-0.256)に有意な相関を認めました。頭部挙上の可否で2群に分類すると、頭部挙上を自力でできない群のほうが、高齢、摂食嚥下障害、低栄養を有意に多く認めました。

摂食嚥下障害を誤嚥の有無、栄養状態を低栄養の有無で2群に分類してロジスティック回帰分析を行うと、頭部挙上の可否と誤嚥の有無、低栄養の有無の間にそれぞれ独立した関連を認めました。

以上より、高齢者の頭部挙上筋力は摂食嚥下障害、栄養障害と関連を認め、頭部挙上筋力は、摂食嚥下障害重症度のスクリーニングとして有用な可能性があります。

Abstract
Aim: The purpose of this study was to assess the association between head lifting strength, dysphagia, and malnutrition in frail elderly.

Methods: A cross-sectional study was performed in 386 frail elderly
aged 65 years and older with dysphagia or suspected dysphagia. Head lifting strength was assessed by the Medical Research Council score. The severity of swallowing and nutritional status was evaluated using the Dysphagia Severity Scale and the Mini Nutritional Assessment Short Form, respectively. Univariate and logistic regression analyses were applied to examine the associations between head lifting strength, dysphagia, and malnutrition.

Results: There were 129 males and 257 females. Mean age was 83 years. The median Barthel Index score was 30 (interquartile range: 5-65). A total of 189 (49%) elderly could independently lift their head. Based on the Dysphagia Severity Scale, 79 participants had no dysphagia, 138 had dysphagia without aspiration, and 169 had dysphagia with aspiration. The Mini Nutritional Assessment Short Form revealed that 175 elderly were malnourished, 171 were at risk for malnutrition, and 40 had a normal nutritional status. The Medical Research Council score in males was higher compared to females. Head lifting strength was significantly correlated with age (r=-0.256), the Barthel Index (r=0.540), the Dysphagia Severity Scale (r=0.458), and the Mini Nutritional Assessment Short Form (r=0.331). In logistic regression analysis, the Medical Research Council score was independently associated with both dysphagia with aspiration and malnutrition.

Conclusions: Head lifting strength is associated with dysphagia with
aspiration and malnutrition in frail elderly.

大腿骨近位部骨折のリハ栄養RCTプロトコール

大腿骨近位部骨折の高齢者に対するリハ栄養のRCTプロトコール論文です。

Malafarina V, Uriz-Otano F, Gil-Guerrero L, Iniesta R, Zulet MA, Martinez JA.Study protocol: High-protein nutritional intervention based on β-hydroxy-β-methylbutirate, vitamin D3 and calcium on obese and lean aged patients with hip fractures and sarcopenia. The HIPERPROT-GER study. Maturitas. 2013 Oct;76(2):123-8.

介入群ではリハ病棟入院中に30日間、ensure plus advanceという栄養剤を1日2本飲んでもらい、ADL改善を一次アウトカムとしています。リハ栄養の介入研究を考えている方には読んでほしい論文です。

ちなみにensure plus advanceは1本220mlで、1.5kcal/ml、蛋白質22%、脂質29%、糖質47%、フラクトオリゴ糖1%です。HMBが0.55g/100ml、ビタミンDが227UI/100ml、カルシウムが160mg/100mlです。こういうリハ栄養用の栄養剤を日本でも販売してほしいですね。

Abstract

INTRODUCTION:

Loss of muscle strength is associated with falls, which, in turn, are the main cause of hip fractures in elderly people. The factors that most influence loss of strength in elderly people are a decrease in muscle mass, i.e. sarcopenia, and an increase in fat, i.e. obesity.

METHODS:

A prospective randomized clinical trial among patients who have undergone an operation for a traumatic hip fracture and who are aged 65 or above will be implemented. We shall compare a control diet against a high-protein diet enriched with β-hydroxy-βmethylbutirate, calcium and vitamin D. The diet will be administered during 30 days of hospitalization in the orthopaedic geriatric rehabilitation unit. There will be 50 patients in each arm of the study. The main objective is to assess whether the experimental diet, together with rehabilitation, improves functional recovery, measured on the Barthel index. Secondary objectives are to assess changes in body composition and the prevalence of sarcopenia, obesity and mortality one year after the hip fracture. We shall also assess whether there is a relationship between specific inflammatory markers, sarcopenia and functional recovery.

CONCLUSIONS:

Ageing is accompanied by changes in body composition that increase the risk of falls and progressive functional loss. These factors are a public health problem because they are highly associated with disability in older people. The present study seeks to gain knowledge of those factors that are most often associated with the onset of disability and those that can be modified through diet.

大腿骨近位部骨折の体重・除脂肪量減少

大腿骨近位部骨折患者の発症後2カ月以内の身体組成変化を調査した論文を紹介します。

C. R. D'Adamo, et al. Short-term changes in body composition after surgical repair of hip fracture. Age Ageing (2013) doi: 10.1093/ageing/aft198 First published online: December 25, 2013

先行研究として発症後1年の身体組成変化（体重・除脂肪量減少）は、障害悪化、骨折再発、死亡と関連します。今回は、155人の大腿骨近位部骨折患者の体重、除脂肪量、骨密度を、DEXAで発症後3日、10日、2ヶ月の3回調査しました。

結果ですが、発症後3日と10日の間には有意差を認めませんでした。一方、発症後10日と2カ月の間に体重減少(−1.95 kg, P < 0.001)、除脂肪量減少(−1.73 kg, P < 0.001)、骨密度低下を認めました。脂肪は有意差なしでした。

以上より、大腿骨近位部骨折の発症後10日～2カ月の間に体重・除脂肪量減少を認めたという結論です。身体組成と予後を改善させる介入の最適なタイミングを知るために、さらなる研究が必要です。

発症前と発症後3日の比較はできませんので、発症後早期に身体組成に変化を認める可能性は否定できません。しかし今回の研究結果から、体重・除脂肪量を改善させる積極的なリハ栄養介入は、急性期より回復期のほうが重要と示唆されます。

抄録しか読めていないので、発症後10日～2カ月の間にどのようなリハや栄養管理が行われていたか不明です。ただしおそらく、通常のリハと栄養管理を行っていると、この間に体重・除脂肪量が減少するのだと推測されます。

日本では大腿骨近位部骨折の発症前から低栄養・サルコペニアの患者も少なくありませんので、発症後10日～2カ月の間で体重・除脂肪量が減少するのは大きな問題です。回復期リハ病棟での積極的な栄養管理の実施が重要と考えます。

Abstract

Background: the deleterious changes in body composition that occur during the year after hip fracture are associated with increased disability, recurrent fracture, and mortality. While the majority of these unfavourable changes have been shown to occur during the first 2 months after fracture, potential changes in body composition occurring earlier than 2 months post-fracture have not been studied. Accordingly, the aim of this study was to rigorously assess short-term changes in body composition after hip fracture.

                 

Methods: total body mass, lean mass, fat mass and total hip and femoral neck bone mineral density (BMD) were assessed via dual energy X-ray absorptiometry at 3 days, 10 days and 2 months post-fracture among 155 hip fracture patients from the Baltimore Hip Studies. Longitudinal regression analysis using mixed models was conducted to model short-term changes in body composition.

                 

Results: no significant changes in body composition were revealed from 3- to 10 days post-fracture. However, significant decreases from 10 days to 2 months post-fracture were noted in the total body mass (−1.95 kg, P < 0.001), lean mass (−1.73 kg, P < 0.001), total hip BMD (−0.00812 g/cm², P = 0.04) and femoral neck BMD (−0.015 g/cm², P = 0.03). No meaningful changes in fat mass were uncovered.

                 

Conclusions: the adverse changes in body composition during the first 2 months after hip fracture appear to have occurred primarily between 10 days and 2 months post-fracture. More research is needed to determine how these findings might help inform the optimal timing of interventions aimed at improving body composition and related outcomes after hip fracture.

脳卒中は急性期病院入院中に栄養状態悪化

この論文も、急性期脳卒中患者の栄養状態が、入院後10日間で悪化することを示した報告です。

Mosselman MJ, Kruitwagen CL, Schuurmans MJ, Hafsteinsdóttir TB.　Malnutrition and risk of malnutrition in patients with stroke: prevalence during hospital stay.　J Neurosci Nurs. 2013 Aug;45(4):194-204. doi: 10.1097/JNN.0b013e31829863cb.

対象は73人の脳卒中患者で、10日間フォローできたのは23人のみです。23人の栄養状態は入院時、91％栄養状態良好、9％低栄養のおそれあり、0％低栄養でした。10日後は35％栄養状態良好、39％低栄養のおそれあり、26％低栄養でした。

以上より急性期病院入院後10日間で、急性期脳卒中患者の栄養状態が悪化することが示唆され、入院時だけでなく入院期間中の栄養スクリーニングが重要といえます。

急性期病院での栄養評価の推移に関する研究は難しい、と個人的に思っていました。しかし、このような形の研究であれば日本でも実現できますね。より多くの対象者数や他の疾患でも同様な研究をすることで、急性期病院での栄養評価と栄養管理の重要性を訴えたいですね。

Abstract

BACKGROUND:

Although various studies have shown high prevalence of malnutrition in hospitalized patients with stroke, recent studies on how the nutritional status of patients with acute stroke develops during the first weeks of hospital stay are scarce. Information is lacking concerning the identification of patients with stroke who are at risk of malnutrition during an acute hospital stay, because these patients may have a significant chance to improve their nutritional status.

PURPOSE:

This study aimed to investigate the prevalence of malnutrition and risk of malnutrition of patients with acute stroke during the first 10 days of hospitalization.

METHODS:

A prospective, descriptive study was conducted in a neurological department of a university hospital in The Netherlands. Seventy-three patients with acute stroke were included, of which 23 patients could be followed up after 10 days. The nutritional status was determined with the Mini Nutritional Assessment at admission and after 10 days.

RESULTS:

At admission, 5% of the patients (n = 73) were malnourished, 14% were at risk of malnutrition, and 81% were well nourished. Of the patients who could be followed up (n = 23), at admission, no patients were malnourished, 9% were at risk of malnutrition, and 91% were well nourished; whereas 10 days later, 26% of these patients were malnourished, 39% were at risk of malnutrition, and 35% were well nourished. This means that, within the followed-up group, the proportion of patients with malnutrition or risk of malnutrition increased significantly during hospital stay from 9% to 65%.

CONCLUSIONS:

Our study shows that the prevalence of malnutrition and risk of malnutrition in patients with acute stroke increases strongly during the first 10 days of admission. Therefore, screening of the nutritional status of these patients throughout this period is highly recommended to enable timely nutritional intervention and nutritional management of these patients.

10日間の入院で脳疾患の低栄養2倍

10日間の入院で、神経疾患患者（約半数が脳卒中）の低栄養の割合が約2倍になるという報告です。MNAで調査して良好、At risk、低栄養が入院時59％、34％、7％だったものが、10日後に21％、57％、22％になっています。急性期病院で栄養状態が悪化するという1つのエビデンスです。

Hafsteinsdóttir TB, Mosselman M, Schoneveld C, Riedstra YD, Kruitwagen CL. Malnutrition in hospitalised neurological patients approximately doubles in 10 days of hospitalisation. J Clin Nurs. 2010 Mar;19(5-6):639-48. doi: 10.1111/j.1365-2702.2009.03142.x.

急性期病院で栄養状態が悪化する理由として、①神経疾患・手術による侵襲、②不適切な栄養管理による飢餓が考えられます。急性期病院で低栄養になり、この状態で回復期リハ病院に転院するので、回復期でも低栄養が多いことになります。

Abstract

AIMS AND OBJECTIVES:

To measure the nutritional status of neurological patients during admission and after 10 days, with a special focus on those with malnutrition and those at risk of malnutrition, and to measure the association of clinical variables and nutritional status, which may be important for the early detection of patients at risk of malnutrition.

BACKGROUND:

Studies have shown high prevalence of malnutrition in hospitalised patients and recommend structured screening and nutritional intervention for these patients. There is a lack of information concerning the nutritional status of neurological patients.

DESIGN:

A prospective descriptive study.

METHOD:

Neurological patients (n = 196) were included from departments of neurology and neurosurgery in Dutch university hospital. Nutritional status was measured with the Mini Nutritional Assessment and functional status with the Barthel Index and the Rankin Scale at admission to the hospital and after 10 days.

RESULT:

Of the patients, 34% were at risk of malnutrition, 7% were malnourished, whereas 59% of the patients were well nourished according to the MNA. After 10 days, 57% were at risk of malnutrition, 22% were malnourished and 21% were well nourished. The total group of patients malnourished and at risk of malnutrition was 41% at admission, which had grown to 79% in 10 days. Significant association was found between various clinical variables and nutritional status.

CONCLUSIONS:

A large group of neurological patients is malnourished and at risk of malnutrition during hospital admission, and the nutritional status of most patients worsens in 10 days. Various clinical variables may be of importance in detecting malnourished patients.

RELEVANCE TO CLINICAL PRACTICE:

Nurses need to observe the symptoms of malnutrition and provide evidence-based nutritional interventions to these patients. Improved education of nurses and good collaboration between the professionals and the facilitation of hospital management is essential to improve nutritional care of neurological patients.

亜急性期高齢脳卒中の低栄養と予後

亜急性期の高齢脳卒中患者では、栄養状態が悪いと入院期間が長く、18カ月後の機能予後が悪く、死亡率が高いという報告です。MNAで30％が低栄養、53％が低栄養のおそれありです。回復期のリハ栄養的に重要な論文だと思います。

Charlton K, Nichols C, Bowden S, Milosavljevic M, Lambert K, Barone L, Mason M, Batterham M.　Poor nutritional status of older subacute patients predicts clinical outcomes and mortality at 18 months of follow-up.　Eur J Clin Nutr. 2012 Nov;66(11):1224-8.

Abstract

BACKGROUND/OBJECTIVES:

Older malnourished patients experience increased surgical complications and greater morbidity compared with their well-nourished counterparts. This study aimed to assess whether nutritional status at hospital admission predicted clinical outcomes at 18 months follow-up.

SUBJECTS/METHODS:

A retrospective analysis of N=2076 patient admissions (65+ years) from two subacute hospitals, New South Wales, Australia. Analysis of outcomes at 18 months, according to nutritional status at index admission, was performed in a subsample of n = 476. Nutritional status was determined within 72 h of admission using the Mini Nutritional Assessment (MNA). Outcomes, obtained from electronic patient records, included hospital readmission rate, total Length of Stay (LOS), change in level of care at discharge and mortality. Survival analysis, using a Cox proportional hazards model, included age, sex, Major Disease Classification, mobility and LOS at index admission as covariates.

RESULTS:

At baseline, 30% of patients were malnourished and 53% were at risk of malnutrition. LOS was higher in malnourished and at risk, compared with well-nourished patients (median (interquartile range): 34 (21, 58); 26 (15, 41); 20 (14, 26) days, respectively; P<0 .001="" 0.001="" 1.07-10.87="" 16.9="" 3.41="" 33.1="" 4.9="" a="" and="" at-risk="" care="" confidence="" death="" discharge="" for="" group.="" group="" hazard="" higher="" in="" interval:="" is="" level="" malnourished="" of="" p="" patients="" rate="" residential="" respectively="" the="" times="" to="" was="" well-nourished="">

CONCLUSION:

Malnutrition in elderly subacute patients predicts adverse clinical outcomes and identifies a need to target this population for nutritional intervention following hospital discharge.

MNA-SFとリハのアウトカム

MNA-SFが高齢リハ患者の臨床的なアウトカムを予測できるかを調査した論文です。オーストラリアの栄養士の論文です。

Andrew Slattery, et al. Does the Mini Nutrition Assessment—Short Form predict clinical outcomes at six months in older rehabilitation patients? Nutrition & Dietetics, DOI: 10.1111/1747-0080.12094

対象はリハ目的で入院した65歳以上の高齢者181人で、後ろ向きコホートのようです。アウトカムは入院期間、入院中の合併症、リハ活動への参加、入院中の機能変化、退院6ヶ月間の急性期病院への再入院と死亡です。

結果ですが、MNA-SFで栄養状態良好は22％、低栄養のおそれありは54％、低栄養は24％でした。低栄養のおそれあり・低栄養群では、入院期間が長く、リハ活動への参加が少なかったです。低栄養群は入院時機能が最も低く、入院中に最も改善しました。

以上より3/4の高齢リハ患者が低栄養のおそれあり・低栄養で、入院時の昨日低下、入院期間、リハ活動への参加と関連していました。低栄養はリハのアウトカムに影響を与えるため、さらなる研究と入院中の栄養状態への注意が必要という結論です。

まさにリハ栄養の論文ですし、後ろ向き研究ですから日本でも十分実現可能な研研究ですし、管理栄養士に行ってほしいです。日本で同じような調査を行えばMNA-SFで低栄養のおそれあり・低栄養の方はより多く、低栄養はリハのアウトカムに影響するでしょう。

Abstract

Aims

This study aimed to determine if nutritional status as assessed by the revised Mini Nutritional Assessment—Short Form is predictive of relevant clinical outcomes within six months in older rehabilitation patients, and to investigate the relationship between admission diagnosis and nutritional status.

Methods

A consecutive retrospective case note audit of 181 patients ≥ 65 years admitted to rehabilitation between May and November 2010 at the Repatriation General Hospital was performed. Nutritional status was assessed using the revised Mini Nutritional Assessment—Short Form. Outcomes measured included length of stay in rehabilitation, complications during admission, participation in rehabilitation activities and change in function during admission. Acute readmissions and mortality were assessed at six months post discharge from rehabilitation.

Results

Thirty-nine (22%) patients had normal nutritional status, 98 (54%) were at risk of malnutrition and 43 (24%) were malnourished. Patients at risk of malnutrition/malnourished had a longer length of stay (P = 0.008) and were more likely to be poor participators in rehabilitation activities (P = 0.006). Malnourished patients had poor function on admission to rehabilitation (P < 0.001) and had the greatest improvement in function during the rehabilitation admission (P = 0.012).

Conclusions

Over three-quarters of older rehabilitation patients were identified as malnourished or at risk of malnutrition, and this was associated with poorer function on admission, increased length of stay and poorer participation in rehabilitation activities. Thus, the issue of malnutrition is a concern as it impacts on clinical outcomes of rehabilitation and therefore, further investigation and attention to nutritional status during admission is required.

プレハビリテーションのメタ解析

プレハビリテーションのメタ解析の論文を紹介します。

D. Santa Mina, et al. Effect of total-body prehabilitation on postoperative outcomes: a systematic review and meta-analysis. Physiotherapy, http://dx.doi.org/10.1016/j.physio.2013.08.008

成人外科患者に対するプレハビリテーションの系統的レビューとメタ解析です。結果ですが、系統的レビューではプレハビリテーションで術後疼痛、入院期間、身体機能は改善しましたが、健康関連QOL、生命予後、有酸素能力は一貫した結果ではありませんでした。

メタ解析では、術後の入院期間が有意に短縮しました。これよりプレハビリテーションは入院期間短縮と術後の身体機能改善に有用な可能性がありますが、論文の質が中～低いためバイアスの可能性があるという結論です。

整形外科領域でのプレハビリテーションは賛否両論のところがありますが、外科領域でのプレハビリテーションは有用なようです。今後はどのようなプレハビリテーション介入（例えば運動＋栄養＋心理）がより有用かの検証が重要と思われます。

Abstract

Objective

To systematically review the evidence of pre-operative exercise, known as ‘prehabilitation’, on peri- and postoperative outcomes in adult surgical populations.

Design

Systematic review and meta-analysis.

Data sources

CENTRAL, Medline, EMBASE, CINAHL, PsycINFO and PEDro were searched from 1950 to 2011.

Methods

Two reviewers independently examined relevant, English-language articles that examined the effects of pre-operative total-body exercise with peri- and postoperative outcome analysis. Given the nascence of this field, controlled and uncontrolled trials were included. Risk of bias was assessed using the Cochrane Risk of Bias Assessment tool. Only data on length of stay were considered eligible for meta-analysis due to the heterogeneity of measures and methodologies for assessing other outcomes.

Results

In total, 4597 citations were identified by the search strategy, of which 21 studies were included. Trials were generally small (median = 54 participants) and of moderate to poor methodological quality. Compared with standard care, the majority of studies found that total-body prehabilitation improved postoperative pain, length of stay and physical function, but it was not consistently effective in improving health-related quality of life or aerobic fitness in the studies that examined these outcomes. The meta-analysis indicated that prehabilitation reduced postoperative length of stay with a small to moderate effect size (Hedges’ g = -0.39, P = 0.033). Intervention-related adverse events were reported in two of 669 exercising participants.

Conclusion

The literature provides early evidence that prehabilitation may reduce length of stay and possibly provide postoperative physical benefits. Cautious interpretation of these findings is warranted given modest methodological quality and significant risk of bias.

Malnutrition is associated with poor rehabilitation outcome in elderly inpatients with hospital-associated deconditioning a prospective cohort study

J Rehabil Medに投稿していた高齢の廃用症候群の低栄養とリハの予後に関する論文が、ようやくEpub ahead of printになりました。まだオープンアクセスではないはずですが、下記のHPで全文見れます。

Wakabayashi H, Sashika H. Malnutrition is associated with poor rehabilitation outcome in elderly inpatients with hospital-associated deconditioning a prospective cohort study. J Rehabil Med, DOI: 10.2340/16501977-1258, Epub ahead of print

http://www.medicaljournals.se/jrm/content/?doi=10.2340%2F16501977-1258&preview=1

この研究をする中で、廃用症候群における廃用性筋萎縮は、サルコペニアを考慮したリハ栄養の視点で考えて対応しないといけないことを確信しました。その点でリハ栄養の考え方を生みだすきっかけとなった研究といえます。

今まできちんとした研究をしないで学会発表、講演、依頼原稿執筆ばかりしてきました。ようやくImpact Factorが2.134でリハのTop journalの1つであるJ Rehabil Medに論文を掲載できて、ほっとしています。

リハ栄養という言葉や考え方は3-4年前に比べればいくらか普及したと思いますが、リハ栄養の土台（エビデンス）作り（IFのある英語雑誌への原著論文掲載）は遅れていました。でもようやく土台作りの第一歩を踏み出すことができました。

今後は一発屋で終わらないように自分がリハ栄養のエビデンスを発信し続けることと、リハ栄養のエビデンスを発信できる仲間を増やすことが、当面の私の使命です。とはいえ研究だけでなくリハ栄養の臨床、教育、管理面でも頑張ります。

Abstract:

Objective: To investigate the association between nutritional status and rehabilitation outcome in elderly inpatients with hospital-associated deconditioning. Design: A prospective cohort study. Subjects/patients: One hundred sixty-nine consecutive elderly inpatients diagnosed with hospital-associated deconditioning. Methods: Nutritional status at referral was assessed by the Mini Nutritional Assessment Short Form at the University Medical Center. Body mass index, haemoglobin, albumin, total lymphocyte count, C-reactive protein, cause of malnutrition, and feeding route were also investigated. Primary outcome was Barthel Index score at discharge. Results: A total of 148 patients (87.6%) were malnourished, and 21 were at risk for malnutrition. There were no patients with normal nutritional status. Malnourished patients had a lower Barthel Index score at discharge than those at risk for malnutrition. Chronic disease-related malnutrition, oral intake, and parenteral nutrition were associated with the Barthel Index score at discharge. There were significant correlations between the Barthel Index score at discharge and nutritional score, albumin, and total lymphocyte count. In multiple regression analysis, Mini Nutritional Assessment Short Form, albumin, and chronic disease-related malnutrition were significantly associated with the Barthel Index score at discharge. Conclusion: Most elderly inpatients with hospital-associated deconditioning are malnourished. Nutritional status, albumin, and chronic disease-related malnutrition are associated with poor rehabilitation outcome in hospital-associated deconditioning.

運動＋蛋白質摂取によるGFR変化

地域在住高齢者における12週間のレジスタンス運動＋運動後のたんぱく質摂取によるGFR（糸球体濾過量）の変化を見た論文を紹介します。

Ramel A, Arnarson A, Geirsdottir OG, Jonsson PV, Thorsdottir I. Glomerular filtration rate after a 12-wk resistance exercise program with post-exercise protein ingestion in community dwelling elderly. Nutrition. 2013 May;29(5):719-23. doi: 10.1016/j.nut.2012.10.002.

レジスタンス運動は12週間、週3回実施しています。たんぱく質はホエイたんぱくもしくは牛乳たんぱくを1日20g摂取、運動後に摂取しています。GFRの平均値は70.7 ± 16.9で、25.4%が60未満でした。

結果ですが、 レジスタンス運動＋たんぱく質20gの摂取によって、GFRは有意に改善しました（介入後平均75.1 ± 20.2）。また、GFR60未満の群でも介入で有意に改善しました（介入前：48.9 ± 10.3、介入後53.4 ± 12.9）。

以上より、地域在住高齢者における12週間のレジスタンス運動＋運動後のたんぱく質20gの摂取は、GFRに悪影響を与えないという結論です。

CKDではたんぱく質摂取を制限することが推奨されがちです。しかし、GFR60未満の群（Stage3）では、12週間の運動＋たんぱく質投与によるGFR悪化は認めず、むしろ改善しました。CKDStage3では運動＋たんぱく質投与をむしろ行うべきかもしれません。

Abstract

OBJECTIVE:

Increased protein intake and resistance exercise can be beneficial for maintenance of lean body mass (LBM) in older adults. However, these factors could also negatively affect renal function. We investigated changes in renal function after a 12-wk resistance exercise program combined with protein supplementation in community dwelling older adults.

METHODS:

Patients (N = 237, 73.7 ± 5.7 y, 58.2% female) participated in a 12-wk resistance exercise program (3 times/wk) designed to increase strength and muscle mass of major muscle groups. Participants were randomly assigned to one of three dietary supplements consumed directly after training: whey protein drink (20 g whey protein, 20 g carbohydrates), milk protein drink (20 g milk protein, 20 g carbohydrates), or carbohydrate drink (40 g carbohydrates). Renal function was estimated as glomerular filtration rate (GFR, Cockcroft-Gault formula), and dietary intake was measured as 3-d-weighed food record at baseline and endpoint.

RESULTS:

During the intervention, energy intake did not increase. Carbohydrate intake increased in the carbohydrate group and protein intake increased in the milk group, both approximately in accordance with the supplementation. In the whey group, protein intake did not increase, but carbohydrate intake did. GFR increased after the intervention (+4.4 mL/min/1.73 m2; P < 0.001), and the changes were similar in men and women or in the age quartiles. Changes in GFR at endpoint were not associated with LBM, dietary supplements, or total protein intake.

CONCLUSIONS:

A 12-wk resistance exercise program combined with protein supplementation in community dwelling older adults does not negatively affect GFR. The supplementation had only minor effects on total dietary intake.

移動障害のある高齢者の低栄養

移動障害のある高齢者における低栄養の役割に関するレビュー論文を紹介します。

Cederholm T, Nouvenne A, Ticinesi A, Maggio M, Lauretani F, Ceda GP, Borghi L, Meschi T. The Role of Malnutrition in Older Persons with Mobility Limitations. Curr Pharm Des. 2013 Sep 18. [Epub ahead of print]

栄養と障害は密接に関連しているというエビデンスが増えてきています。低栄養は機能障害の原因の1つとなります。一方、障害自体が低栄養の原因や悪化となります。虚弱高齢者において栄養の重要性の認識は高まりつつあります。

地中海ダイエットや高蛋白質の食事、カロテノイド、セレン、ビタミンDに関する内容がレビューされています。

虚弱高齢者における低栄養の評価と管理は当然重要ですが、障害のある高齢者ではより低栄養の評価と管理が重要になります。リハ栄養の重要性が高まりつつあることを実感できる論文です。

Abstract

Movement disability has a high prevalence in elderly population, either healthy or with chronic disease. Impaired nutritional status is a very common condition in geriatric patients too, especially if we consider elderly subjects admitted to hospital. There are growing evidences that nutrition and disability are strictly interconnected. On the one side, nutritional status is one of the multiple elements that influence the onset and the course of a functional disability; on the other side, disability itself may contribute to malnutrition onset and worsening. Nutrition may not be the sole factor involved in movement impairment in the elderly, but consciousness of its importance in frail elderly population is growing among clinicians and scientific community. In this paper we review the existing knowledge of these complex relationships, discussing the main observational and interventional studies that explored the role of nutrition in movement disability onset and recovery. We also point out how specific kinds of diet, such as Mediterranean diet or high-protein diet, are involved in disability prevention. Finally, we take a look at the existing evidence of the role of single nutrient dietary intake, such as carotenoids, selenium or vitamin D, in mobility impairment in the elderly population.

高齢者の最適な蛋白質摂取量

エビデンスに基づいた高齢者の最適な蛋白質摂取量に関する方針論文Position Paper を紹介します。

Jürgen Bauer, et al: Evidence-based Recommendations for Optimal Dietary Protein Intake in Older People: A Position Paper From the PROT-AGE Study Group. JAMDA, in press

下記のHPで全文読めると思います。

http://www.jamda.com/article/S1525-8610(13)00326-5/fulltext

高齢者では少なくとも1-1.2g/kg/日の蛋白質摂取が推奨されます。持久性トレーニングとレジスタンストレーニングの実施も推奨され、これらを実施している場合には1.2-1.5g/kg/日の蛋白質摂取が推奨されます。

ただし、重度の腎疾患（例：eGFRが30未満）で透析を行っていない場合には、このルールは当てはまりません。蛋白質の質、摂取のタイミング、他の栄養素摂取に関するエビデンスはまだ不十分です。

運動をしている場合に1.2-1.5g/kg/日の蛋白質摂取が推奨されることは、リハ栄養的にも重要です。また、CKDのStage3（eGFRが30以上）であれば、蛋白質摂取の制限を必要としない（特に運動を行う場合）かもしれません。これも重要ですね。

Abstract
New evidence shows that older adults need more dietary protein than do younger adults to support good health, promote recovery from illness, and maintain functionality. Older people need to make up for age-related changes in protein metabolism, such as high splanchnic extraction and declining anabolic responses to ingested protein. They also need more protein to offset inflammatory and catabolic conditions associated with chronic and acute diseases that occur commonly with aging. With the goal of developing updated, evidence-based recommendations for optimal protein intake by older people, the European Union Geriatric Medicine Society (EUGMS), in cooperation with other scientific organizations, appointed an international study group to review dietary protein needs with aging (PROT-AGE Study Group). To help older people (65 years and older) maintain and regain lean body mass and function, the PROT-AGE study group recommends average daily intake at least in the range of 1.0 to 1.2 g protein per kilogram of body weight per day. Both endurance- and resistance-type exercises are recommended at individualized levels that are safe and tolerated, and higher protein intake (ie, ≥1.2 g/kg body weight/d) is advised for those who are exercising and otherwise active. Most older adults who have acute or chronic diseases need even more dietary protein (ie, 1.2–1.5 g/kg body weight/d). Older people with severe kidney disease (ie, estimated GFR less than 30) but who are not on dialysis, are an exception to this rule; these individuals may need to limit protein intake. Protein quality, timing of ingestion, and intake of other nutritional supplements may be relevant, but evidence is not yet sufficient to support specific recommendations. Older people are vulnerable to losses in physical function capacity, and such losses predict loss of independence, falls, and even mortality. Thus, future studies aimed at pinpointing optimal protein intake in specific populations of older people need to include measures of physical function.

関節リウマチのBMI低値とQOL低下

関節リウマチ患者ではBMI低値はQOL低下と関連するという論文を紹介します。

Wataru Fukuda, et al. Low body mass index is associated with impaired quality of life in patients with rheumatoid arthritis. International Journal of Rheumatic Diseases, DOI: 10.1111/1756-185X.12079

対象は関節リウマチ患者385人です。栄養状態をBMIで評価して、BMI20未満131人、BMI20～25の163人、BMI25以上の91人の3群に分類しています。上腕筋面積も評価しています。QOLはJHAQとEQ5Dで評価しました。

結果ですが、BMI20未満の群ではBMI20～25の群と比較して、有意にQOLが低かったです。ステロイドの使用量やCRPには3群間で有意な差を認めませんでした。多変量解析では、疾患活動度、罹病機関、CRP、AMAがEQ5Dと関連していました。

以上より関節リウマチ患者ではBMI低値はQOL低下と関連するという結論です。骨格筋減少でBMIだけでなくQOLも低下するようです。炎症とは独立してBMIや筋肉量がQOLに影響を与えているようです。これより、るいそうやサルコペニアの改善でQOLが改善する可能性があるといえます。

Abstract

Aim

To investigate the relationship between quality of life (QOL) and rheumatoid chachesia, malnutrition in patients with rheumatoid arthritis (RA).

Methods

EuroQol Group 5-Dimension Self-Report Questionnaire (EQ5D) and Japanese Health Assessment Questionnaire (JHAQ) scores, body mass index (BMI), arm muscle area (AMA) and clinical indicators were measured in 385 RA patients. One-way analysis of variance for obtained data was conducted among three groups: 131 with low BMI (< 20), 163 with moderate (20–25) and 91 with high BMI (≥25). Then multiple regression analyses for JHAQ and EQ5D scores with nutritional and clinical indicators as independent variables were performed.

Results

EQ5D and JHAQ scores were significantly lower and higher, respectively, in the low BMI group than those in the moderate BMI group. Clinical indicators including doses of corticosteroid were similar among the three groups except for disease duration. Disease activity score (DAS) 28, disease duration, C-reactive protein and AMA were significant variables in the regression model for EQ5D.

Conclusion

Low BMI deteriorates the QOL of RA patients. Muscle protein loss apparently leads to a reduction in BMI and QOL.

急性・重症患者ケア2巻2号

急性・重症患者ケアというICUや集中治療に携わる看護師向けの雑誌の2巻2号で、エキスパートが本気で教える重症患者の栄養管理ー知らないと痛い目をみる!?　コツとピットフォールーという特集が組まれています。

http://www.sogo-igaku.co.jp/eshopdo/refer/vid902.html

もちろん侵襲下や疾患別の栄養管理に関する記載が多いですが、栄養の基礎知識の記載も多いです。私は「リハビリテーションと栄養管理～リハと栄養管理はベストカップル～」という原稿を執筆させていただきました。急性・重症患者でも早期リハ栄養管理は大事ですね。

【目　次】 　I．栄養管理に必要な基礎知識
　　栄養管理の基礎知識
　　　～三大栄養素の消化と吸収，排泄まで～（宮澤　靖）
　　体内水分と電解質の関係
　　　～輸液管理の基本を理解するために～（小竹良文，豊田大介）
　　侵襲期における栄養評価・栄養スクリーニング
　　　～Let’s栄養アセスメント！ ICU NSがみるべきポイント～（宮坂友美，大竹美緒，松田兼一）
　　各種栄養素不足による全身への影響
　　　～知らないと痛い目をみる!? 栄養素不足～（山本佳子，長野　修）
　　経腸栄養の基礎知識
　　　～基本を押さえて安全確実な経腸栄養を実施しよう！～（海塚安郎）
　　静脈栄養の基礎知識
　　　～静脈栄養の基本と応用を理解する～（清水孝宏）

　II．侵襲下における栄養管理に必要な知識
　　外因性エネルギーと内因性エネルギー
　　　～知らないと危険です！侵襲下におけるエネルギー供給の基本原理～（寺島秀夫）
　　侵襲時のエネルギー補充の考え方
　　　～既成概念の打破，今こそパラダイムシフト～（寺島秀夫）
　　栄養管理中の血糖管理
　　　～知っておきたいインスリンの使い方，血糖値の測り方～（江木盛時）

　III．栄養管理に欠かせないプラスの知識
　　リハビリテーションと栄養管理
　　　～リハと栄養管理はベストカップル～（若林秀隆）
　　口腔ケア
　　　～見直してみませんか？あなたの口腔ケア～（大野友久）
　　急性期における摂食・嚥下管理
　　　～患者さんが安全に食べられるように知っておきたい，みておきたいポイントとは？～（朝井政治，神津　玲）
　　薬物治療に影響を及ぼす要因
　　　～知っておきたい！薬の効果が変わるワケ～（鈴木彰人）
　　国内で販売されている各種栄養剤の特徴
　　　～病気にも食事の好き嫌いがある!?まずは知っておきたい栄養剤の基本～（平敷好史）

　IV．病態別栄養管理
　　心不全の栄養管理
　　　～より厳密な栄養管理で心不全の治療にも差をつけよう！～（仙頭佳起，幸村英文，祖父江和哉）
　　腎不全の栄養管理
　　　～AKIを合併した患者への蛋白質投与量：その投与量で十分ですか？～（内山壮太，中村智之，西田　修）
　　消化器外科周術期の栄養管理
　　　～手術から順調に回復するために栄養は欠かせない～（福島亮治）
　　重症急性膵炎の栄養管理
　　　～「膵炎で絶飲・絶食」は時代遅れ！～（真弓俊彦）
　　敗血症の栄養管理
　　　～敗血症でも早期に経腸栄養を開始しよう!!～（巽　博臣，升田好樹，今泉　均）
　　多臓器機能障害・多臓器不全における栄養管理
　　　～障害臓器の組合せとその障害程度がとっても大事～（中村卓郎，山田　一）
　　人工呼吸管理を要する急性呼吸不全の栄養管理
　　　～入院時から継続して最適な栄養管理法を考えよう～（海塚安郎）
　　こんな時，栄養投与はストップしたほうがベター？
　　　～“食に勝る薬なし”栄養投与を安易に中止して本当に大丈夫？～（尾迫貴章，小谷穣治）

　V．栄養管理における看護ケア
　　栄養管理におけるナーシングケア
　　　～看護師のかかわり方が重要！栄養に関する合併症を予防するために～（櫻本秀明）

　VI．急性期栄養管理の動向
　　急性期栄養管理におけるガイドラインの紹介
　　　～米国， 欧州， カナダ， 日本のガイドラインに違いがあるの？～（佐藤格夫，邑田　悟，苛原隆之）

　VII．文献レビュー
　　急性期栄養管理における文献レビュー
　　　～エビデンスを知ればケアが変わるってホント!?～（瀬尾龍太郎）
　　
　　書 評：「重症患者と栄養管理Q&A（第3版）」（清水孝宏）
　　付 録：本特集で使われる略語一覧
　　索 引