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ATI #3: Skills Module Guidelines: Nutrition Feeding and Eating PURPOSE: To encourage critical thinking, problem solving, and collaboration through the use of evidence based practice (EBP) studies. COURSE OUTCOMES: This assignment enables the student to meet the following course outcomes. 1. Examine the sources of knowledge that contribute to professional nursing practice. 2. Apply research principles to the interpretation of the content of published research studies. 3. Identify ethical issues common to research involving human subjects. 4. Evaluate published nursing research for credibility and clinical significance related to evidence-based practice. 5. Recognize the role of research findings in evidence-based practice. DUE DATE: · Week #6, Sun. by 11:59pm: Submit in Unit 6, ATI SKILLS MODULE in CANVAS · Please submit by clicking “Module” for Unit 6 where the “Turnitin” function is implemented (NOT via clicking Grade for Unit 6) · The College’s Late Assignment Policy applies to this assignment. TOTAL POSSIBLE POINTS: 150 Points Preparing the Assignment: View and read any relevant resource material that could help you better understand the concept or solve the problem(s) given. You can review the module, this is not a priority for this assignment. · Log into ATI, Select the “Learn” tab. · Click on Skills Modules and title “Nutrition Feeding and Eating” · Click on the “Lesson” tab · Open the “Evidence Based Research” tab at the top of the page. “Turnitin” Percentage · Less than 25 percentage: Acceptable percentage. · Turnitin Draft Submission Box · Submit your draft of paper into Turnitin Draft Submission Box to check your percentage as many times as needed before you submit your final paper to designated Unit. · If your Final paper has 25\% or higher percentage, you must revise/modify your paper contents BEFORE the paper due date and time. · If your Final paper has 25\% or higher percentage AT/AFTER you submit your final paper due date and time, Academic Integrity Violation Procedures will be initiated: · Academic Integrity Violation letter will be sent to student · Assignment Grade will be 0 point · The violation case will be reviewed and a further sanction will be determined by the Administrators. Directions and Assignment Criteria There are five main topics and five associated topics related to each main topic. · Select ONE main topic. · Search for ONE Primary Research study for the selected main topic and get approved by Professor. Submit to Canvas shell after approval · Review article to summarize the required information TOPIC 1: Evaluating Nutritional Status: What methods can be used to assess nutritional status? Example Studies: · Formative evaluation of the feedback components of Children’s and Adolescent’s Nutrition Assessment and Advice on the Web (CANAA-W) among parents of schoolchildren. · Validation of the Diet Quality Index for adolescents by comparison with biomarkers, nutrient and food intakes: the HELENA study TOPIC 2: Identifying those at risk for malnutrition: What methods can be used to identify those at risk for malnutrition? Example Studies: · Beyond malnutrition screening: Appropriate methods to guide nutrition care for aged care residents · Population-specific short-form mini nutritional assessment with body mass index or calf circumference can predict risk of malnutrition in community-living or institutionalized elderly people in Taiwan · Comparison of prevalence of malnutrition diagnosis in head and neck, gastrointestinal and lung cancer patients by three classification methods TOPIC 3: Malnutrition associated with specific health conditions: What specific health conditions increase the risk of malnutrition? Example Studies: · Malnutrition in a sample of community-dwelling people with Parkinson’s disease. · Nutritional risk index as a predictor of postoperative wound complications after gastrectomy. · Risk of malnutrition is associated with mental health symptoms in community living elderly men and women: the Tromso Study. TOPIC 4: Outcomes associated with nutritional status: What associations exist between nutritional status and health outcomes? Example Studies: · Role of nutritional status in predicting quality of life outcomes in cancer – a systematic review of the literature · Nutritional support for liver disease TOPIC 5: Interventions to improve nutritional status: What type of interventions improve adherence to recommendations on nutritional intake? Example Study: · Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults. WRITTEN ASSIGNMENT: · Read the study and answer the required questions for each category · Must write the paper using provided Summary Paper Format on page #3. · Grading Rubric/Description on page 4-5 ATI #3: Skills Module Contents: Summary Paper Format · Bold for each Heading and Subheading · Include in-text citations for all information/contents as needed · Summary paper MUST be written in this format Introduction and Key Points Chosen Topics and Question · Select one topic and question from five main topic list Define the Topic and Question · How do you interpret and/or understand the topic and question you selected? Overview/Significance of Problem · Describe Overview and Significance of Problem of the topic and question you selected · Include in-text citations Article Search Current and credible resources: List Chamberlain library Database(s) used Database search-terms and refinement methods Number of articles located List additional sources outside of ATI module: List all sources you used for article search outside of ATI (CDC, American Diabetic Association, etc.) Article Findings Why was this article chosen? How it addresses the topic? State the “Purpose/Aim of Study” as the author stated in article Type of Research conducted: · Quantitative, Qualitative, Descriptive, or Mixed-Method study? · Briefly describe what was done (sample, methods, measurement tools used) Findings of Research: Comprehensively describe ALL Findings in the article (participant characteristics and Results of Study). Evidence for Practice Summary of Evidence · Briefly summarize the overall purpose and findings of the research. How will this evidence improve current practice? · Briefly describe what the current practice is. · Describe how this evidence improve current practice? How will this evidence decrease a gap in current practice? · Briefly describe difference between the current knowledge, skills, competence, practice, performance or patient outcomes and the ideal or desirable state · Describe how this evidence decrease a gap in the practice? Any concerns or weaknesses in the evidence/finding? (Found in Discussion) Sharing of Evidence Who would you share the information with? (colleagues, other disciplines, patients, families) How would you share this information? (in-services, online education modules, health fair for patients, educate healthcare professionals) What resources would you need to accomplish this sharing of evidence? · List resources you may need for sharing the evidence as you stated in above 2 questions (who and how) (i.e. administrator, manager, support for materials, etc.) Why would it be important to share this evidence with the nursing profession? Conclusion · Summarizes the Theme of Paper, Findings, and Key points. · Do NOT include Conclusion/Implication on the article Assignment Criteria Points \% Description Pick one of the topics and answer the topic question along with providing a current research article, which supports this question, and 300-word summary. The Summary must include the following headings (See rubric for criteria under each heading): a. Introduction and Key Points (10 points) b. Article Search (25 points) c. Article Findings (25 points) d. Evidence of Practice (25 points) e. Sharing of Evidence (25 points) f. Conclusion (20 points) g. APA style (10 points) h. Writing mechanics (10 points) 150 100 Student grades will be based on completing ALL criteria listed and according to the rubric. Please see rubric for specific requirement to achieve full points for this assignment Total 150 100 GRADING RUBRIC Headings Points for Each Heading Heading 1 10 points 7.5 pts 5 pts 2.5 pts 0 pts Introduction and Key points All 4 criteria met: 1) Choose one of assigned Topics and Question 2) Defines the Topic and Question 3) States why it is a problem 4) Information presented in logical sequence 3 of 4 criteria met 2 of 4 criteria met 1 of 4 criteria met Not done Heading 2 25 points 20 pts 15 pts 10 pts 0 pts Article Search All 4 criteria met: 1) Current and credible resource 2) Database search-terms and refinement methods 3) Number of articles located 4) Source outside of ATI module 3 of 4 criteria met 2 of 4 criteria met 1 of 4 criteria met Not done Heading 3 25 points 20 pts 15 pts 10 pts 0 pts Article Finding All 4 criteria met: 1) How it addresses the topic (purpose) 2) Type of research conducted (and include sample, methods) 3) Findings of research 4) Why this article chosen 3 of 4 criteria met 2 of 4 criteria met 1 of 4 criteria met Not done Heading 4 25 points 20 pts 15 pts 10 pts 0 pts Evidence for Practice All 4 criteria met: 1) Summary of evidence 2) How it will improve practice 3) How will this evidence decrease a gap to practice 4) Any concerns or weaknesses located in the evidence 3 of 4 criteria met 2 of 4 criteria met 1 of 4 criteria met Not done Heading 5 25 points 20 pts 15 pts 10 pts 0 pts Sharing of Evidence All 4 criteria met: 1) Who would you share the information with? 2) How would you share this information? 3) What resources would you need to accomplish this sharing of evidence? 4) Why would it be important to share this evidence with the nursing profession 3 of 4 criteria met 2 of 4 criteria met 1 of 4 criteria met Not done Heading 6 20 points 15 pts 10 pts 5 pts 0 pts Conclusion All 4 criteria met: 1) Summarizes the theme of the paper 2) Information presented in logical sequence 3) All key points addressed 4) Conclusion shows depth of understanding 3 of 4 criteria met 2 of 4 criteria met 1 of 4 criteria met Not done Heading 7 10 points 7.5 pts 5 pts 2.5 pts 0 pts APA Style All 4 criteria met: 1) APA style used properly for citations 2) APA style used properly for reference 3) APA style used properly for quotations 4) All references are cited, and all citations have references 3 of 4 criteria met 2 of 4 criteria met 1 of 4 criteria met Not done Heading 8 10 points 7.5 pts 5 pts 2.5 pts 0 pts Writing mechanics All 4 criteria met: 1) No spelling errors 2) No grammatical errors, including verb sentence and word usage 3) No writing errors, including sentence structure, and formatting 4) Must be all original work 3 of 4 criteria met 2 of 4 criteria met 1 of 4 criteria met Not done Total 150 Points Score = 6/21 428 Asia Pac J Clin Nutr 2019:28(3):428-434 Original Article Effects of an individualized nutrition intervention on the respiratory quotient of patients with liver failure Xing Liu M D L2, Ming Kong P h D 13, Xin Hua M Sc4, Yinchuan Yang B S c1, Manman Xu M S c 1, Yanzhen Bi M D 1, Lu Li M D 1, Zhongping Duan P h D 1-3, Yu Chen P h D 1-3 Difficult & Complicated Liver Diseases and Artificial Liver Center, Beijing YouAn Hospital, Capital Medical University, Beijing, China 2 Department o f Infectious Disease, Linyi People’s Hospital, Linyi, China 2 Beijing Municipal Key Laboratory o f Liver Failure and Artificial Liver Treatment Research, Beijing, China ^Department o f Clinical Nutrition, Beijing YouAn Hospital, Capital Medical University, Beijing, China Background and Objectives: Malnutrition and energy metabolism disorders are characterized by a low respira­ tory quotient in patients with liver failure and often lead to poor prognosis. Therefore, early nutrition interven­ tions are crucial for patients with liver failure to ameliorate abnormal metabolic status and malnutrition. This study explored the effect o f an individualized nutrition intervention on the respiratory quotient o f patients with liver failure. Methods and Study Design: An individualized 2-week nutrition intervention was conducted on pa­ tients with nutritional risk caused by liver failure according to patient resting energy expenditure. Patients were separated into two groups for further analysis according to whether their energy intake reached 1.2 times their resting energy expenditure. Results: Fifty-two patients with nutritional risk caused by liver failure were enrolled. Their average respiratory quotient was 0.79 (0.76-0.84) at the baseline. Patients with an energy intake o f >1.2 times their resting energy expenditure had a higher respiratory quotient and lower scores on the model for end- stage liver disease and Child-Pugh test than those with an energy intake o f <1.2 times their resting energy ex­ penditure at weeks 1 and 2 after the intervention. Moreover, no significant differences were observed between the two groups at the baseline. Respiratory quotient was negatively correlated with the model for end-stage liver dis­ ease and Child-Pugh scores. Conclusions: Individualized nutrition interventions with an energy intake >1.2 times the patient’s resting energy expenditure can effectively improve the respiratory quotient and reduce disease severity in patients with nutritional risk caused by liver failure. Key W ords: liver failure, energy m etabolism , resting energy expenditure, respiratory quotient, individualized nutrition intervention INTRODUCTION The liver is a central regulator o f energy metabolism and plays a critical role in the metabolism o f nutrients. Exten­ sive necrosis of hepatocytes can be observed when non­ chronic liver failure occurs, which impairs liver function and leads to malnutrition and various energy metabolism disorders. Malnutrition is a serious complication of liver disease and is almost universal in patients with end-stage liver disease (ESLD).15 The degree of malnutrition is correlated with the severity o f hepatic disease regardless o f the cause.68 Malnutrition leads to increased morbidity and mortality rates0 12 in patients with ESLD. both before and after liver transplantation.21,14 Therefore, conducting nutritional intervention for patients with liver failure at an early stage is vital. Respiratory quotient (RQ)1516 is considered an excel­ lent indicator of substrate oxidation, which is the ratio of the amount o f carbon dioxide produced to the amount of oxygen consumed. The metabolism substrate of patients with ESLD is similar to that of healthy individuals after 3 days o f starvation.17 19 Impaired glycogen storage and insulin resistance result in earlier and more excessive use of fats and proteins as fuel sources.20 This leads to in­ creased free fatty acid and ketone body production; moreover, a significant correlation has been reported be­ tween free fatty acid production and fat oxidation rate in cirrhotic patients.21 Low RQ has been frequently observed in patients with ESLD. Furthermore, significantly lower RQ has been reported in patients with acute-on-chronic liver failure (ACLF) than in patients with cirrhosis or chronic hepatitis B. In patients with ACLF, the RQ of nonsurvivors is significantly lower than that of survi­ vors.22 Therefore, RQ is useful for monitoring changes in energy metabolism and may be related to the prognosis of patients with liver failure. Corresponding Author: Dr Yu Chen. Difficult & Complicated Liver Diseases and Artificial Liver Center. Beijing YouAn Hos­ pital. Capital Medical University, No. 8 Xitoutiao. Fengtai Dis­ trict, Beijing 100069. China. Tel: +86 010 839 97157: Fax: +86 010 632 95285 Email: [email protected] Manuscript received 26 February 2019. Initial review completed 17 March 2019. Revision accepted 31 March 2019. doi: 10.6133/apjcn.201909_28(3).0001 mailto:[email protected] Nutrition on RQ in patients with liver failure 429 A late evening snack (LES) is recommended by both the European Society for Clinical Nutrition and Metabo­ lism guidelines23 and the American Society for Parenteral and Enteral Nutrition24 for improving the catabolic state. Many studies2528 have discovered that LESs can improve fasting RQ and quality o f life in patients with cirrhosis, moreover, one study reported that a high-frequency diet strategy is effective for improving RQ and is beneficial to patients with cirrhosis.29 The fasting RQ o f patients with ACLF also significantly improved after LES supplemen­ tation.30 However, no research has been conducted on improv­ ing RQ in patients with liver failure through individual­ ized nutrition intervention. Therefore, we performed nu­ tritional risk screening o f patients with liver failure using nutritional risk screening 2002 (NRS-2002).31 We also established a nutrition support team (NST) consisting of physicians, dietitians, pharmacists, and nurses who con­ ducted an individualized nutrition intervention on the basis of comprehensive internal medicine treatment for patients with nutritional risk caused by liver failure. The purpose o f this study was to explore the effect of an indi­ vidualized nutrition intervention on RQ in patients with liver failure. METHODS Patients This study was conducted from December 2016 to July 2 0 18 at the Artificial Liver Center, Beijing YouAn Hospi­ tal, Capital Medical University. A total o f 52 patients with nutritional risk caused by liver failure were enrolled in the study. O f these, 2 cases were acute liver failure (ALF), 1 case was sub-acute liver failure (SALF), 49 cas­ es were ACLF. O f the ACLF cases, 42 cases were hepati­ tis B virus-related ACLF, six were caused by alcohol, and one had an unknown cause. The diagnosis of liver failure was based on the guidelines of the 13th Asia-Pacific Congress o f Clinical Microbiology and Infection Consen- sus.32 None of the patients with liver failure had a history o f thyroid dysfunction, neoplasia, diabetes mellitus, or other diseases that can potentially affect energy metabo­ lism. None had hepatic encephalopathy, gastrointestinal bleeding, or fever during the study. None o f the patients were administered drugs that could affect energy metabo­ lism. Each participant signed an informed consent form. The study protocol was in accordance with the ethical guidelines of the Helsinki Declaration of 1975 and was authorized by the Institutional Review Board of Beijing YouAn Hospital, Capital Medical University, Beijing, China (Approval No. 2016-18). The clinical trial was registered at http://www.chictr.org.cn (registration num­ ber: ChiCTR 1900020900). Study design We screened patients with liver failure for nutritional risk using the NRS-2002, and those with nutritional risk caused by liver failure were enrolled in the study. The energy intake of each patient was assessed based on 24- hour dietary records. The resting energy expenditure (REE) and fasting RQ of each patient was measured by indirect calorimetry at the baseline and once each week. The precise energy requirements of patients were deter­ mined according to their REE. The individualized nutri­ tion intervention was conducted by NST and lasted for 2 weeks on the basis o f comprehensive internal medicine treatment for patients with nutritional risk caused by liver failure. All patients were provided with six meals per day and snacks between breakfast, lunch, and dinner and be­ fore going to bed. The American Society for Parenteral and Entemal Nutrition suggests that patients with ESLD have an energy requirement of 1.2-1.4 times their REE.33 Based on an energy intake of 1.2 times their REE, all pa­ tients were divided into two groups: one with an energy intake of no less than 1.2 times their REE (>1.2REE) and one with an energy intake of less than 1.2 times their REE (<1.2REE). We then explored the effects o f the individu­ alized nutrition intervention on RQ in patients with liver failure. A nthropometric variables Body height and weight were measured using a height/weight scale (RGZ120, Wuxi Weighter Factory, Wuxi, China), and the precision of height and weight measurements were to 0.1 cm and 0.1 kg, respectively. Body mass index (BMI) was calculated as kg/m2. Triceps skinfold thickness (TSF) was measured at the midpoint between the olecranon and acromion of the left arm with a skinfold caliper (Changshu Instrument Company, Changshu, China). Midarm circumference (MAC) was measured at the same site as TSF with a tape measure.34 To reduce operational error, TSF and MAC were consec­ utively measured three times and then the average was recorded. Midarm muscle circumference (MAMC) was calculated using the following formula: MAMC (cm) = MAC (cm) - 7i x TSF (cm). Laboratory variables We collected patient demographics, clinical data, and laboratory parameters at the baseline and on a weekly basis. An Olympus Automatic Biochemical Analyzer AU5400 (Olympus, Tokyo, Japan) was used to measure serum biochemical parameters. The severity o f liver fail­ ure was assessed according to the model for end-stage liver disease (MELD) and Child-Pugh scores. Fasting RQ and REE Before indirect calorimetry was performed, patients stayed in bed at least 30 minutes and fasted for at least 8 h in the morning. The humidity o f the quiet room was maintained at 45\%-60\% with a temperature of 24°C - 26°C. REE and fasting RQ were measured using the car­ diorespiratory diagnostics investigation system for nutri­ tion metabolism (Medgraphics corporation, Saint Paul, MN, USA), and the gas and volume were calibrated be­ fore performing tests. The Weir formula, REE (kcal) = 5.50 V 02 + 1.76 V C 0 2 -1 .99 TUN,35 was used for calcu­ lating the actual REE, and the Harris-Benedict formula36 was used for calculating the predicted REE. RQ was cal­ culated as V C 02/V 02. Nutrition intake The energy intake of carbohydrates, proteins and fats ac­ counted for 74\%, 10\%, and 16\%, respectively, in all en­ rolled patients. The precise energy requirements for http://www.chictr.org.cn 430 X Liu, M Kong, X Hua, Y Yang, M Xu, Y Bi, L Li, Z Duan and Y Chen Table 1. Baseline characteristics of patients in the two groups <1.2REE group >1.2REE group p value Number 30 22 — Women, n (\%) 6 (20.0) 2 (9.1) 0.491 Age (y) 46.3±12.4t 41.6± 11.4 0.168 BMI (kg/m2) 23.9±3.7 23.6±3.7 0.813 Etiology, n (\%) 0.113 HBV 27 (90.0) 16(72.7) Alcohol 3 (10.0) 3(13.6) Unknown reason 0 (0.0) 3 (13.6) Classification, n (\%) 0.138 ALF and SALF 0(0.0) 3 (13.6) ACLF 30 (100) 19(86.4) Ascites, n (\%) 24(80.0) 14(63.6) 0.189 Child-Pugh score 11.0. 10.0-12.0* 10.5, 10.0-12.0 0.823 MELD score 25.5, 20.5-28.3 22.0, 19.0-24.3 0.065 Energy intake (kcal/d)/REE 0.84. 0.64-0.93 0.87. 0.74-1.23 0.255 RQ 0.78. 0.75-0.82 0.79, 0.77-0.84 0.163 REE (kcal/d) 1576, 1268-1641 1528. 1338-1660 0.879 TSF (mm) 17.8. 10.5-27.8 14.0, 7.3-22.8 0.374 MAMC (cm) 21.9±3.0 22.5±2.7 0.435 ALT (IU/L) 98.1,55.1-352 93.1.41.8-157 0.578 AST (IU/L) 144. 87.7-227 189. 62.1-199 0.308 TBIL (pmol/L) 381±193 314 ± 13 3 0.164 Albumin (g/L) 32.3,30.7-33.2 31.8, 26.7-35.8 0.598 GLU (mmol/L) 4.8. 3.9-5.4 4.6. 4.0-4.8 0.578 eGFR (ml/min) 11U20.1 115±19.0 0.435 HBV: hepatitis B virus; ALF: acute liver failure; SALF: subacute liver failure; ACLF: acute-on-chronic liver failure; MELD: model for end-stage liver disease; REE: resting energy expenditure; RQ: respiratory quotient; TSF: triceps skinfold thickness; MAMC: midarm mus­ cle circumference; ALT: alanine aminotransferase; AST: aspartate aminotransferase; TBIL: total bilirubin; G1U: fasting glucose; eGFR: estimated glomerular filtration rate fMean±standard deviation (all such values). :Median. interquartile range (all such values). patients were determined on the basis of the REE. At the baseline and after exactly 2 weeks, food intake was rec­ orded and analyzed by two dietitians. Energy and nutrient intakes were calculated according to the standardized Chinese Food Composition Tables. ’7 Statistical analysis Mean ± standard deviation, median, or interquartile range was used to describe continuous variables, and frequency or percentage was used to describe categorical variables. The x2 test and Fisher’s exact test were used to analyze categorical variables. The independent sample t test and Mann-Whitney U test were used to analyze continuous variables. Differences in fasting glucose, TSF, and MAMC were analyzed using the paired t test or Wilcoxon signed rank test in each group. Pearson’s correlation coef­ ficient was used to evaluate correlations of RQ with MELD and Child-Pugh scores. SPSS 19.0 (SPSS, Inc., an IBM Company, Chicago, IL) was used for analysis, and p < 0.05 was considered statistically significant. RESULTS Baseline characteristics o f patients in the two groups No statistically significant differences were observed be­ tween the two groups at baseline with respect to de­ mographics, etiology, energy intake, energy metabolism, disease severity, anthropometric variables, or laboratory data (Table 1). Effects o f individualized nutrition intervention on fa st­ ing RQ At the baseline, the average RQ was 0.79 (0.76-0.84) and no significant difference in RQ was observed between the two groups (0.79, 0.77-0.84 vs 0.78, 0.75-0.82, p = 0 .163). The group with an energy intake of>1.2REE had a higher RQ than the group with an intake of <1.2REE at week 1 and week 2 after the individualized nutrition intervention (wkl: 0.87, 0.82-0.96 vs 0.79, 0.74-0.85, £>=0.003; wk2: 0.83, 0.81-0.88 vs 0.78, 0.74-0.82, £>=0.004) (Figure 1). Effects o f individualized nutrition intervention on MELD and Child-Pugh scores No significant difference was observed between the two groups in terms of MELD score or Child-Pugh score at the baseline (22.0, 19.0-24.3 vs 25.5, 20.5-28.3, £>=0.065; 10.5, 10.0-12.0 vs 11.0, 10.0-12.0, £>=0.823). The >1.2REE group had lower MELD and Child-Pugh scores than the <1.2REE group at week 1 and week 2 after the individualized nutrition intervention (wkl; 18.0, L6.5- 21.5 vs 25.0, 17.0-29.0, £>=0.01; 10.0, 9.0-11.0 vs 11.0, 10.0-11.0, £7=0.045; wk2: 17.5, 15.3-21.8 vs 23.5, 14.8- 28.5, £>=0.033; 9.0, 7.3-10.0 vs 10.5, 10.0-11.0, £7=0.007) (Figure 2). Correlation analysis o f RQ with MELD score and Chihl-Pugh score For all patients, RQ was negatively correlated with MELD score and Child-Pugh score (r=-0.24, £>=0.007; r=—0.35, £><0.001) (Table 2). Nutrition on RQ in patients with liver failure 431 0.6 Figure 1. Effects o f individualized nutrition intervention on fasting respiratory quotient (RQ) on patients in the group with an energy intake no less than 1.2 times their resting energy expenditure (REE; >1.2REE) and those in the group with less than 1.2 times their REE (<1.2REE). Effects o f individualized nutrition intervention on an­ thropometric variables In patients with liver failure, no significant difference was observed between the two groups with respect to TSF or MAMC at the baseline (Table 1). No significant differ­ ence was observed between 2 weeks after the individual­ ized nutrition intervention and the baseline in either group in terms o f TSF or MAMC (TSF: /?=0.428, p= 0.137; MAMC: p=0.071, p=0.363) (Table 3). Side effects No significant difference was noted between the two groups at the baseline with respect to fasting glucose level (Table 1) or in either group in terms of fasting glucose levels 2 weeks after the individualized nutrition interven­ tion compared with the baseline {p= 0.215, p=0.653) (Ta­ ble 4). Moreover, no obvious side effects associated with individualized nutrition intervention were reported. DISCUSSION Malnutrition, which is partly caused by abnormal energy metabolism in patients with liver failure, is almost univer­ sal in patients with ESLD and worsens when liver failure occurs. Increased lipid oxidation rates and decreased glu­ cose oxidation rates, which were associated with de­ creased RQ,22 were observed in patients with ACLF. RQ is strongly associated with liver function and the severity o f liver disease. Nonprotein RQ and malnutrition are both significant independent factors that determine the likeli­ hood o f survival in patients with liver cirrhosis.12-38 An­ other study22 discovered that RQ was significantly lower in patients with ACLF than in patients with liver cirrhosis and that in patients with ACLF, the nonsurvival group had a lower average RQ than did the survival group. Ac­ cording to these findings, RQ may be used as a factor for determining the prognosis of liver failure. Therefore, im­ proving RQ, which is the equivalent of improving the catabolic state, is beneficial to patients with liver failure. RQ values vary with the metabolism of different sub­ strates: 0.7 for fat, 0.8 for protein, and 1.0 for glucose.15-16 In the present study, we discovered that RQ was 0.79 (0.76-0.84) at the baseline in patients with liver failure, indicating an obvious metabolic abnormality. This result is consistent with the findings o f other study.22 If the ab­ normal metabolic status o f patients is not corrected quick­ ly enough, it is detrimental to their recovery. When the NST conducted an individualized nutrition intervention on patients with liver failure, we discovered that an ener­ gy intake of >1.2REE could improve patient RQ, MELD score, and Child-Pugh score and that RQ was negatively correlated with MELD score and Child-Pugh score. These results suggested that an individualized nutrition intervention with an energy intake of>1.2REE could im­ prove the RQ of patients with liver failure and reduce the severity of liver failure. The findings and mechanisms of the study are shown in Figure 3. Serum albumin and prealbumin are synthesized by the liver and are key indicators for evaluating the liver func­ tion and nutritional status o f patients with hepatopathy. Extensive necrosis o f hepatocytes can be observed when nonchronic liver failure occurs and the function of liver synthesis is severely impaired. In the absence of mal- 40 30 V Oo O 20 tu 10- 1 week -Q- <1.2REE group >l.2REEgroup * p < 0.05 -O- <l.2REEgroup >1.2 REE group * /?<0.05 Figure 2. Effects o f individualized nutrition intervention on the model for end-stage liver disease (MELD) score and Child-Pugh score in patients with an energy intake o f no less than 1.2 times their resting energy expenditure (REE; >1.2REE) and in those with an energy intake o f less than 1.2 times their REE (<1.2REE). Table 2. Correlation analysis of RQ with MELD score and Child-Pugh score RQ r p value M ELD score -0.24 0.007 C hild-Pugh score -0.35 <0.001 MELD: model for end-stage liver disease; RQ. respiratory quotient. 432 X Liu, M Kong, X Hua, Y Yang, M Xu, Y Bi, L Li, Z Duan and Y Chen Table 3. Effects o f individualized nutrition intervention on TSF and MAMC TSF (mm) MAMC (cm) p value Baseline Week 2 Baseline Week 2 <1.2REE group 17.8. 10.5-27.8+ 16.5. 10.0-25.8 0.137 21.9±3.0* 21.9±3.6 0.363 >1.2REE group 14.0, 7.3-22.8 14.5. 8.0-20.0 0.428 22.5±2.7 22.0±2.4 0.071 REE: resting energy expenditure; TSF: triceps skinfold thickness; MAMC: midarm muscle circumference. tM eanistandard deviation (all such values). ^Median. interquartile range (all such values). Table 4. Effects o f individualized nutrition intervention on fasting glucose levels Fasting glucose (mmol/L) - p value Baseline Week 2 <1.2REE group 4.8. 3.9-5.4 4.2, 3.6-6.2 0.653 >1.2REE group 4.6, 4.0-4.8 4.5. 4.1-5.3 0.215 REE: resting energy expenditure. Values are expressed as a median, interquartile range nutrition in patients with liver failure, albumin and prealbumin levels also decrease significantly. However, patients with liver failure often receive exogenous albu­ min supplementation. Therefore, serum albumin and prealbumin are not idea) indicators for evaluating the nu­ tritional status of patients with liver failure. Anthropomet­ ric variables such as TSF, MAC, and MAMC are primari­ ly used to analyze lean body mass and fat mass and are not affected by ascites or lower limb edemas. Anthro­ pometry is recognized as a basic indicator for evaluating o f the nutritional status of patients with liver disease and is recommended by the European Society for Clinical Nutrition and Metabolism guidelines.23 Studies39-40 in which adult patients with chronic liver disease were ad­ ministered LESs with different amounts of energy (700 kcal vs 200 kcal) over the course o f a year reported a sig­ nificant increase in the accumulation of lean body mass. In our study on patients with liver failure, no significant difference in terms of TSF or MAMC was observed be­ fore and after the individualized nutrition intervention in the two groups. The individualized nutrition intervention in this study had a duration of only 2 weeks, which was insufficient for improving the TSF and MAMC of pa­ tients with liver failure. The duration of the individualized nutrition intervention should be extended to evaluate the effect on the nutritional status of patients. Figure 3. Conceptual diagram o f the findings and mechanisms o f individualized nutrition intervention in patients with liver failure. Nutrition on RQ in patients with liver failure 433 Several studies have reported that glucose disturbances, especially hyperglycemia, are related to the progression o f liver disease and increased mortality rate in patients with liver cirrhosis.414’1 Moreover, hypoglycemia was also discovered to increase the mortality rate in patients with acute decompensation of liver cirrhosis.44 In our study, we discovered that an individual nutrition intervention with an energy intake o f >1.2REE had no significant ef­ fect on the blood glucose o f patients with liver failure. No obvious side effects associated with individualized nutri­ tion intervention were reported. Therefore, the individual­ ized nutrition intervention is a safe treatment method. In conclusion, an individualized nutrition intervention with an energy intake of >1.2REE can effectively and safely improve the RQ of patients with liver failure and reduce the severity of liver failure. Therefore, clinicians must formulate and implement individualized nutrition interventions as early as possible for patients with nutri­ tional risk caused by liver failure and ensure that their energy intake is >1.2REE to improve the abnormal meta­ bolic status and even prognosis of patients. The sample size o f our study was small and the follow-up time was short; therefore, the sample size must be expanded and the follow-up time must be extended to further explore the effect o f individualized nutrition interventions on the prognosis of patients with liver failure. ACKNOWLEDGEMENTS The authors thank all participants in the study. AUTHOR DISCLOSURES All authors declare no conflict o f interest. 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