目的 构建老年髋部骨折患者围术期营养管理模式,促进患者早手术、早下地、早康复.方法 针对老年髋部骨折患者营养管理现状,采用课题研究型品管圈活动进行改进.经过科学循证、专家指导等,从术前、术后及家庭三个环节,骨科、营养科、家庭三个维度,人员、制度、材料设备、方法、信息五个方面,制定三大对策群组并予以实施,包括组建营养支持团队、构建营养管理策略、搭建多维信息交互平台等.结果 老年髋部骨折患者首次下地时间缩短为26.7 h,平均住院日缩短为5.6 d,实现了早手术、早下地、早康复的目标.结论 对老年髋部骨折患者实施个性化、全流程的序贯性营养干预具有重要意义.后续还需开展大样本多中心研究以进一步验证成效,数据自动采集与智能反馈也是今后研究重点.

Strict and appropriate glycaemic control has a positive impact on long-term clinical outcomes in patients with type 2 diabetes mellitus (T2DM) by delaying and slowing the progression of complications related to diabetes (UK Prospective Diabetes Study (UKPDS) Group, 1998; Klaus-Dieter et al., 2011). Specific treatment such as oral hypoglycaemic agents or insulin is given to patients with T2DM according to their condition. Importantly, the adjustment of suboptimal dietary and lifestyle habits has become the primary therapy for T2DM and an important adjunctive treatment in insulin-dependent T2DM (Tuomilehto et al., 2011). However, there are an increasing number of patients who have never received systematic or scientific management and guidance on their daily diet, leading to a poor glycaemic control or malnutrition. Reducing hyperglycaemia to an appropriate range without significant hypoglycaemia is the primary goal; however, over nutrition and malnutrition in diabetic patients can cause serious concern (Franz et al., 2017).

目的 探讨围术期肠内外序贯营养治疗对膀胱全切回肠代膀胱术患者临床预后的影响及临床效果观察.方法 57例行膀胱全切回肠代膀胱术的膀胱癌患者根据围术期营养支持方式不同分为2组.观察组27例,接受优化的围术期序贯营养治疗;对照组30例,采用本院常规围术期营养治疗.比较两组患者术后的一般情况、肝脏功能、营养状况、临床并发症、住院总费用及日均营养费用.结果 除观察组碱性磷酸酶水平,两组患者手术前后肝脏功能指标变化差异无统计学意义(P＞0.05).观察组术后维生素A结合蛋白[(31.26±10.16)mg/L vs.(24.83士8.48)mg/L,P=0.012]、清蛋白[(39.53±4.11)g/L vs.(38.55±5.62)g/L,P=0.035]及前清蛋白[(158.44±41.67)g/L vs.(130.40±44.04)g/L,P=0.017]均高于对照组,差异有统计学意义.观察组并发症发生率明显低于对照组(x 2=4.041,P=0.044).观察组日均营养费用高于对照组(220.05±77.08)元 vs.(171.93±88.73)元,P=0.034],而住院总费用[(9.20±1.66)万元 vs.(10.19±1.97)万元,P=0.046]及住院时间[(18.22±2.99)d vs.(20.67±5.58)d,P=0.047]较对照组降低,差异有统计学意义.结论 膀胱全切回肠代膀胱术患者围术期的优化肠内外序贯营养治疗是安全、合理、有效的营养治疗方式,在改善患者临床预后、降低并发症发生率方面优于常规围术期营养支持.

目的:研究家庭肠内营养(EN)对老年髋部骨折病人术后人体成分的影响,为推进家庭EN提供科学依据.方法:选取2019年6月～2020年5月在新桥医院骨科诊断为髋部骨折,行全髋或半髋关节置换的老年病人156例,按照随机数字表分为两组.对照组采用常规院外饮食宣教,实验组采用EN联合个体化食谱定制.两组病人均在出院当天、出院后1个月时行人体成分分析,Harris髋关节功能评分,并记录两组病人血浆蛋白水平及伤口愈合情况.结果:出院后1个月,实验组病人体质量、骨骼肌、体脂肪、蛋白质、血浆蛋白水平、Harris评分均明显优于对照组(P＜0.05),伤口愈合不良发生率也明显低于对照组(1.4％vs 8.5％,P＜0.05).结论:合理的家庭EN能显著改善老年髋部骨折病人的营养状况,增加机体瘦体组织,促进伤口愈合及康复.

Objective To determine the effects of glutamine-enhanced nutritional intervention on the tolerance of early postoperative nutritional support and on the inflammatory response in elderly patients after hip fracture surgery. Methods A total of 113 elderly patients admitted to our hospital due to hip fracture from January 2019 to December 2020 were recruited in this study. According to the order of admission, they were divided into control group (n=57, routine nutrition intervention) and experimental group (n=56, nutritional intervention program with adjuvant glutamine enhancement). The incidences of postoperative nausea and vomiting, first postoperative anal exhaust time, first postoperative feeding time, thirst/hunger visual scale scores in 1 h before and after surgery, and serum levels of total protein, albumin and C-reactive protein, neutrophil percentage and white blood cell count on the third day after surgery were compared between the 2 groups. Results No reflux aspiration occurred in the both groups. There were no statistical differences between the 2 groups in the preoperative and postoperative 1-hour scores of thirst vision scale, preoperative 1-hour score of hunger vision scale, and the serum levels of total protein and albumin on the third postoperative day. The experimental group had significantly lower C-reactive protein level on the third day after operation (P < 0.05), earlier first exhaust of anus and first feeding (P < 0.01), higher postoperative 1-hour score of hunger vision scale (P < 0.05), and lower incidences of nausea and vomiting (P < 0.05) when compared with the control group. Conclusion The adjuvant fortified glutamine nutrition intervention program is helpful to improve the early postoperative enteral nutrition tolerance and to reduce postoperative inflammatory response in elderly patients after hip fracture surgery.

To evaluate the effect of medical nutritional therapy (MNT) combined with low glycaemic index (LGI) formula at breakfast for 4 weeks on the glycaemic control of patients with type 2 diabetes mellitus (T2DM). Ninety-six participants were recruited and randomly equally divided into two groups. The intervention group was offered with 40g LGI formula at breakfast adjusted according to MNT, and the control group with regular MNT. After 4 weeks, fasting blood glucose, glycated albumin (GA), insulin, C-peptide levels and metabolic index were compared between the two groups. Compared to the intervention group, the total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), and the change of FBG (-0.64 +/- 1.4 vs. 0.3 +/- 2.2; p < 0.05) and 2h-PBG (-1.8 +/- 3.6 vs.0.8 +/- 3.2; p < 0.01) in the control group were significantly decreased. The LGI formulations, having a significant effect on controlling glucose and lipid metabolism, could be used as a non-pharmacological intervention for T2DM self-management.

Objective: To retrospectively investigate the comparative efficacy, safety and cost-benefits of three nutritional treatment schemes including short peptide jejunal nutrition (SPJN), whole protein jejunal nutrition (WPJN), and partial parenteral nutrition (PPN) in patients underwent esophagectomy for esophageal cancer in our hospital. This study was carried out in accordance with the conceptual framework of nutritional therapy in fast-track rehabilitation surgery. Methods: We retrospectively reviewed 305 patients who were assigned to receive esophagectomy for esophageal cancer. Eligible patients was naturally divided into SPJN group [ n = 98 (32.1%)], WPJN group [ n = 95 (31.1%)], and PPN group [ n = 112 (36.7%)] according to the type of nutritional scheme which was actually prescribed to patients by the attendingphysician in clinical practice. The differences of the serum total protein (TP), albumin (ALB), pre-albumin (PA), hemoglobin (HGB), white blood cells (WBCs), red blood cells (RBCs) and neutrophils were compared among 3 nutritional schemes groups. We also investigated the relationship of the fluid intake, urine output, gastric juice drainage volume and thoracic drainage volume among 3 nutritional groups at 3 days after surgery. Moreover, the differences of cost-benefit indexes, complications, length of hospitalization and hospital expenditure were also compared. Results: The serum TP, ALB, and PA in the SPJN group were all higher than those in the WPJN and PPN groups ( p < 0.05). The gastric juice volume of gastrointestinal decompression drainage and fluid volume of thoracic drainage in the SPJN group were all less than that in the WPJN group ( p < 0.05). The overall hospital stay and post-operative hospital stay in the SPJN group were all shorter than that in WPJN group ( p < 0.05). Moreover, the incidence of post-operative complications including anastomotic leakage, infection, and gastrointestinal reaction was remarkably lower in the SPJN group compared to the WPJN group ( p < 0.05). Interesting, hospital expenditure in the PPN group was less than that in the SPJN and the WPJN groups ( p < 0.001). Conclusion: Patients may obtain benefits in improving protein level after receiving SPJN scheme at the early stage after esophagectomy. Meanwhile, patients may obtain benefits in improving post-operative complications and hospital stay after receiving SPJN or PPN compared to WPJN protocol. However, the difference between SPJN and PPN requires further study because no difference was detected in terms of clinical outcomes including complications and the length of hospitalization although PPN may achieve a possible decrease of medical expenditure.

目的:根据快速康复外科的理念,探讨关节置换围手术期营养支持效果,为关节置换患者围手术期营养治疗提供科学依据.方法:观察2014年1月-2015年12月陆军军医大学新桥医院骨关节病区行关节置换术患者,排除自动出院、严重肝肾功能障碍及高血糖等患者,最终试验组纳入66例、对照组纳入107例.试验组根据快速康复外科理念给予围手术期整蛋白型肠内营养制剂+短肽型肠内营养+益生菌制剂精细化营养治疗方案;对照组常规自行给予营养支持;对比两组患者术前、术后第1天、术后第3天共3次的C反应蛋白、白细胞、红细胞、血红蛋白、血小板计数、血清总蛋白、白蛋白、前白蛋白及术后12月内的并发症情况(创口愈合延迟、感染等).结果:术前,试验组C反应蛋白、白细胞显著高于对照组[(19.1±40.5) mg/Lvs (7.0±8.8) mg/L,P=0.034;(6.9±2.4)×109/L vs (5.9±1.7)×109/L,P=0.002],两组患者术后第1天与术后第3天的各项实验室指标差值比较,试验组血红蛋白下降幅度显著低于对照组[(8.06±11.63) g/L vs (12.27±10.50) g/L,P=0.041];试验组术后1年内并发症发率显著低于对照组(3.0％ vs 13.1％,P=0.027).结论:关节置换围手术期精细化营养治疗可减轻患者术后的炎症反应,减少术后创口愈合延迟、感染等并发症.

目的:比较给予危重症病人同等热卡不同蛋白的营养治疗方案对脏器功能及营养状况的改善效果. 方法:回顾性分析260例行肠外营养和(或)肠内营养治疗7d及7d以上的危重症病人.其中氮热比1:100～133组69例、氮热比1:133～ 167组129例、氮热比1:168 ～ 200组62例. 结果:营养治疗前后,各组危重症病人自身对比,血清平均TP、ALB、PA、TLC均明显升高(P＜0.01),血清平均ALT、AST、SCr无明显差异(P＞0.05).其中氮热比1:100～ 133组的危重症病人营养治疗后的TP、ALB、PA、TLC高于其余两组(P＜0.05),呼吸机脱机时间短于其余两组(P＜0.05).血清平均ALT、AST、SCr、住院时间、住院总费用各组间差异无统计学意义. 结论:氮热比1:100 ～ 133组的危重症病人营养治疗效果优于氮热比偏高组,且并不增加病人脏器负担.

PURPOSE:The concept of enhanced recovery after surgery (ERAS) spread to different surgical specialties to minimize surgical stress response and to reduce length of hospital stay (LOS) and cost. Recently, several studies have reported experience with the ERAS program for spine surgery. The aim of this study is to introduce the establishment and implementation of the ERAS pathway for minimally invasive surgery (MIS) transforaminal lumbar interbody fusion (TLIF).METHODS:A multidisciplinary ERAS team was created to develop and implement a multimodal and evidence-based ERAS protocol for patients undergoing MIS-TLIF at a single spine center from January 2018. Fourty four cases in the ERAS group were compared with a historical cohort of 30 cases (from January 2017 to December 2017) who underwent MIS-TLIF before the pathway implementation (pre-ERAS group). We reviewed the compliance with ERAS components. The primary outcome was LOS. The secondary outcomes included 30-day readmission rate, 30-day reoperation rate, and financial cost. Perioperative factors and perioperative complications were also assessed.RESULTS:The protocol was composed of 11 ERAS components. The ERAS group showed high compliance with the ERAS program. The ERAS group manifested shorter LOS and lower cost compared with the the pre-ERAS group. There were no significant differences in complication rate, 30-day readmission and reoperation rates. Furthermore, the blood loss, operative time, intraoperative fluid infusion and postoperative drainage of the ERAS group decreased.CONCLUSIONS:Our ERAS program tailored for MIS-TLIF is able to reduce LOS and cost with minimal complications. The ERAS pathway expedites recovery in patients undergoing lumbar spine fusion.

Objective To compare the efficacy of proton pump inhibitors (PPI) combined with intensive diet intervention vs PPI alone in the treatment of laryngopharyngeal reflux disease (LPRD). Methods A total of 210 patients diagnosed with LPRD in our hospital during January 2017 and January 2018 were recruited in this study, and were divided into PPI with intensive diet intervention group (PPI+diet group, n=110) and PPI group (n=100). The PPI+diet group received standardized acid suppression therapy and intensified dietary intervention, while the PPI group only received standardized acid suppression therapy and standard diet. Both groups were treated for 12 weeks. Reflux symptom index (RSI) and reflux symptoms score (RFS) was used to evaluate the efficacy before and after treatment. Results There were no statistical differences in age, sex and RSI and RFS scores between the 2 groups. After 8 weeks of treatment, the RSI (P < 0.01) and RFS (P < 0.01) scores were significantly improved in both PPI plus diet group and PPI group. As compared with the PPI group, the PPI plus intensive diet group had lower RSI and RFS scores (P < 0.05), especially in improving the symptoms of throat clearing, postnasal drip, cough and heartburn, chest pain and coughing post-eating or lying down. For the overall effective rate, the effective rate in PPI plus diet group and PPI group was 73.07% and 70.21% after 8 weeks of treatment, and the effective rate was improved to 83.67% and 80.00% after 12 weeks, although there were no significant differences. Conclusion Compared with PPI alone, PPI combined with intensive diet intervention can more significantly improve the RSI and RFS scores of LPRD patients with higher overall efficiency.

目的:比较不同年龄段关节置换患者术前营养状况有无差异,以及采取快速康复围手术期营养治疗后,营养治疗效果有无差异.方法:收集300例初次行单侧全髋或全膝置换术的患者,按照年龄进行分组.非老年组<65岁,普通老年组65～79岁,高龄老年组≥80岁,每组各100例.结果:入院时,高龄老年组血清平均ALB、PA、HGB、TLC均明显低于普通老年组和非老年组(P<0.01),普通老年组血清平均ALB、PA、HGB、TLC均低于非老年组(P<0.05).出院时,行围手术期营养治疗后,各年龄组患者血浆ALB、PA、HGB、TLC均比术后第一天明显上升(P<0.01),且高龄老年组较其余两组上升更明显(P<0.05),普通老年组较非老年组上升更明显(P<0.05).结论:拟行关节置换的高龄老年患者和普通老年患者入院时营养状况较非老年患者差,但行围手术期营养干预后,营养治疗效果明显优于非老年组.

目的:探讨补充β-羟基-β-丁酸甲酯(HMB)对老年髋关节置换病人跌倒风险的干预效果. 方法:选取≥65岁、非髋部骨折拟行单侧髋关节置换术的病人,随机分为试验组和对照组.对照组参照2013年《中国居民膳食营养素参考摄入量》并结合病人自身营养状况和手术需求进行饮食指导和营养支持,并按髋关节置换术后康复方案进行有效功能锻炼.试验组在对照组基础上,增加HMB的摄入.补充方案为:体重≤68kg,补充HMB 2g/d;体重＞68 kg,补充HMB 3 g/d,干预时间为6个月.分别在术后第12周和第24周进行下肢肌肉力量测试-站起测试(CRT)和计时起立行走测试(TUGT),并计算相应的跌倒风险,记录跌倒发生情况. 结果:试验组、对照组术后第12周CRT分别为(14.91±4.34),(16.51±3.73),差异有统计学意义(P＜ 0.05);TUGT分别为(16.95±4.18),(18.47±3.13),差异有统计学意义(P＜0.05);跌倒高风险比例分别为95.5％和98.2％(P＜ 0.05).试验组、对照组术后第24周CRT分别为(14.27±3.99),(16.49±3.56),差异有统计学意义(P＜ 0.05);TUGT分别为(16.51±3.85),(18.11±3.18),差异有统计学意义(P＜0.05);跌倒高风险比例分别为81.8％和94.5％(P＜0.05).术后24周内试验组无跌倒发生,对照组有4例病人发生跌倒(P＜0.05). 结论:补充HMB并配合有效的功能训练可提高THA老年病人的的下肢肌肉力量和平衡力,从而降低老年髋关节置换病人的跌倒风险.

Objective To observe the tolerance of 2 kinds of enteral products and recovery of gastrointestinal function in postoperative spine patients,and evaluate the effect of the early nutritional support.Methods A total of 100 postoperative patients in the orthopedic department of our hospital from March to May 2015 were enrolled in this study.They were divided into the study group (n =50,given the peptidebased enteral products) and the the control group (n =50,given the whole protein enteral products).The serum contents of total proteins,albumin and pre-albumin,first flatus time after surgery,and bowel sounds and incidences of bloating,diarrhea,nausea and vomiting within 24 h postoperatively were measured and recorded,and the results were compared between the 2 groups.Results The first flatus time after surgery was significantly shorter in the study group than the control (14.4 ±5.1 vs 16.8 ±5.0 h,P =0.021).The study group also had obviously lower incidences of bloating and nausea when compared with the control (4％ vs 18％,P =0.025;6％ vs 24％,P =0.012).No significant differences were seen in the serum contents of total proteins,albumin and pre-albumin between the 2 groups after nutrition support (P ＞ 0.05).Conclusion The peptide-based enteral products significantly shorten the recovery time of gastrointestinal function and increase gastrointestinal tolerance in the patients after spinal operation.

目的:比较低血糖指数(GI)全营养素与高蛋白营养素2种不同营养配方预进餐对2型糖尿病患者血糖控制效果的影响.方法:回顾性分析115例2型糖尿病患营养治疗记录,其中高蛋白营养素治疗组31例为高蛋白组、低GI全营养素治疗组39例为低GI组、无肠内营养治疗干预组45例为对照组,每组都进行糖尿病饮食指导、教育并编制糖尿病膳食食谱.观察比较3组患者营养干预前,营养干预后第1d、第3d、第7d的空腹、餐后2h血糖控制情况.结果:与对照组相比,高蛋白组与低GI组空腹血糖在干预前后均没有明显差异,无统计学意义(P＞0.05);餐后2h血糖在干预前、第1d没有差异,无统计学意义(P＞0.05),而在第3d、第7d血糖明显下降,有统计学意义(P＜0.05).与低GI组相比,高蛋白组空腹血糖和餐后2h血糖干预前后均没有明显差异,无统计学意义(P＞0.05).结论:不同营养配方预进餐有利于2型糖尿病患者血糖控制,尤其是餐后2h血糖控制,2种营养配方控制血糖效果相似.

目的:了解添加n-3鱼油脂肪乳全合一静脉营养是否可改善肠外营养引起的肝功能损害和胆汁淤积.方法:将100例需要中长期全合一静脉营养支持的患者随机分为2组:对照组50例,使用普通脂肪乳剂250mL;实验组50例,使用普通脂肪乳剂250mL加鱼油脂肪乳剂100mL.输注肠外营养1w后,比较输注前后2组患者血浆转氨酶、胆红素及血浆蛋白水平.结果:肠外营养治疗前后,实验组患者自身对比,血清平均总胆红素(TBIL)、直接胆红素(DBIL)、丙氨酸氨基转移酶(ALT)、天门冬氨酸氨基转移酶(AST)均明显降低(P＜0.05).对照组患者自身对比,血清平均ALT、碱性磷酸酶(ALP)、γ-谷氨酰转移酶(γ-GT)均明显升高(P＜0.05).实验组在肠外营养支持后血清平均TBIL、DBIL、ALT、AST、ALP、γ-GT均明显低于对照组(P＜0.01).结论:添加n-3鱼油脂肪乳可改善患者的肝功能损害和胆汁淤积.

目的:观察环磷酸腺苷复方制剂对癌性贫血患者治疗效果,为临床进一步使用提供参考.方法:选取2013年4月-2014年8月在第三军医大学新桥院肿瘤科明确诊断肿瘤且合并贫血的住院患者100例,随机分为实验组50例和对照组50例,对照组采用常规治疗,实验组除常规治疗外,给予口服环磷酸腺苷复方制剂(环磷酸腺苷≥10mg/100g),20mL/次,2次/d,连续服用10d;观察两组的血红蛋白(HGB)、红细胞(RBC)、红细胞压积(HCT)、红细胞平均体积(MCV)、红细胞平均血红蛋白量(MCH)、红细胞平均血红蛋白浓度(MCHC)、红细胞分布宽度标准差(RDW-SD).结果:经过10d治疗后,实验组的HGB[(87.65±13.39) vs (77.35±14.09)]g/L、RBC[(2.95±0.55) vs (2.62±0.62)]×1012/L、HCT[(27.38±4.40) vs (23.94±4.63)]％较治疗前明显升高,具有统计学意义(P＜0.01).与对照组相比,实验组治疗后的HGB[(87.65±13.39)vs(77.93±9.29)]g/L、RBC[(2.95±0.55) vs (2.68±0.49)] ×1012/L、HCT[(27.38 ±4.40) vs (24.4±2.92)]％较对照组治疗后明显升高(P＜0.05).结论:补充环磷酸腺苷复方制剂有助于改善癌性贫血惠者的贫血状况.

从第三军医大学新桥医院营养科多年来对实习学员的教育与管理经验出发,着重从加强实习学员入科宣传,严格落实考勤制度；严控带教师生比例,确保学员有所获；重视病例讨论；规范教学查房；完善出科考核制度等方面详细介绍了临床营养学实习学员实习期间的主要学习内容,以期提高实习质量.

【Objective】To observe and analyze the effect of pre meal with whey protein on glycemic control in type 2 diabetic patients.【Method】Totally 100 patients with type 2 diabetes were randomly divided into intervention group with 50 cases and control group with 50 cases.Intervention group were given pre meal with whey protein and received diet control instruction,while control group only received diet control guidance.After the intervention,the changes of blood glucose were compared between the two groups.【Result】After the intervention,each group had a lower level of fasting blood glucose(FBG) and 2h postprandial plasma glucose(2h PG)(P 0.01),but the effection of intervention group was significantly superior to that of control group(P 0.05),the difference had statistical significance.【Conclusion】Diet control could effectively control blood glucose in type 2 diabetes patients.Pre meal with whey protein could help control postprandial glucose in patients with diabetes.

<正>妊娠糖尿病是指妊娠期发生或首次发现的不同程度的葡萄糖耐量异常,约占妊娠合并糖尿病的80%至90%,包括妊娠期糖耐量受损。2007年中华医学会产科分会进行了全国GDM患病率的流行病学研究,显示我国GDM平均患病率为6.6%,并且有逐年增加趋势。益力佳是专为糖尿病患者设计的一种肠内营养粉剂,其特点是以不饱和脂肪酸代替部分碳水化合物,并且含有独特的能量缓释碳水化合物系统。本文就益力佳对妊娠糖尿病患者血糖和相关生化指标的影响做一个初步探讨。