Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018




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On Sep 2018




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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
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Professor and Head
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Saraswati Dental College
Lucknow
On Sep 2018




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Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




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Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
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Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


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Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2011 | Month : February | Volume : 5 | Issue : 1 | Page : 9 - 12 Full Version

A Study Evaluating The Efficacy Of A Home Based Intact Polymeric Formula In The Nutritional Management Of Critically Ill Patients


Published: February 1, 2011 | DOI: https://doi.org/10.7860/JCDR/2011/.1176
DEEPA AGARWAL*, HEMAMALINI A J*, GOPALAN T R*

*Department of Clinical Nutrition, Sri Ramachandra University, Chennai, India

Correspondence Address :
Ms. Deepa Agarwal
PhD Research Scholar
Clinical Nutrition
Sri Ramachandra University
Chennai, India
Email: deepa_24101984@rediffmail.com
Phone: +919940220005

Abstract

Background and Objective: Malnutrition is prevalent to a high degree among hospitalized patients throughout the world. As many as 40% of the adult patients are seriously malnourished at their hospital admission, and two thirds of all patients experience deterioration of their nutritional status during their hospital stay. India, with its nearly 1 billion inhabitants, has an estimated 350-400 million people below the poverty line, 75 per cent of them in the rural areas. Meeting the nutritional requirements of all those under such conditions is a daunting task. Sri Ramachandra University Hospital caters to the needs of people from different socio economic backgrounds and there has been a constant approach in meeting the nutritional requirements of all, irrespective of their socio economic status. A home based intact polymeric formula is being used for more than a decade to meet the nutritional requirement of the patients at the free Inpatient block of the hospital, where patients from poor economical backgrounds are admitted and treated. There has been no documented complaint of any gastrointestinal complication due to the intact polymeric formula, contrary to the published reports by various authors in their research carried out in different hospital settings. Hence, this present study was undertaken to prove the efficacy of this home based intact polymeric formula in the nutritional management and recovery of critically ill patients, while maintaining the safety standards.
Design: A prospective study design was adopted to carry out the study. A total of 30 subjects were studied between the study period from January’09 to March’09. There were 15 subjects each in the two study groups (Patients who were administered the home based Intact polymeric formula and the standard Commercial formula). These patients were followed up for various outcome variables such as nutrient intake, length of stay in the ICU, gastrointestinal complications, duration of mechanical ventilation and feed costs.
Results: Despite receiving different types of formulas, the nutrient intake, length of stay in the ICU and the duration of mechanical ventilation were not significantly different in the two study groups. There was a significant (p<0.05) difference in the feed costs which were incurred to the patients who were fed with both the formulas.
Conclusion: It is inferred from this study, that the home based intact polymeric formula is comparable to the standard commercial formulas, if the formula is planned with nutritionally adequate components, reconstituted adequately and implemented as per the protocols, in improving the expected clinical outcome in the critically ill patients.

Keywords

malnutrition, home based intact polymeric formula, standard commercial formula; clinical outcome

INTRODUCTION
Malnutrition is prevalent to a high degree among hospitalized patients throughout the world (Torosian, 1999). As many as 40% of the adult patients are seriously malnourished at their hospital admission and two thirds of all the patients experience deterioration of their nutritional status during their hospital stay. A nutritionist’s role in the hospital is to formulate the most appropriate nutritional therapy for each patient, based on their nutritional status. Sri Ramachandra University Hospital caters to the needs of people from different socio economic backgrounds and there has been a constant approach in meeting the nutritional requirements of all, irrespective of their socio economic status. A home based intact polymeric formula is being used for more than a decade to meet the nutritional requirement of the patients at the free Inpatient block of the hospital, where patients from a poor economical background are admitted and treated. There has been no documented complaint of any gastrointestinal complication such as diarrhoea, abdominal distension or constipation due to the intact polymeric formula, contrary to the published reports by various authors in their research carried out in different hospital settings. Hence, this present study was undertaken to prove the efficacy of this home based intact polymeric formula in the nutritional management and recovery of critically ill patients, while maintaining the safety standards.
AIM AND OBJECTIVES
This study was conducted with an aim to determine “The efficacy of a home based intact polymeric formula in the nutritional management and outcome of critically ill patients in a multispecialty tertiary care hospital”, and its comparability with that of a standard commercial formula.
The objectives of the study were:
 To assess the nutritional status of critically ill patients requiring enteral nutrition support
 To plan and initiate enteral nutrition support in critically ill patients
 To determine the nutrient intake, timeliness of nutritional support and the factors interfering with the attainment of goals
 To assess the outcome of the patient by using the following parameters:

a. Gastrointestinal complications such as abdominal distension, constipation and diarrhoea
b. Length of stay in the ICU
c. Weaning off ventilation
d. Feed cost

Material and Methods

METHODOLOGY
A prospective study was conducted on 30 subjects who were admitted to the Intensive Care Unit (ICU) in the Service Inpatient Block and in the Medical Centre of Sri Ramachandra University (SRU). The study was conducted for a period of three months from January’09 till March ’09.
The criteria which were followed for the selection of the study subjects were as follows:
Inclusion criteria
• Subjects who were admitted directly in the ICU
• Subjects who stayed in the ICU for > 3 days
• Subjects on Ryles Tube Feeding in the ICU for >7 days were included for analysis
• Subjects who were fed only standard commercial formulas

Exclusion criteria
• Subjects whose ICU stay was < 3 days
• Subjects who were on NPO for more than a week
• Subjects on disease specific enteral nutrition commercial formula
• Subjects on Ryles Tube Feeding in the ICU for <7 days were excluded from the analysis

Results

RESULTS AND DISCUSSION
Subjects of both the genders were followed up during the study period. It was observed that there was an equal distribution of males and females in both the groups. Males constituted around 53.3% of the subjects and females around 46.7%. The mean ages of the males and females who were fed with the intact polymeric formula were 35.75±12.64 and 54.28±16.14 years, whereas the ages of those who were fed with the commercial formula were 44.50±18.92 and 42.28±21.31 years.
It was observed that a large percentage of subjects had neurological complications in both the groups (46.7% and 60.0% in the Intact Polymeric formula and the Commercial formula groups respectively), followed by orthopaedics and pulmonology related complications.
The mean heights of the subjects as determined by the summation of the body parts were 162.0±9.6 cm and 160.0±3.6 cm respectively. The average weights of the subjects in the two study groups were 62.4±9.41 kg and 64.8±10.7 kg respectively.
The recommended energy and protein intake for the subjects who were fed with the intact polymeric formula were 1799.33±379.62kcal and 63.53±18.33gm respectively and these values in those who were fed with the standard commercial formula were 1758.33±244.363 kcal and 62.33±6.87gm.
Nutrition support was initiated on the 3.00±1.55th day and on the 3.40±1.54th day of the ICU stay for the subjects who were being fed with the intact polymeric formula and the standard commercial formula respectively. Subjects receiving the intact polymeric formula were able to meet 100% of their requirements by 5.10±4.30 days and those receiving the standard commercial formula were able to do so by 2.86±0.91 days. Subjects receiving the intact polymeric formula were able to make a transition from enteral nutrition support to oral soft solids within 11.53±4.99 days and those receiving the standard commercial formula were able to do so within 9.46±3.18 days of the initiation of the enteral nutrition support.
Results of the efficacy of both the enteral support formulas on the outcomes of the subjects in this study, along with the feed costs, is presented below.
Nutritional Support Details
Energy and Protein Intake
(Table/Fig 1) provides information on the nutrient intake of the subjects who received either of the formulas.
Advancement of the feeds was done, based on protocols (Heyland D.K ,2003). On the day of initiation, the subjects who were fed with the intact polymeric formula received 788.09±748.95 kcal (40.93±31.21%) and 28.27±31.19 gm (41.13±31.1% ) of protein, whereas the subjects who were fed with the standard commercial formula received 849.07± 506.00 kcal (48.80±28.15%) and 36.89±32.58gm (52.13±30.77%) of protein. The mean energy and protein intake of the two study groups on the day of initiation of the feeds did not show any significant difference.
During the build up phase of the feeding, there was an improvement in the percentage of energy and protein intake in the subjects who were fed with each formula. On the day of transition, the mean energy intake of the subjects who were fed with the intact polymeric formula was 1522.47±630.49kcal (82.40±26.89%) and 54.20±27.46gm (82.27±24.65%) of protein and that of the subjects who were fed with the standard commercial formula was 1695.00± 206.63 kcal (93.80±9.60%) and 85.12±61.72gm (95.27±8.78%) of protein respectively. There was no significant difference between the mean nutrient intakes of the two study groups on the day of transition from enteral to oral feeds, irrespective of the type of formulas which were used. It can be inferred from the above results, that intact polymeric formulas can also provide the same amount of energy and protein as the commercial formulas, if they are appropriately planned and reconstituted.
Timeliness of Nutritional Support
The Timeliness of Nutritional Support includes three factors: the day of initiation of the feeds, the day of attainment of the goals and the day of transition (Susan et al, 2003). In our study, the details regarding the timeliness of nutrition support by using either of the formula has been presented and discussed in (Table/Fig 2) under three factors.
Initiation of the Feeds
Evidence based recommendations indicate that enteral nutrition can be initiated in adult patients within 24-72 hours after injury or acute illness, once the patient is resuscitated and stabilized in the intensive care setting (D.K. Heyland,2003). As can be seen from (Table/Fig 2), enteral nutrition support was initiated by the 3.00 ±1.55th day and the 3.40±1.54th day of the ICU stay for the subjects who were being fed with the intact polymeric formula and the standard commercial formula respectively. No significant difference was found with respect to the day of initiation of the feeds between the two groups who were fed with the two different formulas.
Advancement of the feed rate
Having started the enteral nutrition support, it is essential to advance the feed rate, to enable an early achievement of the goals. Gradual advancement of the feed rate by 15-30cc of feeds every 4-6 hours, would help in reducing the length of stay in the hospital (Heyland DK, 2003) In this study, the advancement of the feed rate was done quarterly by 25ml to the target rate, as per the enteral nutrition support protocols. Subjects receiving the intact polymeric formula were able to meet 100% of their estimated requirements by 5.10±4.30 days and those receiving the standard commercial formula were able to do so by 2.86±0.91 days, inspite of some factors which impeded the nutrient intake. It is evident from the above results that both the type of formulas did not differ significantly with each other in attaining the target rate of feeding and in the attainment of the nutrient intake goals.

Transition of the Feeds
Management of the transition from enteral feeding to oral intake requires careful management. As soon as the patient is alert and is able to manage the mechanics of chewing and swallowing, the transition phase of enteral feeding may be started. When the voluntary intake approaches 50% of the nutrient requirements for more than two or three consecutive days, the enteral tube feedings can either be slowed, or the number of feedings can be progressively decreased (Gottschlich, 1997).
Similar transition protocols were used in the study subjects and it was seen that the subjects who received the intact polymeric formula were able to make a transition from the enteral nutrition support to oral soft solids within 11.53±4.99 days and that those receiving the standard commercial formula were able to do so within 9.46±3.18 days of the initiation of the enteral nutrition support. No significant difference was observed while evaluating the time which was taken to make a transition from the enteral nutrition support to oral soft solids between the study groups who were fed with the two different formulas.
Hence, from the above discussion, it can be observed that there was no significant difference in the day of initiation of the feeds for the subjects in both the ICUs who were under study. The two different formulas which were used for the study did not differ significantly with respect to the day of attainment of the estimated nutrient goals and the day of transition from the enteral to the oral route. Therefore, the choice of formulas can either include an intact polymeric formula or a standard commercial formula for the nutritional support of critically ill patients. However, necessary steps should be followed for the careful reconstitution, administration, advancement and monitoring of nutrition support in order to obtain the necessary clinical outcome.
Clinical Outcomes of Nutritional Support
Gastrointestinal Complications
Only one subject who received the intact polymeric formula out of the 15 subjects who were studied, reported to have three episodes of diarrhoea on only one day during the study period. However, the tube feeding rate was not slowed or halted altogether in this subject because of other possible contributing factors which were unrelated to the enteral formula or feeding such as medication, enteric pathogens, hypoalbuminaemia, and the underlying disease state.
Length of Stay
In our study, enteral nutrition support by using two formulas (the Intact polymeric formula or the Standard commercial formula) was initiated at the earliest i.e., within 72 hours of admission to the ICU.

(Table/Fig 3) shows that the average length of stay of the subjects who were being administered the intact polymeric formula was 17.2±6.5 days and that of those who were administered the standard commercial formula was 15.2±4.2 days.
There was no significant difference between the two study groups in terms of their length of stay in the ICU, irrespective of the type of formula which was used and the severity of the illness. Patients who received the enteral nutrition support within the first 3 days of ICU admission had a significantly shorter stay in the ICU and if evidence based protocols were used in the nutritional management of the critically ill patients, the length of stay of the patients in the ICU could have been shortened, based on the severity of the disease. (Susan et al, 2003; Stephen et al, 200; Diog et al, 2008). Hence, it can be inferred that either of these two formulas can be used for critically ill patients who require enteral nutrition support, provided the nutrition support protocols are adhered to.
Weaning off Ventilation
Mechanical ventilation is a method which can be used to mechanically assist or replace spontaneous breathing. Mechanical ventilation is often a life-saving intervention, but it carries many potential complications including pneumothorax, airway injury, alveolar damage, and ventilator-associated pneumonia. Therefore, weaning off the ventilation at the earliest is necessary to prevent such complications. Studies have shown that early enteral nutrition helps in weaning off the patients from the ventilation faster (Juliana Barr, 2004).

In our study, enteral nutrition support by using both the two formulas was initiated at the earliest i.e., by the third day of admission to the ICU. The influence of the two types of formulas on the ventilator support days is presented in (Table/Fig 4). It was seen that both the formulas had a similar effect on the ventilator support days. Subjects who were fed with the intact polymeric formula had taken 6.4±3.4 days to be weaned off the ventilator and the subjects who were fed with standard commercial formulas took 5.3±1.8 days for the same. However, no significant difference was found between the effects of the two formulas on the ventilator support days.
Feed Costs
In a tertiary care hospital which caters to the needs of patients from different economic backgrounds, selecting the appropriate method of nutrition support formula is necessary, in order for it to be cost effective, especially in developing countries. In our study, enteral nutrition support was being provided by using the intact polymeric formula and the standard commercial formula. The expenditure which was incurred in the usage of both the formulas is tabulated in the (Table/Fig 5). Subjects who were fed with the intact polymeric formula, on an average, spent363.2±293.7 rupees for nutrition support throughout their stay in the ICU. Subjects who were fed with commercial formulas spent 2967.0±1053.8 rupees when they are on enteral nutrition support.
It is generally believed that the overhead charges which are involved in the preparation of intact polymeric formulas are comparatively higher than that which are required for commercial formulas and moreover, the economic advantage of preparing intact polymeric formulas (based only on the cost of the ingredients) may be considerably offset by the increased medical costs resulting from their use (Jalal et al, 2004).


In this study, all the overhead charges which were involved in the preparation of the intact polymeric formula were considered, such as the ingredient charges, fuel charges, electricity charges and labour charges. Having considered all these, it was found that the feed costs of the intact polymeric formula were much lower as compared to that of the standard commercial formulas and the results were statistically significant (p<0.05).

Conclusion

Therefore, in a multi specialty tertiary care hospital which caters to the nutritional needs of patients from different economic backgrounds, the choice of formulas should be made judiciously. If a standardized home based intact polymeric formula with appropriate techniques of reconstituting and administering is followed, the required goal can be achieved successfully without adding on to the economic burden of the poor patients

References

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