bluuebunny/crossref_metadata_2025 huggingface dataset:
Brief refeeding rapidly reverses dietary restriction‐induced nuclear factor‐kappaB downregulation in peritoneal resident cells
Authors: Kang W , Saito H , Fukatsu K , Nagawa H , Ikeda S
Published: May 2008

BACKGROUND: Malnutrition impairs host immunity, resulting in high mortality and morbidity, secondary to infections. Nuclear factor kappaB (NFkappaB) plays a critical role in host defense, but how quickly refeeding normalizes the impaired NFkappaB activity in peritoneal resident cells (PRCs) is unknown. Our aim was to investigate the effects of 1‐day ad libitum refeeding on severe diet restriction‐induced NFkappaB activity in PRCs. METHODS: Mice received chow, 146 g/kg per day (ad libitum) or 36.5 g/kg per day (severe diet restriction), for 7 days. One‐half the mice in the diet‐restricted group were then fed ad libitum for 1 day (refeeding). PRCs were harvested by peritoneal lavage. After incubation with tumor necrosis factor‐alpha (TNF‐alpha), nuclear translocation of NFkappaB in PRCs was investigated using laser scanning cytometry. RESULTS: The main subpopulation of PRCs was macrophages in all groups. Mean fluorescence intensity over the nuclear area at 0 or 100 ng/mL of TNF‐alpha was 16 +/‐ 2 or 31 +/‐ 8* in the ad libitum, 20 +/‐ 4 or 19 +/‐ 3 in the severe diet‐restricted, and 20 +/‐ 4 or 30 +/‐ 5* in the refeeding group, respectively (*p <.05 versus 0 ng/mL of TNF‐alpha in each group versus 100 ng/mL of TNF‐alpha in diet‐restricted group). Cytoplasmic accumulation of NFkappaB was significantly increased after TNF‐alpha stimulation in the refed group but not in the ad libitum group. CONCLUSIONS: The blunted NFkappaB activity in PRCs, after exposure to inflammatory stimuli, was restored after 1 day of refeeding, with increased accumulation of NFkappaB in the cytoplasm. Even brief nutritional replenishment in malnutrition may improve host defense by restoring NFkappaB activity and thereby improving macrophage functions.
The effect of supplemental enteral glutamine on plasma levels, gut function, and outcome in severe burns: a randomized, double‐blind, controlled clinical trial
Authors: Zhou YP , Jiang ZM , Sun YH , Wang XR , Ma EL , Wilmore D
Published: May 2008

BACKGROUND: This research was conducted to evaluate the effect of enterally administered glutamine (gln) dipeptide on metabolic, gastrointestinal, and outcome parameters after severe burn injury. METHODS: Forty thermally injured patients with total body surface burns ranging between 50% and 80%, and third‐degree burns ranging between 20% and 40% and without respiratory injuries, were randomized into a prospective, double‐blind, controlled clinical trial. One group received gln‐enriched enteral nutrition and the other group received the standard enteral formulation. Tube feedings were initiated on postburn day 1 (PBD +1), and isocaloric and isonitrogenous feedings were administered to both groups until PBD +12. The gln was given as the dipeptide of alanyl‐gln (Ajinomoto, Tokyo, Japan), which provided 0.35 g gln/kg body weight/d. Plasma amino acid profiles, serum endotoxin concentrations, and the lactulose/mannitol absorption ratio (which reflects gut permeability) were measured at specific times throughout the clinical course. Wound healing at day 30 was assessed, and length of hospital stay and total costs were determined at discharge. RESULTS: The 2 groups were similar in terms of age and extent of injury. Plasma gln concentrations were approximately 300 umol/L in both groups on PBD +1 and remained low in the control group (399 +/‐ 40 umol/L, mean +/‐ SD) but increased toward normal in the supplemented group to 591 +/‐ 74 (p =.048). Lactulose/mannitol ratios were increased above normal on POD +1 (control, 0.221 +/‐ 0.169; gln, 0.268 +/‐ 0.202; not significant), reflecting increased intestinal permeability after burn injury. On POD +3, the ratio in the gln group was lower than control (0.025 +/‐ 0.008 versus 0.049 +/‐ 0.016; p =.0001), and both groups returned toward normal ratios with time. Endotoxin levels on PBD +1 were elevated in both groups (control, 0.089 +/‐ 0.023 EU/mL; gln, 0.103 +/‐ 0.037 EU/mL; NS) but decreased significantly on PBD +3 in the patients receiving gln. Hospital stay was significantly shorter in the gln group than controls (67 +/‐ 4 days versus 73 +/‐ 6; p =.026). On day 30, wound healing was 86% +/‐ 2% complete in the gln group compared with 72% +/‐ 3% in controls (p =.041). Total cost of hospitalization was 62794 +/‐ 6178 RMB (dollar 7593 +/‐ 747 US dollars) in the gln group and 68996 +/‐ 8620RMB (dollar 8343 +/‐ 1042, p =.031) in controls, although the cost of the enteral nutrition was higher in the gln‐supplemented patients. CONCLUSION: Enteral gln supplementation using a commercially available dipeptide supported plasma gln levels, improved gut permeability, and initially decreased plasma endotoxin levels in severely thermally injured patients. These alterations were associated with a reduction in the length of hospitalization and lower costs.
Gastric electrical stimulation for gastroparesis improves nutritional parameters at short, intermediate, and long‐term follow‐up
Authors: Abell T , Lou J , Tabbaa M , Batista O , Malinowski S , Al‐Juburi A
Published: May 2008

BACKGROUND: Nutritional depletion, either macronutrient‐ or micronutrient‐related, is common in patients with drug‐refractory gastroparesis (GP) for which there is often no effective treatment. We studied a group of 12 patients (4 men, 8 women; mean age, 35.7 years) who had symptoms of GP and were a subset of the Gastric ElectroMechanical Stimulation trial of gastric electrical stimulation. Patients' symptoms were of long duration (7.3 years) and associated with diabetes mellitus (3 patients) or were idiopathic (9 patients) as etiology. METHODS: The patients had permanent gastric electrical stimulation devices surgically implanted after a positive trial of temporary stimulation. Patients had baseline measures of gastrointestinal total symptom score (TSS), laboratory (albumin and related) measures, weight (kg), body mass index, and route of nutrition: oral feeding, enteral tubes, or hyperalimentation, repeated at 3, 6, and 12 months. Intermediate‐term follow‐up was done at 1 to 2 years, and long‐term follow‐up was done at 5 years and included gastrointestinal TSS, weekly vomiting frequency score, and nutrition and overall health‐related quality‐of‐life measures. RESULTS: Gastric electrical stimulation was associated with rapid improvement over the short‐term in TSS (35.6 at baseline to 16.6 at month 12; p <.05), body weight, body mass index, and serum albumin over the short term with most parameters improving by 3 to 6 months. Intermediate (1 to 2 years) and long‐term (5 year) data showed continued improvement in TSS, vomiting frequency (weekly vomiting frequency score 3.9 at baseline to 1.7 at 5 years; p <.01), quality‐of‐life measures, and maintenance of weight gain. CONCLUSIONS: Gastric electrical stimulation implantation resulted in improvement of nutritional parameters throughout the first 12 months, as nausea and vomiting decreased and oral intake increased. This improvement in nutritional measures is maintained long‐term and is associated with improvements in quality of life. Gastric electrical stimulation should be considered as a therapeutic option for any patients with refractory GP and nutritional compromise.
A survey of perceived benefit and differences in therapy provided by credentialed and noncredentialed nutrition support dietitians
Authors: Simmons JF , Skipper A , Lafferty LJ , Gregoire MB
Published: May 2008

BACKGROUND: Benefits of the certified nutrition support dietitian (CNSD) credential to clinicians, their patients, and healthcare administrators have not been defined. A study was designed to measure the difference in cost of therapy provided by credentialed and noncredentialed nutrition support dietitians and to measure the perceived value of the credential to those who hold it. METHODS: Using a modified Delphi technique, a questionnaire was developed to obtain demographic information, responses to statements of perceived benefit of the credential, and costs of therapy selected for patients in common clinical scenarios. RESULTS: Of the 691 questionnaires mailed, 314 (45%) were returned. For 8 of 10 statements of perceived benefit, mean response scores indicated agreement. Respondents did not agree that salary increases resulted from credentialing. There was no difference between groups in the type of monitoring selected or in the time to complete an initial assessment. Cost of therapy was significantly higher for credentialed versus noncredentialed dietitians (dollar 915.67 +/‐ dollar 241.73 versus dollar 851.78 +/‐ dollar 243.44; p =.035), although the survey was not designed to show that the most appropriate care was least expensive. CONCLUSIONS: The CNSD credential is of perceived benefit to practitioners except in obtaining salary increases. Credentialed dietitians selected more expensive therapy than noncredentialed dietitians, which would benefit healthcare administrators only if reduction of other costs resulted. More complex models are needed to fully assess the benefit of credentialed nutrition support dietitians to patients and healthcare administrators.
Early developments and clinical applications of total parenteral nutrition
Authors: Dudrick SJ
Published: May 2008

BACKGROUND: This article recounts the conditions and status of surgical nutrition support in the 1960s and the antecedent basic and clinical investigational work leading to the development of a practical and efficacious method of adequate nourishment entirely by vein in Beagle puppies; describes the subsequent clinical application of the knowledge, techniques, and technology to the first successful long‐term total parenteral nutrition (TPN) support of critically ill pediatric and adult patients; and admonishes nutritionists of all backgrounds that some need for parenteral nutrition will likely always exist and that it is incumbent upon everyone to continue endeavors to advance the germinal methodology to perfection. METHODS: The relevant indications, limitations, hindrances, motivational factors, and studies regarding the development of TPN are reviewed, and the fundamental investigational work culminating in the first successful growth and development of Beagle puppies and a human infant fed entirely by vein are described firsthand. The details of the orderly and logical scientific development of the principles and components of the techniques in animals, infants, and adults are related. RESULTS: Knowledge, techniques, and technologic constituents of the first successful long‐term TPN system were developed in the basic biochemical and animal laboratories initially in 6 puppies and subsequently adapted clinically for the efficacious long‐term i.v. support of 6 critically ill surgical adult patients and a newborn infant before its widespread clinical application. CONCLUSIONS: Long‐term TPN was inaugurated successfully as a safe and effective i.v. feeding technique nearly 4 decades ago. However, basic and clinical investigations must continue to be encouraged, supported, and carried out in the quest to perfect the current rudimentary technology, methodology, and outcomes.
Metabolic response of muscle to alanine, glutamine, and valine supplementation during severe illness
Authors: Gore DC , Wolfe RR
Published: May 2008

BACKGROUND: Alanine and glutamine are released from muscle in response to critical illness. Subsequent depletion of glutamine from muscle is proposed as a principal factor in the limitation of muscle protein synthesis in severely ill patients. The objective of this study was to assess the peripheral metabolic response to enteral supplementation of alanine, glutamine, and valine in critically ill patients. METHODS: Isotopic tracers of alanine, glutamine, and phenylalanine were given IV to 6 critically ill patients and 6 healthy volunteers. Blood sampling from the femoral artery and vein along with muscle biopsies provided assessment of leg (ie, muscle) kinetics. Measurements were obtained during enteral nutrition alone and then with combined alanine (11.25 g), glutamine (7.5 g) and valine (11.25 g) supplementation for 3 hours. RESULTS: Compared with healthy volunteers, critically ill patients had significantly reduced concentrations of alanine and glutamine in arterial plasma (p <.05), which increased significantly with amino acid supplementation. Muscle glutamine concentrations were significantly less in the patients and were not significantly affected by supplementation. Alanine and glutamine transport into and out of muscle and the rates of alanine and glutamine incorporation into and production from muscle were not affected by supplementation. Phenylalanine kinetics, as a marker of muscle protein metabolism, were not significantly altered by alanine, glutamine, and valine intake. CONCLUSIONS: These results demonstrate that alanine, glutamine, and valine administration fails to significantly affect muscle glutamine availability or muscle protein metabolism. These findings suggest that accelerated muscle catabolism in critically ill patients is not in response to any deficiency in alanine or glutamine availability.
Moderate disaccharide malabsorption does not affect weight gain and cecal cell proliferation in piglets
Authors: Kien CL , Cooper JR , Frankel WL
Published: May 2008

BACKGROUND: Intestinal malabsorption of disaccharides or oligosaccharides occurs normally in preterm infants, the majority of the world's adult population when ingesting dairy products, and in sick patients with abnormal intestinal motility or intestinal damage. Although there may be benefit to colonic fermentation, there also could be mucosal damage from excessive fermentation. Moreover, excess fluid in the colon also may impair fermentation. There are few data that address the effects of moderate amounts of carbohydrate, such as 50% of intake, reaching the colon. We addressed the hypothesis that normal weight gain and stool characteristics would occur during disaccharide malabsorption approximating 50% of intake. METHODS: Twelve piglets (aged 17 days) were randomized to receive control sow milk replacement formula (CON; lactose 60 g/L) or CON modified so that lactulose replaced 50% of the lactose (LAC). During a 5‐ to 7‐day period, weight gain and fecal characteristics were observed before autopsy for cecal histology and determination of cecal cell proliferation using bromodeoxyuridine. RESULTS: Neither group developed diarrhea. In LAC and CON, formula intakes (g/kg/d) were similar (279 +/‐ 30 and 280 +/‐ 35), as were the ratios of weight gain:formula intake (g/mL): 0.23 +/‐ 0.04 and 0.22 +/‐ 0.04. Mean cecal cell proliferation was not diminished in the group receiving lactulose (p >.05). CONCLUSION: These data suggest that moderate (50%) disaccharide malabsorption per se does not cause diarrhea and does not impair dietary energy use or colonic cell proliferation.
Clinical relevancy of nonurinary nitrogen excretion in newborns and infants after digestive tract surgery
Authors: Albers MJ , Steyerberg EW , Rietveld T , Tibboel D
Published: May 2008

BACKGROUND: Whether the contribution of nonurinary nitrogen excretion (N2nu) to total nitrogen excretion (N2tot) is clinically relevant has not been tested in children in an intensive care unit. Particularly after digestive tract surgery, fecal nitrogen losses, and losses via nasogastric tubes, enterostomies and wound drains may be large. METHODS: We prospectively measured urinary nitrogen excretion (N2u) and N2nu 4 to 6 days after digestive tract surgery in 78 newborns and infants who were given total parenteral nutrition. RESULTS: Two hundred seven collections of excreta, each representing one 24‐hour period, were obtained. Median N2nu was 15 mg/kg/24 hours (range, 0.4–153), median N2u 153 mg/kg/24 hours (range, 57–558), median N2tot 179 mg/kg/24 hours (range, 72–577), and the median ratio of N2nu and N2u 9.9% (range, 0.2–110). The observed variations could not be attributed to differences in the severity of the underlying disease or the surgical stress. The mean difference between N2tot and N2u was 21 mg/kg/24 hours (95% prediction interval ‐20 to +63). Use of a linear regression equation that predicts N2tot according to N2u and the weights of other excreta eliminated bias and improved precision (95% prediction interval ‐34 to +34 mg/kg/24 hours). For individual measurements, however, considerable imprecision remained. CONCLUSIONS: In newborns and infants, receiving parenteral nutrition 4 to 6 days after digestive tract surgery, N2nu is variable and not to be neglected. The only way to accurately assess N2tot in individual patients is by measuring the nitrogen content of all excreta.
Classification of the degree of obesity by body mass index or by deviation from ideal weight
Authors: Tzamaloukas AH , Murata GH , Hoffman RM , Schmidt DW , Hill JE , Leger A , Macdonald L , Caswell C , Janis L , White RE
Published: May 2008

BACKGROUND: The purpose of this study was to compare classifications of subjects as underweight, normal weight, or obese by body mass index (BMI) and the ratio of body weight to ideal weight (W/IW). METHODS: We performed a theoretical comparison of the 2 indices. We compared classifications of the degree of obesity in 1839 women and 5914 men who were followed up in the primary care clinics of a United States federal hospital. Information was extracted from computerized records. Subjects were classified as underweight (BMI < 18.5 kg/m2, W/IW < 0.9), obese (BMI > or = 30.0 kg/m2, W/IW > or = 1.2), or normal weight (BMI, W/IW values between the cutoff values for underweight and obesity). W/IW values were computed assuming small, medium, and large skeletal frame for all. We compared the classifications of subjects as underweight, normal weight, or obese by BMI and W/IW. We used Cohen's kappa ratio to evaluate the agreement between these classifications. RESULTS: Theoretically, the cutoff values of BMI and W/IW for underweight and obesity are not in agreement. Patient data revealed substantial differences in the classifications of subjects as underweight, normal weight, or obese. Kappa ratios ranged between 0.18 (poor agreement) and 0.71 (reasonable, but not high degree of agreement). In general, kappa ratios were higher when assuming large or medium skeletal frame versus small frame. CONCLUSIONS: There are substantial discrepancies in classifying the subjects of a population as underweight, normal weight, or obese by BMI or W/IW. These discrepancies may cause confusion when 2 or more indices are used simultaneously to classify the degree of obesity.
Transnasal endoscopic placement of feeding tubes in the intensive care unit
Authors: O'Keefe SJ , Foody W , Gill S
Published: May 2008

BACKGROUND: There is an increasing demand for enteral feeding in intensive care unit (ICU) patients. However, gastroparesis is common, and jejunal placement with gastric decompression leads to delays in feeding. In an attempt to minimize delays, we describe our technique and results with transnasal endoscopic placement of double‐lumen gastric aspiration, jejunal feeding tubes (DLFT). METHODS: Fifty‐one consecutive ICU patients referred for nutrition support were studied; 29% had respiratory failure, 28% acute head injury, and 33% acute pancreatitis. A 5.8‐mm ultraslim video endoscope was used to place a guidewire through the nose terminating beyond the Ligament of Treitz. After withdrawal of the endoscope, a DLFT was passed over the wire. Final position of the tube was checked and adjusted under direct vision by reendoscopy though the opposite nasal passage. RESULTS: Initial placement of the guidewire and DLFT was successful in 46 of 51 patients. Massive gastric dilatation and acute pancreatitis complicated by duodenal compression impeded full duodenoscopy in 5 patients, necessitating fluoroscopy for correct guidewire deployment. In confirming correct tube placement, there was near perfect concordance between reendoscopy and x‐ray (45/46). Previously unrecognized upper gastrointestinal tract pathology was detected in most patients, with acute gastritis in 47, superficial gastric ulceration in 24, and erosive esophagitis in 5. CONCLUSIONS: Transnasal endoscopic placement of feeding tubes in the ICU is quick, effective, and minimally disruptive of intensive therapy. In addition, it can reveal unrecognized pathology, which potentially could lead to improvements in overall medical care.
Bioelectrical impedance vs air displacement plethysmography and dual‐energy X‐ray absorptiometry to determine body composition in patients with end‐stage renal disease
Authors: Flakoll PJ , Kent P , Neyra R , Levenhagen D , Chen KY , Ikizler TA
Published: May 2008

BACKGROUND: Patients with end‐stage renal disease (ESRD) have significant shifts in fluid homeostasis that may impair measurements of body composition using methods based upon determinations of body water. Estimates of body water are fundamental for bioelectrical impedance analysis (BIA), which measures electrical resistance to estimate total body water and body composition. METHODS: BIA was compared with 2 other techniques: (1) air displacement plethysmography (ADP), which relies on measurements of body density to estimate body fat and fat‐free masses; and (2) dual‐energy x‐ray absorptiometry (DXA), which depends on the relative attenuation of an x‐ray beam to produce images of body fat and bone mineral. In study 1, BIA and ADP were performed on 38 ESRD patients (21 men and 17 women; age 51.3 +/‐ 2.2 years; weight 79.8 +/‐ 2.9 kg; body mass index [BMI] 27.4 +/‐ 0.9 kg/m2). In study 2, BIA and DXA were performed on 47 patients (22 men and 25 women; age 52.7 +/‐ 2.3 years; weight 73.6 +/‐ 2.9 kg; BMI 25.9 +/‐ 1.0 kg/m2). RESULTS: The ranges of percent body fat using BIA in studies 1 and 2 were from 7% to 57% and from 6% to 52%, respectively. Percent body fat measurements were significantly (p <.0001) correlated for BIA vs ADP (r =.74) and for BIA vs DXA (r =.84). Mean body fat as determined by BIA and ADP in study 1 was 31.8 +/‐ 2.0% and 36.3 +/‐ 1.8%* and by BIA and DXA in study 2 was 29.6 +/‐ 1.5% and 31.8 +/‐ 1.8%*, respectively (*p <.05 vs BIA). All 3 methods had similar variability associated with their measurements (coefficients of variation approximately 5%). The average body fat measured by BIA was less than ADP or DXA, regardless of gender or race. Furthermore, the variation was not greater at lower or higher body fat values. CONCLUSIONS: Body fat measurements using ADP and DXA were correlated with those using BIA across a relatively wide range of body fat levels in adults with ESRD. However, BIA appeared to underestimate body fat and overestimate fat‐free mass, possibly because of increased measurements of body water. Because ADP is convenient and does not use body water content in determination of body density and body composition, it has very good potential as a relatively new technique to estimate percent body fat in adults with ESRD.
Effects of prefeeding a prebiotic on diarrhea and colonic cell proliferation in piglets fed lactulose
Authors: Kien CL , Chang JC , Cooper JR , Frankel WL
Published: May 2008

OBJECTIVES: Severe lactulose malabsorption causes osmotic diarrhea and decreased cecal cell proliferation. We tested the hypothesis that prefeeding with inulin, a prebiotic, would attenuate these effects. METHODS: Piglets aged 10 days were randomized to 3 feeding groups (n = 6 each group): Control (CON), fed sow‐milk replacement formula (SMR; lactose, 60 g/L) for 14 days; a lactulose‐challenged group (LAC) that was fed SMR for 7 days and then a formula containing lactose (30 g/L) and lactulose (60 g/L) for 7 days; and a group prefed SMR containing inulin (3 g/L) for 7 days and then fed the lactulose‐supplemented formula (INULIN). Groups CON and INULIN were pair‐fed to LAC. Then, cecal tissue was collected for histology, determination of crypt cell proliferation index, apoptosis, and Western blot determination of expression of Bax, a pro‐apoptotic protein. RESULTS: The fraction of days when diarrhea was present (mean +/‐ SD) was greater for LAC (0.87 +/‐ 0.14; p =.004) than CON (0.28 +/‐ 0.22; INULIN: 0.52 +/‐ 0.44; p =.058 vs LAC). Cell proliferation index for the total crypt was less for LAC (0.12 +/‐ 0.04; p =.016) compared with CON (0.20 +/‐ 0.04; INULIN: 0.15 +/‐ 0.04; p =.06 vs LAC). BAX protein expression and apoptosis were similar in the 3 groups. CONCLUSIONS: We observed trends consistent with the hypothesis that prefeeding inulin attenuates diarrhea and the reduction in cell proliferation caused by lactulose.
Bowel necrosis caused by water in jejunal feeding
Authors: Schloerb PR , Wood JG , Casillan AJ , Tawfik O , Udobi K
Published: May 2008

BACKGROUND: Fifteen reports of bowel necrosis in patients receiving jejunal feeding have been reported. Etiology remains unexplained. METHODS: A patient with a 60% burn receiving jejunostomy tube feeding developed hypernatremia and was given distilled water in the jejunum, 400 mL every 2 hours. One week later, he developed an acute abdomen with abdominal distention. At operation, he had 4 L of cloudy fluid containing jejunal feeding. Three large duodenal perforations were present. The jejunostomy site was normal. In an animal study, water or normal saline (0.85% NaCl) were infused into the mid small bowel, and sections of bowel were taken 5 minutes later for histologic study. RESULTS: Animal study of the effect of water in the rat intestine revealed disruption of intestinal epithelium. It is suggested that disruption of epithelium by electrolyte‐free water may permit digestion of the bowel wall and result in perforation, as was observed in this patient. This mechanism may have been responsible for some of the cases reported in the literature. CONCLUSIONS: Tap or distilled water may injure intestinal epithelium and should not be infused directly into the small bowel as jejunal feeding.
Monitoring bolus nasogastric tube feeding by the Brix value determination and residual volume measurement of gastric contents
Authors: Chang WK , McClave SA , Lee MS , Chao YC
Published: May 2008

BACKGROUND: Critically ill patients do not always tolerate nasogastric tube feeding. Gastric residual volumes (GRVs), obtained by aspiration from a nasogastric tube, are widely used to evaluate feeding tolerance and gastric emptying, but controversy exists about what constitutes the true GRV (diet formula or digestive juice) and how it should affect management. In this pilot study, we used the Brix value (BV) measurement of gastric contents to monitor both GRV and food content in patients receiving nasogastric feeding. METHODS: Forty‐three patients receiving bolus nasogastric feeding were monitored for 24 hours before entry into the study and then divided into 2 groups according to traditional use of GRV; patients with low GRVs (< 75 mL) were placed in group 1, whereas patients with higher GRVs (> 75 mL) were placed in group 2. All subjects were given 250 mL of polymeric formula by bolus nasogastric infusion, followed by BV measurement of gastric contents at 0, 30, 60, 120, and 180 minutes. All gastric fluid was aspirated after 180 minutes of feeding; the volume was recorded and BV measurement made, then reinstilled with an added 30 mL of dilutional water, after which a final aspiration and BV measurement was performed. Calculated GRV and volume of formula remaining in the stomach was determined by derived equations. RESULTS: Serial BV measurements decreased in both groups after bolus feeding. For patients in group 2, the decrease was less such that at 180 minutes, the mean BV for gastric contents was significantly higher than for those patients in group 1 (10.1 vs 5.1, respectively; p <.01). Aspirated GRV, calculated GRV, and volume of formula remaining in the stomach at 180 minutes were significantly greater for patients in group 2 compared with those in group 1. Use of refractometry in combination with traditional use of GRV identified 4% (1/25) of patients in group 1 with low GRVs who might have possible gastric dysmotility (> 20% of initial 250‐mL volume of formula remaining at 180 minutes) and ensured that 72% (13/18) of patients in group 2 with higher GRVs had sufficient gastric emptying (< 20% of initial 250 mL volume of formula remaining). CONCLUSION: This pilot study raises the feasibility that refractometry and the BV measurement of gastric juice may be a promising tool for bedside monitoring of tolerance and gastric emptying in patients receiving nasogastric feeding, providing valuable complementary information to traditional use of GRV.
Detection of pepsin in tracheal secretions after forced small‐volume aspirations of gastric juice
Authors: Metheny NA , Dahms TE , Chang YH , Stewart BJ , Frank PA , Clouse RE
Published: May 2008

BACKGROUND: Detecting small‐volume aspirations of gastric contents is an important but difficult task. A potentially useful method for this purpose is assaying tracheal secretions for pepsin, an expected constituent of gastric juice. METHODS: A 2‐group experimental design was used. The primary subjects were 161 experimental and 21 control New Zealand white rabbits; 161 acutely ill humans provided the gastric juice used in the project. The animals were anesthetized before being intubated and mechanically ventilated. Three separate boluses of human gastric juice mixed with dye‐stained enteral formula were instilled into the experimental animals' tracheas; the 21 control animals received only 0.9% sodium chloride solution. At the beginning of each experiment, 0.4 mL/kg of the substance was infused over a 30‐minute period; the infusion was then stopped and 90 minutes were allowed to elapse before endotracheal suctioning was performed. This procedure was repeated at hour 2 and hour 4. After completion of the multiple aspiration portion of the study, 23 additional animals were subjected to a single aspiration of 0.4 mL/kg of a mixture of human gastric juice and dye‐stained enteral formula; secretions were obtained at 2 hours, 4 hours, and 6 hours. An immunoassay was used to test for pepsin in all of the tracheal secretions. RESULTS: In the 3‐aspiration group, pepsin was found in all of the secretions from 92.5% (149/161) of the experimental animals; in contrast, no pepsin was found in any of the secretions from the 20 control animals. In the single‐aspiration group, pepsin was found in all of the tracheal secretions from the 23 animals at 2 hours and 4 hours and 21 of the 23 animals at 6 hours. CONCLUSIONS: The immunoassay used in this animal model study was able to detect pepsin in >90% of the experimental animals' tracheal secretions after multiple or single forced aspirations of gastric juice. The extent to which pepsin can be detected in the tracheal secretions of acutely ill tube‐fed humans requires investigation, as does the extent to which clinical outcomes are affected by pepsin‐positive tracheal secretions.
Effects of multilayered bags vs ethylvinyl‐acetate bags on oxidation of parenteral nutrition
Authors: Balet A , Cardona D , Jane S , Molins‐Pujol AM , Sanchez Quesada JL , Gich I , Mangues MA
Published: May 2008

BACKGROUND: We evaluate the effects of multilayered bags vs ethylvinyl‐acetate bags on peroxidate formation of various emulsions for all‐in‐one total parenteral nutrition solutions (TPN) during storage. METHODS: Twenty‐four parenteral nutritions were prepared with 4 commercial i.v. lipid emulsions (Soyacal 20%, Grifols; Intralipid 20%, Fresenius‐Kabi; Lipofundina 20%, Braun; and Clinoleic 20%, Clintex) and 2 different bags (multilayered [ML] bag, Miramed; and 1 ethylvinyl‐acetate [EVA] bag, Miramed). Each kind of TPN was prepared in triplicate. Samples were taken at 3 different times: immediately after preparation (time 0), after 6 days at 4 degrees C and 48 hours at 37 degrees C (time 1), and finally after a total of 14 days at 37 degrees C (time 2). Oxidation of TPN was evaluated by analysis of hydroperoxides by ferrous oxidation‐xylenol orange (FOX) reactive, lipoperoxides by thiobarbituric acid reactive species (TBARS), alpha‐tocopherol by high‐performance liquid chromatography (HPLC), and ascorbic acid and dehydroascorbic acid by HPLC. RESULTS: TPN admixtures in ML bag showed less oxidation evaluated by peroxide determination using FOX than EVA bag. Lipoperoxides by TBARS did not show significant differences between 2 bags. Ascorbic acid and dehydroascorbic acid disappeared in EVA bags at time 1. No important differences were found in alpha‐tocopherol content. CONCLUSIONS: Multilayered bags minimize oxidation.
Liver function and plasma antioxidant status in intensive care unit patients requiring total parenteral nutrition: comparison of 2 fat emulsions
Authors: Antebi H , Mansoor O , Ferrier C , Tetegan M , Morvan C , Rangaraj J , Alcindor LG
Published: May 2008

BACKGROUND: Efficacy and safety of an alpha‐tocopherol‐enriched emulsion incorporating soybean, coconut, olive, and fish oils (SMOF) are compared in terms of biologic parameters to those of soybean oil‐based emulsion (LIPOVEN). METHODS: Twenty stressed patients were randomly assigned in a double‐blind study to receive at least a 5‐day course of total parenteral nutrition. Plasma activities of liver enzymes, C‐reactive protein, antioxidant capacity, alpha‐tocopherol, retinol, and low density lipoprotein (LDL)‐alpha‐tocopherol levels were determined. LDL‐lipid oxidation is measured after incubation of the LDL in the presence of a prooxidant. RESULTS: The plasma activities of liver enzymes and the phospholipids/apo A1 ratio were increased in both groups. However, in the SMOF group the increases were lower than in the LIPOVEN group and non‐significant for the CRP plasma level and the alanineamino‐transferase activity. Before parenteral nutrition, the plasma antioxidant status was markedly reduced in both groups. After parenteral nutrition discontinuation, the antioxidant capacity and the amount of LDL‐derived oxidation by‐products formed were comparable in both groups. There was a significant improvement in plasma lipophilic antioxidant vitamins and LDL‐alpha‐tocopherol levels only in the SMOF group. CONCLUSIONS: The lower increase of plasma liver enzymes and phospholipids/apo A1 ratio in the SMOF group suggest a better liver function than in the LIPOVEN group. This beneficial effect results in a higher liver mobilization and plasma levels of lipophilic antioxidants. They could, together with higher delivery of omega‐3 fatty acids to peripheral tissues, contribute positively to survival rate of stressed patients.
Effects of enteral feeding on antroduodenal motility in healthy volunteers with 2 different fiber‐supplemented diets: a 24‐hour manometric study
Authors: Bouin M , Sassi A , Savoye G , Denis P , Ducrotte P
Published: May 2008

BACKGROUND: Antroduodenal motility during enteral nutrition remains poorly understood. The aim of the study was to evaluate antroduodenal motor activity during intermittent intragastric feeding and between enteral solutions supplemented with new recommended soluble or standard insoluble fibers. METHODS: Two 24‐hour antroduodenal manometric studies were performed with a interval of 1 week in 8 healthy volunteers. Two similar enteral diets except for fiber (soluble vs insoluble) were separately assessed in random order at 2 intervals (lunch and dinner) for 2 hours each. Phase III was studied during three 6 hour‐periods (after lunch, after dinner, and at night). The other quantitative manometric parameters were studied before (1 hour), during (2 hours), and after (2 hours) lunch and dinner. RESULTS: During the 2‐hour postinfusion period, phase III reoccurred in 14 cases during the day and in 16 cases during the night. Phase III was always interrupted during feeding, which reoccurred in 14 cases during the 2‐hour postinfusion period and in 16 cases during the after‐dinner period. Nocturnal phase III was more frequent, lasted longer, with a lower amplitude than the diurnal phase. Addition of either soluble or insoluble fiber did not appear to have an influence on phase III or on the antroduodenal motor activity. CONCLUSIONS: Intragastric feeding interrupted phase III at the antroduodenal stage during infusion but was correlated with interdigestive motility. Antroduodenal motility did not significantly change either during or after intragastric feeding. The addition of either soluble or insoluble fiber does not seem to have an influence on gastroduodenal motor response to intermittent intragastric feeding.
Pump‐Assisted Enteral Nutrition Can Prevent Aspiration in Bedridden Percutaneous Endoscopic Gastrostomy Patients
Authors: Shang Edward , Geiger Nicole , Sturm Joerg W. , Post Stefan
Published: May 2008

The authors of the above article have requested its withdrawal, notifying the Journal that the clinical trials described in the article were not conducted as written in the article. The Editor‐in‐Chief, the American Society for Parenteral and Enteral Nutrition, and the Publisher have determined to retract the article.
Supplementation of total parenteral nutrition with butyrate acutely increases structural aspects of intestinal adaptation after an 80% jejunoileal resection in neonatal piglets
Authors: Bartholome AL , Albin DM , Baker DH , Holst JJ , Tappenden KA
Published: May 2008

BACKGROUND: Supplementation of total parenteral nutrition (TPN) with a mixture of short‐chain fatty acids (SCFA) enhances intestinal adaptation in the adult rodent model. However, the ability and timing of SCFA to augment adaptation in the neonatal intestine is unknown. Furthermore, the specific SCFA inducing the intestinotrophic effects and underlying regulatory mechanism(s) are unclear. Therefore, we examined the effect of SCFA supplemented TPN on structural aspects of intestinal adaptation and hypothesized that butyrate is the SCFA responsible for these effects. METHODS: Piglets (n = 120) were randomized to (1) control TPN or TPN supplemented with (2) 60 mmol/L SCFA (36 mmol/L acetate, 15 mmol/L propionate and 9 mmol/L butyrate), (3) 9 mmol/L butyrate, or (4) 60 mmol/L butyrate. Within each group, piglets were further randomized to examine acute (4, 12, or 24 hours) and chronic (3 or 7 days) adaptations. Indices of intestinal adaptation, including crypt‐villus architecture, proliferation and apoptosis, and concentration of the intestinotrophic peptide, glucagon‐like pepide‐2 (GLP‐2), were measured. RESULTS: Villus height was increased (p <.029) within 4 hours by supplemented TPN treatments. Supplemented TPN treatments increased (p <.037) proliferating cell nuclear antigen expression along the entire intestine. Indicative of an antiapoptotic profile, jejunal Bax:Bcl‐w abundance was decreased (p =.033) by both butyrate‐supplemented TPN treatments, and ileal abundance was decreased (p =.0002) by all supplemented TPN treatments, regardless of time. Supplemented TPN treatments increased (p =.016) plasma GLP‐2 concentration at all time points. CONCLUSIONS: Butyrate is the SCFA responsible for augmenting structural aspects of intestinal adaptations by increasing proliferation and decreasing apoptosis within 4 hours postresection. The intestinotrophic mechanism(s) underlying butyrate's effects may involve GLP‐2. Ultimately, butyrate administration may enable an infant with short‐bowel syndrome to successfully transition to enteral feedings by maximizing their absorptive area.
Effects of L‐arginine infusion during ischemia on gut blood perfusion, oxygen tension, and circulating myeloid cell activation in a murine gut ischemia/reperfusion model
Authors: Fukatsu K , Ueno C , Maeshima Y , Hara E , Nagayoshi H , Omata J , Mochizuki H , Hiraide H
Published: May 2008

BACKGROUND: Gut hypoperfusion is considered to be a mechanism for early multiple‐organ failure after severe surgical insults. L‐Arginine (ARG) may preserve gut microcirculation as a substrate of nitric oxide synthase, but simultaneously may enhance immune cell response. It remains unknown if ARG infusion during gut ischemia improves the outcome after gut ischemia‐reperfusion (I/R). METHODS: Male Institute of Cancer Research mice were randomized to control and ARG groups. After i.v. cannulation, mice underwent 90 (Exp. 1) or 60 (Exp. 2 and 3) minutes of gut I/R. Control mice received normal saline infusion at 1 mL/h for 60 minutes during ischemia, whereas the ARG group was given 1% ARG hydrochloride solution. In Exp. 1, survival was observed for 72 hours (n = 35). In Exp. 2, blood perfusion and oxygen tension of the small intestine were measured (n = 9). In Exp. 3, peripheral blood was obtained at 2 or 4 hours after reperfusion (n = 22). Reactive oxygen intermediate (ROI) production by myeloid cells with or without phorbol myristate acetate (PMA) stimulation and expression of CD11a and CD11b on myeloid cells were examined using flow cytometry. RESULTS: Exp. 1: There was no significant difference in survival times (log rank test, p =.2). However, survival rates at 12 hours were 72% (13/18) for the control group and 35% (6/17) for the ARG group (p <.05 Fisher). Exp. 2: ARG infusion significantly improved gut blood perfusion ratio during ischemia but had no effect on oxygen tension. Exp. 3: In the ARG group, ROI production with PMA and CD11b expression at 4 hours were higher than those at 2 hours, whereas there were no significant changes in the control mice. CONCLUSIONS: ARG infusion improves intestinal blood perfusion during ischemia but primes and activates circulating myeloid cells excessively. Consequently, i.v. infusion of ARG during ischemia reduces survival rate.
Long‐term parenteral nutrition, via the azygos system, in an adolescent with cystic fibrosis
Authors: El Dannawi S , Michaud L , Salakos C , Bonnevalle M , Marciniack B , Turck D , Gottrand F
Published: May 2008

Venous access device is critically needed for long‐term parenteral nutrition (PN), especially in children with chronic disease such as cystic fibrosis, short bowel syndrome, and permanent intestinal failure. When traditional sites are unavailable and venous access is very limited, alternative central routes are required. The access to the azygos system has been shown to be a safe, relatively easy solution in those special situations. We report the case of an adolescent who benefited from this central venous access for long‐term PN and antibiotic treatment for >7 years with a limited number of complications.
Early enteral feedings in adults receiving venovenous extracorporeal membrane oxygenation
Authors: Scott LK , Boudreaux K , Thaljeh F , Grier LR , Conrad SA
Published: May 2008

INTRODUCTION: For over 20 years extracorporeal membrane oxygenation (ECMO) has been an advanced treatment for adults, children and neonates with severe respiratory failure that has failed to respond or improve with conventional therapy. Withholding enteral feeding in patients on ECMO is common practice in many centers, based partly on the risk of splanchnic ischemia resulting in loss of intestinal integrity, predisposing to bacterial translocation and sepsis. We report one center's experience with early enteral nutrition in adult patients receiving venovenous (VV) ECMO for severe respiratory failure. METHODS: Adult patients that received VV ECMO at LSUHSC‐Shreveport over the last 8 years were eligible for inclusion. RESULTS: A total of 27 patients met these criteria and their charts and nutrition therapy reviewed. Average duration of ECMO support was 8.7 +/‐ 3.6 days. Twenty‐six of 27 (96%) received enteral nutrition via gastric tube alone or in combination with total parenteral nutrition (TPN). Eighteen patients received enteral nutrition as their only source of nutritional supplementation, with the remainder receiving partial nutrition support via the parenteral route. Seventy‐five percent of the patients received prokinetic medication within the first 24 hours, with 95% receiving prokinetic therapy by 48 hours. No patients developed intestinal ischemia, gastrointestinal bleeding, or other complications related to early enteral feeding. CONCLUSION: Enteral nutrition started within the first 24 to 36 hours of initiating venovenous ECMO support is safe and well‐tolerated in adults. No serious adverse events were attributable to enteral nutrition in these patients.
Inhibition of 5‐lipoxygenase induces cell death in anti‐inflammatory fatty acid‐treated HL‐60 cells
Authors: Gillis RC , Daley BJ , Enderson BL , Karlstad MD
Published: May 2008

BACKGROUND: Enteral nutrition containing eicosapentaenoic (20:5 omega‐3) and gamma‐linolenic acid (18:3 omega‐6) decreases leukotriene B4 levels and neutrophils in bronchoalveolar lavage fluid of patients and animals with acute respiratory distress syndrome. Reduction in pulmonary inflammation may be caused by decreased neutrophil migration or survival. We showed that apoptosis increases in eicosapentaenoic/gamma‐linolenic acid‐treated HL‐60 cells. We hypothesize that eicosapentaenoic/gamma‐linolenic acid‐induced apoptosis involves downstream metabolic products of lipoxygenase and cyclooxygenase enzymes. This study determined the effects of inhibitors of lipoxygenase and cyclooxygenase enzymes on eicosapentaenoic/gamma‐linolenic acid‐treated HL‐60 cells. METHODS: Cells were incubated with 50 microM eicosapentaenoic/20 microM gamma‐linolenic acid in the presence of an enzyme inhibitor (1–10 microM) for 12 hours. Compounds were used to inhibit cyclooxygenase (ibuprofen), 12‐lipoxygenase (baicalein), or 5‐lipoxygenase (AA‐861). Flow cytometry assessed viability, apoptosis, and necrosis. RESULTS: 5‐Lipoxygenase inhibition decreased cell viability and increased cell death (apoptosis + necrosis) in eicosapentaenoic/gamma‐linolenic acid‐treated HL‐60 cells. Inhibition of cyclooxygenase 1 and 2 and 12‐lipoxygenase had no significant effect on cellular viability and death in eicosapentaenoic/gamma‐linolenic acid‐treated HL‐60 cells. Adding leukotriene B4 counteracted the effect of 5‐lipoxygenase inhibition on apoptosis in eicosapentaenoic/gamma‐linolenic acid‐treated HL‐60 cells. CONCLUSIONS: These data suggest that the processing of eicosapentaenoic and gamma‐linolenic acid by 5‐lipoxygenase is critical to HL‐60 cell survival.
Orotic aciduria and plasma urea cycle‐related amino acid alterations in short bowel syndrome, evoked by an arginine‐free diet
Authors: Pita AM , Fernandez‐Bustos A , Rodes M , Arranz JA , Fisac C , Virgili N , Soler J , Wakabayashi Y
Published: May 2008

BACKGROUND: The small bowel is believed to play a crucial role in endogenous arginine synthesis. Therefore, an insufficient arginine supply in the situation of massive intestinal resection might impede normal arginine metabolism. This study sought to determine the clinical and metabolic effects of an arginine‐free diet in stable short‐bowel patients. METHODS: Four patients, mean age 49 years (range: 26–67), mean time from intestinal resection 46 m (range: 15–97), and remnant small bowel of 30 to 100 cm consumed an L‐amino acid arginine‐free diet (egg pattern) for 5 days (0.9 g protein equivalent/kg/d plus malabsorption adjustments). Fasting plasma amino acids, ammonium, and blood chemistries were assessed at days 0, 3, and 5. Urinary orotate, orotidine, uric acid, urea, creatinine, and total nitrogen were evaluated daily. RESULTS: Significant decreases in plasma levels of arginine, ornithine, and hydroxyproline occurred at day 5. A decreasing trend in plasma citrulline and a significant plasma glutamine increase were also observed in the same period. Conversely, ammonium concentrations remained normal. Regarding urine compounds, striking orotic aciduria with a peak at day 4 (14‐fold vs baseline) and significant decreases in uric acid and urea excretion were found. There were no relevant clinical events. CONCLUSIONS: Despite the limited number of patients in our work and their relative heterogeneity, our results support the idea of the indispensability of an exogenous arginine supply in humans under short bowel syndrome conditions. Studies in larger series are needed to further investigate these findings.