bluuebunny/crossref_metadata_2025 huggingface dataset:
A Pilot Study to Determine Reasons for Patient Withdrawal From a Pelvic Muscle Rehabilitation Program for Urinary Incontinence
Authors: Kincade Jean E. , Johnson Theodore M. , Ashford-Works Carolyn , Clarke M. Kimberly , Busby-Whitehead Jan
Published: June 2009

This project explored reasons why patients with urinary incontinence withdrew from a behavioral treatment program before completion of all sessions. In-depth, semistructured interviews were conducted with 10 of 25 patients who had not completed prescribed behavioral treatment at the University of North Carolina–Chapel Hill School of Medicine Continence Clinic. The women interviewed made positive or neutral comments about Kegel exercises and understood the relationship between urinary incontinence and pelvic muscle weakness. They perceived a relationship between age and urinary incontinence but did not think that incontinence was inevitable with aging. Treatment of urinary incontinence became less of a priority when work, physical impairments, or illness intervened and when there appeared to be some misunderstanding about the treatment. These findings suggest that clinicians need to better understand perceived barriers to adherence in order to discuss these barriers and to design a more individualized approach for each patient in a continence clinic.
Culture, Economics, and Alzheimer's Disease: Social Determinants of Resource Allocation
Authors: Topinková Eva , Callahan Daniel
Published: June 2009

Although the United States and the Czech Republic have approximately the same proportion of people older than ages 65 and 80, there are striking differences in the response to Alzheimer's disease. In the United States, there is considerable public interest, openness about the problem, and a vigorous research effort to cope with the disease. In the Czech Republic, by contrast, there is little government, media, or public interest. The disease is treated as a natural result of aging and thought to be a matter offate and acceptance rather than calling for a medical response. The cultural and historical reasons for this difference are explored, noting that a change in Czech attitudes and practices, important and necessary, will nonetheless come at a price. Both coun tries will in the future face new and daunting problems in caring for those with the disease.
The Life Space Questionnaire: A Measure of the Extent of Mobility of Older Adults
Authors: Stalvey Beth T. , Owsley Cynthia , Sloane Michael E. , Ball Karlene
Published: June 2009

Mobility in older adults is typically discussed in terms of component maneuvers including analy sis of gait and postural instability; activities that depend on mobility such as bathing, dressing, or shopping; or adverse events during mobility such as falls or motor vehicle crashes. None of these approaches reflects a key aspect of mobility-the extent of movement within a person's environment, or life space in the gerontological literature. Here we describe this concept as it applies to mobility and present a questionnaire instrument designed to measure life space in community-dwelling older adults. Results indicate that the Life Space Questionnaire (LSQ) is reliable and has construct and criterion validity in a sample of olderadults. The LSQ can be used to establish the spatial extent of an older person's mobility and may ultimately be useful as an outcome measure in studies evaluating interventions designed to enhance mobility and inde pendence in community-dwelling older populations.
Age-Related Variation in Roles Performed by Hospice Volunteers
Authors: Black Beverly , Kovacs Pamela J.
Published: June 2009

This study examines age-related variation in the roles performed by volunteers in hospice pro grams. Volunteers of varying age groupings display much similarity in their motivations for vol unteering, how they learned about the opportunity to serve, the levels of satisfaction experienced from serving, and various measures of retention. The age of the volunteer significantly influ enced the roles they performed at the hospice. Significantly more younger volunteers provide direct patient care services; and significantly more older volunteers provide both clerical and fund-raising services. Implications for future research and recruitment and retention of hospice volunteers are discussed.
Expectations for Parental Management of Dating in an Ethnically Diverse Sample of Early Adolescents
Authors: Mounts Nina S. , Kim Hyun-Soo
Published: June 2009

This investigation examined mothers’ beliefs about important dating partner characteristics and expectations regarding management of dating in an ethnically diverse sample of 76 early adolescents and their mothers. Open-ended and structured questions were used to identify a range of dating partner characteristics which were important to mothers and a range of dating-management practices expected to be used by the mothers. Adolescents also reported their expectations of the mothers’ management of dating. There were significant differences in mothers’ and adolescents’ reports of expectations of management of dating. Analyses revealed some ethnic differences and few gender differences in important characteristics of dating partners as well as expectations regarding management of dating.
The Perception of Similarities and Differences Among Adolescent Siblings
Authors: Watzlawik Meike
Published: June 2009

During adolescence, identity development reaches its crucial point. Siblings foster the search for their own uniqueness through social comparisons. These comparisons can lead to identification (“I am like you.” or “We are special.”) as well as deidentification (“I am different from you!”). In this study, 204 siblings were interviewed to determine in which aspects/traits twins and nontwins perceive similarities and differences between them and their siblings. The number of similarities and differences mentioned was also examined as well as the frequency with which upward, downward, and neutral comparisons are used. It was assumed that monozygotic twins in particular differ from other twins (dizygotic twins of the same and opposite sex) and nontwins (siblings with a maximum age difference of 24 months) due to different developmental conditions. For all siblings, results show that the areas in which similarities and differences are perceived differ. Similarities are mainly perceived in interests and shared abilities/activities, whereas differences are mainly described with the help of character traits, looks, and athletic abilities. Monozygotic twins perceive fewer differences between them than do the other groups but do not perceive more similarities. Twins and nontwins do not differ in the frequency with which upward, downward, and neutral comparisons are used. Implications of these results are being critically discussed.
Use of B Vitamins to Reduce Homocysteine in Chronic Mesenteric Ischemia
Authors: Willcutts Kate , Minasi John S.
Published: June 2009

Recent research suggests that hyperhomo‐cysteinemia is a significant risk factor for thrombosis. The mechanism for this is not completely understood. However, studies have shown that high intakes of folic acid, vitamin B12, and vitamin B6 can lower homocysteine levels. This case study describes a patient with a 7‐year history of postprandial pain who was diagnosed with mesenteric ischemia. She was found to have moderate hyperhomocysteinemia and was subsequently treated with B vitamins. Unable to tolerate enteral nutrition, the patient was maintained on‐ parenteral nutrition before surgery. After resection of ischemic, strictured gut, her parenteral nutrition was discontinued and she gained weight on an oral diet. Her serum homocysteine level dropped to low‐normal, therefore, vitamin B supplementation continues. Since surgery, the patient has been without symptoms of chronic ischemia.
Comparison of Two Different Low‐Profile Gastrostomy Enteral Feeding Devices in Pediatric Oncology Patients
Authors: Ringwald‐Smith Karen , Hale Gregory , Williams Ruth , Ludwig Michelle , Thompson Alexis , Bowman Laura , Shochat Stephen , Liu Aiyi , Barkley Chris
Published: June 2009

Purpose: To describe the occurrence and type of complications in two low‐profile enteral feeding devices (LPFD) at St. Jude Children's Research Hospital (SJCRH). Methods: The medical records of 36 patients who received gastric feedings via the Bard® or MIC‐KEY® devices between 1994 and 1997 were retrospectively reviewed. Results: Patients began tube feedings at a median age of 12.1 years (range, 1 month to 18.7 years). Twenty‐four patients were at nutritional risk at time of gastrostomy tube (GT) placement. Although 29 patients received GTs originally, 11 eventually received a Bard® Button and 19 eventually received a MIC‐KEY®. Six never received a low‐profile device. Nutrition support continued for a median of 8.3 months (range, 17 days to 23 months). One or more complications occurred in 30 patients and were categorized as mechanical (leakage, 8; broken balloon, 5; deflated balloon, 1; dislodged tube, 11; clogged tube, 1; valve malfunction, 1; damaged cover, 1) or feeding related (nausea/vomiting, 12; nausea/constipation, 4; diarrhea, 3). Twenty patients (56%) achieved or maintained ideal body weights with nutrition support. Conclusions: Both feeding devices are effective in improving or maintaining the nutritional status of pediatric oncology patients undergoing cancer therapy. Mechanical complications were higher in the MIC‐KEY® group due to the balloon. Awareness of the incidence and type of complications allowed us to select one LPFD for use at our institution and to develop uniform standards of care. Despite the higher complication rate, the MIC‐KEY® is preferred because of the decreased level of pain associated with accessing the stoma and ease of care.
Tube Feeding in Patients with Advanced Dementia: A Review of the Evidence
Authors: Bliss Donna Zimmaro
Published: June 2009

Patients with advanced dementia frequently develop eating difficulties and weight loss. Enteral feeding tubes are often used in this situation, yet benefits and risks of this therapy are unclear. We searched MEDLINE, 1966 through March 1999, to identify data about whether tube feeding in patients with advanced dementia can prevent aspiration pneumonia, prolong survival, reduce the risk of pressure sores or infections, improve function, or provide palliation. We found no published randomized trials that compare tube feeding with oral feeding. We found no data to suggest that tube feeding improves any of these clinically important outcomes and some data to suggest that it does not. Further, risks are substantial. The widespread practice of tube feeding should be carefully reconsidered, and we believe that for severely demented patients the practice should be discouraged on clinical grounds. (JAMA 282: 1365–1370, 1999)
Doing the Right Thing: The Utilization of Evidence‐Based Medicine
Authors: Koretz Ronald L.
Published: June 2009

Traditionally, medical decisions have been largely based on personal experiences and/or those of others and rarely has time been taken to look for supporting data in the medical literature. As health care resources become more limited (at least in comparison to the demand), they will have to be used as effectively and efficiently as possible. A new paradigm for decision making will have to be developed, employing the best available medical literature. Evidence‐based medicine, incorporating the systematic review whenever possible, requires identification of the best data and incorporation of this data into a knowledge base, thereby providing care that will be better for patients.
Conservative Treatment for the Removal of a Central Venous Catheter with Large Thrombus: A Case Report
Authors: Sugimachi Keishi , Yonemitsu Yoshikazu , Komori Kimihiro , Sugimachi Keizo
Published: June 2009

Thrombus is one of the serious complications associated with the use of a central venous catheter (CVC). We report the case of a 74‐year‐old Japanese man with a large CVC thrombus who successfully underwent thrombolytic treatment. The infusion of recombinant tissue‐type plasminogen activator (rt‐PA) was effective for achieving a partial dissolution of the thrombus, and the CVC was thereafter successfully removed without any serious complications during both the clinical course and the long‐term follow‐up period. We therefore consider thrombolytic treatment with rt‐PA to be effective and not overly invasive, and may thus be useful in treating patients experiencing a CVC‐related thrombus.
Closed versus Open Enteral Delivery Systems: A Quality Improvement Study
Authors: Vanek Vincent W.
Published: June 2009

The purpose of this study was to review the compliance rate with maximum enteral feeding hang‐time policy and to determine the incidence of tube feeding (TF) contamination. This study found the compliance rate for the maximum TF bag hang‐time was 67% for open delivery system (OS) and 88% for the closed delivery system (CS). The 10 CS bags cultured had hang‐times from 20.8 to 45.8 hours and were all sterile. The 8 OS bags cultured had hang‐times from 6.8 to 26.6 hours with 2 bags being contaminated. The maximum hang‐time for the CS was increased from 24 to 48 hours. The study was repeated with 100% compliance for the CS and still only 50% compliance for the OS. The 14 CS bags cultured had hang‐times from 22.0 to 47.3 hours and were all sterile except for 1 bag that had methylene blue dye added to it. The 9 OS bags cultured had hang‐times from 7.5 to 13.3 hours, and all were sterile. The findings of this study led us to conclude that closed enteral delivery systems should be used whenever possible.
Redefining Drug‐Nutrient Interactions
Authors: Chan Lingtak‐Neander
Published: June 2009

Currently, a standardized definition and classification system for drug‐nutrient interactions does not exist. This may explain the disparity in the perception, recognition, and management of drug‐nutrient interactions among clinicians and researchers. The purpose of this article is to redefine and systematically classify drug‐nutrient interactions according to the most recent understanding in drug and nutrient metabolism and drug‐drug interactions. Drug‐nutrient interactions can be broadly classified into four types based on their mechanisms. This definition and classification system should facilitate patient management, clinical and didactic training for practitioners, and future research direction in this area.
Nutrition Requirements of a Severely Stressed Obese Patient: A Case Study
Authors: Pahwa Neeta , Hedberg Ann‐Marie , Radovancevic Branislav , Jain Surendra
Published: June 2009

This case illustrates that a highly stressed obese patient has a higher basal energy expenditure than a normal‐weight individual. Prealbumin levels were used as an index of response to nutrition support. It was readily determined that much greater levels of calories and protein were necessary to produce anabolism, as demonstrated by prealbumin response and wound granulation, than would have been estimated using conventional methods. Conventional methods used are the Harris‐Benedict formula with stress and activity factor, kcal/kg, body weight, nitrogen balance studies, and using adjusted weight to calculate needs for obese patients.
Transgastric Jejunal Feeding Tubes in Critically III Patients
Authors: Shapiro Trudy , Minard Gayle , Kudsk Kenneth A.
Published: June 2009

Delayed gastric emptying is a common postoperative complication in critically ill patients that impedes successful administration of early enteral feeding. Transgastric jejunal feeding tubes (TJTs) simultaneously decompress the stomach while permitting postpyloric feedings. Earlier designs were associated with inadequate gastric decompression and reflux of feedings into the stomach; however, a new tube (Medical Innovations Corporation, Milpetas, CA) appears to be an improvement, thus warranting an evaluation of its safety and efficacy. TJTs were placed in 29 patients who were followed for complications associated with the tube. Seventeen problems occurred: three were due to user errors, six were due to mechanical dysfunction, and four tubes were dislodged. Ten patients had a nasogastric tube in addition to their TJT; however, only four of the nasogastric tubes were thought to be needed because of inadequate gastric drainage. The TJT adequately decompressed the stomach in most patients, allowing small‐bowel feedings without the need for a separate gastrostomy. Education of hospital staff concerning the insertion and use of TJTs is necessary for optimal use of the tube.
Chronic Hypothermia and Energy Expenditure in a Neurodevelopmentally Disabled Patient: A Case Study
Authors: Gervasio Jane M. , Dickerson Roland N. , Brown Rex O. , Matthews J. Barret
Published: June 2009

Hypothermia is defined as a core body temperature of <35°C and results in a decrease in measured resting energy expenditure. A 51‐year‐old mentally disabled patient experienced chronic hypothermia from neurologic sequelae. Because of her continued weight gain and increased body fat in the presence of presumed hypocaloric nutrition, indirect calorimetry measurements were performed twice in a 3‐month period. The resting energy expenditure measurements prompted a reduction of her daily caloric intake to prevent further overfeeding. Hypothermia reduces oxygen consumption and, as a consequence, decreases resting energy expenditure. In patients for whom chronic hypothermia is a problem, nutritional intake must be adjusted to prevent overfeeding, excessive weight gain, and the long‐term complications of an excess of total calories.
Improvement in the Nutritional and Pulmonary Profiles of Cystic Fibrosis Patients Undergoing Bilateral Sequential Lung and Heart‐Lung Transplantation
Authors: Beck C. E. , Lin A. , Robbins R. C. , Dosanjh A. K.
Published: June 2009

Cystic fibrosis (CF) is the most common lethal genetic disease of the white population and is associated with malnutrition. In patients undergoing thoracic surgery, poor nutrition is a risk factor for postoperative complications. The aim of this study is to characterize the nutritional profiles of CF patients undergoing pulmonary transplantation (heart‐lung or bilateral lung) at our medical center between 1988 and 1996 and to assess the significance of their nutritional status on posttransplantation outcomes. We retrospectively reviewed the charts of the 31 CF patients who underwent lung transplantation. Body mass index (weight/height2) was calculated for the adult patients as an index of their relative body fat before transplantation. Preoperative biochemical nutritional parameters and pulmonary function tests were assessed. The data were then compared with data collected at 1 year after transplantation. Multivariate analysis was used to examine the relationship between preoperative parameters and transplantation outcomes. The outcome variables included initial length of hospital stay, the number of infections within the first 90 days, the number of acute rejection episodes within the first year; the occurrence of obliterative bronchiolitis within the first year; and the change in the forced expiratory volume in 1 second, forced expiratory flow between 25% and 75%, and the forced vital capacity, hematocrit, and cholesterol at 1 year. Significant differences were found in all parameters studied at the end of 1 year (p ≥ .002). An inverse correlation was demonstrated between the pretransplantation total protein/albumin ratio and the number of early infections (p = .029); however, albumin concentration alone showed no correlation. Preoperative diabetes mellitus did not correlate with any of the dependent variables. The multivariate analysis suggests that an increase in the globulin fraction of total protein may be associated with a decrease in early postoperative infections. The nutritional parameters and pulmonary function of the CF patients studied normalized by one year after transplantation. There was no increased risk of rejection or infection observed among the CF diabetic patients transplanted.
Long‐Term Enteral Nutrition: Flexible Management of Hyperkalemia
Authors: Hampton Lisa D. , Heizer William D. , Holcombe Beverly J.
Published: June 2009

Management of hyperkalemia in patients receiving enteral tube feeding is often challenging, particularly in the presence of chronic organ dysfunction. We present a case report describing successful reduction of serum potassium concentration with a tube feeding regimen involving nocturnal infusion of a mixture of Deliver 2.0 (Mead Johnson Nutritionals, Evansville, IN) and sodium polystyrene sulfonate (SPS) powder. The patient described in this report has maintained acceptable serum potassium concentrations without significant alteration of other serum electrolyte parameters. Subsequent in vitro evaluation of Nutren 1.0/SPS (Clintec Nutrition Co, Deerfield, IL) and Deliver 2.0/SPS admixtures revealed that SPS in a concentration of 15 g/L produces a nearly 50% reduction in the potassium content of these enteral feeding formulations. A 30‐g/L SPS concentration reduces potassium content by almost two thirds. This decrease in potassium content is accompanied by a reduction in magnesium content and an increase in sodium content.
Ensuring Optimal Nutrition in Long‐Term Care
Authors: Posthauer Mary Ellen , Russell Carlene
Published: June 2009

Maintaining or improving the nutritional status of the elderly individual who progresses from one care setting to another presents a challenge for the health care team. Identification of risk factors that contribute to undernutrition or malnutrition in nursing home facilities is essential. Federal regulations mandate that nursing facilities provide care that maximizes the resident's quality of life. Protein energy undernutrition has been associated with the development of pressure ulcers, cognitive problems, infections, and increased mortality. Optimizing nutrition screening and interventions helps to achieve positive outcomes for the resident.
Performance Model Anchors Successful Nutrition Support Protocol
Authors: Pace Nancy M. , Long John B. , Elerding Susan , Lim Helena , Kelly Mary , Reed James , Edwards Bruce , Atondo Richard , Romo‐Munday Chris , Wong Jeanette
Published: June 2009

Parenteral nutrition (PN) has been identified as a potentially high risk and costly drug therapy that tends to be overused. A continuous quality improvement (CQI) model, FOCUS‐PDCA, provided the framework used by our Total Parenteral Nutrition (TPN) Subcommittee to develop processes that reduced inappropriate use of PN, improved the quality of patient care, and reduced costs. Through the application of this process from 1992 to 1996, the use of TPN was reduced by 52%, and a 95% appropriateness level was achieved. The success of this methodology also was reflected, during 1996, in an increased use of enteral nutrition, which peaked to 112% from the initial 1995 baseline measurement and in estimated cost savings of $226,184 from reduced use of TPN. Our experience suggests that patients benefit from an improved nutrition screening and assessment program combined with monitoring and education. Achievement of quality nutrition care is cost effective and can be sustained through a nutrition support protocol that adheres to the principles of a performance improvement model.
Metabolic Requirements of the Critically Ill, Mechanically Ventilated Trauma Patient: Measured Versus Predicted Energy Expenditure
Authors: Donaldson‐Andersen Jill , Fitzsimmons Lorraine
Published: June 2009

Nutritional requirements of mechanically ventilated, critically ill trauma patients are to estimate because of the variety of injuries and many variables that must be considered in making an accurate nutrition assessment. The Harris‐Benedict predictive equation is often cited in the literature as an overestimation of caloric requirements in the critically ill when compared with indirect calorimetry, and, additionally, studies examining critically ill populations are inconsistent with the application of two important variables: physical activity and fasting. For this study, measurements of resting energy expenditure were compared with the predicted basal energy expenditure (BEE) using the Harris‐Benedict equation with the addition of a selected injury correction factor (ICF), and potential relationships were evaluated for their agreement. When the elements of routine intensive care unit physical activity (which increases energy expenditure by approximately 10%) and the patient's fasting state (the specific dynamic action of food which increased energy expenditure by 10%) are accounted for by the addition of 20% to the measured resting energy expenditure (MREE), the predicted BEE with ICF was in moderate significant agreement with MREE.
Nasoenteric Tube Complication: A Case Report of Tip Detachment
Authors: Sood Anil K. , Pardubsky Peter D. , Gacuson Marievic , Kumar Girish C. , Sum‐Ping S. T.
Published: June 2009

Enteral feeding is used commonly among critically ill patients. An unusual complication related to a weighted nasoenteric feeding tube is described. The hospital course of a critically ill patient with a disrupted weighted tip from a nasoenteral feeding tube was reviewed. All identified references with relevance to similar complications of nasoenteral tubes were reviewed. A 79‐year‐old woman with intracranial hemorrhage required postoperative mechanical ventilation and enteral feedings using a 12F nasoenteric feeding tube. The weighted tip on the feeding tube became detached during placement and the tungsten discs from this tip were scattered throughout the bowel. The patient passed these discs in her stool by the 12th postoperative day and had no further complications. All nasoenteral tubes should be inspected closely for possible defects before placement. Radiographic confirmation of tube placement should be obtained, and after removal the tip should be examined for any defects.
Methylphenidate for Appetite Stimulation in Older Patients
Authors: Jarvis Catherine
Published: June 2009

Many different pharmacologic agents are available to increase lean body mass and improve nutritional status. A clear understanding of each patient's malnourished state and the underlying cause of poor intake must be identified so the root of the problem can be addressed with an appropriate specific treatment. Depression must be considered as a potential cause of poor nutritional intake, and antidepressants may be more appropriate treatment options than traditional appetite or lean body mass‐enhancing therapy. Conventional antidepressants, however, pose significant problems for older patients. A review of the use of methylphenidate as an antidepressant in the elderly revealed that it is a safe, effective, and relatively inexpensive agent that may be an alternative for nutrition support clinicians who are attempting to increase oral intake in malnourished older patients.
Nutrition After Surgery for Hypoplastic Left‐Heart Syndrome
Authors: Pillo‐Blocka Francy , Miles Cheryl , Beghetti Maurice , Rebeyka Ivan , Freedom Robert M. , McCrindle Brian W.
Published: June 2009

Medical management and care of infants with hypoplastic left‐heart syndrome (HLHS) after a stage I Norwood procedure is intensive and complex. However, failure to thrive is common and increases the length of hospital stay. To evaluate feeding practices of patients with HLHS for factors affecting nutrition, growth, morbidity, and mortality, we undertook a review of 28 infants who survived at least 10 days after a stage I Norwood procedure over a 43‐month period at our pediatric hospital. It took a median 11 days (range, 1 to 23 days) to reach a maximum feeding of 3800 to 4600 kJ/L (800 to 1100 kcal/L); 32% of patients never achieved normal energy requirements in the hospital. Eleven of 19 hospital survivors had not achieved their birth weight by discharge; only 3 achieved average weight gains >20 g/d over 5 days. Rapid advancement of feedings is recommended during the complicated hospitalization of these patients to promote optimal nutritional status.
A Multidisciplinary Approach to Home Enteral Nutrition
Authors: Klein Gloria L. , Rogers Joanne Z. , Friedmann Janet , Jensen Gordon L.
Published: June 2009

Identifying patients who may benefit from home enteral nutrition support, managing the tube feeding regimen, and coordinating patient follow‐up present unique challenges and opportunities for the health care team. The Geisinger Clinic of the Penn State Geisinger Health System, Danville, Pennsylvania, assembled a multidisciplinary team comprising a dietitian, a nurse, a social worker, and a physician to address the concerns of patients receiving home enteral nutrition. A coordinated effort among the patient, caregivers, and health care team is essential for the successful discharge and management of home enteral nutrition patients.
Preplacement Marking for Optimal Gastrostomy and Jejunostomy Tube Site Locations to Decrease Complications and Promote Self‐Care
Authors: Hanlon Maureen D.
Published: June 2009

Placement of surgical and percutaneous gastrostomy and jejunostomy tubes for enteral feeding is routinely done with the patient in a supine position. This may result in a tube exit site located in an abdominal fold or the belt line, near a bony prominence, or beneath a pendulous breast. Poor location can cause discomfort, skin irritation, leakage, and difficulty in stabilizing the tube. A tube exit site that is not easily visibile to the patient can limit resumption of self‐care and independence. Two methods of preplacement marking for feeding tube locations are described. Selecting optimal gastrostomy and jejunostomy tube sites decreases complications and promotes patient independence.
Nutrition Assessment in Pediatric Patients Infected With the Human Immunodeficiency Virus
Authors: Gorbea‐Robles María del Carmen , Flores‐Hernández Luz M. , Torres‐González Félix , Fuchs‐Tarlovsky Vanessa , Martínez‐Rojano Hugo
Published: June 2009

Acquired immunodeficiency syndrome (AIDS) in children is characterized by failure to thrive and usually is associated with protein–energy malnutrition. Infection with the human immunodeficiency virus (HIV) often leads to fever, additional infections, diarrhea, and malabsorption syndrome. The aim of this study was to compare nutritional status of Mexican children with HIV/AIDS to healthy Mexican children.

Thirty‐four patients between 1 month and 15 years of age and infected with HIV/AIDS were subjects of the study. The healthy children used as controls had the same demographics as the experimental group, but without HIV infection or any other chronic or acute illness. All subjects were evaluated to determine nutritional status by using anthropometric, biochemical, and immunologic measurements.

The results showed statistically significant differences in the following parameters: height (p < .05), arm circumference and arm muscle circumference (p < .01), triceps skinfold thickness (p < .01), serum albumin (p < .01), serum transferrin (p < .01), iron‐binding capacity (p < .01), hemoglobin (p < .01), globulin (p < .01), nitrogen balance (p < .01), CD8+ T lymphocytes, CD4+ T lymphocytes, and CD4‐CD8 ratio (p < .01).

Nutritional status in children is strongly influenced by HIV/AIDS, and thus it is important to monitor their nutritional status continuously. Nutrition education as well as nutritional supplementation is essential to reduce the risk of malnutrition, which decreases quality of life and increases the risk of further opportunistic illnesses.
Pharmacomodulation of the Gut: Implications for the Enterally Fed Patient
Authors: Bloss Cynthia S.
Published: June 2009

The level of nutrition support is mostly dictated by the functionality of the gastrointestinal tract. Native pathology and unavoidable iatrogenic disorders that affect gut function may be able to be managed via drug therapy so that the simplest level of enteral feeding may be used. Newer drug therapy modalities include the 5‐hydroxytryptamine‐3 (5‐HT3) antagonists and propofol for nausea and vomiting, erythromycin for motility disorders, octreotide for refractory diarrhea, and naloxone for narcotic‐induced constipation. The 5‐HT3 antagonists have proven their superiority over all other agents for acute nausea and vomiting during highly emetogenic chemotherapy. Their use in anticipatory delayed nausea and vomiting in chemotherapy or with mild‐to‐moderate emetogenic chemotherapy is controversial. The use of 5‐HT3 antagonists in postoperative nausea and vomiting is less clear. Propofol has demonstrated antiemetic properties, and its use as an anesthetic may decrease the incidence of nausea and vomiting and time in the recovery room. For both the 5‐HT3 antagonists and propofol, costeffective analyses are important to determine their role in prevention of postoperative nausea and emetic events. Erythromycin has been used to attenuate motility disorders because it mimics motilin. In low doses, it may serve as an alternative to other promotility agents. Although pharmacologically similar to metoclopramide, it does not offer any advantage in an enteral feeding tube passage. Octreotide, a somatostatin analog, is being investigated to modulate endocrine function on the gastrointestinal tract and pancreas. Of note is its use in treating diarrhea associated with neuroendocrine tumors, acquired immunodeficiency syndrome, ileostomies, and chemotherapy. Finally, naloxone can reverse narcotic‐induced constipation without interfering with effective pain management for most patients. This effect is due to antagonism of the gastrointestinal mu receptors by naloxone during its own absorption process and to a high first‐passextraction for metabolism by the liver, which prevents appreciable systemic levels of this opioid antagonist.
Diarrhea Management in Enterally Fed Patients
Authors: Williams Margery S. , Harper Ruth , Magnuson Barbara , Loan Theresa , Kearney Paul
Published: June 2009

A prospective review of 158 enterally fed intensive care unit (ICU) patients at the University of Kentucky Medical Center revealed a significant variation in the clinical approach to the diagnosis and management of diarrhea. A standard definition for diarrhea was necessary to develop a cost‐effective approach to this problem. A rational treatment algorithm was established for the diagnosis and management of diarrhea in the enterally fed ICU patient.
The Use of a Clinical Practice Guideline to Manage and Verify the Weight Loss Outcomes of Patients Treated With Fen‐Phen in Primary Care Settings
Authors: Pitts Bruce G. , Crosby Ross , Laufenberg Susan , Meidinger Gail , Monson Nancy
Published: June 2009

Fenfluramine and phenteramine (“fen‐phen”) enjoyed immense popularity as a weight loss drug combination until September 151, 1997, when fenfluramine was withdrawn from the market because of evidence that it might cause valvular heart disease. In response to the emergence in 1996 of physician disagreement about the appropriate use of diet pills in weight loss treatment plans, MeritCare Health System developed a practice guideline to assist clinicians in the appropriate use of anoretic drugs. The purpose of this report was to answer two questions about MeritCare's experience with fen‐phen. First, how was MeritCare able to use a practice guideline to mediate conflict among physicians and to rapidly implement practice changes as imformation about the deleterious effects of fen‐phen because available? Second, how effective was fenphen as a weight loss agent when prescribed by doctors who practiced in primary care settings? A retrospective review of the charts of 401 patients treated with fen‐phen by primary care physicians practicing in four of MeritCare's Fargo clinics was conducted and MeritCare's experience with fenphen was reviewed. The data show that patients treated with fen‐phen experienced, on average, a rapid decline in body mass index (BMI) over the first 4 months of treatment, after which the rate of decline slowed and then reached a plateau. There appeared to be little, if any, further mean weight loss after 6 months. Patients did not, as a rule, achieve target BMIs (defined as 26 to 27) even when treatment was continued for up to 19 months. In fact, after 6 months of treatment with fen‐phen, expected decreases in BMI began to be supplanted by increases in BMI, even thought patients remained on fen‐phen. The data also reveal wide variations in the weight loss responses of patients treated with fen‐phen. Practice guidelines are useful tools in mediating physician disagreement about “best practice” and in rapidly deploying practice changes as new information about “best practice” becomes available. Beneficial weight loss responses to fen‐phen prescribed by primary care physicians in standard primary care settings were highly variable and fell short of target weights.
Nutrition Support for a Stem Cell Transplant Patient: A Complicated Teaching Case
Authors: Dickson Tara Coghlin
Published: June 2009

A 36‐year‐old woman received an autologous peripheral blood stem cell transplant for recurrent Hodgkin's disease. Failure to thrive, pancytopenia, and multiple infections complicated her first year after autologous transplant. She required blood products and growth factors on a chronic basis, and nutrition support was begun 8 months after transplant. After other nutrition interventions failed, enteral feeding was initiated, which eventually brought her to her pretransplant weight. Although transplant patients are monitored closely with regard to nutrition, such a difficult course and the need for an extended period of nutrition support are unusual for an autologous transplant patient.
Vitamin D and Minerals: How Much for Preterm Infants During a Multivitamin Shortage?
Authors: Mouser Jay F. , Sacks Gordon S.
Published: June 2009

The case of an infant born prematurely who developed necrotizing enterocolitis and required parenteral nutrition for several months during a nationwide IV pediatric multivitamin shortage is presented. Metabolic bone disease commonly occurs in preterm infants receiving parenteral nutrition because of the failure to attain third‐trimester,in utero, mineral accretion rates. The purpose of this case report is to review the relationships between vitamin D, calcium, and phosphorus for maintaining mineral homeostasis and bone development. Many questions remain to be answered regarding optimal mineral and vitamin D requirements of the preterm infant with suspected metabolic bone disease.
Nutrition Management in Pediatric Small Bowel Transplant
Authors: Strohm Sharon L. , Koehler Anita N. , Mazariegos George V. , Reyes Jorge
Published: June 2009

Fifty‐five children received intestinal transplants (ITx) at the Children's Hospital of Pittsburgh between July 1990 and January 1997. We assessed 23 children who had at least 1 year of follow‐up with functioning intestinal grafts (7 isolated small bowel, 13 liver/ small bowel, and 3 multivisceral) for nutritional status, linear growth, and weight gain. We divided the children into 4 groups by age: infants <1 year (n = 4), toddlers 1–5 years (n = 6), preadolescents 5–10 years (n = 6), and adolescents 10–18 years (n = 7). We began an appropriate elemental formula at an average of 15 days post‐ITx (median, 13 days). At 1‐year post‐ITx, 15 children (65%) were thriving on oral diets, 7 children (31%) required enteral tube feedings that were secondary to oral aversion, and 1 child (4%) received partial parenteral nutrition support. Anthropometric data showed linear growth, appropriate weight in relation to height, and maintenance of fat and muscle stores. Serum albumin increased one‐year post‐ITx in each age group. Serum zinc and red blood cell (RBC) folate levels were commonly found to be abnormal post‐ITx.
Comprehensive Nutritional Status in Patients With Long‐Standing Crohn's Disease Currently in Remission
Authors: Hammond Kathy
Published: June 2009

Malnutrition is observed frequently and is an important complication in patients with Crohn's disease (CD). The pathophysiology of malnutrition in this disorder is complex. To obtain a comprehensive picture of nutritional status in patients with long‐standing CD that was clinically in remission, we assessed four measures of nutritional status in 32 patients (18 women and 14 men) and 32 matched healthy control subjects: (1) body composition, (2) dietary intake, (3) biochemical indexes of nutrition, and (4) and muscle strength (as a functional index). Mean daily intakes of fiber and phosphorus were significantly lower in CD patients than in control subjects. Serum concentrations of several nutrients (β‐carotene, vitamin C, vitamin E, selenium, and zinc) and activity of the enzyme glutathione peroxidase were also significantly lower in CD patients, as were antioxidant status and serum concentrations of magnesium and vitamin D. Percentage body fat and hamstring muscle strength were significantly lower in male CD patients than in control subjects, whereas muscle strength of the quadriceps was preserved. In conclusion, this study showed a variety of nutritional and functional deficiencies in patients with long‐standing CD in remission, especially in male patients with a high lifetime prednisone dose. A comprehensive nutritional assessment seems superior to the assessment of a single dimension of nutritional status.
Compared With Parenteral Nutrition, Enteral Feeding Attenuates the Acute Phase Response and Improves Disease Severity in Acute Pancreatitis
Authors: Boullata Joseph I.
Published: June 2009

Background: In patients with major trauma and burns, total enteral nutrition (TEN) significantly decreased the acute phase response and incidence of septic complications when compared with total parenteral nutrition (TPN). Poor outcome in acute pancreatitis is associated with a high incidence of systemic inflammatory response syndrome (SIRS) and sepsis. Aims: To determine whether TEN can attenuate the acute phase response and improve clinical disease severity in patients with acute pancreatitis. Methods: Glasgow score, Apache II, computed tomography (CT) scan score, C reactive protein (CRP), serum IgM antiendotoxin antibodies (EndoCAb), and total antioxidant capacity (TAC) were determined on admission in 34 patients with acute pancreatitis. Patients were stratified according to disease severity and randomized to receive either TPN or TEN for 7 days and then re‐evaluated. Results: SIRS, sepsis, organ failure, and ITU stay were globally improved in the enterally fed patients. The acute phase response and disease severity scores were significantly improved following enteral nutrition (CRP: 156 (117–222) to 84 (50–141), p < 0.005; APACHE II scores 8 (6–10) to 6 (4–8), p < 0.0001) without change in the CT scan scores. In parenterally fed patients these parameters did not change, but there was an increase in EndoCAb antibody levels and a fall in TAC. Enterally fed patients showed no change in the level of EndoCAb antibodies and an increase in TAC. Conclusion: TEN moderates the acute phase response and improves disease severity and clinical outcome despite unchanged pancreatic injury on CT scan. Reduced systemic exposure to endotoxin and reduced oxidant stress also occurred in the TEN group. Enteral feeding modulates the inflammatory and sepsis response in acute pancreatitis and is clinically beneficial.
Predicting the Duration of Dependence on Parenteral Nutrition After Neonatal Intestinal Resection
Authors: Simpser Edwin
Published: June 2009

Objective: To determine whether there are clinical or physical factors that could be used to predict the duration of dependence on parenteral nutrition (PN) in infants who have undergone resection of small intestine in the neonatal period. Study Design: Medical records of 44 patients who had small intestinal resection as neonates from 1985 to 1996 and who were dependent on PN for at least 3 months were reviewed. Statistical evaluation of patient variables and their impact on duration of dependence on PN were determined by using the Cox Proportional Hazard model. Results: Twenty‐seven patients became independent of PN before the age of 36 months. Seven patients between 40 and 129 months of age are permanently dependent on PN. Outcome could not be determined in 10 patients, four of whom died of hepatic failure while still receiving PN and six of whom are still receiving PN but are younger than 36 months of age. Small bowel length after initial surgery and the percent of daily energy intake received by the enteral route at 12 weeks' adjusted age were significantly related to the duration of dependence on PN. Gestational age, presence of the ileocecal valve, and the development of cholestasis were not significantly related. With the use of the Cox Proportional Hazards survival model, a formula was generated to allow estimation of the duration of dependence on PN. Conclusions: The duration of dependence on PN can be predicted at an early age in neonatal bowel syndrome by using two patient variables: the length of residual small bowel after initial surgery and the percent of daily energy intake tolerated through the enteral route.
The Rates of Spontaneous Transpyloric Passage of Three Enteral Feeding Tubes
Authors: Ahmed Wahaj , Levy Howard , Kudsk Kenneth , Seidner Douglas , Miller Roberta , Chen Jiande , Hayes James , Tomba Todd
Published: June 2009

The rates of spontaneous passage of a self‐propelling tube, a weighted nasoenteric tube (Ross Products Division, Columbus, OH), and a new unweighted transpyloric tube (Ross Products Division) were compared. This prospective, randomized comparison of outcome was performed at five medical centers and included 129 critically ill patients. Placement was confirmed radiologically at 6, 12, 24, 48, and 72 hours. There was no significant difference between group demographics and clinical characteristics. No significant differences in location of the tubes at any time point were found when comparing the self‐propelling vs weighted tubes and self‐propelling vs unweighted transpyloric tubes. A significant difference was noted in transpyloric location for the unweighted transpyloric tubes vs weighted tubes at 48 hours (58% vs 29%; p = .014) and at 72 hours (62% vs 32%; p = .011).
Nutrition After Cardiac Surgery for Infants With Congenital Heart Disease
Authors: Boctor Dana L. , Pillo‐Blocka Francy , McCrindle Brian W.
Published: June 2009

Inadequate nutrition support in the post‐operative period in infants recovering from cardiac surgery can impact morbidity and growth. We sought to determine postoperative nutrition support patterns and identify factors associated with rate of weight gain in infants <1 year. Data were collected from the medical records of 24 infants. The median age at surgery was 2.7 months (range, 1 day to 9 months). The median overall daily weight change during the postoperative ward stay was ‐11 g/d (range, ‐145 to +84 g/d), with a net positive gain in 8 (36%), net loss in 14 (64%) and unknown in 2 infants. The rate of weight change by hospital discharge was related to feeding practice: bottle fed infants gained a median of 20 g/d (range, ‐100 to +73 g/d); breast fed infants who were supplemented with bottle feeds gained a median of 5 g/d (range, ‐83 to +43 g/d); and exclusively breast fed infants lost a median of 49 g/d (range, ‐80 to ‐23 g/d)(p = .04). Patients who were meeting a greater percentage of their energy requirements by the time of hospital discharge had higher rates of weight gain (r = .78; p = .003). Rate of weight gain was not related to cardiac lesion or hospital length of stay. We conclude that weight gain after cardiac surgery in infants is sub‐optimal and is related to feeding practices. Greater attention to achieving energy requirements during postoperative recovery is necessary, especially in breast fed infants.