bluuebunny/crossref_metadata_2025 huggingface dataset:
Arginine Deficiency‐Induced Hyperammonemia in a Home Total Parenteral Nutrition‐Dependent Patient: A Case Report
Authors: Kapila Shikha , Saba May , Lin Chuan‐Hao , Bawle Erawati V.
Published: May 2008

Background: Patients with short bowel syndrome and renal dysfunction with TPN dependence are at high risk for developing hyperammonemia if the TPN does not contain sufficient quantities of arginine. Providing proper nutrition support is essential in the management of these patients. Methods: We report on a patient with short bowel syndrome, TPN dependence, and normal renal function who developed hyperammonemic encephalopathy due to inadvertent lack of arginine in his TPN. Results: The patient was successfully treated with hemodialysis and an IV arginine infusion to resolve the hyperammonemia. His home TPN was also adjusted such that arginine was added to his subsequent solutions. Conclusions: Our patient underscores the importance of adequate and sustained arginine supplementation to avoid hyperammonemia in TPN dependent patients with short bowel syndrome. (Journal of Parenteral and Enteral Nutrition 25:286–288, 2001)
Alteration of Hepatic Fatty Acid Metabolism After Burn Injury in Pigs
Authors: Martini Wenjun Z. , Irtun Oivind , Chinkes David L. , Rasmussen Blake , Traber Daniel L. , Wolfe Robert R.
Published: May 2008

Background: The primary goal of this study was to investigate hepatic fatty acid (FA) metabolism after severe thermal injury. Methods: Sixteen pigs were divided into control (n = 8) and burn (n = 8, with 40% full thickness total body surface area burned) groups. Catheters were inserted in the right common carotid artery, portal vein, and hepatic vein for blood sampling. Flow probes were placed around the hepatic artery and portal vein for blood flow measurements. Animals were given pain medication and sedated until the tracer study on day 4 after burn. The pigs were infused for 4 hours with U‐13C16‐palmitate in order to quantify hepatic FA kinetics and oxidation. Results: Liver triglyceride (TG) content was elevated from 162 ± 16 (control) to 297 ± 28 μmol TG/g dry liver wt. (p <.05). Hepatic FA uptake and oxidation were similar between the 2 groups, as were malonyl‐coenzyme A (CoA) levels and activities of acetyl‐CoA carboxylase and adenosine monophosphate (AMP)‐activated protein kinase. In contrast, incorporation of plasma‐free fatty acids into hepatic TG was elevated (p <.05) and very low density lipoprotein TG (VLDL‐TG) secretion was decreased from 0.17 ± 0.02 (control) to 0.03 ± 0.01 μmol/kg per minute in burned pigs (p <.05). Conclusions: The accumulation of hepatic TG in burned animals is due to inhibition of VLDL‐TG secretion and to increased synthesis of hepatic TG. Fatty acids are not channeled to TG because of impaired oxidation. (Journal of Parenteral and Enteral Nutrition 25:310–316, 2001)
Protein Energy Supplements in Unwell Elderly Patients—A Randomized Controlled Trial
Authors: Potter Jan M. , Roberts Margaret A. , McColl John H. , Reilly John J.
Published: May 2008

Background: To determine whether oral protein energy supplements, prescribed during hospitalization to elderly medical admissions, affect nutritional status and if baseline nutritional state influences this status. We also considered the effects on mortality, length of hospital stay, functional recovery, and institutionalization. Methods: A prospective randomized controlled trial with no placebo. Consenting patients were stratified in 3 nutritional categories, and patients from each stratum were randomized into treatment or control. Observers were blinded to randomization. The participants were emergency admissions from home to a Medicine for the Elderly Unit in a Scottish hospital. The inclusion criteria were as follows: no known malignancy, the ability to swallow, and nonobesity (BMI < 75th percentile). The intervention was a prescription of 120 mL sip feed, 3 times daily (540 kcal, 22.5 g protein per day) throughout hospitalization, using the medicine prescription chart. The trial was powered to detect change in mean percentage weight. The following outcomes were also considered: anthropometry; mortality, length of hospital stay, functional recovery, and rates of institutionalization. Results: Included in the trial were 381 patients. Nutritional supplementation was associated with significantly better energy intake (p =.001) and weight gain (p =.003) pooled across all nutritional categories. In the most poorly nourished patients, the intervention was associated with reduced mortality (5/34 versus 14/40, p <.05) and more patients improved functionally (17/25 versus 11/28, p <.04). Overall mortality results were 21/186 versus 33/195, odds ratio (OR) 0.62, 95% confidence interval (CI) 0.35, 1.13. Conclusions: Prescribing sip feed supplements in the medicine prescription chart during hospital stay reduces weight loss. Our data also support other evidence for a reduction in mortality noted in elderly patients on nutritional supplementation. There were suggestions of other clinical benefits. (Journal of Parenteral and Enteral Nutrition 25:323–329, 2001)
Alanyl‐Glutamine Enriched Total Parenteral Nutrition Improves Local, Systemic, and Remote Organ Responses to Intraperitoneal Bacterial Challenge
Authors: Lin Ming‐Tsan , Saito Hideaki , Furukawa Satoshi , Fukushima Ryoji , Kazuhiko Fukatsu , Lee Po‐Huang , Chang King‐Jen , Chen Wei‐Jao
Published: May 2008

Background: Standard total parenteral nutrition (STD‐TPN) may diminish host defense against infection. Glutamine (Gln) is suggested to enhance host immunity. This study investigated the effects of antecedent alanyl‐glutamine enriched TPN (Ala‐Gln‐TPN) on host responses to intraperitoneal bacterial challenge compared with STD‐TPN. Methods: Rats were divided into STD‐TPN and Ala‐Gln‐TPN groups. They received isocaloric and isonitrogenous nutrition for 7 days and were challenged intraperitoneally with E. coli. Rats were killed before (0 hour) challenge and at 2 and 6 hours after challenge. Bacterial numbers in peritoneal lavage fluid (PLF), liver, spleen, and blood were determined. Tumor necrosis factor‐α (TNF), interleukin (IL)‐8, and interferon‐γ (IFN) in plasma and PLF were measured. Hepatic TNF, splenic TNF, and splenic IFN levels were determined. Results: The numbers of E. coli in systemic blood at 2 hours after intraperitoneal bacterial challenge were significantly lower in the Ala‐Gln‐TPN than in STD‐TPN group. E. coli numbers in blood significantly correlated with those in the liver. The Ala‐Gln‐TPN also resulted in significantly higher PLF and hepatic TNF levels, higher splenic IFN levels, and lower plasma IL‐8 levels at 6 hours after challenge compared with the STD‐TPN. Conclusions: Antecedent Ala‐Gln enriched TPN enhance local, systemic, and remote organ immune responses to intraperitoneal bacterial challenge. Ala‐Gln‐TPN may enhance host defense and be more beneficial than standard TPN in sepsis. (journal of Parenteral and Enteral Nutrition 25:346–351, 2001)
Accuracy of predictive methods to estimate resting energy expenditure of thermally‐injured patients
Authors: Dickerson RN , Gervasio JM , Riley ML , Murrell JE , Hickerson WL , Kudsk KA , Brown RO
Published: May 2008

BACKGROUND: The purpose of this study was to evaluate the bias and precision of 46 methods published from 1953 to 2000 for estimating resting energy expenditure (REE) of thermally injured patients. METHODS: Twenty‐four adult patients with > or =20% body surface area burn admitted to a burn center who required specialized nutrition support and who had their REE measured via indirect calorimetry (IC) were evaluated. Patients with morbid obesity, human immunovirus, malignancy, pregnancy, hepatic or renal failure, neuromuscular paralysis, or those requiring a FiO2 >50% or positive end expiratory pressure (PEEP) > or =10 cm H2O were excluded. One steady‐state measured REE measurement (MEE) was obtained per patient. The methods of Sheiner and Beal were used to assess bias and precision of these methods. The formulas were considered unbiased if the 95% confidence interval (CI) for the error (kilocalories per day) intersected 0 and were considered precise if the 95% CI for the absolute error (%) was within 15% of MEE. RESULTS: MEE was 2780+/‐567 kcal/d or 158%+/‐34% of the Harris Benedict equations. None of the methods was precise (< or =15% CI error). Over one‐half (57%) of the 46 methods had a 95% confidence interval error >30% of the MEE. Forty‐eight percent of the methods were unbiased, 33% were biased toward overpredicting MEE, and 19% consistently underpredicted MEE. The pre‐1980s methods more frequently overpredicted MEE compared with the 1990 to 2000 (p <.01) and 1980 to 1989 (p <.05) published methods, respectively. The most precise unbiased methods for estimating MEE were those of Milner (1994) at a mean error of 16% (CI of 10% to 22%), Zawacki (1970) with a mean error of 16% (CI of 9% to 23%), and Xie (1993) at a mean error of 18% (CI of 12% to 24%). The “conventional 1.5 times the Harris Benedict equations” was also unbiased and had a mean error of 19% (CI of 9% to 29%). CONCLUSIONS: Thermally injured patients are variably hypermetabolic and energy expenditure cannot be precisely predicted. If IC is not available, the most precise, unbiased methods were those of Milner (1994), Zawacki (1970), and Xie (1993).
Effects of cyclosporine A and prednisone treatment on mixed meal disposition in dogs with hepatic denervation
Authors: Moore MC , Cherrington AD , Palmer B , Lacy DB , Goldstein RE
Published: May 2008

BACKGROUND: Compared with untreated dogs, normal dogs treated for 7 days with cyclosporine A and prednisone exhibited a 25% reduction in the absorption of glucose from a mixed meal and a 4‐ to 5‐fold increase in net hepatic glucose uptake, without reduction of postprandial glycemia. The hepatic nerves are also involved in directing postprandial glucose disposition. Therefore, we hypothesized that the combination of immunosuppressive therapy and hepatic denervation would create additional alterations in the disposition of glucose from a mixed meal. METHODS: Six 24‐hour‐fasted conscious dogs that had undergone surgical hepatic denervation (DN) and received cyclosporine A 15 mg/kg daily and prednisone 5 mg twice daily for 7 consecutive days before study (DN + CyP group) received an intragastric mixed‐meal feeding over 30 minutes. The results were compared with those from a group of 8 normally innervated dogs receiving the same immunosuppressives (CyP group). RESULTS: Arterial blood glucose concentrations remained elevated over basal in both groups at the end of the 480 minutes postprandial period. The arterial plasma insulin response was no different in the 2 groups (area under the curve 119+/‐25 and 100+/‐40 nmol/L in DN + CyP and CyP, respectively). In both groups, net gut glucose output was equivalent to approximately 45% of the glucose in the meal, and net hepatic glucose uptake accounted for approximately 54% to 66% of the absorbed glucose. Arterial blood lactate concentrations and net hepatic lactate output were not different between groups at any time. CONCLUSIONS: Immunosuppressive therapy is responsible for most of the alterations in postprandial carbohydrate metabolism observed in this model; the lack of hepatic nerves has little additional impact.
Diet, length of gestation, and fecal short chain fatty acids in healthy premature neonates
Authors: Favre A , Szylit O , Popot F , Catala I , Rondeau C , Maurage C , Gold F , Borderon JC , Butel MJ
Published: May 2008

BACKGROUND: Excretion of fecal short‐chain fatty acids (SCFAs) may indicate changes in colonic or colonocyte metabolism. The aim of this study was to detect the influence of gestational age and feeding practices on SCFA concentrations and profiles in healthy preterm infants. METHODS: A total of 198 fecal samples (28 infants) were collected from 8 to 21 days of age from 3 groups of preterm infants born at 33 to 37 weeks of gestation and fed either breast milk (group I) or Nutramigen, a lactose‐free formula (group II), and extremely preterm infants born before 33 weeks of gestation and fed breast milk (group III). Total SCFA concentrations and SCFA profiles were analyzed using a gas chromographic (GC) procedure. RESULTS: Total fecal SCFA excretion did not differ significantly between group I (mean, 24.0 micromol/g; range, 1.3 to 118.8 micromol/g) and group II (mean, 23.0 micromol/g; range, 3.0 to 73.3 micromol/g). Conversely, differences occurred between SCFA profiles and became significant after day 17. The main differences were a significant increase in the butyric acid concentration (12% versus 30%) with group II. Compared with group I, fecal SCFA concentrations were 3.2‐fold lower (7.4 micromol/g; range, 0.3 to 37.4 micromol/g) in group III with no significant changes in the profiles. CONCLUSIONS: Fecal SCFA excretion may vary in absence of any digestive disease. During this study, in terms of gestational age, total SCFA concentrations were significantly lower in extremely premature infants compared with infants born less premature, despite their known higher deficiency in intestinal lactase activity. In terms of diet, the absence of lactose did not lead to a decrease in colonic fermentation and induced changes in SCFA patterns. These new baseline data may offer clues to further development of milk formulas.
Iron deficiency anemia in patients receiving home total parenteral nutrition
Authors: Khaodhiar L , Keane‐Ellison M , Tawa NE , Thibault A , Burke PA , Bistrian BR
Published: May 2008

BACKGROUND: Certain patients receiving home total parenteral nutrition (HPN) are likely to develop iron‐deficiency anemia because of inadequate absorption or chronic iron loss from gastrointestinal lesions. The objective of this study was to examine the incidence and prevalence of iron deficiency anemia in patients on long‐term HPN (>6 months) and to investigate both the efficacy of and rate of adverse reactions to parenteral iron dextran therapy. METHODS: The records of 55 patients treated with HPN for >6 months between January 1, 1994 and December 31, 1999 were examined. RESULTS: Thirty patients (55%) had evidence of iron‐deficiency anemia. Ten patients were diagnosed at the initiation of HPN, and in 20 patients, iron deficiency developed after receiving HPN. The time between initiation of HPN and development of anemia ranged from 2 to 97 months (mean 28.8+/‐26.2 months). Mild iron loss from the gastrointestinal tract seemed to be the predominant reason for iron deficiency. Regular treatment with small amounts of iron in HPN appeared to be safe and efficacious, with no reported side effects. Total dose infusion of iron was associated with adverse reactions in as many as 25% of these patients, although all reactions were mild and self‐limited. CONCLUSIONS: Iron‐deficiency anemia is common in patients receiving chronic HPN. Regular small doses of iron in HPN formula, rather than total dose infusion, is the preferred treatment.
Magnesium, calcium, zinc, and nitrogen loss in trauma patients during continuous renal replacement therapy
Authors: Klein CJ , Moser‐Veillon PB , Schweitzer A , Douglass LW , Reynolds HN , Patterson KY , Veillon C
Published: May 2008

BACKGROUND: Whether standard nutrition support is sufficient to compensate for mineral loss during continuous renal replacement therapy (CRRT) is not known. METHODS: Adult men with traumatic injuries were recruited; one‐half of recruits required CRRT for acute renal failure. All urine and effluent (from CRRT) were collected for 72 hours. Urine, effluent, and dialysate were analyzed for magnesium, calcium, and zinc using atomic absorption spectrometry. Urea nitrogen in blood, urine, and effluent were determined by measuring conductivity changes after the addition of urease. Blood was analyzed for magnesium and calcium as part of routine care. Intake was calculated from orders and intake records. RESULTS: Patients receiving CRRT (n = 6) lost 23.9+/‐3.1 mmol/d (mean +/‐ SEM) of magnesium and 69.8+/‐2.7 mmol/d of calcium compared with 10.2+/‐1.2 mmol/d and 2.9+/‐2.5 mmol/d, respectively, lost in patients not in acute renal failure (n = 6; p <.01). Zinc intake was significantly greater than loss in both groups (p <.03). Urea nitrogen excretion did not differ between groups. Serum magnesium was 0.75+/‐0.04 mmol/L for CRRT patients, significantly lower than the 0.90+/‐0.03 mmol/L for control patients (p <.01). Total blood calcium was below normal in both groups; ionized calcium was below normal in CRRT patients. CONCLUSIONS: CRRT caused significant loss of magnesium and calcium, necessitating administration of more magnesium and calcium than was provided in standard parenteral nutrition formulas. However, additional zinc was not required. CRRT removed amounts of urea nitrogen similar to amounts removed by normally functioning kidneys.
Homocysteine blood level in long‐term care residents with oropharyngeal dysphagia: comparison of hand‐oral and tube‐enteral‐fed patients
Authors: Leibovitz A , Sela BA , Habot B , Gavendo S , Lansky R , Avni Y , Segal R
Published: May 2008

BACKGROUND: Levels of homocysteine, methylmalonic acid, and relevant vitamins were measured and evaluated in patients with oral dysphagia (OD) receiving long‐term care (LTC). METHODS: Group A was composed of 26 orally fed patients, and group B was composed of 25 patients who were fed by nasogastric tube. All patients were hospitalized in the LTC departments of the Geriatric Medical Center, Shmuel Harofe. General and nutritional status were assessed, and levels of vitamins including B12, folate, and B6 were measured along with serum homocysteine and urine methylmalonic acid levels. RESULTS: Homocysteine levels were significantly higher in the orally fed patients (p <.001); 92% had higher‐than‐normal homocysteine levels. The levels of vitamins B12, folate, and B6 were significantly lower in the orally fed patients (p <.001), although in most patients levels were in the normal range. Notably, the levels of homocysteine were significantly correlated with the levels of all vitamins but not with the albumin or hemoglobin values. Levels of methylmalonic acid were also higher in the orally fed patients, but the difference was not statistically significant, and there was no correlation between vitamin level and methylmalonic acid level. CONCLUSIONS: Orally fed patients with OD have substantially higher homocysteine levels and appreciably lower levels of the relevant vitamins than patients with OD who receive tube feeding. Therefore, homocysteine measurement may be the preferred indicator of vitamin intake in orally fed patients with OD.
A double‐blind, randomized, placebo‐controlled trial of n‐3 versus n‐6 fatty acid‐based lipid infusion in atopic dermatitis
Authors: Mayser P , Mayer K , Mahloudjian M , Benzing S , Kramer HJ , Schill WB , Seeger W , Grimminger F
Published: May 2008

BACKGROUND: In the involved epidermis of patients with atopic dermatitis, changes in the metabolism of eicosanoids with increased quantities of the arachidonic acid (AA)‐derived lipoxygenase products have been observed. Free eicosapentaenoic acid (EPA), a fish oil‐derived alternative (n‐3) fatty acid, may compete with AA, resulting in an anti‐inflammatory effect. METHODS: In a 10‐day double‐blind, randomized, placebo‐controlled trial, 22 patients hospitalized for moderate‐to‐severe atopic dermatitis were randomly assigned to receive daily infusions of either a n‐3 fatty acid‐based lipid emulsion (fish oil, 10%; 200 mL/d) or a conventional n‐6‐lipid emulsion (soybean oil, 10%; 200 mL/d). Topical treatment was restricted to emollients. The severity of disease was evaluated daily with scoring of erythema, infiltration, and desquamation and by subjective patient scoring of clinical manifestations. In addition, plasma‐free and total‐bound fatty acids and the composition of membrane fatty acids in blood cells (thrombocytes, granulocytes, and erythrocytes), lipid mediators from isolated neutrophils and platelets, and lymphocyte‐activation parameters were determined. RESULTS: Twenty patients completed the trial. Marked improvement from baseline was seen in both groups. On days 6, 7, 8, and 10, disease severity score‐defined as the sum of all scores‐was more pronounced (p <.05) in the n‐3 group compared with the n‐6 group. Free arachidonic acid in plasma did not change substantially in both groups, whereas plasma‐free EPA, total‐bound EPA, and the membrane EPA/AA ratio markedly increased in response to n‐3‐lipid infusion. In parallel, EPA‐derived lipid mediators appeared, whereas lymphocyte functions were unaffected. In the post‐treatment period (2/4 weeks), relapse was observed in some patients after n‐3 psoralene‐ultraviolet A (PUVA) infusion, whereas there was a marked long‐term improvement in the n‐6 group. CONCLUSIONS: IV n‐3‐fatty acid administration is effective in acutely improving the severity of atopic dermatitis, paralleled by changes in plasma and membrane fatty acid composition and lipid mediator synthesis. The long‐term beneficial effects of IV n‐6 fatty acids should be evaluated further.
Longitudinal assessment of outcome, health status, and changes in lifestyle associated with long‐term home parenteral and enteral nutrition
Authors: Malone M
Published: May 2008

BACKGROUND: The purpose of this study was to assess the health status, frequency of therapy‐related symptoms, and impact of home parenteral and enteral nutrition (HPEN) on lifestyle in patients who were stable and had nonmalignant diagnoses. Assessments were made at 2 time points, 3 years apart. METHODS: Institutional review board approval was obtained. Adult HPEN patients self‐completed a general health status questionnaire (SF‐36) and a lifestyle‐symptom questionnaire in 1993 and 1996. Demographic data relating to underlying disease state and infusion regimen were also collected. RESULTS: Seventeen patients (7 men, 10 women; 13 receiving home parenteral nutrition [HPN] and 4 receiving home enteral nutrition [HEN]) participated in the study. The mean (SEM) duration of HPEN therapy at the start of the study was 7.1 (1.6) years. Although health status as assessed by SF‐36 scores was lower in all categories when compared with age‐ and gender‐matched control data from the general US population (p <.05), there was no significant difference in SF‐36 scores between the 2 time periods (p >.05). Sleep, travel, and social activities were the most affected aspects of the patient's lifestyle. CONCLUSIONS: These data suggest that patients with nonmalignant underlying disease receiving HPEN maintain a stable health status over a prolonged period.
Motility of the gastrointestinal tract and gallbladder during long‐term total parenteral nutrition in dogs
Authors: Kaji T , Takamatsu H , Kajiya H
Published: May 2008

BACKGROUND: The motility of the gastrointestinal tract during total parenteral nutrition (TPN) remains poorly understood. The objective of this study was to determine the motility pattern not only in the gastrointestinal tract but also in the gallbladders of dogs maintained by TPN. METHODS: Central venous catheters were inserted through the external jugular vein of 5 dogs and 6 strain gauge force transducers were sewn to the stomach, small intestine, and gallbladder. Two weeks later, oral food was discontinued and motility was recorded for 24 hours after the first migrating motor complex (MMC) was confirmed in the stomach as pre‐TPN. TPN was started and continued for 4 weeks, and patterns of motor activity during TPN were recorded for 24 hours at the end of each week. RESULTS: The durations of MMC in the stomach, duodenum, and gallbladder in pre‐TPN were 118 +/‐ 3 minutes, 118 +/‐ 2 minutes, and 118 +/‐ 2 minutes, respectively, but in the first week of TPN they were 432 +/‐ 56 minutes, 431 +/‐ 56 minutes, and 386 +/‐ 29 minutes, respectively. TPN times were significantly longer than those of pre‐TPN (corrected p <.005). The durations of MMC in jejunoileum did not alter between pre‐TPN and TPN. The occurrences of phase III in the stomach, duodenum, and gallbladder in pre‐TPN were 12/d, but during TPN they were reduced significantly (corrected p <.005). CONCLUSIONS: TPN did not affect the motility of the jejunoileum but did inhibit the motor activities of the stomach, duodenum, and gallbladder. The inhibition of gallbladder contraction observed during TPN may be one of the factors inducing gallbladder disease.
Continuation of transpyloric feeding during weaning of mechanical ventilation and tracheal extubation in children: a randomized controlled trial
Authors: Lyons KA , Brilli NRJ , Wieman RA , Jacobs BR
Published: May 2008

BACKGROUND: Nutrition support is essential in the management of critically ill children. There is no current literature to support the common practice of discontinuing enteral nutrition delivered through a transpyloric feeding tube during the tracheal extubation process. We conducted a prospective, randomized controlled trial in mechanically ventilated children to examine the safety and efficacy of continuous transpyloric feeding compared with interrupted transpyloric feeding at the time of tracheal extubation. METHODS: Subjects were randomly assigned to receive transpyloric feeding throughout the tracheal extubation process (Continuous Group) or to have transpyloric feeding discontinued 4 hours before tracheal extubation and restarted 4 hours after tracheal extubation (Interrupted Group). Data consisting of patient demographics, admission pediatric risk of mortality (PRISM) score, diagnoses, adverse events (feeding intolerance, gastroesophageal reflux, and pulmonary aspiration), daily feeding volume, and caloric intake were recorded for the 3 days surrounding tracheal extubation. RESULTS: Fifty‐nine patients completed the study (29 in Continuous Group, 30 in Interrupted Group). There was no episode of pulmonary aspiration in either group. The Continuous Group experienced 4 adverse events, whereas the Interrupted Group experienced 3 adverse events (p = not significant). The Continuous Group received 92 +/‐ 2.5% of their caloric goal on the day of weaning from the ventilator (day 1) and 93 +/‐ 3.2% on the day of tracheal extubation (day 2) compared with 76 +/‐ 4.2% and 43 +/‐ 4.3%, respectively, in the Interrupted Group (p <.004 and p <.0001, respectively). CONCLUSIONS: Continuous transpyloric feeding during weaning from the ventilator and tracheal extubation is safe and results in the delivery of more optimal nutrition.
Sleep patterns of cyclic parenteral nutrition, a pilot study: are there sleepless nights?
Authors: Scolapio JS , Savoy AD , Kaplan J , Burger CD , Lin SC
Published: May 2008

BACKGROUND: Cyclic home parenteral nutrition (HPN) is 1 of the few medical therapies given during normal nocturnal sleep hours, and it is possible that infusion may alter normal sleep patterns. The aim of this pilot study was to evaluate the sleep patterns of 5 patients receiving HPN. METHODS: An Epworth sleep questionnaire was completed and wrist Actigraph data were collected before admission to the sleep laboratory. Formal overnight polysomnography was then preformed for 3 consecutive nights. The first night served as the acclimatization period. On the second and third nights, patients were randomized to receive either no infusion or infusion of their standard parenteral nutrition. Results were reported as the median and range and were compared with historical aged‐matched controls. RESULTS: Five patients (3 women and 2 men) with a mean age of 61 years (40 to 73 years) were studied. Patients had been HPN‐dependent for a median of 23 months (4 to 60 months). Patients were receiving HPN because of short bowel syndrome (2), chronic pancreatitis (2), and intestinal pseudoobstruction (1). A 1.5‐liter HPN formula, infused over 10 hours, included approximately 25 kcal/kg/d with 30% lipid and 1.0 to 1.5 g/kg/d of protein. All solutions included multiple trace elements and standard multivitamins. During total parenteral nutrition (TPN) infusion, the percent of sleep efficiency was higher than without infusion, 81% versus 72%. Sleep efficiency in age‐matched controls was approximately 88%. Sleep latency was longer in patients compared with controls, and longer in patients during infusion than without infusion, 35 versus 28 minutes. During TPN infusion, the percent of stage‐1 (2%), stage‐2 (52%), slow‐wave (24%) and random eye movement (REM) sleep (21%) was similar to values during the night without infusion. Controls had lower slow‐wave and REM times. The median Epworth sleep score was 3, which is the normal reported range. CONCLUSIONS: Although sleep quality is reduced in patients receiving HPN compared with aged‐matched controls, sleep quality does not seem to be negatively effected by cyclic HPN infusion.
Specific intraluminal nutrients alter mucosal blood flow during gut ischemia/reperfusion
Authors: Kozar RA , Hu S , Hassoun HT , DeSoignie R , Moore FA
Published: May 2008

BACKGROUND: We have previously demonstrated in a rodent model the differential effects that specific intraluminal nutrients exert on gut ischemia/reperfusion (I/R) injury. Alanine was shown to amplify, whereas glucose protected against, gut I/R injury and associated gut dysfunction. The objective of this study was to determine whether these specific nutrients are associated with alterations in mucosal perfusion during gut I/R. METHODS: Sprague‐Dawley rats had either a laser doppler probe or a tonometer inserted into a jejunal sac filled with either 10 mmol/L alanine, glucose, or mannitol (osmotic control) followed by 60 minutes of superior mesenteric artery occlusion and 60 minutes of reperfusion. Laser doppler mucosal blood flow and regional PCO2 (PrCO2) measurements were obtained. RESULTS: Mucosal blood flow was significantly increased during both ischemia and reperfusion when intraluminal glucose was present compared with intraluminal alanine. Blood flow changes were reflected by lower jejunal PrCO2 measurements with intraluminal glucose compared with intraluminal alanine. CONCLUSIONS: Intraluminal glucose can augment mucosal blood flow during gut I/R and may explain the protective effect we previously observed.
Evaluation of stress factors and body weight adjustments currently used to estimate energy expenditure in hospitalized patients
Authors: Barak N , Wall‐Alonso E , Sitrin MD
Published: May 2008

BACKGROUND: The purpose of this study was to critically examine current approaches for estimating energy expenditure and requirements of hospitalized patients requiring nutrition support. METHODS: All indirect calorimetry tests performed by our adult nutrition support service from 1991 to 2000 were reviewed. Stress factors were calculated as the measured energy expenditure divided by the predicted energy expenditure using the Harris‐Benedict equation. Various methods for adjusting the body weights of obese subjects for use in the Harris‐Benedict equation were evaluated. RESULTS: The average stress factor for these hospitalized patients was 1.25, and there were no differences in the stress factors between men and women. For obese subjects, using an adjusted body weight equal to ideal body weight plus 50% of the difference between ideal and actual body weight in the Harris‐Benedict equation gave stress factors comparable with normal weight subjects. For underweight subjects, using the actual rather than ideal body weight gave stress factors that were most similar to normal weight patients. Disease‐specific stress factors were calculated and compared with literature values. Mechanical ventilation, recent feeding, fever, and restlessness during the indirect calorimetry measurement increased the measured energy expenditure. CONCLUSIONS: Our findings provide nutrition support services with updated information on disease‐specific stress factors that can be used for estimating energy expenditure in hospitalized patients. An adjusted body weight equal to ideal body weight plus 50% of the excess body weight should be used for estimating the energy requirements of obese patients requiring nutrition support.
Understanding and augmenting human intestinal adaptation: a call for more clinical research
Authors: Tavakkolizadeh A , Whang EE
Published: May 2008

Since its description in the early 20th century, the phenomenon of intestinal adaptation has been the focus of considerable interest. However, there is a paucity of evidence documenting the significance of this phenomenon in man. Indeed, our understanding of intestinal adaptation is based almost exclusively on extrapolations from studies of laboratory rodents. Given the possibility of pharmacologically modifying select components of adaptation as a therapeutic strategy for patients with intestinal insufficiency, a clear understanding of human intestinal adaptation is of paramount importance.
Diet restriction impairs extracellular signal‐regulated kinase activation of peritoneal exudative cells after N‐formyl‐methionyl‐leucyl‐phenylalanine stimulation in a murine peritonitis model
Authors: Kang W , Saito H , Fukatsu K , Hidemura A , Matsuda T
Published: May 2008

BACKGROUND: Phosphorylation of extracellular signal‐regulated kinase (ERK) enhances various inflammatory responses in immune cells. It is unknown whether dysfunction of immune cells during malnutrition is attributed to derangement of ERK activation. METHODS: Male Institute of Cancer Research (ICR) mice received chow (146 g/kg per day, ad libitum or 36.5 g/kg per day, diet‐restricted) for 7 days. Mice (n = 55) were given 6.5 mg/kg of an ERK inhibitor (PD98059) or vehicle intraperitoneally (IP), at 2 hours before cecal ligation and puncture (CLP). Survival was observed up to 60 hours. Detection of phosphorylated ERK (pERK) in the peritoneal exudative cells (PECs) was done as follows. In a separate study, PECs were harvested by peritoneal lavage 2 hours after an IP injection of 1% glycogen. PECs were incubated with or without 100 nmol/L N‐formyl‐methionyl‐leucyl‐phenylalanine (fMLP) for 1 minute. PEC ERK activation was detected with Western blot analysis (n = 38), by densitometric quantification, and with a laser scanning cytometer (LSC; n = 13). Subpopulations of PECs were determined by Wright‐Giemsa staining. Unstimulated pERK expression was normalized to 100% for Western blot analysis. RESULTS: Diet restriction reduced survival after CLP compared with the ad libitum mice. ERK inhibition showed no effect on survival in diet‐restricted mice but reduced survival in ad libitum mice. There were no differences in subpopulations of PECs 2 hours after glycogen injection between the groups. Western blot analysis revealed that fMLP stimulation significantly increased the phosphorylation of ERK1/2 in PECs from the ad libitum group (ERK1, 199 +/‐ 41%; ERK2, 211 +/‐ 49%; p <.03) but not in those from diet‐restricted mice (ERK1, 98 +/‐ 10%; ERK2, 91 +/‐ 9%). Mean fluorescence intensity (MFI) of pERK in PECs obtained by LSC was significantly elevated after fMLP in the ad libitum group (from 19.4 +/‐ 1.5 MFI to 22.4 +/‐ 1.2 MFI; p <.05) but did not change in the diet‐restricted group (from 19.4 +/‐ 1.8 MFI to 19.1 +/‐ 1.5 MFI). CONCLUSIONS: ERK activation is essential for survival in this murine sepsis model. Impaired ERK activation of PECs may, at least in part, impair host defense during malnutrition.
Effect of upper extremity posturing on measured resting energy expenditure of nonambulatory tube‐fed adult patients with severe neurodevelopmental disabilities
Authors: Dickerson RN , Brown RO , Hanna DL , Williams JE
Published: May 2008

PURPOSE: To ascertain the effect of upper extremity posturing on measured resting energy expenditure (MEE) for patients with severe neurodevelopmental disabilities. METHODS: Twenty‐four nonambulatory adult patients with severe neurodevelopmental disabilities referred for evaluation of enteral tube feeding and who had a steady‐state MEE performed were studied. Steady‐state indirect calorimetry measurements were done through a canopy system. Patients were stratified according to the topography of their neuromotor impairment and motor function as having either fixed upper extremity contractures (Fixed UE) or with preservation of limited functional and nonfunctional upper extremity movement (Preserved UE). RESULTS: Despite a similar age, weight, height, and gender distribution between groups, those patients with Fixed UE (n = 13) had a significantly lower MEE than those with Preserved UE (n = 11): 893 +/‐ 91 versus 1144 +/‐ 262 kcal/d (p <.01), respectively. The Harris‐Benedict equations' predicted energy expenditures were similar to MEE for patients with Preserved UE (1212 +/‐ 156 versus 1144 +/‐ 262 kcal/d, respectively, p = N.S.). Patients with Fixed UE had a significantly lower MEE than predicted by the Harris‐Benedict equations (893 +/‐ 91 versus 1128 +/‐ 123 kcal/d, respectively, p <.01) CONCLUSIONS: Patients with fixed upper extremity contractures have a significantly lower MEE than those with preserved upper extremity movement. MEE for nonambulatory tube‐fed adult patients with severe neurodevelopmental disabilities and fixed upper extremity contractures is significantly lower than predicted by the Harris‐Benedict equations.
Omega‐3 fatty acid supplementation reduces tumor growth and vascular endothelial growth factor expression in a model of progressive non‐metastasizing malignancy
Authors: Tevar R , Jho DH , Babcock T , Helton WS , Espat NJ
Published: May 2008

BACKGROUND: Omega‐3 fatty acids, the principal component of fish oil, have been demonstrated to have antiinflammatory properties. The role of eicosapentaenoic acid (EPA) supplementation for cancer patients is currently under investigation; however, the mechanisms of EPA activity have not been defined. The purpose of this study was to characterize tumor‐specific and treatment‐specific effects of supplemental dietary EPA in an animal model of progressive malignancy. METHODS: Fischer 344 rats (200–250 g) underwent flank implantation of the methycholanthrene (MCA)‐induced fibrosarcoma on day 0. Rats were randomly divided into 3 treatment groups on day 13: EPA (1 mL, 5.0 g/kg per day) + 10 IU vitamin E; corn oil (1 mL) + 10 IU vitamin E, and saline (1 mL) + 10 IU vitamin E (vitamin E was used to prevent fatty acid oxidation). On day 14, gavage feeding was started and was continued through day 28. The animals were killed on day 29, and the tumors were removed. The tumors were weighed and divided by the tumor‐free carcass weight to obtain percentage of tumor volume, and the livers were flash frozen. Vascular endothelial growth factor‐alpha (VEGF‐alpha) and cyclo‐oxygenase 2 (COX‐2) mRNA were measured by reverse transcription‐polymerase chain reaction (RT‐PCR). RESULTS: EPA rats had significant reductions in tumor volume compared with isocaloric corn oil and control saline animals (25%, p <.01 and 33%, p <.01, respectively). Rats receiving EPA demonstrated decreased VEGF‐alpha mRNA levels (0.023 +/‐ 0 0.001) compared with those receiving corn oil (0.129 +/‐ 0.047) or saline (0.150 +/‐ 0.026; p <.05). CONCLUSIONS: These data demonstrate that EPA supplementation inhibits tumor growth, potentially through alterations in the expression of the pro‐angiogenic VEGF‐alpha. The mechanism(s) of EPA as an inhibitor of tumor‐related angiogenic growth factors may be associated with COX‐2 enzyme fatty acid metabolism and merits further study.
Physical characteristics of total parenteral nutrition bags significantly affect the stability of vitamins C and B1: a controlled prospective study
Authors: Dupertuis YM , Morch A , Fathi M , Sierro C , Genton L , Kyle UG , Pichard C
Published: May 2008

BACKGROUND: Vitamin degradation occurring during the storage of total parenteral nutrition (TPN) mixtures is significant and affects clinical outcome. This study aimed to assess the influence of the TPN bag material, the temperature, and the duration of storage on the stability of different vitamins. METHODS: Solutions of multivitamin and trace elements at recommended doses were injected into either an ethylvinyl acetate (EVA) bag or a multilayered (ML) bag filled with 2500 mL of an identical mixture of carbohydrates (1200 kcal), fat (950 kcal), and amino acids (380 kcal). The bags were then stored at 4 degrees C, 21 degrees C, or 40 degrees C. Concentrations of vitamins A, B1, C, and E were measured up to 72 hours after compounding, using high‐pressure liquid chromatography. RESULTS: Ten percent to 30% of vitamin C degradation occurred within the first minutes after TPN compounding. Vitamin C was more stable in ML bags (half‐life: 68.6 hours at 4 degrees C, 24.4 hours at 21 degrees C, and 6.8 hours at 40 degrees C) than in EVA bags (half‐life: 7.2 hours at 4 degrees C, 3.2 hours at 21 degrees C, and 1.1 hour at 40 degrees C). Moreover, appearance of dehydroascorbic acid in the TPN mixture did not compensate for vitamin C losses. Vitamin B1 was stable at 21 degrees C, but a 43% loss occurred at 40 degrees C after 72‐hour storage in EVA bags. The other vitamins were stable in the TPN mixture stored in both bags at any temperature and without daylight protection. CONCLUSIONS: Degradations of vitamins C and B, are significantly reduced in ML bags compared with EVA bags. To prevent vitamin C deficiencies, its initial dose should be adapted to its degradation rate, which depends on the TPN bag material, the ambient temperature, and the length of time between TPN compounding and the end of infusion to the patient.
Glutamine supplementation fails to affect muscle protein kinetics in critically ill patients
Authors: Gore DC , Wolfe RR
Published: May 2008

BACKGROUND: In vitro work suggests that glutamine availability may be an important factor in controlling the rate of muscle protein synthesis. The objective of this study was to determine if enteral administration of glutamine affects muscle protein metabolism in critically ill patients. METHODS: Six postsurgical patients requiring prolonged mechanical ventilation for pneumonia (age, 51 +/‐ 12 years, Acute Physiology and Chronic Health Evaluation [APACHE] 22 +/‐ 6, mean +/‐ SEM) and 6 normal healthy volunteers (age, 33 +/‐ 4 years) underwent evaluation of whole body and muscle protein metabolism using an 8‐hour infusion of d5‐phenylalanine, 5(15)N glutamine, and d3‐alanine with serial blood sampling from the femoral artery and vein and biopsies from the vastus lateralis muscle. Metabolic measurements were obtained while subjects received Peptamen enterally (Basal Period) and with glutamine supplementation (24 g/3 h; Glutamine Period). RESULTS: Glutamine concentration in muscle was significantly less in the critically ill patients. Glutamine supplementation increased the arterial plasma concentration of glutamine, yet with no demonstratable effect on muscle glutamine concentration or on the rate of muscle protein synthesis in either volunteers or patients. Furthermore, muscle glutamine kinetics (incorporation into muscle, release from muscle, and rate of de novo glutamine synthesis in muscle) were not affected by glutamine supplementation in the critically ill patients. In contrast, there was a significant decrease in these kinetic parameters with glutamine supplementation within the muscle of healthy subjects. Metabolism of alanine was unaffected by administration of glutamine in either group. CONCLUSIONS: Enteral glutamine supplementation to critically ill patients fails to alter muscle glutamine metabolism or muscle protein synthesis. This suggests a possible restriction in transport of glutamine into muscle of critically ill patients.
Body composition changes in cachectic patients receiving home parenteral nutrition
Authors: Matarese LE , Steiger E , Seidner DL , Richmond B
Published: May 2008

BACKGROUND: The purpose of this study was to evaluate the initial body compositional changes experienced by malnourished patients requiring home parenteral nutrition (HPN) for repletion. METHODS: Eight patients were prospectively studied for 3 months. Body composition was determined by dual‐energy X‐ray absorptiometry (DXA), and a comprehensive nutrition assessment was performed including body weight, visceral proteins, triceps skinfold (TSF), midupper arm circumference (MUAC), midupper arm muscle circumference (MUAMC), body mass index (BMI), delayed hypersensitivity skin tests (DHST), and diet history. RESULTS: Body composition measured by DXA showed an increase in (mean +/‐ SD) total fat from 5770 +/‐ 2805 to 10581 +/‐ 1980 g (p <.001) and bone mineral content from 2155 +/‐ 429 to 2190 +/‐ 443 g (p =.047). Lean soft tissue remained unchanged. Body weight and BMI increased from 47.7 +/‐ 6.6 to 53.6 +/‐ 8.2 kg (p =.006) and from 16.6 +/‐ 1.5 to 18.6 +/‐ 1.5 kg/m2 (p =.005), respectively. TSF increased from 6.3 +/‐ 3.1 to 10.4 +/‐ 4.0 mm (p <.001), and MUAMC remained stable. There was a significant improvement in transferrin from 191 +/‐ 82 to 326 +/‐ 128 mg/dL (p =.043), and a trend toward improvement in albumin and DHST. Body weight was highly correlated with DXA weight at baseline (r =.997; 95% confidence interval [CI], 0.98 to 1.00; p <.001) and at 3 months (r =.988; 95% CI, 0.93 to 1.00; p <.001). TSF correlated with total fat as measured by DXA at baseline (r =.839; 95% CI, 0.33 to 0.97; p =.009) but not at 3 months (r =.693; 95% CI, ‐0.02 to 0.94; p =.057). MUAMC correlated with lean soft tissue measured by DXA both at baseline (r =.739; 95% CI 0.07 to 0.95; p =.036) and at 3 months (r =.870; 95% CI, 0.43 to 0.98; p =.005). Physical activity, on a subjective scale of 1 (low activity) to 3 (high activity), improved over the 3‐month period from 1.3 +/‐ 0.5 to 2.2 +/‐ 0.8 (p =.031). CONCLUSIONS: Initial weight gain experienced by malnourished HPN patients is primarily fat. Bone mineral content increases, but lean soft tissue does not change. Overall nutritional status is improved as exhibited by significant improvements in body weight and serum transferrin and a trend toward improvement in albumin and delayed hypersensitivity skin tests.
Use of bioelectrical impedance analysis to predict energy expenditure of hospitalized patients receiving nutrition support
Authors: Barak N , Wall‐Alonso E , Cheng A , Sitrin MD
Published: May 2008

BACKGROUND: The energy requirement of a patient receiving nutrition support is typically estimated by calculating the basal energy expenditure (BEE) using the Harris‐Benedict equations and multiplying by stress and activity factors. Because fat‐free mass (FFM) and fat mass (FM) are important determinants of BEE, we hypothesized that body composition estimates derived from bioelectrical impedance analysis (BIA) could be used to develop predictive equations for resting energy expenditure (REE) that were more accurate than those calculated using the Harris‐Benedict equations. METHODS: Seventy‐six adults referred to the nutrition support service were studied. REE was measured by indirect calorimetry, and single‐frequency BIA was used to estimate FFM and FM. Using the first 20 male and 20 female patients, predictive equations for REE were developed by multiple regression analysis, using BIA‐derived body composition values, age, and gender. The next 36 patients were used to compare the accuracy of these equations with the Harris‐Benedict equations in estimating REE. RESULTS: Using BLA‐derived body composition values, gender, and age, predictive equations were developed for REE that explained approximately 65% of the variance. Inclusion of other BIA or anthropometric parameters did not improve the equations. When compared with the Harris‐Benedict equations, the equations developed in this study were significantly more accurate, providing an REE estimate that was closer to the measured value in about 75% of patients. CONCLUSIONS: These results indicate that BLA‐derived body composition estimates may be used to more accurately predict the energy requirements of patients receiving nutrition support than calculations based on the Harris‐Benedict equations.