bluuebunny/crossref_metadata_2025 huggingface dataset:
Pediatric Enteral Nutrition
Authors: Axelrod David , Kazmerski Kimberly , Iyer Kishore
Published: May 2008

Common to all pediatric patients receiving enteral nutrition is the inability to consume calories orally. This is often secondary to issues of inadequate weight gain, inadequate growth, prolonged feeding times, weight loss, a decrease in weight/age or weight/height ratios, or a persistent triceps skinfold thickness <5% for age. Enteral nutrition requires enteral access. In the neonatal period the nasoenteric route is usually used. In pediatric patients requiring long‐term enteral access, surgically, endoscopically, or radiologically placed percutaneous feeding tubes are common. Jejunal feeding tubes are used in pediatric patients with gastric feeding intolerance or persistent gastroesophageal reflux. Low‐profile enteral access devices are preferred by most pediatric patients because of their cosmetic appearance. For most children, a standard pediatric polypeptide enteral formula is well tolerated. There are specialized pediatric enteral formulas available for patients with decreased intestinal length, altered intestinal absorptive capacity, or altered pancreatic function. Weaning patients from tube feeding to oral nutrition is the ultimate nutrition goal. A multidisciplinary approach to patients with short bowel syndrome will maximize the use of enteral nutrition while preserving parenteral nutrition for patients with true enteral nutrition therapy failure. (Journal of Parenteral and Enteral Nutrition 30:S21‐S26, 2006)
Care and Long‐Term Maintenance of Percutaneous Endoscopic Gastrostomy Tubes
Authors: McClave Stephen A. , Neff Rita L.
Published: May 2008

Placement of a percutaneous endoscopic gastrostomy (PEG) tube creates a controlled perforation of a hollow viscous organ and an acute surgical wound. Physicians who place PEG tubes endoscopically or fluoroscopically often do not have the opportunity to provide these patients with long‐term follow‐up care. Thus, nutrition support specialists who do treat these patients may be the one member of the health care team who is in the most advantageous position for ongoing inspection and maintenance of the access device. Carefully monitored surveillance and adherence to routine principles of wound care assure the health of the skin, the underlying tissue, and the tract into the abdominal cavity through which the PEG passes. Having knowledge of the types of tubes placed, performing a regular physical examination of the PEG site, and maintaining good communication with the endoscopist results in early identification of problems, promotes rapid simple strategies to correct deficiencies, and the opportunity to minimize long‐term complications. Dietitians, wound‐care ostomy nurses, and other nutrition support specialists are encouraged to be more proactive with their participation in the care and management of the PEG site. (Journal of Parenteral and Enteral Nutrition 30:S27‐S38, 2006)
Vascular Access in the Adult Home Infusion Patient
Authors: Sands Mark J.
Published: May 2008

The dependence of IV hyperalimentation programs on the achievement and maintenance of reliable vascular access in the home infusion patient population has necessitated a review of the current methods used to establish and maintain adequate long‐term vascular access. Vascular access device‐related complications are significant contributors to the medical course and costs associated with the care of home parenteral nutrition (HPN) patients. The purpose of this manuscript is to review current thoughts on the establishment of long‐term vascular access for HPN with regard to techniques used, device selection, and associated complications. (Journal of Parenteral and Enteral Nutrition 30:S57‐S64, 2006)
Dysfunction and Thrombotic Complications of Vascular Access Devices
Authors: Steiger Ezra
Published: May 2008

Catheter dysfunction occurs frequently in patients receiving home parenteral nutrition (HPN). Catheter‐associated thrombosis can be life threatening and limit future vascular sites. Both of these complications can be minimized and treated by proper catheter placement and being aware of preventative and therapeutic measures. (Journal of Parenteral and Enteral Nutrition 30:S70 ‐S72, 2006)
Treatment of Catheter Occlusion in Pediatric Patients
Authors: Kerner John A. , Garcia‐Careaga Manuel G. , Fisher Amy A. , Poole Robert L.
Published: May 2008

A proper initial assessment of catheter occlusion is the key to successful management. The assessment screens are for both thrombotic and nonthrombotic causes (including mechanical occlusion). If mechanical occlusion is excluded, thrombotic occlusion is treated with alteplase. Nonthrombotic occlusions are treated according to their primary etiologies: lipid occlusion is treated with 70% ethanol, mineral precipitates are treated with 0.1‐N hydrochloric acid (HCl), drug precipitates are treated according to their pH—acidic drugs can be cleared with 0.1‐N HCl, basic medications can be cleared with sodium bicarbonate or 0.1‐N sodium hydroxide (NaOH). Prevention of occlusion of central venous access devices is also critical. To date, no data conclusively show heparin flushes to be superior to saline flushes. No prophylactic regimen, including low‐dose warfarin, low‐molecular‐weight heparin, or 1 unit heparin/mL of parenteral nutrition has been endorsed by any major medical, nursing, or pharmacy group due to lack of scientific evidence. The most encouraging information on decreasing occlusion rate comes from experience with positive‐pressure devices that attach to the hub of most catheter lumens and prevent retrograde blood flow and, consequently, decrease the risk of thrombus formation in the catheter lumen. (Journal of Parenteral and Enteral Nutrition 30:S73‐S81, 2006)
Are Plasma Citrulline and Glutamine Biomarkers of Intestinal Absorptive Function in Patients With Short Bowel Syndrome?
Authors: Luo Menghua , Fernández‐Estívariz Concepción , Manatunga Amita K. , Bazargan Niloofar , Gu Li H. , Jones Dean P. , Klapproth Jan‐Michael , Sitaraman Shanthi V. , Leader Lorraine M. , Galloway John R. , Ziegler Thomas R.
Published: May 2008

Sensitive biomarkers for intestinal absorptive function would be clinically useful in short bowel syndrome (SBS). Citrulline (Cit) is a product of the metabolism of glutamine (Gln) and derived amino acids by enterocytes. Cit is produced almost exclusively by the gut, which is also a major site of Gln metabolism. The goals of this study were to examine whether plasma Cit and Gln concentrations are biomarkers of residual small intestinal length and nutrient absorptive functions in adult SBS patients followed prospectively. We studied 24 stable adults with severe SBS receiving chronic parenteral nutrition (PN) in a double‐blind, randomized trial of individualized dietary modification± recombinant human growth hormone (GH). During a baseline week, intestinal absorption studies (% absorption of fluid, kcal, nitrogen, fat, carbohydrate, sodium, phosphorus, and magnesium) were performed and concomitant plasma Cit and Gln concentrations determined. Individualized dietary modification and treatment with subcutaneous injection of placebo (n = 9) or GH (0.1 mg/kg daily × 21 days, then 3 times/week; n = 15) were then begun. PN weaning was initiated after week 4 and continued as tolerated for 24 weeks. Repeat plasma amino acid determination and nutrient absorption studies were performed at weeks 4 and 12. Residual small bowel length at baseline was positively correlated with baseline plasma Cit (r= 0.467;p= .028). However, no significant correlations between absolute Cit or Gln concentrations and the percent absorption of nutrient substrates at any time point were observed. Similarly, no correlation between the change in Cit or GLN concentration and the change in % nutrient absorption was observed (baselinevsweeks 4 and 12, respectively). By weeks 12 and 24, 7 and 13 subjects were weaned completely from PN, respectively. However, baseline plasma Cit or Gln did not predict PN weaning at these time points. We concluded that plasma Cit (but not Gln) concentrations appeared to be an indicator of small intestinal length in adult SBS. However, neither plasma Cit nor Gln was a biomarker for intestinal absorptive function in this cohort of patients with SBS.
Does Glutamine Supplementation Decrease the Response of Muscle Glutamine Synthesis to Fasting in Muscle in Adult and Very Old Rats?
Authors: Mignon Michelle , Lêvêque Loïc , Bonnel Emilie , Meynial‐Denis Dominique
Published: May 2008

Background: Glutamine synthetase (GS), a key enzyme in the production of glutamine, is preserved in rat skeletal muscle during aging but is increased with advanced age in vivo. The aim of this study was to determine whether glutamine supplementation affects up‐regulation of GS by fasting in vivo in adult and very old female rats. Methods: Muscle GS activities were assessed in 5‐day‐fasted female Wistar adult (6 months) and very old (27 months) rats refed and supplemented with glutamine or other amino acids (alanine or glycine). Fed rats were used to investigate the possible effect of glutamine supplementation in the fed state. Results: After 5 days' fasting, the up‐regulated GS activity was decreased whatever the type of amino acid supplementation (glutamine, alanine, and glycine) in adults, whereas it was only decreased by glutamine supplementation in very old rats). In the fed state, no effect of glutamine supplementation was observed even if GS activity remained up‐regulated whatever the age and the period of supplementation. Conclusions: These results confirm that glutamine has a specific role in very old rats. The up‐regulated GS activity was decreased by an exogenous supply of glutamine only if intramuscular glutamine was depleted; this was confirmed by studies in the fed state. The up‐regulated GS activity in both fed and fasted rats may be associated with increased glutamine requirements in the whole body.
Effects of Cysteine on the Pharmacokinetic Parameters of Omeprazole in Rats With Protein‐Calorie Malnutrition: Partial Restoration of Some Parameters to Control Levels by Oral Cysteine Supplementation
Authors: Lee Dae Y. , Lee Inchul , Lee Myung G.
Published: May 2008

Background: It has been reported that omeprazole is mainly metabolized via the hepatic cytochrome (CYP) 1A1/2, 3A1/2, and 2D1, and the expressions and mRNA levels of CYP1A2, 2C11, and 3A1/2 decreased in protein‐calorie malnutrition (PCM) rats compared with controls. Interestingly, the decreased CYP1A2, 2C11, and 3A1/2 in PCM rats returned fully or partially to control levels by oral cysteine supplementation (PCMC rats). Hence, it could be expected that some pharmacokinetic parameters of omeprazole might change in PCM rats and partially restore to control levels in PCMC rats. The purpose of this study is to investigate the pharmacokinetic changes of omeprazole in PCM rats and restoration of the parameters in PCMC rats to control levels. Methods: Omeprazole was administered intravenously (20 mg/kg) and orally (40 mg/kg) to control, PCM, and PCMC rats. Results: The following pharmacokinetic parameters were changed in PCM rats and partially returned to control levels in PCMC rats: the area under the plasma concentration‐time curve (AUC; 387, 762, and 539 μg min/mL for control, PCM, and PCMC rats, respectively, after intravenous [IV] administration, and the corresponding values after oral administration: 115, 304, and 201 μg min/mL), total body clearance (51.7, 25.5, and 37.1 mL/min/kg, respectively), nonrenal clearance (51.5, 25.4, and 36.1 mL/min/kg, respectively), and in vitro intrinsic clearance (0.158, 0.118, and 0.138 mL/min/mg protein). Conclusions: PCM was associated with significant changes in some omeprazole pharmacokinetics and the pharmacokinetic parameters restored to control levels by oral cysteine.
Parenteral Nutrition and Fasting Reduces Mucosal Addressin Cellular Adhesion Molecule‐1 (MAdCAM‐1) mRNA in Peyer's Patches of Mice
Authors: Gomez F. Enrique , Lan Jinggang , Kang Woodae , Ueno Chikara , Kudsk Kenneth A.
Published: May 2008

Background: Mucosal addressin cellular adhesion molecule‐1 (MAdCAM‐1) in Peyer's patches (PP) is the gateway molecule for cellular migration into the mucosal immune system. Lack of enteral feeding during parenteral nutrition (PN) rapidly decreases PP MAdCAM‐1, leading to drops in mucosal T and B cells and intestinal and respiratory IgA. We determined the molecular events associated with MAdCAM‐1 mRNA and protein during PN (short and long term) and fasting (1 and 2 days). Methods: Experiment 1: Cannulated mice received PN for 8 hours (short‐term PN, n = 6) or chow + saline (chow, n = 6). Experiment 2: Cannulated mice received PN (long‐term PN, n = 4) or chow (n = 3) for 5 days. Experiment 3: Noncannulated chow mice were fasted for 1 and 2 days (n = 2/time). Total cellular RNA from the PP was quantified for MAdCAM‐1 mRNA by real‐time polymerase chain reaction (PCR). MAdCAM‐1 protein was measured by Western blot. Results: PN rapidly down‐regulated MAdCAM‐1 gene expression. After 8 hours of PN with lack of enteral feeding, MAdCAM‐1 mRNA levels dropped 20% (0.8‐fold vs chow, p > .05); 5 days of PN reduced MAd‐CAM‐1 levels 64% (0.34‐fold vs chow, p < .05). PN reduced MAdCAM‐1 protein levels by 30% (chow: 329 ± 14 vs PN: 230 ± 35, p < .05) after 5 days. Fasting of uncannulated mice decreased MAdCAM‐1 mRNA levels by 16% (0.84‐fold, p < .05) at day 1 and 30% (0.7‐fold, p< .05) by day 2 compared with chow. Conclusions: Both PN with lack of enteral feeding and fasting down‐regulate MAdCAM‐1 mRNA and protein levels in PP. The MAdCAM‐1 changes are due to lack of enteral stimulation rather than toxic effects of PN.
Wernicke's Encephalopathy During Parenteral Nutrition
Authors: Francini‐Pesenti Francesco , Brocadello Filippo , Famengo Stefania , Nardi Mariateresa , Caregaro Lorenza
Published: May 2008

Background: Thiamine deficiency in humans affects the cardiovascular, muscular, nervous, and gastrointestinal systems. Wernicke's encephalopathy is described in alcoholism, in hyperemesis gravidarum, and in prolonged IV feeding without vitamin supplementation. Methods: We report a case of a 66‐year‐old man undergoing surgery for acute necrotic‐hemorrhagic pancreatitis, who presented a Wernicke's syndrome during parenteral nutrition (PN). After surgery, he was treated with infusion of industrial 3‐compartment bags, without vitamin supplementation. On the seventh postoperative day, nausea and vomiting began, and 5 days later the patient showed diplopia, ataxia, general muscular stiffness, reduction of osteotendinous reflexes, confusional state, and thrombocytopenia. The magnetic resonance scan evidenced pathologic changes in the medial thalamus, in the third and fourth ventricular floor, in the cerebellar vermis, and in the periaqueductal gray substance. Results: All neurologic signs and platelet blood count gradually normalized after IV supplementation of thiamine, 100 mg daily. The magnetic resonance scan repeated 40 days after the first one was normal. Conclusions: Our report points out the risk of incorrect procedures in management of industrial 3‐compartment bags. Moreover, we suggest that thrombocytopenia may be related to thiamine deficiency.
Optimizing the Dose of Glutamine Dipeptides and Antioxidants in Critically Ill Patients: A Phase I Dose‐Finding Study
Authors: Heyland Daren K. , Dhaliwalm Rupinder , Day Andrew , Drover John , Cote Helene , Wischmeyer Paul
Published: May 2008

Background: Supplementation with glutamine and antioxidants may be associated with an improvement in clinical outcomes, but the optimal dose of these substrates is unknown. The purpose of this study was to determine the safety of high doses of glutamine combined with antioxidants in critically ill patients. Methods: We conducted a single‐center, open‐label, dose‐escalating clinical trial. Mechanically ventilated adult patients with clinical evidence of hypoperfusion were sequentially enrolled to 1 of 5 groups. Group 1 (n = 30): no supplementation; group 2 (n = 7): 0.35 g/kg/d of glutamine IV; group 3 (n = 7): same as group 2 plus 15 g/d of glutamine and 150 μg of selenium enterally; group 4 (n = 7): same as group 2 plus 30 g/d of glutamine and 300 μg of selenium enterally; and group 5 (n = 7): same as group 4 plus an additional 500 μg of selenium IV. After enrollment, nutrients were started as soon as possible. All patients were fed enterally according to clinical practice guidelines. Results: The primary outcomes for this study were change in sequential organ function assessment (SOFA) score and safety parameters. Secondary outcomes included whole blood glutathione (GSH), thiobarbituric acid reactive substances (TBARS), and blood cells' mitochondrial DNA/nuclear DNA ratio (RATIO). There were no adverse events attributable to the study nutrients, and the maximum and Δ SOFA did not differ across groups. In group 2, a significant decrease in GSH levels was observed (p = .03). With subsequent groups, the slopes straighten out and the p values are no longer significant, suggesting a greater preservation of GSH levels with escalating doses. In group 2, the slope of the line representing TBARS was horizontal. With subsequent groups, the slopes decrease, and by group 5, this decrease reaches statistical significance (p = .03), suggesting a greater reduction in oxidative stress with the higher doses in group 5. The difference in slopes across all groups describing the mitochondrial RATIO is statistically significant (p = .001), again suggesting that, with higher doses, there is increased mitochondrial function. Conclusions: The doses of glutamine and antioxidants tested in this study seem to be safe and may have positive effects on some mechanistic endpoints. A larger trial will be necessary to confirm their therapeutic effects.
Systemic Inflammatory Mediators and Bone Homeostasis in Intestinal Failure
Authors: Compher Charlene , Pazianas Michael , Benedict Stephen , Brown John C. , Kinosian Bruce P. , Hise Mary
Published: May 2008

Background: A proinflammatory state has been described in patients with intestinal failure. The prevalence of metabolic bone disease in this group is considerable. It is not known whether this proinflammatory state is related to bone parameters, though bone disease is recognized as a proinflammatory process in postmenopausal women. The purpose of this study was to examine whether inflammation was related to bone disease. Methods: Eight patients with parenteral nutrition (PN)‐dependent intestinal failure but no recent infections or immunosuppressive medications had serum assayed for interleukin‐6 (IL‐6), tumor necrosis factor (TNF)‐α, and its receptors (TNFR‐I and TNFR‐II), C‐reactive protein, and whole blood for lymphocyte proliferation. Routine clinical laboratory measures of vitamin D, parathyroid hormone, serum calcium, and phosphorus within 3 months of the inflammatory measures were compared by Pearson's correlation to the inflammatory measures. Results: Mean values for calcium, phosphorus, and albumin were normal, but 25‐hydroxy vitamin D was reduced and parathyroid hormone and alkaline phosphatase elevated. Serum total calcium was negatively related to TNFR‐II, TNF‐α and positively to T‐helper cells. Longer PN dependence was associated with inflammation and negatively with T‐helper cells. Conclusions: These preliminary findings are hypothesis generating only but support an association of low calcium and longer duration of PN with inflammation in patients with intestinal failure. Whether the inflammation results from vitamin D deficiency or the vitamin D deficiency develops secondary to excessive use of activated vitamin D to modulate inflammation from some other cause, such as a component of PN or repeated infectious challenge, requires further study.
Physical Stability of 20% Lipid Injectable Emulsions via Simulated Syringe Infusion: Effects of Glass vs Plastic Product Packaging
Authors: Driscoll David F. , Ling Pei‐Ra , Bistrian Bruce R.
Published: May 2008

Background: The United States Pharmacopeia (USP) has proposed large‐globule‐size limits to ensure the physical stability of lipid injectable emulsions, expressed as the percent fat >5 μm, or PFAT5, not exceeding 0.05%. Visibly obvious phase separation as free oil has been shown to occur in some samples if PFAT5 is >0.4%. We recently found that lipids, newly packaged in plastic (P), exceed the proposed USP limits and seem to produce less stable total nutrient admixtures compared with those made from conventional glass (G), which do meet proposed USP standards. We tested the possible stability differences between 20% lipid injectable emulsions in either P or G in a simulated neonatal syringe infusion study. Methods: Eighteen individual syringes were prepared from each 20% lipid injectable emulsion product (n = 36) and attached to a syringe pump set at an infusion rate of 0.5 mL/hour. The starting PFAT5 levels were measured at time 0 and after 24 hours of infusion, using a laser‐based light obscuration technique as described by the USP Chapter <729>. The data were assessed by a 2‐way analysis of variance (ANOVA) with Container (G vs P) and Time as the independent variables and PFAT as the dependent variable. Results: At time 0, the starting PFAT5 level for lipids packaged in G was 0.006% ± 0.001% vs 0.162% ± 0.026% for P, whereas at the end of the infusion they were 0.013% ± 0.003% and 0.328% ± 0.046%, respectively. Significant differences were noted overall between groups for Container, Time, and Container‐Time interaction (all p < .001). Bonferroni tests showed significant differences in PFAT5 levels between Containers at time 0 (T‐0; p < .001) and T‐0 vs T‐24 for P‐based lipids (p< .001), whereas no such differences were noted for Time for the G‐based lipids. Similar results were noted for PFAT10 levels. Conclusions: We confirm that presently available lipid injectable emulsions packaged in newly introduced plastic containers exceed the proposed USP <729> PFAT5 limits and subsequently become significantly less stable during a simulated syringe‐based infusion. Although modest growth (p = NS) in large‐diameter fat globules was observed for the glass‐based lipids, they remained within proposed USP globule size limits throughout the study. Glass‐based lipids seem to be a more stable dosage form and potentially a safer way to deliver lipids via syringe infusion to critically ill neonates.
Bombesin Prevents the Atrophy of Peyer's Patches and the Dysfunction of M Cells in Rabbits Receiving Long‐Term Parenteral Nutrition
Authors: Fujimura Yoshinori , Haruma Ken , Owen Robert L.
Published: May 2008

Background: Long‐term parenteral nutrition (PN) induces atrophy of the gut‐associated lymphoid tissue (GALT). We examined whether bombesin could ameliorate this atrophy of Peyer's patches and the down‐regulation of particle transport by M cells, which was also observed in rabbits undergoing PN. Methods: Adult female rabbits were randomized into 6 groups to receive chow ad libitum, chow + bombesin, PN, or PN + bombesin (20μ g/kg, subcutaneously every 8 hours) for 2 or 4 weeks. At the end of each nutrition period, a laparotomy was performed under anesthesia and a suspension of 1 × 1010/mL of 0.5‐μm fluorescent microspheres was injected into the lumen of intestinal segments containing Peyer's patches and incubated for 2 hours. After the incubation, segments were harvested and prepared for light microscopy, immunohistochemistry, fluorescent microscopy, and electron microscopy. Results: Long‐term PN reduced the size of ileal Peyer's patches, the number of microspheres that was taken up into the follicle‐associated epithelium of lymphoid nodules, and the area of Peyer's patch surface occupied by M cells. The number of intraepithelial lymphocytes within the follicle‐associated epithelium near the perifollicular crypts of Peyer's patches was also reduced by long‐term PN. These consequences were dramatically ameliorated by treatment with bombesin. No ultrastructural alteration of the M cells of Peyer's patches was found in the chow, the PN, or the PN + bombesin groups. Conclusions: Bombesin prevents PN‐induced atrophy of GALT, reduction of M cell numbers, and decrease in particulate transport by M cells during long‐term PN. Bombesin may modulate the genesis of and particulate transport by M cells through stimulation of lymphoid cells in Peyer's patch epithelium near perifollicular crypts, where M cells and other constituents of lymphoid follicle epithelium are generated, thereby preserving mucosal immunity.
Effects of Parenteral Fish‐Oil Emulsion (Omegaven) on Cutaneous Wound Healing in Rats Treated With Dexamethasone
Authors: Gercek Arzu , Yildirim Ozlem , Konya Deniz , Bozkurt Suheyla , Ozgen Serdar , Kilic Turker , Sav Aydin , Pamir Necmettin
Published: May 2008

Background: The aim was to assess wound healing when parenteral fish‐oil emulsion is given to rats receiving dexamethasone. Methods: For 5 days after skin wounding, group S (control; n = 7) received saline 1 mL/kg intraperitoneal (IP); group D (n = 7), dexamethasone 0.2 mg/kg IP; and group DO (n = 9), dexamethasone 0.2 mg/kg IP plus 1 mL/kg Omegaven (Fresenius Kabi, Austria). Wound specimens were assessed for hydroxyproline level, wound depth, histology (epidermal/dermal regeneration, granulation tissue thickness, and angiogenesis), and expression of transforming growth factor‐β (TGF‐β) and platelet‐derived growth factor‐AA (PDGF‐AA). Results: Compared with D and DO specimens, controls had higher hydroxyproline (p < .01), deeper wounds (p < .05), and better histologic scores (p < .01 angiogenesis; others p< .05). There were no significant differences between the group D and DO means for hydroxyproline level, wound depth, or histologic scores (p> .05 for all). Controls had higher TGF‐β expression scores than the other groups (p < .01 for both) and a higher PDGF‐AA expression score than group DO (p < .01). Groups D and DO had statistically similar TGF‐β scores, but group D had a higher PDGF‐AA score (2.71± 0.75 vs 1.55 ± 0.72, respectively; p < .05). Conclusions: According to the parameters we studied, adding parenteral ω‐3 and ω‐6 fatty acids to the nutrition regimen of rats treated with dexamethasone does not seem to have adverse effects on wound healing, and effects on wound healing may not need to be considered when determining if these agents should be supplemented in nutrition support regimens.
A Short‐Term Long‐Chain Triglycerides Infusion Has No Influence on Immune Function of Adult Patients Undergoing Gastrointestinal Surgery
Authors: Li Xiaogang , Ying Jiaoqian , Zeng Shan , Shen Liangfang , Wan Xiaoping , Li Xiaorong , Tan Hui , Pei Haiping , Zhou Jun , Shen Hong
Published: May 2008

Background: Parenteral nutrition (PN) support containing long‐chain triglycerides (LCT) plays a critical supportive role in surgical patients' management. This study aims to investigate the effects of intravenous (IV) LCT emulsion on human immune function in adult patients receiving a gastrointestinal surgical procedure. Methods: Sixty adult patients were randomly assigned either to the LCT treatment group (n = 32) or to the control group (n = 28). After an abdominal operation, the subjects received PN treatment with or without LCT for 5 days. Neutrophil, peripheral blood mononuclear cell (PBMC), lymphocyte and CD4/CD8, serum immunoglobulin A (IgA), IgG, IgM, complement C3 and C4, interleukin (IL)‐2, IL‐4, IL‐10, IL‐12, tumor necrosis factor (TNF)‐α, and interferon (IFN)‐γ were measured and statistically analyzed. Results: The LCT and control groups did not differ significantly at entry in terms of general features. Except for a significant increase of neutrophil number at 24 hours after the surgery in both groups (p < .01), all parameters representing the patients' immune function had no significant difference between the LCT and the control groups with respect to neutrophil and PBMC count, lymphocyte, CD4/CD8, serum IgA, IgG, IgM, complement C3, C4, IL‐2, IL‐4, IL‐10, IL‐12, TNF‐α, and IFN‐γ (p > .05, respectively) 24 hours before the operation, and 24 hours and 120 hours after the operation. Conclusions: The regimens of LCT administration may have diverse effects on human immune function in different patient populations. However, LCT emulsion at an appropriate dose and infusion speed does not alter human immune function of adult patients undergoing moderate gastrointestinal surgery.
Glycine Does Not Add to the Beneficial Effects of Perioperative Oral Immune‐Enhancing Nutrition Supplements in High‐Risk Cardiac Surgery Patients
Authors: Tepaske Robert , te Velthuis Henk , Oudemans‐van Straaten Heleen M. , Bossuyt Patrick M. M. , Schultz Marcus J. , Eijsman León , Vroom Margreeth
Published: May 2008

Background: Elderly patients and patients with a poor cardiac function have increased morbidity rates when undergoing cardiac surgery. The aim of this study was to determine whether addition of glycine to a standard preoperative oral immune‐enhancing nutrition supplement (OIENS) improves outcome. Glycine‐enriched OIENS was compared with 2 formulas: standard OIENS and control. Methods: In this double‐blind, 3‐armed study, patients scheduled to undergo cardiac surgery with the use of extracorporeal circulation received either the glycine‐enriched OIENS (OIENS + glyc, n = 24), standard OIENS (OIENS, n = 25), or control formula (Control, n = 25) for minimally 5 preoperative days. Patients were included if they were aged 70 years or older, had a compromised left ventricular function, or were planned for mitral valve surgery. Main outcome measures were postoperative infectious morbidity, organ function, and postoperative recovery. Results: Infectious morbidity was significantly lower in both treatment groups compared with the control group (p = .02). An infection was diagnosed in 5 and 4 patients in the OIENS + glyc and OIENS groups, respectively, and in 12 control patients. Less supportive therapy was necessary to stabilize circulation in both treatment groups compared with the control group. Median length of hospital stay was 7.0, 6.5, and 8.0 days in the OIENS + glyc, OIENS, and control groups, respectively. Inflammatory responses, as measured by systemic levels of proinflammatory cytokines and surface markers on polymorphonuclear cells, were comparable for all groups. Conclusions: Preoperative OIENS reduces postoperative infectious morbidity and results in a more stable circulation; the addition of glycine does not result in any beneficial effect over standard OIENS.
Clinical Costs of Feeding Tube Placement
Authors: de Aguilar‐Nascimento Jose Eduardo , Kudsk Kenneth A.
Published: May 2008

Background: Although small‐bore tube placement is common, insertion can lead to serious complications. We investigated the use of radiographs, fluoroscopy, feeding tubes, and complications associated with blind feeding‐tube placement. Methods: The electronic and paper records of adult patients receiving a small‐bore feeding tube in 2005 were retrospectively reviewed for the following variables: demographics, desired location (gastric or postpyloric), number of radiographs, number of tubes per individual, time interval between medical prescription, tube placement and delivery of the diet, complications, transport for fluoroscopy, and hospital location of placement (intensive care unit vs floor). Results: We identified 1822 tubes placed into 729 patients (male: 449, 61.6%; female: 280, 38.4%; median age: 59 years old, range 18–98). All tubes were placed by nurses unless fluoroscopically placed in radiology or placed after head and neck surgery in the operating room. An average of 2.5 (range 1–20) tubes was used per patient. A total of 2696 radiographs were obtained for an average of 3.7 (range 0–32) films per patient and 1.5 (range 0–11) per feeding tube. Successful placement was higher for intragastric (93.3%) than for postpyloric position (60.4%; p < .001). Fluoroscopy was needed in 18.6% of the patients, mostly for postpyloric insertion (p < .001). Respiratory tree misplacement occurred in 23 (3.2%) patients; 9 (1.2%) had a pneumothorax and 4 (0.5%) died. Patients with a malpositioned feeding tube underwent more tube insertions (6.8 ± 5.4; range 2–20) than patients without complications (2.2 ± 1.8; range 1–18; p < .001). Conclusions: The incidence of airway misplacement of feeding tubes (3.2%) at a major tertiary referral university hospital was alarming. Mandatory radiographs may eliminate the risk of respiratory administration of feedings but not misplacements. The associated costs of radiographs, unsuccessful placements, fluoroscopy, and complications are significant. A solution to this problem will require focused attention and development of specific protocols, possibly using new technologies.
Risk Factors of Catheter‐Related Bloodstream Infections in Parenteral Nutrition Catheterization
Authors: Yilmaz Gurdal , Koksal Iftihar , Aydin Kemalettin , Caylan Rahmet , Sucu Nurgun , Aksoy Firdevs
Published: May 2008

Background: Intravascular catheters are integral to the practice of modern medicine. Potential risk factors for catheter‐related bloodstream infection (CRBSI) include underlying disease, method of catheter insertion, and duration and purpose of catheterization. The administration of parenteral nutrition (PN) through intravascular catheters increases CRBSI risks. The purpose of this study was to evaluate the risk factors of CRBSI in patients with PN administration. Methods: This study was conducted at the Karadeniz Technical University Hospital between October 2003 and November 2004. All the patients to whom PN was administered through intravascular catheters were prospectively monitored for the presence of CRBSI and risk factors. Results: During the study period, 111 intravascular catheters through which PN was administered were monitored for a total of 1646 catheter‐days. CRBSI was determined in 31 cases, a CRBSI rate of 18.8 per 1000 catheter‐days. When risk factors affecting CRBSI were investigated using logistic regression, an increase in APACHE II score (OR, 1.10; 95% CI, 1.01–1.21; p = .012), prolongation of catheterization (OR, 1.08; 95% CI, 1.02–1.14; p = .004), catheterization in emergent conditions (OR, 5.45; 95% CI, 1.20–24.82; p = .016), and poor patient hygiene (OR, 4.38; 95% CI, 1.39–13.78; p = .019) were all determined to be independent risk factors. Proper implementation of hand hygiene and maximal barrier precautions during the insertion of catheters reduced CRBSI levels (OR, 0.28; 95% CI, 0.09–0.88; p = .003 and OR, 0.26; 95% CI, 0.08–0.93; p = .017, respectively). Conclusions: It was concluded that the duration of catheterization should be shortened; that the intravascular catheter, which is inserted in urgent situations, should be removed as soon as possible; and that maximal sterile barrier precautions should be taken and due attention should be paid to hand hygiene.
Nutrition Status and Pressure Ulcer: What We Need for Nutrition Screening
Authors: Hengstermann Susanne , Fischer Andreas , Steinhagen‐Thiessen Elisabeth , Schulz Ralf‐Joachim
Published: May 2008

Background: Pressure ulcers (PU) and malnutrition exist in elderly hospitalized patients as a significant and costly problem. The aim of the study was to compare different screening tools to assess nutrition status and to verify them for usage in clinical routine. Methods: Nutrition status (body mass index [BMI], Mini Nutritional Assessment [MNA], weight loss) was determined in 484 (326 female/158 male) multimorbid elderly patients with mean age of 79.6 ± 7.6 (80.9 ± 7.4 female/76.9 ± 7.4 male) years. Bioelectrical impedance analysis (BIA; Nutrigard 2000‐M) was used for evaluation of body composition. Activities of daily living (ADL) were measured with the Barthel Index. PUs were divided into stages I–IV (European Pressure Ulcer Advisory Panel [EPUAP]) and were assessed by the Norton scale. Results: The prevalence of PU was 16.7%, with a median Norton scale of 20 (range, 17–24). According to MNA, 39.5% of the PU patients were malnourished, and 2.5% were well nourished. By contrast, 16.6% of the non‐PU patients were malnourished, and 23.6% were well nourished. BMI decreased significantly in PU patients (p < .008). BIA resulted in no significant resistance and reactance but in a significant reduction of phase angle in PU. According to a significantly reduced body cell mass and lean body mass in PU patients, the ADL decreased in these patients, too. Furthermore, we analyzed a significant effect of age, ADL, MNA, BMI, phase angle, and body cell mass on the Norton scale. Conclusions: The MNA as a screening and assessment tool is easy to use to determine the nutrition status in multimorbid geriatric patients with PU. Further studies are needed to show an improved outcome of PU healing if evaluation of nutrition status is part of routine clinical practice in multimorbid elderly risk patients within the first day after admission.
Prognostic Factors in the Resumption of Oral Dietary Intake After Allogeneic Hematopoietic Stem Cell Transplantation (HSCT) in Children
Authors: Bechard Lori J. , Guinan Eva C. , Feldman Henry A. , Tang Vivian , Duggan Christopher
Published: May 2008

Background: Parenteral nutrition (PN) is a common supportive care therapy in patients undergoing hematopoietic stem cell transplantation (HSCT). Inadequate oral dietary intake may necessitate prolonged courses of PN, which have been associated with metabolic, infectious, and hepatobiliary complications. The objective of this study was to identify demographic, clinical, and nutrition factors associated with the resumption of oral dietary intake following HSCT. Methods: This was an observational cohort study of 37 children undergoing allogeneic HSCT. Repeated‐measures regression analysis was performed to identify factors associated with the resumption and macronutrient composition of oral nutrient intake after HSCT. Results: Mean oral dietary intake during the first 2 weeks after HSCT was <280 kcal/d. At all times, oral carbohydrate intake was high, ranging from 58% to 74% of oral energy. Age, time since transplant, degree of oral mucositis, and severity of graft‐vs‐host disease (GVHD) were all significantly correlated with the resumption of oral energy intake, as well as oral intake of carbohydrates. Oral protein and fat intake were also associated with elapsed time since HSCT, severity of mucositis, and GVHD. Factors not associated with oral dietary intake included gender, pre‐HSCT nutrition status, diagnosis, type of donor, and infections. Conclusions: Children undergoing HSCT exhibit a marked reduction in oral dietary intake and a preference for a diet high in carbohydrates. Careful attention should be directed to the oral dietary intake and nutrient requirements of children during HSCT, especially in younger patients and those who experience severe mucositis or GVHD.
Wernicke's Encephalopathy After Laparoscopic Cardiomyotomy for Achalasia
Authors: Kennedy R. , Hunt S. , Ahmad J. , Menezes C. , Clements W. B. , Kennedy J. A.
Published: May 2008

Achalasia is an incurable neuromuscular disorder of the esophagus, resulting from destruction of the esophageal myenteric plexus. This leads to aperistalsis and failure of the lower esophageal sphincter to relax after swallowing. Symptoms of achalasia are gradual in onset and include dysphagia, regurgitation, and weight loss. Severe malnutrition can ensue. Wernicke's encephalopathy (WE) is a serious, potentially fatal, neurologic disorder caused by thiamine deficiency (vitamin B1), classically described as presenting with a triad of ocular abnormalities, ataxia, and confusion. The incidence is uncertain, and many cases likely go unrecognized. It is usually diagnosed in the alcoholic population. We describe its onset after the successful surgical treatment of achalasia.
Intestinal Polymeric Immunoglobulin Receptor Is Affected by Type and Route of Nutrition
Authors: Sano Yoshifumi , Gomez F. Enrique , Kang Woodae , Lan Jinggang , Maeshima Yoshinori , Hermsen Joshua L. , Ueno Chikara , Kudsk Kenneth A.
Published: May 2008

Background: Secretory immunoglobulin A (SIgA) prevents adherence of pathogens at mucosal surfaces to prevent invasive infection. Polymeric immunoglobulin receptor (pIgR) is located on the basolateral surface of epithelial cells and binds dimeric immunoglobulin A (IgA) produced by plasma cells in the lamina propria. This IgA‐pIgR complex is transported apically, where IgA is exocytosed as SIgA to the mucosal surface. Our prior work shows that mice fed intragastric (IG, an elemental diet model) and IV parenteral nutrition (PN) solution have reduced intestinal T and B cells, SIgA, and interleukin‐4 (IL‐4) compared with mice fed chow or a complex enteral diet (CED). Prior work also demonstrates a reduction in IgA transport to mucosal surfaces in IV PN–fed mice. Because IL‐4 up‐regulates pIgR production, this work studies the effects of these diets on intestinal pIgR. Methods: Male Institute of Cancer Research (ICR) mice were randomized to chow (n = 11) with IV catheter, CED (n = 10) or IG PN (n = 11) via gastrostomy and IV PN (n = 12) for 5 days. CED and PN were isocaloric and isonitrogenous. Small intestine was harvested for pIgR and IL‐4 assays after mucosal washing for IgA. IgA and IL‐4 levels were analyzed by enzyme‐linked immunosorbent assay and pIgR by Western blot. Results: Small intestinal pIgR expression, IgA levels, and IL‐4 levels decreased significantly in IV PN and IG PN groups. Conclusions: Lack of enteral stimulation affects multiple mechanisms responsible for decreased intestinal SIgA levels, including reduced T and B cells in the lamina propria, reduced Th‐2 IgA‐stimulating cytokines, and impaired expression of the IgA transport protein, pIgR.
Effect of Active Hexose Correlated Compound on the Production of Nitric Oxide in Hepatocytes
Authors: Matsui Kosuke , Kawaguchi Yusai , Ozaki Takashi , Tokuhara Katsuji , Tanaka Hironori , Kaibori Masaki , Matsui Yoichi , Kamiyama Yasuo , Wakame Koji , Miura Takehito , Nishizawa Mikio , Okumura Tadayoshi
Published: May 2008

Background: Active hexose correlated compound (AHCC) is a“ complex compound” containing polysaccharides. AHCC has been reported to improve the prognosis of postoperative hepatocellular carcinoma patients. However, the molecular mechanism of this improvement is not fully understood. In the diseased liver, nitric oxide (NO) generated by inducible nitric oxide synthase (iNOS) is considered to be a causal factor for various hepatopathies. In this study, the possibility of AHCC regulation of NO production by iNOS was pursued as a potential liver‐protecting mechanism. Methods: Primary cultured rat hepatocytes were treated with interleukin‐1β (IL‐1β) in the presence or absence of AHCC. NO production, iNOS induction, and iNOS signal were analyzed. Results: IL‐1β stimulated iNOS induction through the activation of nuclear factorκ B (NFκB), leading to NO production. The addition of AHCC inhibited NO production, showing >80% inhibition at 8 mg/mL. AHCC also decreased the levels of iNOS protein and mRNA. However, AHCC influenced neither the degradation of inhibitory protein κB (IκB) nor the activation of NFκB stimulated by IL‐1β. Transfection experiments with an iNOS promoter‐luciferase construct (iNOS‐Luc) revealed that AHCC had no effect on the transactivation activity of the iNOS promoter. By contrast, AHCC inhibited the activity of iNOS‐Luc containing a 3′untranslated region (UTR) with adenosine and uridine (AU)–rich elements, which shows the stabilizing activity of iNOS mRNA. Conclusions: Results indicated that AHCC inhibits the induction of iNOS at the level of transcription, causing a decrease in NO production in hepatocytes. AHCC seems to decrease the levels of iNOS mRNA by reducing mRNA stabilization rather than inhibiting its synthesis.
Influence of Adding Fish Oil to Parenteral Nutrition on Gut‐Associated Lymphoid Tissue
Authors: Maeshima Yoshinori , Fukatsu Kazuhiko , Moriya Tomoyuki , Ikezawa Fumie , Ueno Chikara , Saitoh Daizoh , Mochizuki Hidetaka
Published: May 2008

Background: Lack of enteral nutrition reduces gut‐associated lymphoid tissue (GALT) mass and function, a mechanism underlying the increased morbidity of infectious complications in severely injured or critically ill patients. Strategies to restore parenteral nutrition (PN)–induced changes of GALT mass and function have been pursued. However, the influences of adding fish oil to PN on gut immunity remain to be clarified. Methods: Male Institute of Cancer Research (ICR) mice (n = 50) were randomized to 4 groups: ad libitum chow (chow), fat free PN (fat (–)‐PN), PN + fish oil (FO‐PN), and PN + safflower oil (SO‐PN). The PN groups were given isocaloric and isonitrogenous PN solutions. The FO‐ and SO‐PN groups received 20% of total calories from fat emulsions. After 5 days of feeding, lymphocytes from Peyer's patches (PPs), the intraepithelial space (IE), and the lamina propria (LP) of the entire small intestine were isolated. GALT lymphocyte numbers and phenotypes (CD4+, CD8+, αβTCR+,γδ TCR+, B220+ cells) were determined. Immunoglobulin A (IgA) levels of small intestinal washings were also measured by enzyme‐linked immunosorbent assay. Another set of mice (n = 24) was used to determine plasma fatty acid compositions after feeding. Results: Lymphocyte numbers from PPs and the LP and intestinal IgA levels were significantly lower in the PN groups than in the chow group, with no significant differences between any 2 PN groups. The FO‐ and SO‐PN groups showed moderate recovery of IE cell numbers compared with the fat (–)‐PN group. Ω‐3 and ω‐6 fatty acid levels were increased with fish and safflower oil additions, respectively, compared with the fat (–)‐PN group. Conclusions: Adding fish oil to PN does not exacerbate PN‐induced GALT changes but rather partially reverses these changes, with increased plasma ω‐3 fatty acid levels.
Does Long‐Term Intermittent Treatment With Glutamine Improve the Well‐being of Fed and Fasted Very Old Rats?
Authors: Mignon Michelle , Beaufrère Anne‐Marie , Combaret Lydie , Meynial‐Denis Dominique
Published: May 2008

Background:Glutamine is known to have a specific role in very old rats (>25 months of age). For this reason, we have orally supplemented female rats with glutamine (20% of diet protein) intermittently. The treatment started before animals became very old and lasted 5 months. Very old rats were studied in fed state or after 5‐day fasting after the last glutamine cure. The aim of this study was to determine whether thisin vivopretreatment improves the well‐being of very old rats (muscle sarcopenia decrease, gut integrity improvement, decrease of the known up‐regulated glutamine synthetase observed regardless of nutrition state).Methods:Protein turnover was measured in epitrochlearis muscle, whereas glutamine synthetase (GS) activities were assessed in tibialis anterior muscle from fed and 5‐days‐fasted female Wistar adult (6 months) and very old (27 months) rats, pretreated or not with glutamine. Furthermore, gut was dissected and weighed.Results:Long‐term treatment with glutamine had positive effects on very old rats: (1) it prevented the loss of body weight, but, (2) it did not prevent the inevitable sarcopenia regardless of nutrition state, and (3) it maintained the gut mass. Surprisingly, the muscle up‐regulated GS activity observed in fed and fasted very old rats was only decreased in the fed state when rats were supplemented, without change in plasma and muscle glutamine concentrations.Conclusions:Long‐term treatment with glutamine started before advanced age had essentially a beneficial role on the gut. It may play a role in maintaining intestine integrity and intestinal immune function. Further investigations would be warranted to explore these mechanisms.