bluuebunny/crossref_metadata_2025 huggingface dataset:
Treatment of Unintentional Weight Loss in Patients With Cancer
Authors: Mattox Todd W.
Published: May 2008

Malnutrition from anorexia and reduced nutrient intake is common in patients with cancer. Abnormalities in gastrointestinal function caused by the tumor or treatment of the tumor may be direct causes for nutrition challenges. However, other patients may present with cancer cachexia, a wasting syndrome characterized by weight loss, anorexia, early satiety, progressive debilitation, and malnutrition that results in a greater risk of organ dysfunction and death. Changes in host metabolism and energy expenditure are thought to contribute to the development of cachexia, although this relationship is not clear. There is evidence that the etiology of these metabolic changes may be mediated by a neurohormonal response stimulated by the tumor. Because a single cause for these metabolic abnormalities has not been identified, several approaches to treatment of cancer cachexia have been reported. After correction of any underlying gastrointestinal abnormalities, single nutrients or other pharmacologic agents have been used in an attempt to favorably affect appetite or counter metabolic abnormalities that cause inefficient nutrient use. A variety of agents have been studied for their positive effects on appetite, including progestational agents, glucocorticoids, cannabinoids, cyproheptadine, olanzapine, and mirtazapine. Other agents have been investigated for their anti‐inflammatory properties, including thalidomide, pentoxyphylline, melatonin, and ω‐3 fatty acids. Anabolic agents such as testosterone derivatives have been investigated as well. The decision to treat symptoms of cancer cachexia should be based on the patient's desires and current medical condition. Choice of the most appropriate agent to treat unintentional weight loss in patients with cancer should include consideration of effects on appetite, weight, quality of life, and risk of adverse effects according to current evidence‐based medicine, and cost and availability of the agent.
Nutrition Issues in Hematopoietic Stem Cell Transplantation: State of the Art
Authors: Lipkin Ann Connell , Lenssen Polly , Dickson Barbara J.
Published: May 2008

There have been many changes in hematopoietic stem cell transplantation (HSCT) that affect the patient's nutrition support. In the early 1970s, allogeneic transplants were the most common types of HSCTs; today, autologous transplants are the most common. Bone marrow, peripheral blood, and umbilical cord blood all now serve as sources of stem cells. Conditioning therapies include myeloablative, reduced‐intensity myeloablative, and nonmyeloablative regimens. New medications are being developed and used to minimize the toxicities of the conditioning therapy and to minimize infectious complications. Supportive therapies for renal and liver complications have changed. In the past, HSCT patients received parenteral nutrition (PN) throughout their hospitalization and sometimes as home therapy. Because of medical complications and cost issues associated with PN, many centers are now working to use less PN and increase use of enteral nutrition. The immunosuppressed diet has changed from a sterile diet prepared under laminar‐flow hoods to a more liberal diet that avoids high‐risk foods and emphasizes safety in food handling practices. This article will review these changes in HSCT and the impact of these changes on the nutrition support of the patient.
Graft‐vs‐Host Disease: Nutrition Therapy in a Challenging Condition
Authors: Roberts Susan , Thompson Jennifer
Published: May 2008

Graft‐vs‐host disease (GVHD) is a major complication after allogeneic hematopoietic stem cell transplantation. Both acute and chronic forms of GVHD are challenging to manage medically and nutritionally. Patients with advanced GVHD commonly become depleted nutritionally, with loss of lean body mass (LBM) and functional status. We present 2 case reports of patients who developed GVHD and subsequent nutrition decline. Although both patients were candidates for specialized nutrition support (SNS), only 1 was able to receive enteral and parenteral nutrition due to GVHD complications preventing access for provision of SNS. Fortunately, the patients have remained in remission from their hematologic malignancy, but they continue to cope with chronic GVHD and its consequences. These cases exhibit the complexity of managing a patient with extensive GVHD and nutrition interventions for clinicians to consider to optimize outcomes.
Adjusted Body Weight, Con: Why Adjust Body Weight in Energy‐Expenditure Calculations?
Authors: Ireton‐Jones Carol
Published: May 2008

Evaluation of energy requirements of normal individuals and hospitalized patients is most often accomplished using an energy equation. Energy equations attempt to measure resting metabolic rate (RMR), the largest factor in total daily energy expenditure. Components of most energy equations include height, weight, age, and gender. These factors are related to energy expenditure; however, each factor has individual characteristics that affect energy expenditure. Body weight is a major factor in RMR and total daily energy expenditure. For obese individuals, estimation of energy expenditure may be a challenge due to the increased body weight. Therefore, some equations attempt to minimize the effect of body weight on energy expenditure assessment by adjusting the obese individual's body weight. Data do not support adjustment of body weight in normal individuals. In hospitalized patients, there are several equations that are used to estimate energy expenditure of obese patients, which include adjusting the body weight and modifying the overall energy requirements. Measurement of RMR can obviate the need for estimating energy expenditure. It is important to evaluate any energy‐expenditure equation that is used to estimate energy needs in normal people and hospitalized patients before applying it to patient care.
Gastrointestinal Manifestations of Food Allergies in Pediatric Patients
Authors: Garcia‐Careaga Manuel , Kerner John A.
Published: May 2008

Foods that account for 90% of allergic reactions in children are cow's milk protein, eggs, peanut, soy, tree nuts, fish, and wheat. Food allergy can manifest as urticaria/angioedema, anaphylaxis, atopic dermatitis, respiratory symptoms, or a gastrointestinal (GI) disorder. GI allergic manifestations can be classified as immunoglobulin E (IgE) mediated (immediate GI hypersensitivity and oral allergy syndrome); “mixed” GI allergy syndromes (involving some IgE components and some non‐IgE or T‐cell‐mediated components) include eosinophilic esophagitis and eosinophilic gastroenteritis. Non‐IgE‐mediated or T‐cell‐mediated allergic GI disorders include dietary protein enteropathy, protein‐induced enterocolitis, and proctitis. All these conditions share a common denominator: the response of the immune system to a specific protein leading to pathologic inflammatory changes in the GI tract. This immunological response can elicit symptoms such as diarrhea, vomiting, dysphagia, constipation, or GI blood loss, symptoms consistent with a GI disorder. The detection of food allergies can be accomplished by the use of radioallergosorbent (RAST) testing and skin prick tests in helping to assess the IgE‐mediated disorders. Patch tests may help evaluate delayed hypersensitivity reactions. Treatment of GI allergic disorders ranges from strict dietary elimination of offending food(s), use of protein hydrolysates, and use of l‐amino acid–based formula when protein hydrolysates fail. Treatment with topical (for eosinophilic esophagitis) or systemic steroids is used if all dietary measures are unsuccessful. Maternal breast feeding or the use from birth of hydrolysate formulas (extensive or partial hydrolysates) may be efficacious in the prevention of atopic disease in “high‐risk” families (with at least 1 parent or sibling with a history of atopic disease).
D‐Lactic Acidosis
Authors: Petersen Craig
Published: May 2008

d‐Lactic acidosis, also referred to as d‐lactate encephalopathy, is a rare neurologic syndrome that occurs in individuals with short bowel syndrome or following jejuno‐ileal bypass surgery. Symptoms typically present after the ingestion of high‐carbohydrate feedings. Neurologic symptoms include altered mental status, slurred speech, and ataxia, with patients often appearing drunk. Onset of neurologic symptoms is accompanied by metabolic acidosis and elevation of plasma d‐lactate concentration. In these patients, malabsorbed carbohydrate is fermented by an abnormal bacterial flora in the colon, which produces excessive amounts of d‐lactate. High amounts of d‐lactate are absorbed into the circulation, resulting in an elevated concentration of d‐lactate in the blood. Development of neurologic symptoms has been attributed to d‐lactate, but it is unclear if this is the cause or whether other factors are responsible. This review examines the pathophysiology of the production and accumulation of d‐lactate while exploring the potential factors contributing to the development of neurologic manifestations. Methods of diagnosis and treatment are reviewed. Areas requiring further investigation are identified.
Oxidative Stress and Antioxidant Capacity in Smoking and Nonsmoking Men With HIV/Acquired Immunodeficiency Syndrome
Authors: Cole Suzanne B. , Langkamp‐Henken Bobbi , Bender Bradley S. , Findley Kimberly , Herrlinger‐Garcia Kelli A. , Uphold Constance R.
Published: May 2008

Background: Past studies document decreased levels of antioxidants and selenium and increased levels of oxidative stress in people living with HIV/acquired immunodeficiency syndrome (AIDS). Cigarette smoking is another source of oxidative stress. Excessive oxidative stress can induce HIV replication, resulting in disease progression. The purpose of this study was to determine whether subjects with HIV/AIDS who smoke cigarettes have increased oxidative stress and decreased antioxidant status compared with nonsmokers with HIV/AIDS. Methods: Thirty‐one men with HIV/AIDS (adhering to highly active antiretroviral therapy for the previous 3 months) were recruited during regular visits to a Veterans Affairs Medical Center Infectious Disease Clinic in a southeastern US city. Plasma was obtained from a 1‐time blood draw for this comparison study. Plasma lipid peroxide (LPO) was used as a marker of oxidative stress. Indicators of antioxidant capacity included plasma glutathione peroxidase (GPx, the functional indicator of selenium status), vitamin C, and antioxidant potential (AOP). Results: Fifteen smokers and 10 nonsmokers with HIV/AIDS were enrolled. Median plasma LPO level was above the normal range of 0–1.3μ mol/L in both nonsmokers (2.5 [0–23.4] μmol/L, median [range]) and smokers (4.0 [0–47.5] μmol/L), but there was no difference between groups. Plasma GPx concentration was significantly lower in smokers (169 [118–295] μmol/min/L) compared with nonsmokers (197 [149–414] μmol/min/L). Vitamin C and AOP levels were not different between groups. Conclusions: This pilot study suggests that effects of smoking on oxidative stress are not additive, as no striking differences were observed in oxidative stress or antioxidant capacity between clinically stable smoking and nonsmoking men with HIV/AIDS.
Gluten‐Free Diet: The Medical and Nutrition Management of Celiac Disease
Authors: See Jacalyn , Murray Joseph A.
Published: May 2008

Celiac disease (CD) is a chronic disease causing inflammation of the proximal small intestine that occurs in genetically predisposed individuals when they eat gluten, which is the storage protein in wheat, barley, and rye. The disease injury usually resolves when gluten is excluded from the diet. Although the injury will heal, the reaction to gluten is permanent and will recur with the reintroduction of gluten. The condition is surprisingly common, affecting as many as 1% of white populations. The consequences of the disease are predominantly those of malnutrition due to maldigestion and malabsorption, such as diarrhea, weight loss, and anemia. Symptoms caused by inflammation of the small intestine are also common. CD, although it is common and its pathology is well understood, frequently goes undiagnosed, probably because of the nonspecific or vague nature of many of the symptoms that occur.

The cornerstone of treatment for CD is elimination of gluten from the diet. In most patients diagnosed with CD, a strict gluten‐free diet (GFD) alone should result in complete symptomatic and histologic resolution of the disease and reduce risk of complications. Noncompliance with diet is the leading cause of failure to respond in patients with CD. For these reasons, thorough assessment and counseling at the time of diagnosis and ongoing care are crucial. In this article, we address briefly what is known about the pathogenesis and diagnosis of CD and address its treatment in detail.
Acute Complications Associated with Bedside Placement of Feeding Tubes
Authors: Baskin William N.
Published: May 2008

Several types of feeding tubes can be placed at a patient's bedside; examples include nasogastric, nasointestinal, gastrostomy, and jejunostomy tubes. Nasoenteral tubes can be placed blindly at bedside or with the assistance of placement devices. Nasoenteric tubes can also be placed via fluoroscopy and endoscopy. Gastrostomy and jejunostomy tubes can be placed using endoscopic techniques. This paper will describe the indications and contraindications for different types of tubes that can be placed at the bedside and complications associated with tube placement. Complications associated with nasoenteral tubes include inadvertent malpositioning of the tube, epistaxis, sinusitis, inadvertent tube removal, tube clogging, tube‐feeding‐associated diarrhea, and aspiration pneumonia. Complications from percutaneous gastrostomy and jejunostomy tube placements include procedure‐related mishaps, site infection, leakage, buried bumper syndrome, tube malfunction, and inadvertent removal. These complications will be reviewed, along with a discussion of incidence, cause, treatment, and prevention approaches.
Guidelines for the Use of Orexigenic Drugs in Long‐Term Care
Authors: Thomas David R.
Published: May 2008

Undernutrition is defined as a state induced by nutrient deficiency that may be improved solely by administration of nutrients. By this definition, provision of adequate protein and energy sources should reverse the clinical presentation and correct the problem. However, a large number of patients who seem to be undernourished fail to respond to refeeding. A developing understanding of the acute‐phase inflammatory response to illness and the role of cytokines in the pathophysiology of chronic illness has challenged the current diagnostic paradigm of undernutrition. In the presence of adequate food, weight loss is most often due to cytokine‐associated cachexia and anorexia. Failure of appetite, or anorexia, may play a role in involuntary weight loss. Intervention for involuntary weight loss should aim first at the provision of adequate calories and protein, often in the form of high‐density nutrition supplements. However, cytokine‐mediated cachexia is remarkably resistant to hypercaloric feeding. With continued weight loss, the use of an orexigenic drug should be considered. Orexigenic drugs have been demonstrated to improve appetite and produce weight gain. The mechanism is unknown but may relate to suppression of proinflammatory cytokines. General guidelines for the use of orexigenic agents are presented. Although much work remains to be done, anticytokine drugs seem to be a promising avenue for the treatment of involuntary weight loss.
Food Chaining: A Systematic Approach for the Treatment of Children With Feeding Aversion
Authors: Fishbein Mark , Cox Sibyl , Swenny Cheryl , Mogren Chris , Walbert Laura , Fraker Cheri
Published: May 2008

Food chaining has been developed as a systematic method for the treatment of children with extreme food selectivity. Food chaining is an individualized, nonthreatening, home‐based feeding program designed to expand food repertoire by emphasizing similar features between accepted and targeted food items. This chart review illustrates the efficacy of food chaining in treating aversive feeding disorders.
Liver Disease and Osteoporosis
Authors: Sanchez Antonio J. , Aranda‐Michel Jaime
Published: May 2008

Metabolic bone disease (osteodystrophy) is an important complication of patients with chronic liver disease; its etiology is complex and multifactorial. Osteodystrophy is manifested as osteopenia/osteoporosis. Osteoporosis can predispose patients to bone fractures, increasing morbidity and mortality, especially after liver transplantation. Early evaluation, screening, and treatment of bone disorders in patients with liver disease are essential to minimize fracture risk and to improve clinical outcome and quality of life.
Examining the Role of Tube Feeding After Liver Transplantation
Authors: Hasse Jeanette M.
Published: May 2008

The rates of morbidity and mortality after liver transplantation are related to the degree of malnutrition. Because malnutrition is prevalent among liver transplant recipients, nutrition care practitioners must be aggressive in providing nutrition support to these patients in the perioperative period. Postoperative tube feeding (TF) has been studied for its role in improving short‐term posttransplant outcomes. This paper evaluates published research that studied postoperative TF in liver transplant recipients; the methodology and outcomes are reviewed and drawbacks of these studies are considered. Case studies of liver transplant patients who received postoperative TF illustrate the variability of patient profiles and posttransplant complications that influence the provision and duration of posttransplant TF.
Current Clinical Applications of Ω‐6 and Ω‐3 Fatty Acids
Authors: Lee Sang , Gura Kathleen M. , Kim Sendia , Arsenault Danielle A. , Bistrian Bruce R. , Puder Mark
Published: May 2008

Background: Recent years have brought a resurgence of research interest in fatty acids, with studied fields running the gamut of human disease. This movement has run in parallel with an increased interest in using nutrition modalities as therapeutic measures, as opposed to their conventional role as energy sources. The aim of this manuscript is to provide a basic review of current clinical applications of ω‐6 and ω‐3 fatty acids, with a particular focus on the latter. Methods: A selective review of the voluminous literature, including randomized controlled trials, meta‐analyses, population studies, and case reports, was used to compile data and identify trends in pertinent clinical applications of fatty acid therapy. Conclusions: There are a myriad of disorders and maladies that seem to benefit from fatty acid supplementation, specifically ω‐3 fatty acids. It has clearly been shown that ω‐3 fatty acid supplementation provides a protective benefit in heart disease, and in particular sudden cardiac death. Rheumatoid arthritis (RA) is another disease entity that has been proven to benefit from this nutrition intervention, with improvement in symptoms and diminished nonsteroidal antiinflammatory drug (NSAID) usage. In addition, many psychiatric disorders, particularly schizophrenia and major depressive disorder (MDD), have shown positive results when supplementation has been used as an adjunct to standard pharmacotherapy. The remainder of clinical applications for ω‐3 fatty acids requires further investigation. Specifically, according to preliminary clinical evidence, parenteral administration of fatty acids warrants further study.
The Use of IV Fat in Neonates
Authors: Kerner John A. , Poole Robert L.
Published: May 2008

IV fat emulsion (IVFE) is an integral part of the parenteral nutrition (PN) regimen in neonates. It provides a concentrated isotonic source of calories and prevents or reverses essential fatty acid deficiency. Continuous administration of IV fat with PN regimens prolongs the viability of peripheral IV lines in infants who might have limited venous access. IVFE must be administered separately from the PN solution in neonates. The acidic pH of a PN solution is necessary for maximum solubility of calcium and phosphorus. If fat emulsion is added to the PN solution, as is done in 3‐in‐1 (total nutrient admixture) solutions, the high amount of calcium and phosphorus needed by these infants may result in an unseen precipitate with serious consequences. Continuous fat infusion over 24 hours is the preferred method in neonates. The administration rate of 0.15 g/kg/hour for IVFE in the neonate should not be exceeded. Essential fatty acid deficiency can be prevented in neonates by providing IVFE in a dose of 0.5–1.0 g/kg/day. Carnitine is not routinely required to metabolize IVFE in the neonate. Infants should receive 20% lipid emulsion to improve clearance of triglycerides and cholesterol. Serum triglyceride levels should be maintained at <150–200 mg/dL in neonates. There are concerns about potential adverse effects of early administration of IV fat in very‐low‐birth‐weight infants weighing <800 g. We hold the IV fat dose at 1.0–1.5 g/kg/day until the second week of life in infants <30 weeks gestation.
Outcomes of Early Nutrition Support in Extremely Low‐Birth‐Weight Infants
Authors: Donovan Ramona , Puppala Bhagya , Angst Denise , Coyle Bryan W.
Published: May 2008

Background: Early nutrition intervention, both parenteral and enteral, is becoming a standard of care for the extremely low‐birth‐weight infant (ELBW; <1000 g) in many neonatal intensive care units (NICU) across the United States. However, there are no published or widely accepted guidelines regarding nutrition support strategies for this population. Most NICU clinicians have developed their own guidelines, so nutrition practices vary widely. In an effort to standardize our practice, we implemented nutrition support guidelines for ELBW infants, initiating both parenteral nutrition (PN) and minimal enteral feedings (MEFs) within the first 24 hours of life, whenever possible. The purpose of this study was 2‐fold: (1) to evaluate the adherence to the nutrition guidelines and (2) to compare pre‐ and postguideline outcomes such as time to regain birth weight, time to reach full enteral feedings, and average daily weight gains. Methods: The study was conducted at a level III NICU from January 2002 until February 2003. Charts of 70 infants with a birth weight ≤1250 g were reviewed as part of a quality‐assurance project to monitor adherence to the newly established guidelines. Another 23 charts of ELBW infants who were admitted and cared for in the NICU before the initiation of the nutrition guidelines were reviewed as a control group. Data collected from the charts included the hour of life PN and MEFs were started, the day of life infants reached full enteral feedings, infant weights for the first 4 weeks of life, incidence of early hyperglycemia, occurrence of necrotizing enterocolitis, and length of neonatal birth hospital stay. Student's t‐tests were used to compare clinical outcomes between infants receiving early nutrition support (≤24 hours of life) vs those who were started later. Results: Of eligible infants, 82.6% began receiving nutrition support within 24 hours of life. The average time to begin PN was 22 hours after the adoption of the guidelines vs 64.4 hours before guideline implementation (p < .01). In the postguideline group, MEFs were initiated at mean 27.1 hours of age vs 80.4 hours in the preguideline group (p < .01). Those who were started on early nutrition support reached full enteral feedings significantly sooner than those who received delayed nutrition support (12.7 days vs45.8 days; p < .01). Early nutrition support also resulted in earlier regain of birth weight (day 13.3 vs 15.4 days, p < .05). Although not statistically significant, infants who received earlier nutrition support showed trends toward greater overall weight gain in weeks 3 and 4 of life and a lower incidence of elevated serum blood glucose. Conclusions: The implementation of early nutrition support guidelines influenced the timeliness of initiating nutrition support in our unit. Early initiation of nutrition support in ELBW infants produces a rapid regain of initial weight loss, improves weight gain, and enhances earlier achievement of full enteral feedings.
Vanishing Bowel: A Therapeutic Challenge
Authors: Sandy Jessica E. , Lazar Linda F. , Helms Richard A.
Published: May 2008

“Vanishing bowel” has been rarely reported in the literature. This case and discussion are intended to describe the surgical, medical, and nutrition management of this unusual congenital abnormality. Of 3 reported cases surviving vanishing bowel, one had substantial residual small bowel, another had residual small bowel and bowel‐lengthening procedure, and one received an intestinal liver transplant. The patient presented in this case had residual small bowel and lengthening procedure. The patient described is well as of October 2005 (age 3.5 years), still receiving nocturnal parenteral nutrition (PN), but is eating solid foods without significant malabsorption or abdominal distention. He has experienced modest weight gain over the past 2 months.
Fostering Coping Skills and Resilience in Home Enteral Nutrition (HEN) Consumers
Authors: Thompson Cheryl W. , Durrant Lynne , Barusch Amanda , Olson Lenora
Published: May 2008

Background: Home enteral nutrition (HEN) is a lifesaving therapy that provides benefits along with countless challenges. This qualitative study examined how HEN consumers learned to cope successfully with HEN‐related challenges and uncovered how healthcare providers could help foster the process of coping in other HEN consumers. Methods: Twelve adult HEN consumers who perceived that they were coping successfully and overcoming the adversity associated with HEN, and met the criteria for resilience using the Resilience Scale, self‐selected for the study. Participants engaged in a series of 2 in‐depth interviews. Data were coded and analyzed using grounded theory methodology. Results: One overarching theme and 5 main categories emerged from the data, revealing that these individuals coped successfully with HEN by developing an attitude of personal responsibility to accept new life conditions, take charge of their own well‐being, seek and accept support, maximize independence and normality, and focus on the positive. In addition, these participants used a variety of problem‐ and emotion‐focused coping strategies and shared resilient characteristics such as self‐efficacy and perseverance. Conclusions: Implications for clinical practice and HEN education, along with suggestions for healthcare providers to foster coping with HEN are provided. An educational manual with self‐help suggestions for adult HEN consumers is also available at http://www.copingwell.com.
Reinstituting Oral Feeding in Tube‐Fed Adult Patients With Dysphagia
Authors: Crary Michael A. , Groher Michael E.
Published: May 2008

Feeding tubes are valuable assets in the rehabilitation of adult patients with dysphagia. Feeding tubes may be placed in response to perceived risks of airway compromise or insufficient nutrient intake. However, not all patients require long‐term enteral feeding. With intensive dysphagia therapy, many patients will experience resolving deficits or improvement in swallowing ability. These patients require an appropriate strategy to transition from tube to oral feeding. This article reviews some of the basic characteristics of dysphagia and identifies specific swallowing difficulties in 2 groups of patients who often benefit from temporary enteral feeding: stroke survivors and patients treated for head and neck cancer. Specific suggestions are offered for clinical strategies to reinstitute oral feeding in these groups of tube‐fed patients.
Intestinal Failure‐Associated Metabolic Bone Diseases and Response to Teriparatide
Authors: Pazianas Michael , Compher Charlene , Schiavone‐Gatto Phyllis , Kinosian Bruce P.
Published: May 2008

Patients requiring home parenteral nutrition (PN) may develop metabolic bone disease, the etiology of which can be multifactorial. We report a case of significantly low bone mass in a postmenopausal woman with history of short bowel syndrome, renal impairment, and previous radiation exposure who responded to intermittent subcutaneous administration of parathyroid hormone. Her bone mineral density normalized after she completed a course of 18 months of treatment, and a bone isotope scan was negative for skeletal malignancy.
Maladaptive Eating Patterns After Weight‐Loss Surgery
Authors: Rusch Mark D. , Andris Deborah
Published: May 2008

Weight‐loss surgery has been shown to contribute to the improved health and well‐being of the clinically severe obese, and for many has been seen as their“ last resort.” Although the majority of patients who choose this option as a means to achieve a healthier weight are successful, for some patients it is not beneficial. Bariatric surgery is not a panacea, and its immediate and long‐term success depends on the patient's ability to incorporate lifestyle and behavioral changes.

Patients who are not successful in achieving and maintaining their anticipated weight loss struggle to comply with diet, exercise, and vitamin regimens. Not only do these patients exhibit diminished weight loss, they have put themselves at risk for vitamin and mineral deficiencies and protein malnutrition. Their problematic response to weight‐loss surgery may or may not be due to a worsening of presurgical depression, binge eating, emotion‐triggered eating, body image, or eating behaviors associated with specific situations such as social events.

This paper describes clinical responses we have observed in our bariatric practice. Several case studies are presented to highlight problems we have encountered when following bariatric surgery patients in the early postoperative period, as well as in a long‐term setting. Recommendations are made for screening and follow‐up of at‐risk patients.
Diet Manuals to Practice Manuals: The Evolution of Nutrition Care
Authors: Chima Cinda S.
Published: May 2008

Although the role of nutrition as a therapy for the sick has been recognized for centuries, the science of nutrition is a relatively young discipline. The first modern attempt to document and standardize appropriate nutrition care was the diet manual. The evolution from “diet manual” to “practice manual” is less a change in purpose than an expansion of scope. This paper reviews the history of diet manuals in the United States, focusing on the evolution of nutrition therapy and the transformation of diet manuals into practice manuals for nutrition care providers. Included is a practice‐oriented summary of 7 diet manuals published by Cleveland Metropolitan General Hospital in Cleveland from 1939 to 1984, when the hospital began using nationally distributed practice manuals. These manuals exemplify changes in the practice of medicine and in the role of nutrition providers on the healthcare team. A review of the evolution of clinical decision‐making as documented in diet and practice manuals reflects increasing rigor in referencing scientific evidence. Nutrition therapies that seem quaint to us now reflect the traditional origins of many medical practices that persist today. Knowledge of this history should motivate us to critically evaluate the research base that supports all aspects of nutrition therapy, develop protocols to assess practices that remain unexamined, and embrace the discipline of evidence‐based practice.
Microbes and the Developing Gastrointestinal Tract
Authors: Neu Josef , Douglas‐Escobar Martha , Lopez Mariela
Published: May 2008

During the course of mammalian evolution, there has been a close relationship between microbes residing in the gastrointestinal (GI) tract and the mammalian host. Although the host provides the microbes with a warm environment and nutrients, they, in turn, undergo various metabolic processes that aid the host. The host has developed weapons against microbes that are considered foreign, as well as mechanisms to tolerate and live synergistically with most of the microbes in the GI tract. This relationship is proving to be important not only in the neonatal period and during infancy, but it is becoming increasingly evident that microbial colonization in early life may affect the individual's health throughout life. Here we will review this relationship in terms of health and disease, with a focus on the aspects of this relationship during maturation of the host.
Update on Enteral Nutrition Support for Cystic Fibrosis
Authors: Erskine Jamie M. , Lingard Catherine , Sontag Marci
Published: May 2008

Cystic fibrosis (CF) is an inherited disease affecting the respiratory, gastrointestinal, hepatobiliary, and reproductive systems. Nutrition status in persons with CF is often compromised due to increased energy needs, frequent infections, pancreatic insufficiency, lung disease, or CF‐related diabetes. Maintaining good nutrition status has been associated with better pulmonary function, reduced hospitalizations, and increased longevity. Nutrition support as oral supplementation (used in >37% of the CF population) or tube feeding (used in >13% of the CF population) is often required for children and adults with CF. The purpose of this update is to describe current consensus and evidence for enteral nutrition support guidelines, reported complications of enteral feeding in the CF population, evidence of expected outcomes, and to discuss related areas requiring further research. A case report is provided to illustrate potential outcomes of aggressive enteral support.
Use of Probiotics in Pediatrics: Rationale, Mechanisms of Action, and Practical Aspects
Authors: Saavedra Jose M.
Published: May 2008

The use of probiotics (ingested microbes that can modify intestinal microbial populations in a way that benefit the host) has moved from concept to actual demonstration of specific benefits by specific microorganisms for specific populations. It is increasingly clear that these benefits to the host are mostly mediated by the profound effect that intestinal microflora (microbiota) have on gut barrier function and host immune response.

Intestinal bacteria are more numerous than the human cells of the host that harbors them. Despite having many potential pathogens in this microflora, humans do not routinely get infected. It is no coincidence that gut‐associated immune tissue constitutes approximately 80% of all immunologically active cells in the human host. The gut interacts with intestinal bacteria, both resident and ingested, to develop protective mechanisms (via improving gut barrier function and immune stimulation for defense) and appropriate, nonexaggerated responses (via immune modulation and immune tolerance) to support host health. The mechanisms of this interaction between host and bacteria are increasingly being unraveled and in great part explain the clinical benefits that have been reported with specific probiotic bacteria by enhancing host defense mechanisms (such as for treatment and prevention of viral diarrhea and reducing risk of necrotizing enterocolitis), mitigating antibiotic‐associated diarrhea, and modulating host immune response (such as in allergic disease).
Peripherally Inserted Central Catheter Placement @ the Speed of Sound
Authors: Hunter Mark
Published: May 2008

Over the past few years, one of the major advancements in bedside peripherally inserted central catheter (PICC) placement has been the addition of portable ultrasound for vascular access. Traditional bedside PICC insertion success rates varied from 65% to 75% due to the limited visualized area of access available for PICC placement (1.5 inches above to 1.5 inches below the antecubital fossa). With the implementation of ultrasound, success rates have climbed to 91%–94% for bed‐side‐placed PICC. This article reviews the dynamics of ultrasound, provides practical tips to use image visualization, and illustrates the important key functions of this technology.
A Review of the Use of Handheld Computers in Medical Nutrition
Authors: Holubar Stefan , Harvey‐Banchik Lillian
Published: May 2008

Handheld computers, or personal digital assistants (PDAs), have been used to assist clinicians in medical nutrition since the early 1980s. The term PDA was originally applied to programmable calculators; over time, the capabilities of these devices were expanded to allow for the use of more complicated programs such as databases, spreadsheets, and electronic books. Slowly, the device evolved into what is more commonly thought of as a PDA, that is, a device such as a PalmOS (PalmSource, Inc, Tokyo, Japan) or PocketPC (Microsoft, Redmond, WA) unit. We present a review of the literature about the use of PDAs in medical nutrition, followed by a discussion of the different types of PDAs and mobile technologies that are commercially available. This is followed by a discussion of software applications that are currently available for use by nutrition clinicians, focusing on freeware applications. Finally, future technologies and applications are discussed.
Bedside Electromagnetic‐Guided Feeding Tube Placement: An Improvement Over Traditional Placement Technique?
Authors: Gray Rebecca , Tynan Cameo , Reed Lisa , Hasse Jeanette , Kramlich Mary , Roberts Susan , Suneson Judy , Thompson Jennifer , Neylon Jacquelyn
Published: May 2008

Background: Registered dietitian/registered nurse (RD/RN) teams were created to place small bowel feeding tubes (SBFT) at the bedside in intensive care unit (ICU) patients using an electromagnetic tube placement device (ETPD). The primary objective of this study was to evaluate the safety of placing feeding tubes at the ICU bedside using an ETPD. Secondary outcomes included success rate, cost, and timeliness of feeding initiation. Methods: Data were collected prospectively on 20 SBFT blind placements in ICU patients (control group). After implementing a protocol for RD/RN teams to place SBFTs with an ETPD, 81 SBFTs were placed (study group). Complications, success rate, number of x‐rays after tube placement, x‐ray cost, and time from physician order to initiation of feedings were compared between the groups. Results: No adverse events occurred in either group. Successful SBFT placement was 63% (12/19) in the control group and 78% (63/81) in the study group (not significant, NS). The median time between physician order for tube placement and feeding initiation decreased from 22.3 hours (control group) to 7.8 hours (study group, p = .003). The median number of x‐rays to confirm correct placement was 1 in the study group compared with 2 in the control group (p = .0001), resulting in a 50% decrease in the mean cost for x‐rays. Conclusions: No adverse events occurred with the implementation of bedside feeding tube placement using an ETPD. In addition, SBFT placement with an ETPD by designated ICU RD/RN teams resulted in lower x‐ray costs and more timely initiation of enteral feedings compared with blind placement.
Implementation of the Canadian Clinical Practice Guidelines for Nutrition Support: A Multiple Case Study of Barriers and Enablers
Authors: Jones Naomi E. , Suurdt Jeanette , Ouelette‐Kuntz Hélène , Heyland Daren K.
Published: May 2008

Background: The Canadian Nutrition Support Clinical Practice Guidelines (CPGs), published in 2003, were designed to improve nutrition support practices in intensivecare units (ICUs). However, their impact to date has been modest. This study aimed to identify important barriers and enablers to implementation of these guidelines. Methods: Case studies were completed at 4 Canadian ICUs. Semistructured interviews were conducted with 7 key informants at each site. During the interviews, the key informants were asked about their perceptions of the barriers and enablers to implementation of the Canadian Nutrition Support CPGs. Interview transcripts were analyzed qualitatively, using a framework approach. Results: Resistance to change, lack of awareness, lack of critical care experience, clinical condition of the patient, resource constraints, a slow administrative process, workload, numerous guidelines, complex recommendations, paucity of evidence, and outdated guidelines were cited as the main barriers to guideline implementation. Agreement of the ICU team, easy access to the guidelines, ease of application, incorporation into daily routine, education and training, the dietitian as an opinion leader, and open discussion were identified as the primary enabling factors. Although consistent across all sites, the influence of these factors seemed to differ by site and profession. Conclusions: Our findings suggest that implementation of the Canadian Nutrition Support CPGs is profoundly complex and is determined by practitioner, patient, institutional, and guideline factors. Further research is required to quantify the impact of each barrier and enabler and the mechanism by which they influence guideline adherence.
Therapeutic Efficacy of Intestinal and Multivisceral Transplantation: Survival and Nutrition Outcome
Authors: Matarese Laura E. , Costa Guilherme , Bond Geoffrey , Stamos June , Koritsky Darlene , O'Keefe Stephen J. D. , Abu‐Elmagd Kareem
Published: May 2008

The clinical introduction of intestinal transplantation has added a new dimension and offered a valid therapeutic option for patients with irreversible intestinal failure. In the year 2000, the Center for Medicare& Medicaid Services (CMS) recognized intestinal, combined liver‐intestinal, and multivisceral transplantation as the standard of care for patients with irreversible intestinal and parenteral nutrition (PN) failure. Accordingly, the indications for the procedure are currently limited to those who develop life‐threatening PN complications. However, a recent improvement in survival similar to other solid organ transplant recipients should justify lifting the current restricted criteria, and the procedure should be considered before the development of PN failure. Equally important is the awareness of the recent evolution in nutrition management and outcome after transplantation. Early and progressive enteral feeding using a complex polymeric formula is safe and effective after successful transplantation. Full nutrition autonomy is universally achievable among most intestinal and multivisceral recipients, with enjoyment of unrestricted oral diet. Such a therapeutic benefit is commonly maintained among long‐term survivors, with full rehabilitation and restoration of quality of life.
Pretransplant Obesity: A Weighty Issue Affecting Transplant Candidacy and Outcomes
Authors: Hasse Jeanette
Published: May 2008

Because of the global increase in prevalence of obesity, many more overweight and obese individuals are undergoing evaluation for transplantation than in the past. Although obesity seems to provide a survival benefit in dialysis patients, obesity has traditionally been considered a contraindication for transplantation of most organs. It is theorized that obesity will contribute to worse transplant outcomes, including lower rates of graft and patient survival and higher rates of delayed graft function and infection. This review evaluates the available literature evaluating outcomes of obese patients with end‐stage organ failure who undergo transplantation. Obesity seems to be associated with increased rates of wound infection after transplantation. However, other adverse transplant outcomes related to obesity seem to be dependent on the type of organ being transplanted and the degree of obesity. For example, a body mass index (BMI) of 30 kg/m2may reduce short‐term survival in lung transplant recipients; however, obesity does not seem to confer an adverse effect on short‐ or long‐term survival in liver transplant patients until a much higher BMI is reached (such as 35 or 40 kg/m2). Each transplant center must determine weight guidelines and criteria for identifying the level of obesity as a contraindication for transplantation. This must be based on organ type, each center's transplant and complication statistics, and available donor pools. Guidelines must also consider the morbidity and mortality risks of the obese patient with organ failure who does not receive a transplant.
Nutrition, Pregnancy, and Transplantation
Authors: McGrory Carolyn H. , Ondeck‐Williams Michele , Hilburt Nicole , Constantinescu Serban , Silva Patricio , Daller John A. , Coscia Lisa A. , Armenti Vincent T.
Published: May 2008

One benefit of transplantation, along with the restoration of health, is the opportunity for successful pregnancies. A growing number of pregnancies have been reported among all types of solid‐organ recipients. There is an increasing need for practice guidelines that include nutrition information in order to assist practitioners caring for and counseling these high‐risk patients. In the transplant community, guidelines for managing pregnancies in transplant recipients have been evolving but lack specific nutrition recommendations. As for all pregnancies, there is a need to optimize nutrition for the mother and her infant, with additional consideration given to the transplant recipient's graft. This article reviews outcomes of posttransplant pregnancies and management guidelines, with special emphasis on nutrition in this unique population.
A Pilot Study to Evaluate the Effectiveness of Glargine and Multiple Injections of Lispro in Patients With Type 2 Diabetes Receiving Tube Feedings in a Cardiovascular Intensive Care Unit
Authors: Grainger Angela , Eiden Kelly , Kemper Judy , Reeds Dominic
Published: May 2008

Background: The purpose of this study was to evaluate the effectiveness of insulin lispro and insulin glargine at controlling blood glucose in patients with type 2 diabetes mellitus in a cardiovascular intensive care unit (CICU) and receiving enteral tube feedings. Methods: This was a pilot study with a retrospective control designed to evaluate an insulin protocol in patients admitted to the CICU in a level 3 teaching institution. Patients were 18–99 years of age with type 2 diabetes mellitus, receiving bolus tube feeding. The control group included 24 patients who were retrospectively studied to determine mean blood glucose level. A glycemic management protocol was developed that included glargine and lispro insulins to maintain blood glucose levels between 80 and 140 mg/dL. The study group consisted of 28 patients who were treated according to the glycemic management protocol. Results: The mean blood glucose level of the retrospective control group was 225 mg/dL. The mean blood glucose level of the intervention group was 148 mg/dL. After protocol institution, 48.6% of blood glucose levels were within the goal blood glucose range of 80–140 mg/dL vs 8.26% (p = .01) before protocol institution. Hyperglycemia decreased from 90.0% to 47.2% (p < .0001) with institution of the protocol. Conclusions: The average blood glucose of the intervention group was slightly above the goal blood glucose range of 80–140 mg/dL; however, the study protocol was superior to the previous CICU blood glucose management protocol.
Outcomes Research in Specialized Nutrition Support
Authors: August David A. , Serrano Denise
Published: May 2008

Outcomes research can play an important role in the development and evolution of the specialty practice of nutrition support. This manuscript discusses the current state and future prospect of outcomes research in specialized nutrition support. It is concluded that there is an important role in the field for research that focuses on “what works, and what does not” in nutrition support practice.