bluuebunny/crossref_metadata_2025 huggingface dataset:
Effect of Intragastric pH on the Absorption of Oral Zinc Acetate and Zinc Oxide in Young Healthy Volunteers
Authors: Henderson Lisa M. , Brewer George J. , Dressman Jennifer B. , Swidan Sahar Z. , DuRoss Daniel J. , Adair Constance H. , Barnett Jeffrey L. , Berardi Rosemary R.
Published: May 2008

Background: Zinc is an important nutrient and is necessary to maintain a multitude of physiologic processes. Mineral supplements that provide physiologic doses of zinc may be used when dietary zinc is inadequate. Zinc is also used in pharmacologic doses to treat zinc deficiency and diseases such as Wilson's disease and acrodermatitis enteropathica. Although there are several zinc salts available, they are not equal in solubility, which is thought to be a key factor in zinc absorption. Moreover, the solubility of the salts is affected by pH, which may vary between pH 1 and 7 under various physiologic conditions in the stomach. The objectives of this 2‐way 4‐phase crossover study were to evaluate the effect of high (≥5) and low (≤3) intragastric pH on the absorption of zinc from the acetate and oxide salt in young healthy volunteers. Methods: After a 9‐hour fast, 10 healthy subjects (5 males and 5 females) were given a single oral dose of 50 mg of elemental zinc as the acetate or the oxide salt and under either high or low intragastric pH conditions. In all phases, a Heidelberg capsule pH detector‐transmitter was used to continuously monitor intragastric pH. During the high pH phases, single oral doses of famotidine 40 mg oral suspension were administered before the zinc to raise the intragastric pH above 5. Intragastric pH ≤ 3 was maintained in the low pH phases. Results: The mean plasma zinc area under the curve for zinc acetate at low pH (AL), zinc acetate at high pH (AH), zinc oxide at low pH (OL), and zinc oxide at high pH (OH) were 524, 378, 364, and 66 μg x h/dL, respectively. The highest zinc plasma concentrations occurred with the acetate salt at a low intragastric pH, while the lowest plasma concentrations occurred with the oxide salt at a high intragastric pH. The importance of pH to the dissolution of these salts was verified by in vitro tests. Twenty‐four‐hour urinary zinc excretion was the highest for the AL phase and lowest for the OH phase. Conclusion: This study indicates that intragastric pH and salt solubility‐dissolution are important in the oral absorption of zinc. Specifically, the oxide salt is not an appropriate zinc salt to use in those patients with elevated intragastric pH. (Journal of Parenteral and Enteral Nutrition 19:393–397, 1995)
Gastrointestinal Surface Protection and Mucosa Reconditioning
Authors: Bengmark Stig , Jeppsson Bengt
Published: May 2008

Background: There is increasing evidence that preservation of the ecology of the gastrointestinal tract and the surface protection system—surfactants, mucus, and fiber—is important for the outcome in postoperative trauma patients, patients after bone marrow and liver transplantation, and patients with HIV or AIDS. Approximately 50% of the nourishment of the small intestine and >80% of the nourishment of the large intestine comes from the lumen. This is especially deleterious to the large intestine. Within less than a week of intestinal starvation— even in the presence of intense parenteral nutrition—a mucosal atrophy is observed, promoting translocation of potentially pathogenic microorganisms. Enteral nutrition is crucial to the outcome in many of these conditions. If however, such a nutrition is based on simple carbohydrates, peptides, amino acids, or fatty acids, most of the nutrition administered will be absorbed in the upper gastrointestinal tract. Complex fibers and proteins can be regarded as nutrients especially destined to the lower gastrointestinal tract. They are fermented by the probiotic flora, normally colonizing the colonic mucosa, and the necessary nutrients: short‐chain fatty acids and amino acids such as arginine and glutamine are produced at the level of the colonic mucosa. Careless antibiotic treatment reduces or eliminates this flora, induces local mucosal starvation, and makes the patients vulnerable to opportunistic infections and microbial intestinal translocation. Methods and Results: In this review the role of the different ingredients of the surface protection system are discussed. A program to recondition the intestines, particularly the colonic mucosa by resupply of species‐specific lactobacilli, surfactants, amino acids (especially glutamine), and oat fiber (β‐glucans) is suggested. Extensive experience in animal models and early experience in a patient population are summarized and discussed. Oat has been chosen as a substrate for fermentation because it contains 100 times more of membrane lipids (surfactants) than any other food, has a favorable amino acid pattern (rich in glutamine), and is rich in water‐soluble, fermentable‐fiber β‐glucans. More than 1000 isolates of human‐specific lactobacilli have been studied. Some strains, especially those of plantarum type, have proven effective in colonizing the colonic mucosa, suppressing the potentially pathogenetic flora, and may have other probiotic effects as well. Conclusion: A totally new enteral formula has been designed based on probiotic bacteria and fiber and aimed at colonizing the intestinal mucosa with a local probiotic effect and fermentation of fiber. (Journal of Parenteral and Enteral Nutrition 19:410–415, 1995)
TPN‐Induced Sympathetic Activation Is Related to Diet, Bacterial Translocation, and an Intravenous Line HELTON WS, ROCKWELL M, GARCIA RM, ET AL: Arch Surg 130:209–214, 1995
Authors: Sax Harry C.
Published: May 2008

Total parenteral nutrition (TPN) has been associated with impaired immune response, breakdown in gut mucosal integrity, and the development of hepatic toxicity. Diet alone, however, may not account for increases in bacterial translocation (BT) and mucosal permeability.1,2 There is increasing recognition of the role of neural innervation of visceral organs such as the gut and the potential mediating effects of parenteral nutrition. Catecholamines, including epinephrine and norepinephrine, may be further inhibitory to immune function.3

Male Sprague‐Dawley rats were randomized to one of four groups: sham operation and food feeding (C); IV line, saline, and food feeding (S); IV TPN (T); or IV line and oral TPN (O). Urine was collected for catecholamine determination. On day 7, animals were killed, and mesenteric lymph nodes were cultured to assess BT.

Food‐fed animals (C) gained significantly more weight than either groups T or O despite isocaloric feeds. Animals with IV lines (S, T, and O) manifest BT at a rate of 40% to 50%, whereas animals with no lines had sterile lymph nodes. Both groups T and O had higher levels of catecholamine secretion; the presence of a central line alone minimally increased catecholamine levels.

Data were pooled to examine specific factors. The provision of TPN, whether via oral or IV routes significantly increased both norepinephrine and epinephrine secretion. When catecholamine secretion was correlated with BT, a twofold increase in norepinephrine output was noted in those animals with BT (126 ± 23 vs 64 ± 14 pmol/μmol creatinine, p <.05).
Improved Clinical Status and Length of Care With Low‐Fat Nutrition Support in Burn Patients
Authors: Garrel Dominique R. , Razi Mohammad , Larivière François , Jobin Nathalte , Naman Nazem , Emptoz‐Bonneton Agnes , Pugeat Michel M.
Published: May 2008

Background: The optimal amount and type of fat in the nutrition support of burned patients have not been determined. The aim of this study was to test low‐fat nutritional solutions, with or without fish oil, on protein metabolism, morbidity, and length of care in severely burned adults. Methods: In a prospective randomized clinical trial, 43 patients were assigned to one of the following groups: control (35% fat), low‐fat solution (ie, 15% of total calories as fat), low‐fat with fish oil, given for 30 days. Nitrogen balance, urinary 3‐methylhistidine excretion, urinary cortisol, and clinical status were measured daily. Corticosteroid‐binding globulin and total and free serum cortisol were measured every 3 days. Results: Compared with controls, patients on low‐fat support had fewer case of pneumonia: 3/24 vs 7/13 (p =.02), better respiratory and nutrition status, and shorter time to healing: 1.2 vs 1.8 days/% burned area (p = 0.01). There was no difference in nitrogen balance between groups, and 3‐methylhistidine excretion was higher and serum free cortisol was lower in low—fat—fed patients than in controls. There was no difference between the two low‐fat groups in any of the parameters measured. Conclusions: These study showed that low‐fat nutrition support decreases infectious morbidity and shortens length of stay in burn patients. Fish oil does not seem to add clinical benefit to low‐fat solutions. In addition, this study provides the first evidence that nutrition intervention modulates cortisol‐binding globulin and the concentration of free circulating cortisol after a severe stress. (Journal of Parenteral and Enteral Nutrition 19:482–491, 1995)
Glutamine Dipeptide—Supplemented Parenteral Nutrition Reverses Gut Atrophy, Disaccharidase Enzyme Activity, and Absorption in Rats
Authors: Schröder J. , Wardelmann E. , Winkler W. , Fandrich F. , Schweizer E. , Schroeder P.
Published: May 2008

Background: Total parenteral nutrition (TPN) is associated with intestinal atrophy and dysfunction possibly attributed to the absence of the nonessential amino acid glutamine from commercially available TPN solutions because of the instability of the monoamino acid during heat sterilization and storage. The use of stable dipeptides may overcome this problem. In this study we tested the hypothesis that glutamine dipeptide supplementation with alanyl‐L‐glutamine during TPN for 10 days would reverse small bowel atrophy and TPN‐induced dysfunction in rats. Methods: A conventional TPN solution (250 kcal/kg bw) was compared with an isocaloric and isonitrogenous TPN supplemented with alanyl‐L‐glutamine dipeptide. A food‐fed control group was included (n = 6 each group). Jejunum mucosal architecture, absorption of water and glucose, and disaccharidase activity of maltase and alkaline phosphatase were evaluated. Results: TPN‐induced villous atrophy, significantly reduced absorption rate, and decreased activity of villous enzymes, compared with the TPN group, could be reversed by supplementation of glutamine dipeptide alanyl‐L‐glutamine to parenteral nutrition solutions with no difference to the control group. Conclusions: Glutamine dipeptide‐enriched parenteral nutrition preserves mucosal structure and reversed atrophy‐associated dysfunction. (Journal of Parenteral and Enteral Nutrition 19:502–506, 1995)
Evaluation of Retinol, α‐Tocopherol, and Carotenoids in Serum of Men With Cancer of the Larynx Before and After Commercial Enteral Formula Feeding
Authors: Olmedilla Begona , Granado Fernando , Blanco Inmaculada , Rojas‐Hidalgo Enrique
Published: May 2008

Background: Both epidemiologic and in vitro studies have indicated the inverse correlation between intake and/or blood concentrations of different carotenoids, retinol, and tocoferol with different chronic and degenerative disturbances (cancer, cardiovascular diseases, cataracts, aging). The purpose of this study was to determine the fat‐soluble vitamin and carotenoid levels in men with recently diagnosed cancer of the larynx (n = 51) who had undergone total or partial laryngectomy and compare them with those of an age‐ and sex‐matched control group (n = 51). In addition, the effects of commercial enteral formula feeding were assessed in a subgroup of these patients (n = 35). Methods: A validated high‐performance liquid chromatography method was used to determine the concentrations of six carotenoids (lutein, zeaxanthin, β‐cryptoxanthin, lycopene, α‐carotene, and β‐carotene), retinol, and α‐tocopherol in serum. Commercial, rather than blender prepared, enteral formulas were supplied to the patients as the only food source for an average period of 12 days. The statistical analysis was based on non‐parametric methods (Mann‐Whitney and Wilcoxon). Results: The levels of all compounds analyzed were significantly lower in men with laryngeal cancer than in the control group. Retinol and tocopherol increased significantly after enteral formula feeding, although they continued to be significantly lower than those of the controls. The carotenoid levels decreased after enteral nutrition. Conclusions: The retinol and carotenoid concentrations should be monitored on a routine basis in these patients because of their relationship to this type of cancer. Moreover, it would be of interest to assess the effects of the addition of carotenoids to enteral formulas because they may offer protection from oxidative damage and potentiate the immune system. (journal of Parenteral and Enteral Nutrition 20:145–149, 1996)
Insulin‐Like Growth Factor‐I but Not Growth Hormone Attenuates Dexamethasone‐Induced Catabolism in Parenterally Fed Rats
Authors: Lo Hui‐Chen , Hinton Pamela S. , Huan Yang  , Unterman Terry G. , Ney Denise M.
Published: May 2008

Background: We demonstrated that recombinant human insulin‐like growth factor‐I (rhIGF‐I) or growth hormone (rhGH) produces identical body weight gain during total parenteral nutrition (TPN) in surgically‐stressed rats. Our current objective was to evaluate the relative anabolic and metabolic effects associated with administration of rhIGF‐I and/or rhGH during hypocaloric TPN in rats with dexamethasone (DEX)‐induced catabolism. Methods: Male Sprague‐Dawley rats (~270 g) given TPN and DEX were treated with IGF‐I and/or GH for 6 days. Two control groups, TPN and DEX, were included. Anabolic response was assessed by change in body protein content and nitrogen balance. Metabolic response was assessed by determination of serum concentrations of IGF‐1, IGF binding proteins (IGFBPs), insulin, glucose, triacylglycerol, glycerol, and free fatty acids. Results: Compared with GH, IGF‐I attenuated DEX‐induced loss of body protein and decreased serum concentrations of glucose, free fatty acids, glycerol, and triglycerol. Treatment with IGF‐I plus GH showed an anabolic response similar to IGF‐I alone. IGF‐I and/or GH increased serum concentrations of IGF‐I and IGFBP‐3. IGF‐I alone increased serum level of IGFBP‐5. Conclusion: Administration of IGF‐I, but not GH, attenuates DEX‐induced protein catabolism in association with increased insulin sensitivity in rats. Glucocorticoid excess may limit the response to GH therapy during TPN. (Journal of Parenteral and Enteral Nutrition 20: 171–177, 1996)
IV Chenodeoxycholate Prevents Calcium Bilirubinate Gallstones During Total Parenteral Nutrition in the Prairie Dog
Authors: Broughton George , Fitzgibbons Robert J. , Geiss Roger W. , Adrian Thomas E. , Anthone Gary
Published: May 2008

Background: The purpose of this study was to determine whether IV chenodeoxycholate (CDC) could prevent total parenteral nutrition (TPN)‐associated pigmented gallstones in the prairie dog. Methods: Twelve prairie dogs were divided into two equal groups, each receiving an identical TPN regimen. Each animal received 92 kcal/d with 61% of the calories from carbohydrate. The total volume of infusate delivered to each animal was 59 mUd. Animals in one group, termed the TPN + CDC group, received a daily bolus injection of CDC at a dose of 15 mg/kg. Prairie dogs in the second group, termed the TPN group, received water (vehicle carrier) 1 mL/kg/d. The TPN and TPN + CDC groups received TPN for 40.3 ± 1.3 and 42.5 ± 0.6 days, respectively. Results: There was no statistical difference in the initial and final weights between the two groups. None of the TPN + CDC‐treated animals had gallstones or calcium bilirubinate crystals. In contrast, all of the TPN‐treated animals had calcium bilirubinate crystals (p =.002), and five of six had macroscopic black pigmented gallstones (p =.015). Cholesterol crystals were not observed in either group of animals. The amount of biliary bilirubin and ionized calcium was significantly greater in the TPN group (both P <.001); however, both groups had a similar total biliary calcium concentration. Conclusion: IV CDC is effective in preventing TPN‐associated gallstones in the prairie dog. (Journal of Parenteral and Enteral Nutrition 20:187–193, 1996)
Significance of Nucleosides and a Nucleotide Mixture Infusion on Hepatic Energy Metabolism of 70% Hepatectomized Rabbits in Postoperative Phase
Authors: Jin Maeng Bong , Yamaguchi Tetsuya , Shimahara Yasuyuki , Ichimiya Masato , Kinoshita Kolichi , Oka Takahiro , Ozawa Kazue , Yamaoka Yoshio
Published: May 2008

Background: The influence of administration of a nucleoside‐nucleotide mixture on hepatic energy metabolism was investigated in 70% hepatectomized rabbits from 48 to 72 hours after hepatectomy. Methods: From 48 to 72 hours after hepatectomy, animals underwent continuous IV infusion of 2 mL/kg body weight/h of 9 g/LNaCl (group S), 5.99 mmol/Lnucleoside‐nucleotide mixture (group N1) or 11.98 mmol/L nucleoside‐nucleotide mixture (group N2). Results: At 72 hours, there was no significant difference in the hepatic adenylate energy charge among groups (S, 0.84 ± 0.01; N1, 0.82 ± 0.02; N2, 0.85 ± 0.01). The hepatic mitochondrial phosphorylation rate was 66.9 ± 2.5, 76.3 ± 11.1, and 108.4 ± 14.1 nmol ATP/mg mitochondrial protein/ min in groups S, N1, and N2, respectively. The value of group N2 was significantly higher than the value of group S (p <.01). In addition, DNA concentration of the remnant liver was 2.27 ± 0.07, 2.56 ± 0.17, and 3.19 ± 0.42 mg/g wet liver in groups S, N1, and N2, respectively, showing a significant increase in group N2 compared with group S (p <.05). Conclusion: A continuous IV infusion of a nucleoside‐nucleotide mixture to 70% hepatectomized rabbits from 48 to 72 hours after hepatectomy prolonged an enhancement of the hepatic mitochondrial phosphorylation rate and elevated DNA content of the remnant liver. (journal of Parenteral and Enteral Nutrition 20:211–214, 1996)
Single‐Stage Percutaneous Gastrostomy Button Insertion: A Leap Forward
Authors: Griffiths M.
Published: May 2008

Background: Gastrostomy buttons are widely used in adults and children with neurologic and nutritional problems. Methods: The development of the Medicina gastrostomy button (which uses a Foley‐type balloon for retention) and the Cope needle (for controlling the stomach) has allowed the development of a single‐stage percutaneous technique for gastrostomy button insertion rather than the two‐stage technique currently used. Results: Seven patients (aged 1 to 14 years) had a percutaneous gastrostomy button inserted with no mortality and only minor morbidity. No balloon failed. Conclusion: This technique is safe and avoids the potential morbidity of a second anesthetic in this high‐risk group of patients. (Journal of Parenteral and Enteral Nutrition 20:237–239, 1996)
Metabolic and Respiratory Effects of Sodium Lactate During Short IV Nutrition in Critically III Patients
Authors: Chioléro René , Schneiter Philippe , Cayeux Christine , Temler Evelyne , Jéquier Eric , Schindler Charles , Tappy Luc
Published: May 2008

Background: Hyperglycemia and an increased ventilatory demand secondary to an increased CO2 production are frequent undesirable effects of total parenteral nutrition (TPN) in critically ill patients. This study was performed to assess whether sodium lactate as a metabolic substrate may affect these variables. Methods: Five male patients with multiple trauma during the flow phase were studied during two consecutive 3‐hour periods of isocaloric (1.1 x resting energy expenditure) TPN. Sixty‐five percent of total calories was provided as carbohydrate, 15% as lipids, and 20% as amino acids during the first period (TPN‐glucose), whereas 35% carbohydrate, 30% lactate, 20% lipids, and 15% amino acids (TPN‐lactate) were substituted during the second period. Respiratory gas exchanges and net substrate oxidation were assessed by means of indirect calorimetry. Glucose kinetics was determined by primed‐constant infusion of U‐13C glucose. Results: Compared with TPN‐glucose, TPN‐lactate decreased glycemia by 20%, insulinemia by 43%, net carbohydrate oxidation (assessed from indirect calorimetry) by 34%, and plasma glucose oxidation (assessed from 13CO2) by 54%. Respiratory oxygen exchanges were increased by 3.7% due to a 20% thermic effect of lactate, but respiratory CO2 exchanges did not change. Pao2 decreased by 11.3 mm Hg, indicating that the increased O2 consumption was not matched by an appropriate increase in spontaneous ventilation. Arterial pH increased from 7.41 ± 0.04 to 7.46 ± 0.05. Conclusion: Sodium lactate as a metabolic substrate limits hyperglycemia but induces metabolic alkalosis and does not spare the ventilatory demand. (Journal of Parenteral and Enteral Nutrition 20:257–263, 1996)
Reducing the Inappropriate Use of Parenteral Nutrition in an Acute Care Teaching Hospital
Authors: Maurer James , Weinbaum Fred , Turner James , Brady Terrence , Pistone Barbara , D'Addario Virginia , Lun Wing , Ghazali Baseth
Published: May 2008

Background: Parenteral nutrition (PN) is a form of nutrition that can be life‐saving, but its use has inherent risks and it is expensive. Nutrition support teams have been shown to reduce both the rate of complications and excessive use of PN. Methods: Criteria were established to evaluate the appropriateness of PN use in a 487‐bed community teaching hospital. A prospective study of 50 consecutive patients, who received either central or peripheral PN, was conducted. Results: The 50 patients received 469 days of PN. We found that 233 (49.7%) of the 469 days of PN were avoidable. This resulted in the creation of a formal approval process that required prior approval by a physician‐directed multidisciplinary advisory committee before PN could be instituted. The amount of PN subsequently decreased from 500 patient days of PN per month to less than 100. Conclusions: This study supports the idea that inappropriate use of PN can be reduced by physician education plus the continuing oversight of a physician‐directed multidisciplinary advisory group. (Journal of Parenteral and Enteral Nutrition 20 :272–274, 1996)
Effects of In‐Line Filtration on Lipid Particle Size Distribution in Total Nutrient Admixtures
Authors: Driscoll David F. , Bacon Marc N. , Bistrian Bruce R.
Published: May 2008

Background: The recent Food and Drug Administration Safety Alert recommends in‐line filtration for all total parenteral nutrition admixtures. Although rigid crystalline particulates can be effectively removed by in‐line filters, the fate of flexible lipid droplets (LDs) enlarged through electromechanical destabilization is less clear. Lipid globules > 5 μm could lodge in the pulmonary microvasculature and produce an embolic syndrome. Recent evidence suggests that TNAs (Total Nutrient Admixtures) with LDs of 5 μm or more constituting >0.4% of the final fat concentration are unstable. Methods: Six pairs of 1.5‐L TNA dispersions of varying degrees of stability were prepared in duplicate (n = 12) and studied over 30 hours. The number of enlarged fat globules was assessed by laser light extinction for all LDs ≥ 1.75 μm at 0, 6, 24, and 30 hours after preparation. After LD assessments at time 0, admixtures were placed in a temperature‐controlled chamber at 25°C ± 0.1°C. At 6 hours, a simulated patient infusion was begun using a 1.2‐μm filter at a continuous flow rate of 55 mL/h. Pre‐ and postfiltration samples were taken at 6, 24, and 30 hours, equal to times 0, 18, and 24 hours of the simulated infusion. A repeated measure two‐way analysis of variance assessing treatment and time was performed. Dependent variable analyses included number‐weighting of fat globules as >5 μm (LD1), total number ≥ 1.75 μm (LD2), LD1‐LD2 ratio (as %), and volume‐weighted percent of fat (PFAT) > 5 μm. Results: In all cases, time was a significant factor and was an expected finding as the stability of all extemporaneously prepared admixtures deteriorates with time. Of the number‐weighted variables, a significant postfiltrate reduction was observed in LD1 (p =.041), LD2 (p <.001), and LD1‐LD2 ratio (p <.0001). Of greatest clinical importance, the volume‐weighted PFAT > 5 μm was significantly reduced by the in‐line filter (p =.029). Conclusions: The TNA1 1.2‐μm filter significantly reduced the total number and concentration of enlarged fat globules. The higher LD1‐LD2 ratio may reflect the effects of filtration on electrically destabilized fat globules. However, total exposure to unstable and very large LDs was significantly reduced, suggesting that in‐line TNA filtration should be a standard part of nutrition therapy. (Journal of Parenteral and Enteral Nutrition 20:296–301, 1996)
Gastroduodenal Motility in Mechanically Ventilated Critically III Patients: A Manometric Study A DIVE, M MOULART, P JONARD, ET AL Crit Care Med 22:441–447, 1994
Authors: Kearns Patrick J.
Published: May 2008

This study determines characteristics of gastroduodenal motility in mechanically ventilated, critically ill patients. A multilumen perfused catheter pressure monitoring technique was used. Twelve patients and 12 volunteers were compared. All subjects fasted, and patients were mechanically ventilated receiving various medications. Characteristics evaluated include occurrence of activity fronts progressing along the antroduodenum, duration of migrating motor complex, relative contribution of three phases of motor activity to cycle length, propagation characteristics of the activity front, and total number of contractions. The measurements revealed 1.5 antral activity fronts in control and 0 in ventilated patients. Phase 3 activity was comparable in controls and patients in the duodenum. Occurrence of activity fronts demonstrated greater regularity in control. The conclusions are that motility is severely impaired in this group of mechanically ventilated patients. Activity fronts failed to originate in the stomach. The loss of peristaltic activity in the stomach may have important implications for occurrence of microbial overgrowth in mechanically ventilated patients.
Assessment of Involuntary Muscle Function in Patients After Critical Injury or Severe Sepsis
Authors: Finn Patrick J. , Plank Lindsay D. , Clark Matthew A. , Connolly Andrew B. , Hill Graham L.
Published: May 2008

Background: Study of involuntary skeletal muscle function (MFA) has been well accepted in the area of nutrition assessment and potentially offers a means for following progress of the critically ill patient. We report on the application of this technique to intensive care patients. Methods: MFA was performed by study of the contraction/relaxation characteristics of the adductor pollicis muscle of the thumb after ulnar nerve stimulation. Serial measurements were made in 16 critically injured patients and 28 patients with severe sepsis and were compared with those obtained from 26 control subjects. Extent of loss of total body protein (TBP) was quantified with in vivo neutron activation. Results: Significant difficulties exist in applying this technique to intensive care patients. In the critically injured, only five acceptable traces could be obtained from a possible 58 measurements. For patients with severe sepsis it was possible to obtain an acceptable trace on 12 of 56 occasions. Neuromuscular blockade and lack of patient cooperation were significant impediments to MFA study. Although frequently perceived as unpleasant by these patients, there was no long‐term morbidity associated with MFA. No significant differences were seen in maximal relaxation rate at 30 Hz (MMR30) or force frequency ratios (F10/50 and F30/ 50) between trauma patients and controls. In the sepsis patient group, a significantly higher F10/50 was measured (52% ± 3% severe sepsis vs 40% ± 1% control subjects, p <.01). Six patients had MFA measured approximately 21 days after the illness, by which stage they had lost 11% of their initial TBP Compared with control subjects, no significant differences were observed in MRR30 or F30/50, whereas a higher value for F10/50 was measured (48% ± 1% critical illness vs 40% ± 1% control subjects, p <.01). Conclusions: The MFA technique is difficult to apply to intensive care patients. No significant disturbance to MFA is seen after critical injury. Severe sepsis results in an elevation of F10/ 50 only. When able to be obtained, MFA results do not reflect the extent of proteolysis but are indicative of the state of cellular energetics. (Journal of Parenteral and Enteral Nutrition 20:332–337, 1996)
Luminal Short‐Chain Fatty Acids and Postresection Intestinal Adaptation
Authors: Thompson Jon S. , Qugley Eamonn M. , Palmer J.M. , West William W. , Adrian Thomas E.
Published: May 2008

Background: Short‐chain fatty acids (SCFAs) reportedly have a trophic effect on the small intestine. However, it is unclear if this is a local or primarily systemic effect. Loss of the ileocolonic junction (ICJ) may result in increased SCFAs and bacteria in the small intestine from colonic reflux. Our aim was to evaluate the effect of bypass of the ICJ on intestinal SCFA content and postresection adaptation. Methods: Thirty dogs were studied : transection control (TC, n = 10), distal resection of 50% in testine (DR, n = 10), and distal resection with bypass of ICJ (DRBP, n = 10). Animals were killed at 4 and 12 weeks. Luminal SCFAs and bacteria and adaptation of the small intestine were evaluated. Results: Caloric intake was significantly less in the two resected groups (67 ± 3 DR and 63 ± 3, DRBP vs 78 ± 5 kcal/kgl d TC, p <.05). Body weight and albumin levels were decreased at 12 weeks but were similar between the resected groups (81% ± 3% and 74% ± 6% initial and 1.9 ± 0.1 and 2.1 ± 0.2 g/dL, DR and DRBP, respectively). Steatorrhea was present for 12 weeks after resection and was greater after DRBP (14.2% ± 3.8% vs 8.6% ± 1.9% at 4 weeks and 13.6% ± 2.5% vs 6.7% ± 0.6% at 12 weeks, p <.05). Bypassed animals had elevated intraluminal SCFA content (3126 ± 1094 vs 1791 ± 538 DR and 1600 ± 446 μg/mL TC, p <.05) and anaerobic bacterial counts (100% vs 50% and 44%, respectively). Tissue inflammation and myeloperoxidase activity were similar. Small intestinal length (174 ± 10 and 180 ± 10 cm) and circumference (5.2 ± 0.4 and 5.2 ± 0.3 cm) increased to a similar extent in both resected groups at 12 weeks. Thickness of mucosa (1939 ± 162 vs 1662 ± 162 μm) and muscle (865 ± 45 vs 978 ± 79 [μm) layers were similar after DR and DRBP. Conclusion: (1) Bypass of the ICJ after distal resection results in increased growth of anaerobic bacteria and luminal SCFA and is associated with more marked steatorrhea. (2) Bypass of the ICJ does not influence structural adaptation of the small intestine. (3) These findings do not support a local trophic effect for SCFA. (Journal of Parenteral and Enteral Nutrition 20:338–343, 1996)
Sequential Changes in Insulin‐Like Growth Factor 1, Plasma Proteins, and Total Body Protein in Severe Sepsis and Multiple Injury
Authors: Clark Matthew A. , Hentzen Bianca T.H. , Plank Lindsay D. , Hill Graham L.
Published: May 2008

Background: Our group wanted to test the hypothesis that plasma levels of insulin‐like growth factor 1 (IGF‐1), transferrin, and prealbumin are useful markers of nutritional progress in severe sepsis and multiple injury. Methods: Measurements of IGF‐1 and plasma proteins were made in critically ill patients as soon as they were hemodynamically stable and 5, 10, 15, and 21 days later. The magnitude and direction of the measured changes were compared with the magnitude and direction of the change in total body protein in the same time period. Results: Fourteen patients with severe sepsis and 10 multiply injured patients were studied. As a group they had an increased metabolic expenditure that peaked at 153% of normal and lost ~12.0% of total body protein. An early fall in IGF‐1 and plasma proteins accompanied a marked acute phase response, and recovery occurred while hypermetabolism and net proteolysis continued. No correlation existed between changes in IGF‐1 or plasma proteins and the change in total body protein. Conclusions: Plasma levels of IGF‐1, transferrin, and prealbumin are not useful for following changes in protein stores early in the course of critical illness. (Journal of Parenteral and Enteral Nutrition 20:363–370, 1996)
New Treatment for Patients With Short‐Bowel Syndrome: Growth Hormone, Glutamine and a Modified Diet T. A. BYRNE, R. L. PERSINGER, L. S. YOUNG, ET AL Ann Surg 222.‐243–255, 1995
Authors: Sax Harry C.
Published: May 2008

After massive enterectomy, the remnant bowel must undergo both morphologic and physiologic adaptation if the patient is to wean to volitional enteral support. Those patients who are unable to adapt require long‐term total parenteral nutrition (TPN) with its concomitant high cost and metabolic anomalies. Previously, it was believed that adaptation ceased after a period of 1 to 2 years. In 1992, Byrne et al presented the theory that further adaptation could be elicited in a group of 8 patients who had been on TPN for up to 6 years by treatment with a combination of growth hormone, free glutamine, and a diet high in fiber and low in fat.1 This paper did not delineate the specific mechanisms or present long‐term results. The current study involves 47 patients with short‐bowel syndrome dependent on TPN for an average of 6 years. Average age was 46 with a mean jejunoileal length of 50 ± 7 cm. Half of the patients had <35 cm of small bowel. Etiologies included volvulus, SMA thromboses, or adhesions in the vast majority. Eleven patients had Crohn's disease. All but four patients had at least some colon or rectum remaining in the circuit.

Patients were admitted to an inpatient residential environment (the Nutritional Restart Center), where baseline studies of nutrient balance were obtained on the patient's normal intake. They were then placed on a diet high in complex carbohydrates and low in fat for the next 3 weeks. Feedings were divided into six equal parts and isotonic fluids were allowed ad libitum. Groups were also randomized to receive human growth hormone, 0.14 mg/kg/d, or enteral glutamine, 0.6 mg/ kg/d, or both. At the conclusion of the 4‐week stay, patients were discharged on only the diet and supplemental glutamine.

The combination of growth hormone, glutamine, and the diet led to a near 40% improvement in daily nitrogen balance and a 33% decrease in stool weight. Sodium balance was similarly improved, although this may reflect growth hormone's effect on water retention. Twenty‐seven patients were able to eventually be weaned off TPN. There was no significant difference in small bowel length or the presence or absence of colon compared with those patients who still required TPN. Eight patients eventually required reinstitution of TPN over the long term, usually due to recurrence of previously quiescent inflammatory bowel disease or dietary noncompliance. Nonetheless, 60% of patients remained either completely free of TPN or required TPN at a lower rate.

Nutritional indices were not changed. Serum albumin remained in the 3.6 to 3.8 range in all groups, both at baseline and after the period of intervention. Weight remained stable, except for the eight patients requiring continued TPN who showed an average of a 2‐kg weight loss. Cost savings even in those patients who could not be completely weaned from TPN averaged $80,000 per year. This is exclusive of the cost of the diet or supplemental growth hormone and glutamine.
Alanyl‐Glutamine‐Supplemented Total Parenteral Nutrition Improves Survival and Protein Metabolism in Rat Protracted Bacterial Peritonitis Model
Authors: Naka Shuji , Saito Hideaki , Hashiguchi Yojiro , Lin Ming‐Tsan , Furukawa Satoshi , Inaba Tsuyoshi , Fukushima Ryoji , Wada Nobuaki , Muto Tetsuichiro
Published: May 2008

Background: The effects of glutamine‐enriched total parenteral nutrition (TPN) solution on survival, and protein turnover in the whole body and in individual organs were investigated in a rat protracted peritonitis model. Methods: Twenty‐three rats underwent venous catheter insertion. Osmotic pumps were implanted in the peritoneal cavity to allow continuous delivery of Escherichia coli (4 × 108 CFU/d). The conventional TPN group received a conventional amino acid solution. The Ala‐Gln TPN group received an alanyl‐glutamine‐enriched TPN solution. The two TPN solutions were isocaloric and isonitrogenous. Results: Over the 5 days of TPN treatment, the survival rate of the Ala‐Gln group was significantly higher than that of the conventional group. The Ala‐Gln group tended to have increased whole‐body protein turnover compared with the conventional group. Fractional protein synthetic rates (FSR) in the liver and gastrocnemius muscle of the Ala‐Gln group were significantly higher than those of the conventional group. The serum glutamine concentration correlated positively with the FSR of both liver and muscle. The Ala‐Gln group showed significantly greater mucosal height and mitoses per crypt, in the small intestine, than did the conventional group. Conclusions: Our results suggested that, in comparison with standard glutamine‐free TPN, Ala‐Gln‐supplemented TPN increases protein synthesis in the liver and skeletal muscle, protects the morphology of the intestinal mucosa, and improves survival in protracted bacterial peritonitis. Ala‐Gln supplementation may be useful in septic patients. (Journal of Parenteral and Enteral Nutrition 20:417–423, 1996)
Albumin Kinetics in Hypoalbuminemic Patients Receiving Total Parenteral Nutrition
Authors: Spiess Anita , Mikalunas Vida , Carlson Stephen , Zimmer Michael , Craig Robert M.
Published: May 2008

Background: By using undenatured purified albumin preparations radiolabeled with iodine, the half‐life of serum albumin in well patients who are stable is known to be approximately 17 days. However, when a patient is suffering with an acute illness such as sepsis, trauma, burns or after an extensive operative procedure, the serum albumin level decreases. It is not known whether this fall in serum albumin is due to increased catabolism, decreased synthesis, or a combination of both factors. This study explores the kinetics of albumin catabolism under these circumstances to clarify the issue. Methods: 125I‐labeled albumin was administered intravenously to 10 critically ill, hypoalbuminemic patients receiving total parenteral nutrition (TPN). Each subject had frequent blood samples taken for at least 10 days to measure the decline of plasma radioactivity over time. None was receiving unlabeled albumin during the investigation. It was assumed that the plasma decay would follow first‐order kinetics after the early equilibration phase. Radioactivity of heparinized blood samples (counts/2 mL sample) were counted and the results were graphically expressed. Results: One subject was not evaluated because he was discharged on the 8th day. The APACHE (acute physiology and chronic health evaluation) score for the other nine subjects ranged from 4 to 18 (mean, 7.5). The serum albumin remained below 3.0 g/dL in each subject and did not change statistically throughout the study. The radioiodinated albumin half‐life ranged from 5.52 to 11.76 days (mean 9.10 days; compared with published normal of approximately 17 days). The equilibration time was 3 to 7 days. The average albumin catabolized for this group is similar to previously reported normal subjects, 0.18 g/kg/d. Conclusion: Hypoalbuminemic patients receiving TPN have markedly shortened plasma albumin half‐lives, but the albumin catabolized per day is similar to normal patients. These data argue for both a synthetic and catabolic defect that explains the hypoalbuminemia in this patient group. (Journal of Parenteral and Enteral Nutrition 20:424–428, 1996)
Hyperkalemia Secondary to Concurrent Pharmacotherapy in a Patient Receiving Home Parenteral Nutrition
Authors: Brown Rex O. , Hamrick Karen D. , Dickerson Roland N. , Lee Nancy , Parnell Donald H. , Kudsk Kenneth A.
Published: May 2008

We report a case of probable combined octreotide‐and heparin‐induced hyperkalemia. The patient had been receiving home parenteral nutrition, enoxaparin, and octreotide for 10 months. She required very little potassium in her PN solution to maintain serum potassium concentrations in the normal range. The patient reportedly did not receive other medications or have clinical conditions that, to our knowledge, cause hyperkalemia. She maintained normal renal function throughout the hospitalization and did not appear to have any significant acid‐base disorders. Practitioners should be aware of the potential for octreotide and heparin to cause hyperkalemia. Regular monitoring of serum potassium concentrations should be done for patients receiving octreotide and heparin to avoid hyperkalemia.(Journal of Parenteral and Enteral Nutrition20:429–432, 1996)
Peritoneal Leakage of Gastric Contents, A Rare Complication of Percutaneous Endoscopic Gastrostomy
Authors: Haslam N. , Hughes S. , Harrison R.F.
Published: May 2008

Background: A 94‐year‐old man underwent a routine percutaneous endoscopic gastrostomy but 7 days later developed abdominal pain and died of a previously unreported late complication. Methods: A case report of the main clinical and pathological findings and a brief discussion of the significance of the case. Results: Postmortem examination revealed a chemical peritonitis due to leakage of 2.8 L of formula into the peritoneal cavity through an enlarged gastrostomy hole around a correctly positioned tube. Conclusion: This is a previously unreported complication that occurred because of repeated pulling on the tube by a confused patient, causing a loss of the usual apposition of the gastric and the anterior abdominal walls. The importance of the case is to emphasize that late, even fatal, complications can occur until a permanent fibrous tract has been formed between the skin and the gastric wall. (Journal of Parenteral and Enteral Nutrition 20:433–434, 1996)
Gastrointestinal, Hepatic, and Metabolic Effects of Enteral and Parenteral Nutrition in Rats Infused With Tumor Necrosis Factor
Authors: Raina Nilima , Cameron Ross G. , Jeejeebhoy Khursheed N.
Published: May 2008

Background: We previously showed that continuous infusion of tumor necrosis factor‐α (TNF‐α) in orally fed rats caused weight and muscle wasting mainly because of anorexia. However, when we tried to prevent weight loss by giving total parenteral nutrition (TPN), TNF‐infused rats developed hyperglycemia, azotemia, and hepatic abnormalities. The present study was designed to determine whether the enteral (ENT) feeding resulted in fewer complications than parenteral (TPN) feeding in TNF‐infused rats (100 μg/kg/d). Methods: Forty‐two rats were randomly allocated to four groups as follows: controls: TPN and ENT, and TNF‐infused: TPN + TNF and ENT + TNF. All groups received the same liquid defined formula diet either enterally or parenterally (isocaloric and isonitrogenous). Twenty‐six rats were used for studies of body composition and metabolism and 16 for vascular permeability. Results: TPN + TNF and ENT + TNF rats showed significantly increased liver weights and significantly reduced carcass weights compared with controls. A significant reduction in the muscle weights and total protein, as well as hyperglycemia, azotemia, and abnormal liver enzymes was also seen in ENT+TNF rats compared with ENT rats. The gastric and small intestinal mucosa was inflamed in the ENT+TNF but not in the ENT, TPN+TNF, and TPN rats. The plasma TNF levels determined by bioassay were significantly increased in the TPN + TNF and ENT+TNF rats compared with controls. There was increased vascular permeability in the stomach and small and large intestine in the ENT+TNF rats compared with ENT rats. No significant changes in vascular permeability were seen in TPN and TPN+TNF rats. Conclusions: ENT, but not TPN, resulted in prominent changes in the body composition and marked metabolic effects in the TNF‐infused rats. (Journal of Parenteral and Enteral Nutrition 21:007–013, 1997)
Efficacy of Different Triglycerides in Total Parenteral Nutrition for Preventing Atrophy of the Gut in Traumatized Rats
Authors: Linseisen Jakob , Wolfram Günther
Published: May 2008

Background:The efficacy of different fat emulsions as components of a total parenteral nutrition (TPN) regimen on the integrity of the gut was assessed in traumatized rats. With the release of the short‐chain fatty acids butyric or propionic acid during the hydrolysis of a structured triglyceride containing butyric acid (C4‐L‐C4‐TG) or the β‐oxidation of nonanoic acid from trinonanoin (C9TG), respectively, the infusion of these two triglycerides was supposed to reveal positive effects against the TPNinduced atrophy of the intestine.Methods:After 3 days of fiber‐free liquid diet, rats were traumatized (laparotomy) and catheterized. Afterwards they received equicaloric TPN that delivered 1008 kJ (241 kcal)/kg of body weight per day and 30% nonprotein calories as fat emulsion. The four fat emulsions tested in four groups of six animals contained either long‐chain triglycerides (LCT), medium‐chain triglycerides (MCT)‐LCT (1:1), C9TG/LCT (1:1) or C4‐L‐C4‐TG. Animals of a control group were infused with isovolemic 0.9% NaCl solution and were offered oral standard chow.Results:After 7 days of MCT/LCT administration, the mass‐to‐length ratio of the total small bowel as well as the masses of mucosa/submucosa and muscularis/serosa in 10‐cm segments of the distal half of the small bowel were significantly higher than that found in the other TPN groups or not different from controls. Histometric measurement of the villus height in the ileum revealed no statistically significant differences from controls for the rats of the MCT/LCT and C4‐L‐C4‐TG groups. In the colon, no statistically significant differences between TPN groups were found for either parameter.Conclusions:Within the tested fatty substrates the MCT/LCT fat emulsion revealed less structural impairments in the distal half of the small bowel regarding mucosa/submucosa (mass and villus height), but also muscularis/ serosa (mass). (Journal of Parenteral and Enteral Nutrition21:021–026, 1997)
Total Parenteral Nutrition Increases Uptake of Latex Beads by Peyer's Patches
Authors: Khan Jesmine , Boshi Yasuhiko , Nezu Rchiro , Chen Kai , Cui Li , Yoshida Hiroshi , Wasa Masafumi , Fukuzawa Masahiro , Kamata Shinkichi , Takagi Yoji , Okada Akira
Published: May 2008

Background: Dysfunction of the intestinal barrier, as evidenced by increased intestinal permeability and bacterial translocation, has been reported under total parenteral nutrition (TPN). However, the role of Peyer's patches on the intestinal barrier in TPN is not well understood. We investigated whether TPN alters the uptake of microparticles by the follicle‐associated epithelium of Peyer's patches. Methods: Twenty rats were divided into two groups, a control group and a TPN group. Fluorescent polystyrene latex beads, 3.2 ± 0.2 μm in diameter, were used as a probe for measuring the uptake by Peyer's patches. After 1 week of consuming either the control or TPN diet, rats were killed. On the day of killing, 0.1 mL of latex beads solution was injected into a 1‐cm length of ileal loop, within 10 cm of the ileocecal valve. Samples were taken after 30 minutes of injection, sectioned by cryostat, and then viewed under a fluorescent microscope. Follicle‐associated epithelial length and particles were counted using a confocal laser scanning microscope. The number of particles within each compartment was standardized per unit length of epithelium of Peyer's patches. Results: Particle numbers within Peyer's patch dome of the TPN group were significantly increased compared with those of the control group (p <.01). Conclusions: These data suggest that dysfunction of the intestinal barrier in TPN might be associated with a change of uptake by Peyer's patches. (Journal of Parenteral and Enteral Nutrition 21:031–035, 1997)