bluuebunny/crossref_metadata_2025 huggingface dataset:
Differential Effect of Weight Loss on Insulin Resistance in Surgically Treated Obese Patients
Authors: Hughes Caren , Ferrone Marcus
Published: May 2008

Purpose: To compare the effects of equivalent weight loss induced by two bariatric surgical techniques on insulin action in severely obese patients. Methods: Eighteen nondiabetic patients with severe obesity (mean [± SD] body mass index: 53.5 ± 9 kg/m2) and 20 sex‐ and age‐matched lean subjects (body mass index: 23.8 ± 3 kg/m2) underwent metabolic studies, including measurement of insulin sensitivity by the insulin clamp technique. Patients then underwent either vertical banded gastroplasty with Roux‐en‐Y gastric bypass or biliopancreatic diversion and were restudied at 5–6 months and again at 16–24 months postsurgery. Results: At baseline, patients were hyperinsulinemic (194 ± 47 pmol/L vs 55 ± 25 pmol/L, p < .0001), hypertriglyceridemic (1.56 ± 0.30 mmol/L vs 0.78 ± 0.32 mmol/L, p < .0001), and profoundly insulin resistant (insulin‐mediated glucose disposal: 20.8 ± 4.4μ mol/min/kg fat‐free mass vs 52 ± 10.1 μmol/min/kg, p < .0001) as compared with controls. Weight loss by the 2 procedures was equivalent in both amount (averaging –53 kg) and time course. In the gastric bypass group, insulin sensitivity improved (23.8± 6 μmol/min/kg at 5 months and 33.7 ± 11.3 μmol/min/kg at 16 months, p < .01 vs baseline and controls). In contrast, in the biliopancreatic diversion group, insulin sensitivity was normalized already at 6 months (52.5 ± 12.4 μmol/min/kg, p = .72 vs controls) and increased further at 24 months (68.7 ± 9.5 μmol/min/kg, p < .01 vs controls), despite a persistent obese phenotype (body mass index 33.2 ± 8 kg/m2). Conclusions: In surgically treated obese patients, insulin sensitivity improves in proportion to weight loss with use of predominantly restrictive procedures (gastric bypass) but is reversed completely by predominantly malabsorptive approaches (biliopancreatic diversion) long before normalization of body weight. Selective nutrient absorption and gut hormones may interact with one another in the genesis of the metabolic abnormalities of obesity.
Ethical Issues in Artificial Nutrition and Hydration
Authors: Fine Robert L.
Published: May 2008

From the time of Hippocrates, approximately 2500 years ago, medical ethics has been seen as an essential complement to medical science in pursuit of the healing art of medicine. This is no less true today, not only for physicians but also for other essential professionals involved in patient care, including clinical nutrition support practitioners. One aspect of medical ethics that the clinical nutritionist must face involves decisions to provide, withhold, or withdraw artificial nutrition and hydration. Such a decision is not only technical but often has a strong moral component as well. Although it is the physician who writes any such order, the clinical nutritionist as fellow professional should be a part not only of the scientific aspects of the order but of the moral discourse leading to such an order and may certainly be involved in counseling physicians, other healthcare providers, patients, and families alike. This paper is intended to give the clinical nutritionist a familiarity with the discipline of medical ethics and its proper relationship to medical science, politics, and law. This review will then offer a more specific analysis of the ethical aspects of decisions to initiate, withhold, or withdraw artificial nutrition and hydration (ANH) and offer particular commentary on the ethically significant pronouncements of Pope John Paul II in March of 2004 related to vegetative patients and artificial or“ assisted” nutrition and hydration.
Nutrition Modulation of Cachexia/Proteolysis
Authors: Siddiqui Rafat , Pandya Darshak , Harvey Kevin , Zaloga Gary P.
Published: May 2008

Cachexia represents progressive wasting of muscle and adipose tissue and is associated with increased morbidity and mortality. Although anorexia usually accompanies cachexia, cachexia rarely responds to increased food intake alone. Our knowledge of the underlying mechanisms responsible for cachexia remains incomplete. However, most states of cachexia are associated with underlying inflammatory processes and/or cancer. These processes activate protein degradation and lipolytic pathways, resulting in tissue loss. In this article, we briefly review the pathophysiology of cachexia and discuss the role of specific nutrient supplements for the treatment of cachexia. The branched chain amino acid leucine, the leucine metaboliteβ ‐hydroxy‐β‐methylbutyrate, arginine, glutamine, ω‐3 long chain fatty acids, conjugated linoleic acid, and polyphenols have demonstrated some efficacy in animal and/or human studies. Optimal treatment for cachexia is likely aimed at maximizing muscle and adipose synthesis while minimizing degradation.
Parenteral Nutrition‐Associated Liver Disease in Adult and Pediatric Patients
Authors: Kumpf Vanessa J.
Published: May 2008

There are essentially 3 types of hepatobiliary disorders associated with parenteral nutrition (PN) therapy: steatosis, cholestasis, and gallbladder sludge/stones. Reported prevalence rates of PN‐associated liver disease (PNALD) vary greatly, and there are distinct differences between adult and pediatric patients. Various etiologic factors have been evaluated for significance in contributing to PNALD, including enteral feeding history, septic events, bacterial overgrowth, length of intestinal resection, and prematurity/low birth weight. Etiologic factors specifically related to the PN formulation or nutrient intake have also been evaluated, including excessive calorie intake, dextrose‐to‐lipid ratio, amino acid dose, taurine deficiency, IV fat emulsion (IVFE) dose, carnitine deficiency, choline deficiency, and continuous vs cyclic infusion. Minor increases in serum aminotransferase concentrations are relatively common in patients receiving PN therapy and generally require no intervention. The primary indicator of cholestasis is a serum conjugated bilirubin >2 mg/dL. When a patient receiving PN develops liver complications, it is necessary to rule out all treatable causes and minimize other risk factors. All potential hepatotoxic medications and herbal supplements should be eliminated. Modifications to the PN regimen that may be helpful include reduction of calories, reduction of IVFE dose to <1 g/kg/d, supplementation of taurine in the infant, and use of cyclic infusion. Initiation of even small amounts of enteral nutrition and use of ursodiol may be beneficial in stimulating bile flow. In the long‐term PN patient with severe and progressive liver disease, intestinal or liver transplantation may be the only remaining treatment option.
Nutrition Support in Adult Trauma Patients
Authors: Todd S. Rob , Kozar Rosemary A. , Moore Frederick A.
Published: May 2008

Nutrition supplementation is paramount to the care of severely injured patients. Despite its widespread use in trauma patients, many areas of clinical practice remain controversial. The purpose of this paper is to critically review the literature studying the use of enteral vs parenteral nutrition (PN) and to provide the rationale for early enteral nutrition. Additional controversies confronting clinicians are reviewed, including the use of immune‐enhancing agents and the optimal site for enteral nutrition delivery (gastric vs small intestinal). Evidence‐based recommendations for clinical practice are presented when available.
Antioxidant Micronutrients in Major Trauma and Burns: Evidence and Practice
Authors: Berger Mette M.
Published: May 2008

There has been a growing interest in micronutrients as a result of their essential role in endogenous antioxidant defense mechanisms and immunity. Critically ill burn and trauma patients are characterized by an increased free radical production, which is proportional to the severity of the injury. In addition, they are at high risk of negative trace element balances, which contribute to the imbalance in endogenous antioxidant capacity and the extension of primary lesions. Although selenium, zinc, and vitamin C and E status are altered in all injured patients, patients with major burns are unique for having copper deficiency. In major burns, high‐dose ascorbic acid for 24 hours achieves reduction of resuscitation fluid requirements by endothelial antioxidant mechanisms both in animal models and in 1 human trial. Supplementation trials in trauma and burns including selenium and zinc have shown that early provision of micronutrients improves recovery. Vitamin supplementation trials without selenium have not achieved definitive effects. The human studies show that reinforcing antioxidant defenses early in the course of major injury is rational and that substituting the large initial micronutrient losses of selenium and zinc is safe in trauma, as is the addition of copper in burns. The IV route seems the only way to deliver the doses required to obtain a clinical effect.
Traumatic Brain Injury in the Pediatric Population
Authors: Redmond Carrie , Lipp Joanna
Published: May 2008

Traumatic brain injury (TBI) is a common injury among children. Most TBIs are mild and do not require hospitalization. However, whether or not the patients require acute hospitalization, TBIs may have long‐lasting consequences. There is little research on the nutrient needs of these patients, and recommendations are frequently based on data from adults with TBI. It is clear that calorie and protein needs are elevated with acute TBI. However, calorie needs are also decreased by therapies such as sedation, chemical paralysis, and barbiturate coma. Long‐term calorie needs may be lower for “comatose” patients. Enteral feeding is preferred and possible for patients with TBI, though gastric feeding may be problematic in some patients. In the acute phase, patients with TBI can also have dysregulation of fluid and electrolyte balance, which may require alterations in nutrition care. Dysphagia is common after moderately severe TBI and requires a multidisciplinary approach for treatment. Future opportunities for research on pediatric TBI are numerous and may include ongoing clarification of macronutrient needs, as well as investigation into the roles of specific nutrients such as zinc, antioxidants, and anti‐inflammatory compounds.
Nationwide Survey of Hospital Practices When Compounding Parenteral Nutrition Solutions in Latex‐Allergic Patients
Authors: El‐Atti Samia Abd , Martinelli Barbara , Yourich Bryan , Wasicek Kelley , Weber Robert
Published: May 2008

We surveyed 100 institutions in 50 states, varying in size from 50 to 1000 beds. The purpose of this survey was to examine the policies and techniques hospitals used in confirming latex allergy (LA) in patients and preparing parenteral nutrition (PN) for LA patients.

Our survey indicated that within the institutions in our study, many inpatient pharmacists do not use any defined method for confirming LA other than what is documented in the patient profile upon admission. Most inpatient pharmacies are not aware of any institutional policy concerning parenteral medications in LA patients, and some do not identify the importance of LA in preparing PN.

It is apparent from the results of this survey that uniform guidelines or practice standards for this important issue should be developed. Although the publications on LA are numerous, they mostly deal with the exposure to latex gloves or latex devices. Knowledge of preparing parenteral medications for LA patients in the literature is minimal. It is also clear that awareness and knowledge of pharmacy personnel should be enhanced. Finally, we are hoping that this survey will send a clear message to pharmacy organizations to develop guidelines or pharmacy practice standards for this issue, and for health institutions to develop policies and make them available to their personnel.
Nutrition Support and the Chronic Critical Illness Syndrome
Authors: Hollander Jason M. , Mechanick Jeffrey I.
Published: May 2008

Critical illness can be viewed as consisting of 4 distinct stages: (1) acute critical illness (ACI), (2) prolonged acute critical illness, (3) chronic critical illness, and (4) recovery. ACI represents the evolutionarily programmed response to a stressor. In ACI, substrate is shunted away from anabolism and toward vital organ support and inflammatory proteins. Nutrition support in this stage is unproven and may ultimately prove detrimental. As critical illness progresses, there is no evolutionary precedent, and man owes his life to modern critical care medicine. It is at this point that nutrition and metabolic support become integral to the care of the patient. This paper (1) delineates and develops the 4 stages of critical illness using current evidence, clinical experience, and new hypotheses; (2) defines the chronic critical illness syndrome (CCIS); and (3) details an approach to the metabolic and nutrition support of the chronically critically ill patient using the metabolic model of critical illness as a guide. It is our hope that this clinical model can generate testable hypotheses that can improve the outcome of this unique population of patients.
The History of Surgically Placed Feeding Tubes
Authors: Minard Gayle
Published: May 2008

Although supplemental enteral nutrition may have first been delivered by enema, the modern era of surgically placed feeding tubes began in the mid to late 1800s. Early procedures were generally disastrous, however, techniques rapidly improved. The basic techniques of surgical enteral access have not changed significantly in the last century, although endoscopic, radiologic and laparoscopic modifications have been described and adopted in the last 25 years. This article reviews some of the landmark surgical highlights in the United States and European literature regarding surgical enteral access.
Risk of Catheter‐Related Bloodstream Infection With Peripherally Inserted Central Venous Catheters Used in Hospitalized Patients
Authors: Ferrone Marcus
Published: May 2008

Background: Peripherally inserted central venous catheters (PICCs) are now widely used for intermediate and long‐term access in current‐day healthcare, especially in the inpatient setting, where they are increasingly supplanting conventional central venous catheters (CVCs) placed percutaneously into the internal jugular, subclavian, or femoral veins. Data on the risk of PICC‐related bloodstream infection (BSI) with PICCs used in hospitalized patients are limited. Study Objectives: To determine the risk of PICC‐related BSI in hospitalized patients. Study Design: Prospective cohort study using data from 2 randomized trials assessing the efficacy of chlorhexidine‐impregnated sponge dressing and chlorhexidine for cutaneous antisepsis. Methods: PICCs inserted into the antecubital vein in 2 randomized trials during from 1998 to 2000 were prospectively studied; most patients were in an ICU. PICC‐related BSI was confirmed in each case by demonstrating concordance between isolates colonizing the PICC at the time of removal and from blood cultures by restriction‐fragment DNA subtyping. Results: Overall, 115 patients had 251 PICCs placed. Mean duration of catheterization was 11.3 days (total 2832 PICC‐days); 42% of the patients were in an ICU at some time, 62% had urinary catheters, and 49% had received mechanical ventilation. Six PICC‐related BSIs were identified (2.4%), 4 with coagulase‐negative staphylococcus, 1 with Staphylococcus aureus, and 1 with Klebsiella pneumoniae, a rate of 2.1 per 1000 catheter‐days. Conclusions: This prospective study shows that PICCs used in high‐risk hospitalized patients are associated with a rate of catheter‐related BSI similar to conventional CVCs placed in the internal jugular or subclavian veins (2–5 per 1000 catheter‐days), much higher than with PICCs used exclusively in the outpatient setting (approximately 0.4 per 1000 catheter‐days) and higher than with cuffed and tunneled Hickman‐like CVCs (approximately 1 per 1000 catheter‐days). A randomized trial of PICCs and conventional CVCs in hospitalized patients requiring central access is needed. Our data raise the question of whether the growing trend in many hospital hematology and oncology services to switch from use of cuffed and tunneled CVCs to PICCs is justified, particularly because PICCs are more vulnerable to thrombosis and dislodgement and are less useful for drawing blood specimens. Further, PICCs are not advisable in patients with renal failure and impending need for dialysis, in whom preservation of upper‐extremity veins is needed for fistula or graft implantation. (Chest. 2005;128:489–495).
Enteral Nutrition Support of Head and Neck Cancer Patients
Authors: Raykher Aleksandra , Russo Lianne , Schattner Mark , Schwartz Lauren , Scott Burma , Shike Moshe
Published: May 2008

Patients with head and neck cancer are at high risk for malnutrition due to dysphagia from the tumor and treatment. Despite difficulty with oral intake, these patients usually have a normal stomach and lower gastrointestinal tract. Enteral nutrition support via percutaneous endoscopic gastrostomy (PEG) administered in the home by the patient helps to prevent weight loss, dehydration, nutrient deficiencies, treatment interruptions, and hospitalizations. It also improves quality of life. Successful management of these patients requires orderly care and follow‐up by a multidisciplinary nutrition team.
Enhancing Parenteral Nutrition Therapy for the Neonate
Authors: Valentine Christina J. , Puthoff Teresa D.
Published: May 2008

The neonate receiving parenteral nutrition (PN) therapy requires a physiologically appropriate solution in quantity and quality given according to a timely, cost‐effective strategy. Maintaining tissue integrity, metabolism, and growth in a neonate is challenging. To support infant growth and influence subsequent development requires critical timing for nutrition assessment and intervention. Providing amino acids to neonates has been shown to improve nitrogen balance, glucose metabolism, and amino acid profiles. In contrast, supplying the lipid emulsions (currently available in the United States) to provide essential fatty acids is not the optimal composition to help attenuate inflammation. Recent investigations with an ω‐3 fish oil IV emulsion are promising, but there is need for further research and development. Complications from PN, however, remain problematic and include infection, hepatic dysfunction, and cholestasis. These complications in the neonate can affect morbidity and mortality, thus emphasizing the preference to provide early enteral feedings, as well as medication therapy to improve liver health and outcome. Potential strategies aimed at enhancing PN therapy in the neonate are highlighted in this review, and a summary of guidelines for practical management is included.
Vitamin D and Rehabilitation: Improving Functional Outcomes
Authors: Shinchuk Leonid , Holick Michael F.
Published: May 2008

Vitamin D inadequacy is pandemic among rehabilitation patients in both inpatient and outpatient settings. Male and female patients of all ages and ethnic backgrounds are affected. Vitamin D deficiency causes osteopenia, precipitates and exacerbates osteoporosis, causes the painful bone disease osteomalacia, and worsens proximal muscle strength and postural sway. Vitamin D inadequacy can be prevented by sensible sun exposure and adequate dietary intake with supplementation. Vitamin D status is determined by measurement of serum 25‐hydroxyvitamin D. The recommended healthful serum level is between 30 and 60 ng/mL. 25‐Hydroxyvitamin D levels of >30 ng/mL are sufficient to suppress parathyroid hormone production and to maximize the efficiency of dietary calcium absorption from the small intestine. This can be accomplished by ingesting 1000 IU of vitamin D3 per day, or by taking 50,000 IU of vitamin D2 every 2 weeks. Vitamin D toxicity is observed when 25‐hydroxyvitamin D levels exceed 150 ng/mL. Identification and treatment of vitamin D deficiency reduces the risk of vertebral and nonvertebral fractures by improving bone health and musculoskeletal function. Vitamin D deficiency and osteomalacia should be considered in the differential diagnosis of patients with musculoskeletal pain, fibromyalgia, chronic fatigue syndrome, or myositis. There is a need for better education of health professionals and the general public regarding the optimization of vitamin D status in the care of rehabilitation patients.
Low Serum Total Calcium Concentration as a Marker of Low Serum Ionized Calcium Concentration in Critically Ill Patients Receiving Specialized Nutrition Support
Authors: Dickerson Roland N. , Henry Natohya Y. , Miller Patrice L. , Minard Gayle , Brown Rex O.
Published: May 2008

Background: The intent of this study was to ascertain to what extent serum total calcium concentration (tCa) <7 mg/dL reflects hypocalcemia (defined by ionized calcium concentration [iCa] of ≤1.12 mmol/L) in critically ill patients receiving specialized nutrition support. Methods: Adult patients (≥18 years) admitted to the trauma, surgical, medical, burn, or neurosurgical intensive care units, trauma stepdown unit, or progressive care unit and referred to the nutrition support service were retrospectively identified for potential inclusion into the study. Serum chemistries, arterial blood gas measurements, nutrition markers, and serum iCa were simultaneously obtained from each patient approximately 1 day after initiation of specialized nutrition support. Patients with a serum creatinine ≥2 mg/dL, hyperphosphatemia (≥6 mg/dL), severe hypomagnesemia (≤1.12 mg/dL), history of metabolic bone disease, or parathyroid disease were excluded from the analysis. Results: One hundred ninety‐five patients (91% who had multiple trauma, with a mean Injury Severity Score 31± 13) were enrolled into the study. Specialized nutrition support was initiated 2.8 ± 1.8 days and calcium status was studied 4.2 ± 3.1 days after hospital admission, respectively. The majority (28 of 33, or 85%) of patients with a tCa <7 mg/dL were hypocalcemic compared with 33% (22 out of 66) of patients with a tCa of 7–7.4 mg/dL, and 11% (11 of 96) of those with a tCa of 7.5–7.9 mg/dL (p < .001). Conclusions: Critically ill patients with a serum total calcium concentration of <7 mg/dL have a high rate of hypocalcemia (iCa ≤1.12 mmol/L). Hypocalcemia, defined as a serum iCa of ≤1.12 mmol/L, occurs in 85% of acutely ill patients with a serum tCa <7 mg/dL.
Bioimpedance Spectroscopy for Clinical Assessment of Fluid Distribution and Body Cell Mass
Authors: Earthman Carrie , Traughber Diana , Dobratz Jennifer , Howell Wanda
Published: May 2008

Body composition assessment has been used to evaluate clinical interventions in research trials, and has the potential to improve patient care in the clinical setting. Body cell mass (BCM) is an important indicator of nutrition status; however, its measurement in the clinic has been limited. BCM can be estimated by the measurement of intracellular water (ICW). The assessment of extracellular water (ECW) is also important because many clinical populations undergo alterations in fluid distribution, particularly individuals with wasting, those receiving dialysis, and obese individuals. Bioimpedance spectroscopy (BIS) is a unique bioimpedance approach that differs in underlying basis from the more readily recognized single‐frequency bioelectrical impedance analysis (SF‐BIA) in that it does not require the use of statistically derived, population‐specific prediction equations. It has the potential advantage of not only measuring total body water (TBW), as does SF‐BIA, but also offering the unique capacity to differentiate between ECW and ICW and, thus, to provide an estimate of BCM. This literature review was conducted to compare available BIS devices to multiple dilution for measuring fluid compartments or BCM in a number of populations. Variable results regarding the ability of BIS to measure absolute volumes, as well as the observation of wide limits of variation, make BIS problematic for individual assessment in the clinic, particularly in populations with abnormal fluid distribution or body geometry. BIS has been found to be more accurate for measuring changes in fluid volumes or BCM, particularly in post‐surgical and human immunodeficiency virus (HIV)‐infected individuals. It is certainly possible that population‐specific adjustments may improve the accuracy of BIS for assessing individuals in the clinical setting; however, additional research and development is needed before the method can be accepted for routine clinical use.
Computer Technology and the Nutrition Support Professional: Make It Work For You!
Authors: Charney Pamela
Published: May 2008

Healthcare professionals caring for patients receiving enteral and parenteral nutrition (PN) are faced with the need to develop and expand their technologic skills. Patients and their caregivers are finding information from the Internet that healthcare professionals are then tasked with evaluating for accuracy and veracity. Healthcare professionals themselves must be able to rapidly find information to answer clinical questions that arise during daily practice. Information‐seeking skills must be well developed in order to find information from the Internet, as well as in the professional literature. Such skills include the ability to formulate a search strategy that limits extraneous results as much as possible yet ensures that relevant results are not missed.

In addition, electronic health records are being implemented in many facilities now, with a national goal of an electronic health record in place by 2014. Clinicians must be involved with implementation at all stages, including planning, purchasing, implementing, and evaluating an electronic system. Electronic health records can include very sophisticated components that provide for computerized physician order entry (CPOE) and decision support. Nutrition support must be an integral part of these systems.

This paper provides some background information on the Internet and the World Wide Web, along with strategies to find information using search engines. Information is also provided on the use of MEDLINE to search medical literature. Finally, a brief overview of the electronic health record is provided, with suggestions for involvement by nutrition support clinicians in implementation of electronic health records in the workplace.
Review of Incidence and Management of Chylous Ascites After Small Bowel Transplantation
Authors: Weseman Rebecca A.
Published: May 2008

Nutrition management of intestinal transplant recipients continues to be a challenging and essential component of the early postoperative care of this patient population. The absorptive capacity of the graft can be affected by immunologic and nonimmunologic factors, including enteric lymphatic disruption, preservation injury, central denervation, viral enteritis, systemic infections, and rejection. Chylous ascites, the extravasation of milky chyle into the peritoneal fluid, defined by elevated triglycerides levels of ≥200 mg/dL, can occur as a result of trauma, obstruction, or interruption of the lymphatic system. It seems the incidence of chylous ascites after small bowel transplantation is low; however, this may be due in part to the limitation of enteral long‐chain triglycerides in the early posttransplant period of 2–6 weeks. After this time frame, clinical evidence suggests that fat assimilation normalizes. In the event that chylous ascites develop as a posttransplant complication, limitation of oral or enteral nutrition support to a very‐low‐fat regimen may be required, or parenteral nutrition (PN) will need to be provided until clinical status improves. Long‐term posttransplant, lymphatic regeneration generally occurs and the majority of intestinal transplant recipients achieve the ultimate goal of nutrition autonomy.
Bone Health and Osteoporosis: The Role of Vitamin K and Potential Antagonism by Anticoagulants
Authors: Pearson Debra A.
Published: May 2008

Background: Vitamin K's effects extend beyond blood clotting to include a role in bone metabolism and potential protection against osteoporosis. Vitamin K is required for the γ‐carboxylation of osteocalcin. Likewise, this γ‐carboxylation also occurs in the liver for several coagulation proteins. This mechanism is interrupted by coumarin‐based anticoagulants in both the liver and bone. Methods: A thorough review of the literature on vitamin K, osteocalcin and their role in bone metabolism and osteoporosis, as well as the potential bone effects of anticoagulant therapy was conducted. Conclusions: Epidemiological studies and clinical trials consistently indicate that vitamin K has a positive effect on bone mineral density and decreases fracture risk. Typical dietary intakes of vitamin K are below the levels associated with better BMD and reduced fracture risk; thus issues of increasing dietary intakes, supplementation, and/or fortification arise. To effectively address these issues, large‐scale, intervention trials of vitamin K are needed. The effects of coumarin‐based anticoagulants on bone health are more ambiguous, with retrospective studies suggesting that long‐term therapy adversely affects vertebral BMD and fracture risk. Anticoagulants that do not affect vitamin K metabolism are now available and make clinical trials feasible to answer the question of whether coumarins adversely affect bone. The research suggests that at a minimum, clinicians should carefully assess anticoagulated patients for osteoporosis risk, monitor BMD, and refer them to dietitians for dietary and supplement advice on bone health. Further research is needed to make more efficacious decisions about vitamin K intake, anticoagulant therapy, and bone health.
Nonvitamin, Nonmineral Dietary Supplementation in HIV‐Positive People
Authors: Sansevero Mara R. , Houser Robert , Phelan Grace , Wanke Christine , Tang Alice , Hendricks Kristy
Published: May 2008

Background: Many consumers with chronic diseases attempt to take control of their health by using dietary supplements. The objective of this study was to describe current nonvitamin, nonmineral (NVNM) supplement use of HIV‐infected persons in the Nutrition for Healthy Living (NFHL) cohort, the financial burden that buying these supplements might pose to this population, and to review current literature on potential interactions between NVNM supplements. Methods: At baseline visit, participants were educated by a registered dietitian on keeping a complete 3‐day food record (including all supplements) for 2 weekdays and 1 weekend day. Seventy‐two subjects reported consumption of NVNM supplements, and their food records were reviewed in detail. Results: Each of the 72 subjects in this study used a mean of 6 NVNM supplements, which may have been in the form of a pill, powder, bar, or liquid. The 6 most common were glutamine (51%), N‐acetyl‐cysteine (36%), fish oil (33%), α‐lipoic acid (32%), acetyl‐l‐carnitine (28%), and coenzyme Q10 (28%). Participants were also taking an average of 4 vitamin/mineral supplements; the 6 most common were multivitamin/multimineral (83%), vitamin E (51%), vitamin C (47%), vitamin B complex (43%), calcium (29%), and selenium (28%). Conclusions: With a total of 107 different types of NVNM supplements, our estimated cost examples indicated a weekly supplement regimen cost of between $25 and $40 dollars. According to literature review, taking an NVNM supplement may involve some risk because many components have not been studied and these products are not tightly regulated.
Glucose Control and the Inflammatory Response
Authors: Collier Bryan , Dossett Lesly A. , May Addison K. , Diaz Jose J.
Published: May 2008

Though first introduced more than 130 years ago, the concept of stress diabetes or stress hyperglycemia has gained tremendous attention in recent years in view of the landmark article by van den Berghe and colleagues in 2001. As opposed to earlier work that suggested that hyperglycemia in the acute clinical setting may be beneficial, it now appears that lower glucose levels are associated with improved outcomes. The mechanisms behind the improved outcomes are numerous and seem to be tied to the inflammatory process. Both lower glucose values and insulin therapy seem to be anti‐inflammatory, whereas hyperglycemia increases the proinflammatory process and negatively affects the innate immune system. Despite the numerous approaches to achieve normoglycemia described in the literature, only modest success has been achieved. Understanding the pathophysiology driving stress hyperglycemia—the stress response and modulation of the inflammatory process—seems to be the key to improving the care of the most critically ill and injured patients.
Neurodegeneration and Inflammation
Authors: DeLegge Mark H. , Smoke Addy
Published: May 2008

Recent studies have demonstrated a strong link between neurodegeneration and chronic inflammation. The central nervous system (CNS) has very limited regenerative capacity. Neural cell death occurs by apoptosis and necrosis. Necrosis in the CNS usually follows ischemic or traumatic brain injury. Apoptosis is known as programmed cell death and often demonstrates histologic features of acute and chronic neurologic diseases. The innate immune response is protective to the CNS to defend against pathogens. Temporary up‐regulation of inflammatory events is natural and does not lead to cell death. If this inflammatory process is up‐regulated, neurodegenerative changes may occur. There has been a proven link between the inflammatory response, increased cytokine formation, and neurodegeneration. Both pharmaceutic and nutrition interventions for treating chronic neurodegenerative diseases, such as Alzheimer's disease or multiple sclerosis, will be focused on reducing or terminating the chronic inflammatory response.
Screening for Celiac Disease in Short Bowel Syndrome
Authors: Keswani Rajesh N. , Neven Kimberly , Semrad Carol E.
Published: May 2008

Background: Malabsorptive diarrhea due to short bowel syndrome (SBS) results in nutrition compromise, often requiring parenteral nutrition (PN). Activation of latent celiac disease can occur after gastrointestinal surgery. Our objective was to determine whether undiagnosed celiac disease contributes to malabsorption in patients with SBS. Methods: Adult subjects with SBS were tested for celiac disease using immunoglobulin A (IgA) tissue transglutaminase (TTG) antibody and total IgA level. Subjects with an elevated IgA tissue transglutaminase were offered upper endoscopy with biopsies of the duodenum. Results: Eighteen subjects were enrolled. The subjects were predominantly white, and the most common cause of SBS was Crohn's disease. The mean length of remaining small bowel was 93.1 ± 54.6 cm. All subjects had undergone surgeries, resulting in loss of the ileocecal valve. Five subjects were found to have an elevated total IgA. A single patient was found to have an elevated IgA tissue transglutaminase antibody, and subsequent endoscopy demonstrated active gastroduodenal Crohn's disease, without features of celiac disease. Conclusions: No subjects were IgA deficient, but 5 subjects were found to have elevated IgA levels. Undiagnosed celiac disease did not contribute to malabsorption in our small cohort of predominantly white SBS patients. Larger studies are warranted.
Toxic Epidermal Necrolysis
Authors: Lacy Joseph A.
Published: May 2008

Toxic epidermal necrolysis is a rapidly progressive dermatologic condition associated with high mortality. Several factors have been implicated in the development of toxic epidermal necrolysis including drugs, vaccinations, infections, and neoplasia. Toxic epidermal necrolysis therapy has been compared with partial‐thickness burn injury treatment. The absence of burned tissue can dampen fluid requirements and metabolic needs of toxic epidermal necrolysis in comparison to equivalent burn injury. In the following case report, a 69‐year‐old woman with multiple medical problems developed toxic epidermal necrolysis after treatment with metolazone and phenytoin. Her measured energy expenditure (3360 kcal) was considerably higher than previously reported caloric expenditure in toxic epidermal necrolysis patients (2500 kcal).
Invited Review: Catheter Infection Control in Parenteral Nutrition
Authors: Cahill Susan L. , Benotti Peter N.
Published: May 2008

Catheter sepsis rates related to total parenteral nutrition are variable and depend on several patient‐specific factors. These factors include the presence of immunosuppression or critical illness, the use of multiple intravascular catheters, and bacterial translocation. Catheter‐related sepsis may present in the patient as fever, chills, change in mental status, hypotension, and leukocytosis. In patients with suspected catheter‐related infection whose peripheral blood cultures do not grow the same organism as a blood culture drawn from the catheter, a guidewire exchange of the catheter has been shown to be effective. This technique should be considered a surgical procedure. Complications that are associated with guidewire exchange of central venous catheters are catheter malposition, embolism of air or septic thrombi, and cardiac arrhythmias.
Invited Review: Quality of Care Concepts and Nutrition Support
Authors: Srp Faith , Ayello Elizabeth A. , Andujar Elizabeth , Konstantinides Nancy N.
Published: May 2008

The Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) Agenda for Change has refocused and redefined quality monitoring in health care. The JCAHO has operationalized these new concepts of quality monitoring and evaluation by means of a 10‐step process that includes the development of clinical indicators. Theoretical frameworks for the 10‐step process were drawn from the work of theorists whose applications of quality‐monitoring methods occurred in business and industry. An enhanced understanding of the current JCAHO definitions of quality and processes for quality measurement will help practitioners prepare for future accreditation surveys. A review of quality monitoring and evaluation activities in nutrition support has demonstrated a need for more published accounts to document these important activities.
A Historical Perspective and Review of the Safety of Lipid Emulsion in Pregnancy
Authors: Amato Paul , Quercia Robert A.
Published: May 2008

Total parenteral nutrition for pregnant patients is essential to maintain or restore optimal nutritional status for both the mother and fetus when adequate protein and caloric intake by the oral or enteral route is not feasible. This report reviews the safety of intravenous lipid emulsions in total parenteral nutrition programs for pregnant patients. Controversy regarding the adverse effects of intravenous lipid emulsion when administered to pregnant patients is based on early reports of the use of cottonseed oil lipid emulsions. The adverse effects reported included infarction of the placenta, ketonemia, increased myometrial activity, and induction of labor. In 32 subsequent case reports in which soybean oil‐ or soybean/safflower oil‐based emulsions were used in total parenteral nutrition programs for pregnant patients, there was no relationship apparent between onset of labor and harmful maternal or fetal effects associated with the administration of lipid emulsion. It appears that the currently available soybean and soybean/safflower lipid‐based emulsions can be safely administered to pregnant patients.
Growth Hormone and Nutritional Support: Adverse Metabolic Effects
Authors: Lehmann Sharon , Cerra Frank B.
Published: May 2008

The use of growth hormone in clinical nutritional support has received considerable attention over the past decade. The most encouraging results have been improved nitrogen retention and protein synthesis in the presence of hypocaloric nutritional support. Adverse effects, however, can limit the clinical usefulness of this technology. In the following case study, an obese 71‐year‐old man with a history of chronic obstructive pulmonary disease remained ventilator dependent 2 months following anterior cervical fusion and had severe depletion of visceral proteins despite nitrogen equilibrium. He was treated with 10 mg of recombinant human growth hormone (Genentech) subcutaneously every other day while also receiving nutritional support. We hypothesized that growth hormone administration could promote both protein synthesis and the development of muscle mass, particularly in the respiratory muscles, without increasing nutrient intake and, therefore, without increasing CO2 production. The patient, however, developed two potentially life‐threatening adverse effects: hyperglycemia and fluid retention. The severity of these adverse effects led to discontinuation of this mode of therapy.
Invented Review: Nutrition Support in Inflammatory Bowel Disease
Authors: Sitrin Michael D.
Published: May 2008

Many patients with the inflammatory bowel diseases, Crohn's disease, or ulcerative colitis have significant protein‐calorie malnutrition and micronutrient deficiencies. Factors that contribute to these nutritional deficits include inadequate nutrient intake, malabsorption, excessive nutrient secretion across the diseased gastrointestinal tract, drug‐nutrient interactions, and increased nutrient requirements. In this review, the use of enteral and parenteral nutrition support as primary therapy for active Crohn's disease and ulcerative colitis is discussed. Other roles for nutrition support in patients with inflammatory bowel disease, including preoperative nutrition support, nutritional treatment of intestinal fistulas and growth retardation, and home parenteral nutrition for gut failure, are also reviewed.
Combined Parenteral and Enteral Nutrition in Severe Trauma
Authors: Wagner David R. , Elmore Michael F. , Tate John T.
Published: May 2008

Early enteral feeding is increasingly advocated for the nutrition support of severely stressed patients. The successful use of this modality in critical illness is often limited by the patient's condition, the availability of access for feeding, and the patient's tolerance of the enteral formula. Factors such as abdominal injury or constraints on fluid volume also complicate nutrition support in this setting. Attention to a secure and well‐maintained small bowel access tube and appropriate formula selection allow safe tube feeding in these patients. This case report describes the clinical course of a patient with severe chest and abdominal trauma who received enteral nutrition despite a large, open abdominal wound.
Invited Review: Selection of Optimal Lipid Sources in Enteral and Parenteral Nutrition
Authors: Gottschlich Michele M.
Published: May 2008

The manipulation of dietary fat intake can affect the response to disease, injury, and infection. These effects include enhancement or inhibition of immune function, altered susceptibility to cardiovascular disease, promotion or maintenance of gut integrity, and prevention of total parenteral nutrition‐induced hepatic dysfunction. These effects may occur as a result of changes in the fatty acid composition of biomembranes or changes in concentrations of lipid moieties such as prostaglandins or leukotrienes. Those fats that have been shown to affect physiologic function include long‐chain, medium‐chain, and short‐chain fatty acids and ω‐3 and ω‐6 fatty acids. Currently available enteral and parenteral products used for nutrition support contain widely varied amounts of these different fatty acids. Therefore, the selection of the most appropriate product or nutrition support regimen for an individual patient requires an understanding of the metabolism of these different fat substrates, their therapeutic indications, and the contraindications and controversies that surround their use. This article reviews these issues and also focuses on several alternate lipid sources such as short‐chain fatty acids, medium‐chain fatty acids, ω‐3 fatty acids, and blended and structured lipids.
Selection of Nutrition Support Regimens
Authors: Dechicco Robert S. , Matarese Laura E.
Published: May 2008

The selection of a nutrition support regimen should be the product of a logical, stepwise process. After an appropriate candidate is selected, the integrity and function of the gastrointestinal tract must be assessed to determine if nutrients can be administered enterally or must be given by vein. The anticipated length of therapy will help determine the type of feeding access. Long‐term nutrition support requires permanent access, such as a percutaneously or surgically placed feeding tube for enteral nutrition or a tunnelled catheter or implanted port for parenteral nutrition. Formula selection for enteral nutrition, providing adequate liver and renal function, depends largely on the patient's ability to assimilate intact nutrients. The primary decision in parenteral formula selection is whether to provide the macronutrients as a mixed fuel system. The ultimate goal of nutrition support is to make a smooth transition to oral feedings while maintaining adequate nutritional intake.
Invited Review: Current Status of Home Infusion Therapy
Authors: Crocker Kathleen S.
Published: May 2008

The growth of home infusion therapy has been influenced by external forces that have changed the access to and use of health care. As home infusion therapy expands into other alternate care settings, clinicians, regardless of discipline, must be cognizant of how daily clinical practice is affected by regulations, changes in legislation, and consumerism.
A Standardized System for Assessment and Delivery of Nutrition Support in a Large Teaching Hospital
Authors: Cicci Anita , Sunyecz Lisa A. , Mirtallo Jay , Flancbaum Louis J.
Published: May 2008

The nutrition support service (NSS) is consulted to evaluate and provide nutrition support to 500 patients per year. To facilitate this process, three forms—a consultation request form and preprinted parenteral and enteral nutrition order forms are used. The NSS Consult Request form was developed to provide consistency in medical, dietetic, nursing, and pharmacy patient assessments. This form is organized so that it includes clinical information necessary for nutrition assessment. Specifically, the NSS completes a nutrition assessment that includes a diet history; indirect calorimetry, only when indicated; a laboratory (metabolic) assessment; a clinical impression used to put the above‐mentioned information into a nutrition perspective; and recommendations for either enteral or parenteral therapy. The recommendation for implementing nutrition support as either total enteral nutrition or total parenteral nutrition is made by using the respective order forms for enteral or parenteral nutrition. These include orders for specific formulas and additives and orders for laboratory monitors, nursing care, and criteria for notification of the physician. These forms facilitate the accurate transcription, preparation, and delivery of NSS orders by pharmacy, dietetics, and nursing departments. This approach provides an excellent framework in which to teach dietitians, pharmacists, nurses, and physicians a method for the delivery of appropriate nutrition support and provides a database for the performance of quality assurance analysis and clinical research.
Nutrition Support Teams—Alive, Well, and Still Growing
Authors: Regenstein Marsha
Published: May 2008

This report summarizes data collected from 1680 hospitals that responded to the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Nutrition Support Team Survey. The survey was conducted primarily to determine the prevalence, composition, and funding of existing and planned Nutrition Support Teams. Results tend to verify the importance of the Nutrition Support Team within the hospital's organizational structure. In addition, A.S.P.E.N. hoped to develop a national directory of Nutrition Support Teams as a byproduct of the survey. Details about the Nutrition Support Team Directory appear at the conclusion of this report.