bluuebunny/crossref_metadata_2025 huggingface dataset:
Enteral Feeding: The Art and the Science
Authors: Parrish Carol Rees
Published: May 2008

Enteral feeding (TEN) is the preferred method for hospitalized patients requiring nutrition support. However, real and perceived barriers to implementation exist, with gastrointestinal (GI) intolerance being the most common. The purpose of this article is to identify common GI obstacles to effective TEN and to review current practices of TEN delivery and evidence to support such practices. The article reviews the GI anatomy and physiology that affect TEN practices and also identifies related evidence on the most common GI barriers limiting effective TEN delivery. Suggested solutions are provided.
Metabolic Outcomes of Gastric Bypass
Authors: Collene Angela Lynn , Hertzler Steven
Published: May 2008

Gastric bypass surgery may be the most successful treatment for morbid obesity. However, postoperative patients are susceptible to deficiencies of several nutrients, including iron, vitamin B12, and folate. Careful monitoring and supplementation are recommended to prevent negative outcomes of nutrient deficiencies. Metabolic benefits, on the other hand, include improvements in glycemic control and biochemical risk factors for cardiovascular disease. Pursuing surgery as an option for treating morbid obesity requires long‐term dedication from the patient and the healthcare team.
An Update on Medical Therapy for Obesity
Authors: Ness‐Abramof Rosane , Apovian Caroline M.
Published: May 2008

Obesity is a risk factor and exacerbates many chronic conditions, particularly diabetes, but also hypertension, hyperlipidemia, heart disease, stroke, certain cancers, arthritis, and obstructive sleep apnea. Despite increased awareness within the public and healthcare system, there has still been a persistent rise in the prevalence of obesity over the past half‐century. Failure to halt this epidemic is related to difficulties in adherence to lifestyle changes, forceful counter‐regulatory mechanisms opposing weight loss, and the lack of efficient long‐term therapy for obesity. This article summarizes the current medical approach to the treatment of obesity, reviewing strategies for lifestyle modification, available pharmacotherapy both as an adjunct to diet and exercise and to ameliorate comorbidities, and an overview of new pharmaceutical agents being developed.
Quality of Life and Length of Survival in Advanced Cancer Patients on Home Parenteral Nutrition
Authors: Bozzetti F , Cozzaglio L , Biganzoli E , Chiavenna G , De Cicco M , Donati D , Gilli G , Percolla S , Pironi L
Published: May 2008

Background: The use of home parenteral nutrition (HPN) in patients with advanced cancer is controversial because survival is usually short and there are no data regarding the quality of life (QoL). Methods: Sixty‐nine advanced cancer patients enrolled in a program of HPN in six different Italiancenters were prospectively studied as regards nutritional status (body weight, serum albumin, serum transferrin and total lymphocyte count), length of survival and QoL through the Rotterdam Symptom Checklist questionnaire. These variables were collected at the start of HPN and then at monthly intervals. All these patients were severely malnourished, almost aphagic and beyond possibility of any cure. Results: Nutritional indices maintained stable until death. Median survival was 4 months (range 1–14) and about one‐third of patients survived more than 7 months. QoL parameters remained stable till 2–3 months before death. Conclusions: HPN may benefit a limited percentage of patients who may survive longer than the time allowed by a condition of starvation and depletion. Provided that these patients survive longer than 3 months, there is some evidence that QoL remains stable for some months and acceptable for the patients.
Limited Effects of Micronutrient Supplementation on Strength and Physical Function After Abdominal Aortic Aneurysmectomy
Authors: Watters JM , Vallerand A , Kirkpatrick SM
Published: May 2008

BACKGROUND: Tissue injury following ischemia‐reperfusion is mediated in part by free oxygen radicals. We hypothesized that perioperative micronutrient supplementation would augment antioxidant defenses, minimize muscle injury, and minimize postoperative decreases in muscle strength and physical function following abdominal aortic aneurysmectomy. SETTING: A university‐affiliated hospital and regional referral center. DESIGN: A randomized, double‐blind, placebo‐controlled trial of supplementation with beta‐carotene, vitamins C and E, zinc, and selenium for a period of 2–3 weeks prior to surgery and 1 week thereafter. STUDY POPULATION: Patients undergoing elective abdominal aortic aneurysmectomy (n=18 per group). PRINCIPAL MEASUREMENTS: Handgrip and other measures of strength and physical function. RESULTS: Handgrip and quadriceps strength decreased following surgery, but not to a significantly different extent in the placebo and supplemented groups. Self‐rated physical function decreased following surgery in the placebo group and was preserved in the supplemented group. CONCLUSIONS: Perioperative supplementation with micronutrients with antioxidant properties has limited effects on strength and physical function following major elective surgery.
C‐Reactive Proteins and Chronic Disease: What Role Does Nutrition Play?
Authors: Liepa George U. , Basu Hemendra
Published: May 2008

The following review provides an update on C‐reactive proteins (CRPs) and how they are related to chronic diseases and diet. Emphasis is placed on the mechanism that is involved in the infection/stress‐induced formation of CRPs. CRPs' role as biomarkers for coronary heart disease is discussed. This review also discusses the roles that obesity, diabetes, smoking, and synthetic hormones play in increasing serum CRP concentrations. It also summarizes information about how dietary manipulation and exercise can decrease CRP concentrations. The dietary components that seem to lead to a decrease in CRPs include ω‐3 fatty acids (fish oil), vitamin E, and moderate amounts of alcohol. Aspirin intake is also discussed as a method that can be used to decrease CRP concentrations.
The European View of Hospital Undernutrition
Authors: Beck Anne M. , Balknäs Ulla N. , Camilo Maria E. , Fürst Peter , Gentile Maria G. , Hasunen Kaija , Jones Liz , Jonkers‐Schuitema Cora , Keller Ulrich , Melchior Jean‐Claude , Mikkelsen Bent E. , Pavcic Marusa , Schauder Peter , Sivonen Lauri , Zinck Orla , Øien Henriette , Ovesen Lars
Published: May 2008

Disease‐related undernutrition is significant in European hospitals but is seldom treated or prevented. In 1999, the Council of Europe decided to collect information regarding nutrition programs in hospitals, and for this purpose, a network consisting of national experts from 12 of the Partial Agreement member states was established. The aim was to review the current practices in Europe regarding hospital food provision, to highlight deficiencies, and to issue recommendations to improve the nutritional care and support of hospitalized patients. Five major common problems were identified: 1) lack of clearly defined responsibilities, 2) lack of sufficient education, 3) lack of influence and knowledge of the patients, 4) lack of cooperation between different staff groups, and 5) lack of involvement from the hospital management. To solve the problems highlighted, a combined timely and concerted effort is required from national authorities and hospital staff, including managers, to ensure appropriate nutritional care and support.
Hypercalcemia and Peptic Ulcer Disease–Related Milk‐Alkali Syndrome
Authors: Grundfast Matthew B. , Still Christopher D. , Komar Michael J.
Published: May 2008

Milk‐alkali syndrome was considered “extinct” by 1985 because of the advent of non‐alkaline ulcer medications (ie, histamine‐2 receptor blockers and proton pump inhibitors). At that time, it was thought to cause<1% of hypercalcemia, which occurred when one ingested a sufficient quantity of calcium and alkali together. This case emphasizes the importance of considering this syndrome in patients who self‐medicate for control of symptoms related to gastroesophageal reflux and peptic ulcer disease and for those using calcium supplementation for prevention or treatment of osteoporosis.
Management of the Home Parenteral Nutrition Patient
Authors: Ireton‐Jones Carol , DeLegge Mark H. , Epperson Lou Anne , Alexander Julee
Published: May 2008

Parenteral nutrition (PN) support can be managed in the home setting for both a short‐term and long‐term period or for a lifetime, permitting individuals who cannot adequately absorb nutrients enterally to achieve a normal lifestyle. Nutrition support professionals must be aware of home PN (HPN) management principles before discharge to ensure a smooth transition to home with all requisite monitoring. This article will discuss the initiation and monitoring of patients on HPN, the prevention and treatment of potential complications, the contributions of the home infusion provider, and the home nutrition support team and the outcomes of HPN.
Update on Parenteral Iron Therapy
Authors: Kumpf Vanessa J.
Published: May 2008

The role of parenteral iron therapy has been expanding with the growing use of erythropoietin therapy. Much of the clinical experience regarding the use of IV iron therapy in combination with erythropoietin therapy is based on the hemodialysis patient, but the combination therapy has been used in other patient populations as well. In addition, parenteral iron may be indicated in patients receiving long‐term parenteral nutrition and in other clinical situations of iron deficiency when the absorption of iron is impaired or tolerance limited. Once the indication for parenteral iron therapy is established, a selection of the most appropriate agent is required. There are currently 3 parenteral iron preparations available, including iron dextran, sodium ferric gluconate, and iron sucrose. Although all agents have been shown to be effective in correcting iron deficiency, there are differences that exist between them. Both sodium ferric gluconate and iron sucrose have been associated with lower rates of serious adverse reactions than iron dextran, although comparative studies are lacking. In patients with previously documented intolerance to iron dextran, sodium ferric gluconate and iron sucrose have been safely administered. In addition to the immediate and delayed reactions associated with the use of parenteral iron, the risk of iron overload and the potential increased risk of infection are of concern. This article will review the clinical experience of the 3 parenteral iron preparations, discuss safety issues, and provide guidelines on proper dosing and administration.
The Role of Nutrition in the Adaptation of the Small Intestine After Massive Resection
Authors: Ireton‐Jones Carol
Published: May 2008

Background: The demonstration that weight gain, growth, and development can be achieved by supplying all essential nutrients exclusively by vein prompted the laboratory evaluation of this parenteral feeding technique in animals that had undergone enterectomy. This study was undertaken to determine the role of nutrition and anabolism in compensation of the small intestine after massive intestinal resection. Methods: Three or 4 littermate beagle puppies from 10 litters, obtained 8 weeks after weaning and weighing 2 to 3 kg, underwent enterectomy at 10 weeks of age. In the standardized operation, 90% or 95% of the small intestine was removed, as measured from the tail of the pancreas to the ileocecal junction. After enterectomy, the dogs were divided into 2 groups, 1 group being fed exclusively with a kennel diet and the other offered the orally administered diet, whereas all the required nutrients were by vein. After 1 month of continuous infusion, the puppies were weaned from the IV‐administered nutrient solution and maintained solely on the standard, orally administered diet. Results: Thirty‐four puppies were evaluated for up to 1 year with their control littermates with no resection. Normal growth and development occurred in all puppies after enterectomy during the total IV administration of nutrition. After the parenteral feeding, the dogs with a 90% resection achieved near normal weight gain in contrast to the orally fed dogs with enterectomy that grew to only one‐half normal size. In the 95% resected group, 5 of 6 dogs survived more than 4 months after parenteral feedings, whereas only 1 of 5 lived more than 1 month while receiving oral feedings alone. At 1 year, the intestine from the parenterally fed dogs that had undergone enterectomy demonstrated increased mucosal cellularity, marked villus hypertrophy, and increased intestinal weight gain per unit length when compared with the orally fed dogs that had undergone resection and the control littermates. Conclusions: By providing all essential nutrients by vein for 30 days, significant improvement in survival, growth, and nutrition was noted in puppies after massive intestinal resection.
Prophylactic Pancreatic Enzymes to Reduce Feeding Tube Occlusions
Authors: Bourgault Annette M. , Heyland Daren K. , Drover John W. , Keefe Laurie , Newman Paula , Day Andrew G.
Published: May 2008

Background: Small‐bore, feeding tube occlusion is reported to be as high as 23% to 35%. Pancreatic enzyme solution has been used to dissolve internal clots in feeding tubes. This study examined the prophylactic use of pancreatic enzyme solution with continuous enteral feeding in critically ill patients. Methods: This was a randomized, unblinded trial conducted in an intensive care unit at a tertiary care hospital. Feeding tubes were randomized to receive pancreatic enzyme solution every 4 hours or usual care. Pancreatic enzyme solution contained lipase 8,000 units, amylase 30,000 units, protease activity 30,000 units, sodium bicarbonate 300 mg, and 5 mL warm sterile water. Results: Ninety‐five feeding tubes were followed up in 101 patients. Ten feeding tubes (9.9%) developed primary occlusions. Analysis revealed 2/52 (4%) of the tubes in the enzyme arm had occlusions, whereas 8/49 (16%) of control tubes had occlusions (p = .04). Time to occlusion was significantly longer in the pancreatic enzyme arm (p = .02). Conclusions: The use of prophylactic pancreatic enzymes may reduce the incidence of feeding tube occlusions.
Gut Immunology and the Differential Response to Feeding and Starvation
Authors: Jabbar Abdul , Chang Wei‐Kuo , Dryden Gerald W. , McClave Stephen A.
Published: May 2008

Animal and human research has established the beneficial effects of enteral nutrition on the gut. Both the innate and acquired immune systems are bolstered by enteral alimentation. Emerging clinical concepts tie these beneficial effects to a significant influence on the host immune response to stressors during critical illness. In this article, we examine how enteral nutrition impacts gastrointestinal immunity and demonstrate how these changes may affect the body's systemic immune response to nongastrointestinal challenges. This modulatory effect occurs because of changes in the pattern of cytokine secretion and alterations in lymphocyte and neutrophil recruitment. Imbalances in these regulatory mechanisms may be the engine driving hyperresponsiveness to subsequent challenges in the critically ill patient.
Severe Acute Pancreatitis: Nutritional Management in the ICU
Authors: Kaushik Neeraj , O'Keefe Stephen J. D.
Published: May 2008

Patients with acute pancreatitis have elevated nutritional needs due to increased energy expenditure and catabolism. It is a clinical challenge to provide adequate nutrition to these patients while maintaining gut function, preventing pancreatic stimulation, and minimizing the risk of septic and metabolic complications associated with nutritional support. We present the case of a patient who had severe acute pancreatitis and was initially given total parenteral nutrition. After a period of initial improvement, he developed hyperglycemia, bacteremia, and sepsis. Parenteral nutrition was discontinued and infection was treated with antibiotics. Subsequent nutritional support consisted of enteral feeding with an elemental diet infused via a nasojejunal feeding tube. His condition improved gradually and he made a full recovery. This case illustrates the difficulties encountered while managing a case of severe acute pancreatitis and provides an evidence based approach to the nutritional management of severe acute pancreatitis in the intensive care unit setting.
Management of Chronic Pancreatitis
Authors: Giger Urs , Stanga Zeno , DeLegge Mark H.
Published: May 2008

Chronic pancreatitis (CP) is an inflammatory disorder that results in permanent impairment of the glandular anatomy of the pancreas with or without functional abnormalities. The pathogenesis of CP is usually unclear, except in the case of alcohol‐induced disease. The most common symptoms of CP are abdominal pain, diarrhea, and weight loss often requiring recurring hospitalization. Over time, pancreatic endocrine and exocrine dysfunction may develop as the disease progresses, and a variety of complications can occur. Among the possible complications are nutrient malabsorption and diabetes mellitus.

The treatment of CP is difficult and challenging for every physician. Relieving pain is the first step in treating CP. This symptom needs to be controlled, often with narcotics, which can cause dependence. Diarrhea usually indicates the presence of steatorrhea, which is often treated with a high‐calorie, high‐protein, and low‐fat diet to minimize symptoms of the underlying disease and to promote weight retention or gain. Pancreatic replacement therapy is used to combat maldigestion and malabsorption. Patients with diabetes may need insulin therapy for glycemic control. The use of parenteral nutrition for bowel rest is a standard approach in patients with symptomatic CP. The use of jejunal enteral feeding recently has been evaluated for efficacy in CP patients.

The role of pancreatic endotherapy in the management of CP is evolving. Several reports have suggested that endoscopic therapy aimed at decompressing the obstructed pancreatic duct can be associated with pain relief in some patients. Surgery should be considered in patients who fail medical therapy.
Management of Parenteral Nutrition in Acutely Ill Patients With Hyperglycemia
Authors: McMahon M. Molly
Published: May 2008

Many hospital clinicians manage patients with hyperglycemia receiving nutrition support. Recent studies underscore the importance of tight glucose control in hospitalized patients. Over the short term, hyperglycemia can adversely affect fluid balance, immune function, inflammation, and outcome; glucose control can improve these effects. Because this appears to be true for patients with and without a known diagnosis of diabetes, hyperglycemia should be aggressively treated in all patients. Avoidance or minimization of hypoglycemia also is important. In general, the nutrition assessment, indications for nutrition support, and estimate of nutrition requirements for critically ill patients with hyperglycemia are similar to those of nondiabetic patients. Because overfeeding may cause hyperglycemia, appropriate provision of calories is essential. Although the technology to deliver tight glycemic control in intensive care unit settings is widely available, implementing a safe and effective program requires standardized approaches. Studies testing which insulin infusion safely achieves tight glucose control are limited. Further research should focus on the risks and benefits of parenteral nutrition use in this group of patients, as well as on optimal methods of achieving glucose control.
Evidence‐Based Medical Nutrition Therapy for Diabetes
Authors: Franz Marion J.
Published: May 2008

The 2002 American Diabetes Association (ADA) nutrition principles and recommendations are classified according to the level of evidence available using the ADA evidence grading system. Research also supports medical nutrition therapy (MNT) as an effective therapy in reaching treatment goals for glycemia, lipids, and blood pressure. Recommendations for carbohydrate, protein, dietary fat, micronutrients, and alcohol are summarized. The first priority for persons requiring insulin therapy is to identify a food/meal plan that can be used to integrate an insulin regimen into the person's lifestyle. MNT for type 2 diabetes progresses from prevention of obesity or weight gain to improving insulin resistance to contributing to improved metabolic control. The progressive decline in β‐cell failure requires that MNT progress from MNT as monotherapy to MNT in combination with oral glucose‐lowering agents to MNT with insulin therapy. Monitoring of outcomes is essential to assess the outcomes of lifestyle interventions or to determine if changes in medication(s) are necessary.
Pancreatic Islet Cell Transplantation: A Treatment Strategy for Type I Diabetes Mellitus
Authors: Onaca Nicholas , Klintmalm Goran B. , Levy Marlon F.
Published: May 2008

Type I diabetes mellitus continues to be a serious disease with long‐term morbidity from complications of the disease, despite better knowledge of physiology and better patient care. Pancreatic islet cell transplantation, still experimental, is gaining acceptance as a treatment strategy for individuals with type 1 diabetes who have poor glucose control and frequent hypoglycemic episodes despite maximal care. The procedure can improve glucose control, avoiding further hypoglycemic episodes, and can achieve insulin‐independence at the expense of immunosuppression treatment. Islet cell transplantation does not correct all the metabolic abnormalities seen in type 1 diabetes, and glucose tolerance can remain abnormal. The dietary management of the patients still needs to be defined. Further research is focused at improvement in islet isolation and the refinement of immunosuppression strategies aiming toward immune tolerance, bringing hope for a cure of diabetes.
New Drugs for Management of Diabetes: Insulin Analogues, Inhaled Insulin, Pramlintide, and Novel Peptides
Authors: Mouser Jay F.
Published: May 2008

Diabetes mellitus has reached epidemic proportions and contributes to considerable morbidity and mortality in the form of metabolic, microvascular, and macrovascular complications. Although there is no cure, large controlled studies demonstrate the importance of strict glycemic control in reducing progression of microvascular disease and associated morbidity. Insulin replacement is necessary for all patients with type 1 diabetes. In treatment of type 2 diabetes, more timely addition of insulin as patients fail to attain glycemic targets on combinations of oral agents has become widely accepted.

Pharmacokinetic properties of human insulins limit their ability to mimic physiologic insulin secretion. Analog insulins (prandial and basal) are designed with improved physiologic pharmacokinetic characteristics to enable more simplified insulin dosage adjustments and a reduced risk for hypoglycemia. Inhaled administration has emerged as a promising route for noninvasive prandial insulin. Clinical trials are under way to further characterize safety and efficacy of inhaled insulin preparations.

Despite numerous pharmacologic advancements, the majority of diabetic patients continue to have inadequate glycemic control. New information regarding biochemistry and pathophysiology of the disease is providing exciting opportunities for drug development. Promising new therapeutic classes include the synthetic analog of amylin (pramlintide), glucagon‐like peptide (GLP‐1) derivatives, and dipeptidyl peptidase IV inhibitors. Intriguingly, GLP‐1 hormones may have important biologic actions aside from stimulating insulin release, including inhibition of gastric motility and acid secretion, suppression of glucagon secretion, and islet cell proliferation. Although additional studies are needed, perhaps these emerging agents will have greater efficacy and safety because of a higher degree of selectivity for their molecular targets.
Enhancing the Response to Parenteral Nutrition in Critical Care
Authors: Sacks Gordon S.
Published: May 2008

Parenteral nutrition (PN) is an essential component in the support of critically ill patients with gastrointestinal dysfunction. Although PN cannot fully reverse hypermetabolism and accelerated skeletal muscle breakdown observed during periods of critical illness, it can prevent the adverse effects associated with malnutrition. The use of PN is not without complications, so care must be taken to ensure successful clinical outcomes with this complex therapy. Strategies have been developed by practitioners to promote safe practices with implementation of PN therapy and optimize a patient's response to PN. Identification of appropriate patient populations, strict glucose control, and manipulation of macro‐ and micronutrients are techniques being used to augment a patient's response to PN administration. This article will review the novel methods used to enhance benefits received from PN during critical illness.
Anabolic Agents: Adjuncts to Nutrition Support
Authors: Gervasio Jane
Published: May 2008

Anabolic agents as adjuncts to nutrition support therapy have been used to improve malnutrition and establish anabolism. Growth hormone, insulin‐like growth factor, and anabolic steroids have been studied for their potential to reverse the catabolic process and promote anabolism. This paper reviews several anabolic agents and their possible role in nutrition support therapy.
Predicting Energy Needs in Obese Patients
Authors: Breen Heather B. , Ireton‐Jones Carol S.
Published: May 2008

Obesity has become an epidemic in the United States, with other western countries also reporting increases in incidence of obesity. With many associated comorbidities, it is the most common nutritional disorder facing the medical team. However, the assessment of macronutrient needs for nutrition support regimens in obese adults is controversial. This review summarizes existing research on popular predictive approaches, including the Harris‐Benedict equation, kilocalories per kilogram, and the Ireton‐Jones equations. Complications including special considerations for patients who have undergone bariatric surgeries and current evidence on hypocaloric regimens are also discussed.
Multicentre, Cluster‐Randomized Clinical Trial of Algorithms for Critical‐Care Enteral and Parenteral Therapy (ACCEPT).
Authors: Martin CM , Doig GS , Heyland DK , Morrison T , Sibbald WJ
Published: May 2008

Background: The provision of nutrition support for patients in intensive care units (ICUs) varies widely both within and between institutions. We tested the hypothesis that evidence‐based algorithms to improve nutrition support in the ICU would improve patient outcomes. Methods: A cluster‐randomized controlled trial was performed in the ICUs of 11 community and 3 teaching hospitals between October 1997 and September 1998. Hospital ICUs were stratified by hospital type and randomized to the intervention or control arm. Patients at least 16 years of age with an expected ICU stay of at least 48 hours were enrolled in the study (n = 499). Evidence‐based recommendations were introduced in the 7 intervention hospitals by means of in‐service education sessions, reminders (local dietitian, posters) and academic detailing that stressed early institution of nutrition support, preferably enteral. Results: Two hospitals crossed over and were excluded from the primary analysis. Compared with the patients in the control hospitals (n = 214), the patients in the intervention hospitals (n = 248) received significantly more days of enteral nutrition (6.7 vs 5.4 per 10 patient‐days; p = .042), had a significantly shorter mean stay in hospital (25 vs 35 days; p = .003) and showed a trend toward reduced mortality (27% vs 37%; p = .058). The mean stay in the ICU did not differ between the control and intervention groups (10.9 vs 11.8 days; p = .7). Interpretation: Implementation of evidence‐based recommendations improved the provision of nutrition support and was associated with improved clinical outcomes.
A Review of Nutrition in Human Immunodeficiency Virus Infection in the Era of Highly Active Antiretroviral Therapy
Authors: Coyne‐Meyers Kristen , Trombley Lisa E.
Published: May 2008

Background: Nutrition complications of HIV infection, including wasting syndrome, nutrient deficiencies, and metabolic complications, have been well documented over the last 25 years. Methods: A systematic review of the literature was performed using the keywords HIV; nutrition; nutrition support; vitamins A, B, C, and E; selenium; zinc; and glutamine through MEDLINE using Medscape and PubMed. Results: Although no accurate prediction equations exist for determining energy needs in patients with HIV/acquired immunodeficiency syndrome (AIDS), the Harris‐Benedict equation with a 1.3 stress factor has been used for weight maintenance. Some experts recommend protein requirements of 1.0 to 1.4 g/kg for maintenance and 1.5 to 2.0 g/kg for anabolism. There is a general consensus that all individuals with HIV benefit from a daily multivitamin and mineral supplement at levels of 100% of the US recommended daily intake (RDI). Nutrition therapy for HIV wasting is similar to that for other chronic diseases and begins with nutrition counseling. For persistent weight loss, standard oral supplements may be useful. The benefit of specialized supplements has yet to be proven. Enteral and parenteral nutrition support has produced positive outcomes related to mortality and quality of life in patients with HIV. Conclusions: Although the benefit of providing adequate amounts of calories, protein, and micronutrients for persons with HIV is well accepted, the exact amounts of nutrients and optimal feeding modalities are less clear. Long‐term clinical trials are needed to provide more conclusive data on nutrition intervention in HIV infection, particularly related to supplementation of specific nutrients.
Treatment of HAART‐Induced Lactic Acidosis With B Vitamin Supplements
Authors: Bowers Jennifer Muir , Bert‐Moreno Aimee
Published: May 2008

Lactic acidosis, a rare but life‐threatening condition is fairly common in HIV‐infected individuals. The cause of lactic acidosis appears to stem from the use of HAART, causing mitochondrial dysfunction and the depletion of flavoprotein cofactors necessary for electron transport. Deficiencies of riboflavin or thiamin can contribute to the development of hyperlactic acidemia. Further, the high incidence of liver disease (hepatitis B or C and alcoholic liver disease) in this population predisposes HIV patients to metabolic abnormalities. Supplementation with thiamin or riboflavin, depending on the individual patient's condition, can reduce elevated lactic acid levels.
Beneficial Effects of Adenosine Triphosphate on Nutritional Status in Advanced Lung Cancer Patients: A Randomized Clinical Trial
Authors: Agteresch HJ , Rietveld T , Kerkhofs LGM , van den Berg WO , Wilson JHP , Dagnelie PC
Published: May 2008

Background: In a randomized clinical trial in patients with advanced non–small‐cell lung cancer (NSCLC), infusion with adenosine 5′‐triphosphate (ATP) inhibited loss of body weight and quality of life. In the present article, the effects of ATP on body composition, energy intake, and energy expenditure as secondary outcome measures in the same patients are reported. Methods: Patients with NSCLC, stage IIIB or IV, were randomized to receive either 10 IV, 30‐hour ATP infusions every 2 to 4 weeks, or no ATP. Fat mass (FM), fat‐free mass (FFM), and arm muscle area were assessed at 4‐week intervals for 28 weeks. Food intake, body cell mass (BCM), and resting energy expenditure (REE) were assessed at 8‐week intervals for 16 weeks. Between‐group differences were tested for statistical significance by repeated‐measures analysis of covariance. Results: Fifty‐eight patients were randomized (28 ATP, 30 control). No change in body composition over the 28‐week follow‐up period was found in the ATP group, whereas per 4 weeks, the control group lost 0.6 kg of FM (p = .004), 0.5 kg of FFM (p = .02), 1.8% of arm muscle area (p = .02), and 0.6% of BCM per kilogram body weight (p = .054) and decreased 568 kJ/day in energy intake (p = .0001). Appetite also remained stable in the ATP group but decreased significantly in the control group (p = .0004). No significant differences in REE between the ATP and control groups were observed. Conclusions: The inhibition of weight loss by ATP infusions in patients with advanced NSCLC is attributed to counteracting the loss of both metabolically active and inactive tissues. These effects are partly ascribed to maintenance of energy intake.
Monitoring Therapeutic Interventions in Critically Ill Septic Patients
Authors: Marik Paul E.
Published: May 2008

Sepsis is the leading cause of admission to intensive care units in the United States. Although the treatment of sepsis is complex and multimodal, nutrition support plays an important role in the management of these patients. The diagnosis of sepsis, disease category, and severity of illness and the change in sepsis severity and organ function over time affect the delivery of nutrition support. This paper reviews the diagnostic criteria of sepsis, the use of “sepsis biomarkers,” and regional and global markers of organ function in sepsis and quantitative measures of illness severity and organ dysfunction.
The Mini Nutritional Assessment as an Assessment Tool in Elders in Long‐Term Care
Authors: Hudgens Jan , Langkamp‐Henken Bobbi
Published: May 2008

The prevalence of malnutrition increases with age and is most common in the institutionalized individual. Malnutrition is a condition associated with greater susceptibility to infection, longer hospital stay, and increased mortality. Detection of risk of malnutrition in elders and early intervention may lessen these negative consequences. A tool that has been used for assessing nutritional status of elders is the Mini Nutritional Assessment, or MNA. The MNA tool was originally validated in relatively healthy elders in France and New Mexico, but assessment scores seem to correlate with immune function, morbidity, and mortality of elders in long‐term care. One of the advantages of using the MNA for assessing nutritional status of elders in long‐term care is that it does not need any biochemical tests, such as serum albumin or prealbumin. A weakness of the MNA is that a number of questions target independent‐living elders but not elders in long‐term care or elders receiving nutrition support. The benefits, limitations, and interpretations in the use of this tool in a long‐term care setting are discussed.
Permissive Underfeeding of the Critically Ill Patient
Authors: Jeejeebhoy Khursheed N.
Published: May 2008

The rise in the popularity of nutrition support in the 1970s was associated with the concept of “hyperalimentation.” This concept was based on the early findings that increased metabolic rates were observed in various disease states such as trauma, sepsis, and burns. The aim was to feed 40% to 100% above the basal metabolic rate to avoid weight loss associated with critical illness. Since that time, several observations have indicated that permissive underfeeding may be beneficial because: (a) the metabolic rate is not markedly increased in most patients with critical illness except burns; (b) weight gain during nutrition support in critical illness is not caused by a gain in nitrogen but fat; (c) energy intake as glucose in excess of needs causes increased carbon dioxide production and a fatty liver; (d) hyperglycemia increases the risk of infective complications; and (e) a controlled trial of preoperative nutrition in which patients received 1000 kcal above the metabolic rate increased infectious complications.
Defining and Assessing Tolerance in Enteral Nutrition
Authors: Bernard Andrew C. , Magnuson Barbara , Tsuei Betty J. , Swintosky Marjorie , Barnes Stephen , Kearney Paul A.
Published: May 2008

Nutrition support has become widely recognized as an essential component of optimal care for acutely ill patients. Enteral nutrition is preferred over parenteral routes when possible. However, prescribed enteral nutritional regimens are sometimes met with side effects and even complications. These adverse events have been collectively termed “intolerance,” and forms of intolerance occur in a spectrum from bothersome at least to life threatening when most severe. Here we discuss nutritional access and its maintenance, introduce and define intolerance, and then review the current literature with regard to principal forms of enteral nutrition intolerance.
Benefits of Postpyloric Enteral Access Placement by a Nutrition Support Dietitian
Authors: Jimenez L. Lee , Ramage James E.
Published: May 2008

Background: Although enteral nutrition is considered the preferred strategy for nutrition support, it is often precluded by nasogastric feeding intolerance or the inability to place feeding access into the postpyloric position. In an effort to improve enteral nutrition (EN) outcomes at our institution, the nutrition support dietitian (NSD) began placing postpyloric feeding tubes (PPFT) in intensive care unit patients. Methods: Intensive care unit patients who received blind, bedside PPFT placements by the NSD (n = 18) were compared with a concurrent age‐ and diagnosis‐matched control group that received standard nutritional care without NSD intervention (n = 18). Interruption of EN infusion, appropriateness of parenteral nutrition (PN) prescription (based on American Society of Parenteral and Enteral Nutrition guidelines), and incidence of ventilator‐associated pneumonia (VAP), as defined by the American College of Chest Physicians practice guidelines, were determined in each group. Results: The NSD was successful in positioning the PPFT at or distal to the third portion of the duodenum in 83% of attempts. The PPFT group demonstrated no interruption of enteral feeding compared with 56% in the control group (p < .01) and required 1 (6%) PN initiation in contrast to 8 (44%) in the control group (p < .01). There was a trend toward reduced VAP in the PPFT group (6% vs 28%, p = .07). Of the PN initiations in the control group, 88% were deemed to be potentially avoidable; 6 of 8 PNs were initiated because of gastric residuals. Conclusions: Enteral nutrition facilitated by NSD placement of postpyloric feeding access is associated with improved tube feeding tolerance and reduced PN use. Further studies are needed to evaluate a possible effect of postpyloric feeding on the incidence of VAP.
The Impact of Implementing an Enteral Tube Feeding Protocol on Caloric and Protein Delivery in Intensive Care Unit Patients
Authors: Arabi Yaseen , Haddad Samir , Sakkijha Maram , Al Shimemeri Abdullah
Published: May 2008

Background: The purpose of this study was to determine the effect of an enteral tube feeding protocol on caloric and protein delivery to intensive care unit (ICU) patients. Methods: This prospective study consisted of 2 phases: before and after the implementation on an enteral‐feeding protocol. The following data were collected: demographics, Acute Physiology and Chronic Health Evaluation II score and Simplified Acute Physiology Score II, caloric and protein requirements, the location of the feeding tube tip, and prokinetic agents use. The primary endpoint was caloric and protein intake as a percentage of the requirement. Secondary endpoints were gastric residuals >150 mL, vomiting episodes, ICU and hospital lengths of stay, mechanical ventilation duration, and ICU and hospital mortality. Results: There were no significant differences between the control (n = 100) and protocol groups (n = 103) in baseline characteristics. The protocol was associated with significant improvement in the 7‐day average of caloric intake/requirement (53.9 ± 2.3% vs 64.5 ± 2.2%, p = .001) and protein intake/requirement (56.7 ± 2.6% vs 67.4% ± 2.7%, p = .005). Caloric and protein intake improved whether the patient was receiving prokinetic agent or not. There was a trend toward lower gastric residual volumes and vomiting episodes in the protocol group. Patients receiving gastric feeding showed significant improvement in caloric intake to levels comparable to patients with postpyloric feeding. Conclusions: Enteral tube feeding protocol is effective in improving feeding delivery in ICU patients independent of prokinetic agent use. Protocol for enteral tube feeding should be considered in the management of ICU patients, given the positive impact of this nonpharmacologic, noninterventional tool.
The Impact of IV Fat Emulsion Administration in Acute Lung Injury
Authors: Lekka ME , Liokatis S , Nathanail C , Galani V , Nakos G
Published: May 2008

The aim of this study was to evaluate the effect of parenteral nutrition containing medium‐ and long‐chain triglycerides on the function of the respiratory system and to investigate mechanisms involved in this process. We studied 13 patients with acute respiratory distress syndrome (ARDS), 8 receiving lipid and 5 placebo, and 6 without ARDS, receiving lipid. Bronchoalveolar lavage (BAL) was performed before and 1 hour after administration of lipid or placebo. In patients with ARDS, lipid administration resulted in deterioration of oxygenation (PaO2/FIO2: from 129 ± 37 to 95 ± 42), compliance of respiratory system (from 39.2 ± 12 to 33.1 ± 9.2 mL/cm H2O), and pulmonary vascular resistance (from 258 ± 47 to 321 ± 58 dyne·s·cm–5). In the BAL fluid of the same group, an increase in total protein and phospholipid concentrations, phospholipase activities, platelet‐activating factor and neutrophils, and alterations in BAL lipid profile were observed. No significant changes were observed in the control or in the ARDS‐Placebo groups. In conclusion, this study indicates that administration of medium‐ and long‐chain triglycerides in patients with ARDS causes alterations in lung function and hemodynamics. Inflammatory cells, possibly activated by lipids, release phospholipase A2 and platelet‐activating factor, enhancing edema formation, inflammation, and surfactant alterations.
The Acute Respiratory Distress Syndrome: Role of Nutritional Modulation of Inflammation Through Dietary Lipids
Authors: Mizock Barry A. , DeMichele Stephen J.
Published: May 2008

The acute respiratory distress syndrome (ARDS) is the most serious form of acute hypoxic respiratory failure. ARDS represents the expression of an acute, diffuse, inflammatory process in the lungs consequent to a variety of infectious and noninfectious conditions. It is characterized pathologically by damage to pulmonary epithelial and endothelial cells, with subsequent alveolar‐capillary leak and exudative pulmonary edema. The main clinical features of ARDS include rapid onset of dyspnea, severe defects in gas exchange, and imaging studies demonstrating diffuse pulmonary infiltrates. The role of nutrition in the management of ARDS has traditionally been supportive. Recent research has demonstrated the potential of certain dietary oils (eg, fish oil, borage oil) to modulate pulmonary inflammation, thereby improving lung compliance and oxygenation, and reducing time on mechanical ventilation. This article reviews the alterations in the immune response that underlie ARDS, discusses the physiology of dietary oils as immunonutrients, summarizes animal and human studies that explore the therapeutic effects of dietary oils, and provides clinical recommendations for their use.
Nutrition for Patients With Cystic Fibrosis
Authors: Olson Diane L. , Schwenk W. Frederick
Published: May 2008

Cystic fibrosis (CF) is the most frequent, lethal genetic disorder among northern Europeans. The etiology of this autosomal recessive disease is known to be a defect in the cAMP activation of chloride (Cl—) channels in secretory cells in many organs of the body. Although this defect usually leads to severe lung disease, many of these patients also have nutritional deficiencies. Nutrition is one of the key components in the management of CF. Patients are at high risk for malnutrition, which may result in accelerated progression of the disease and increased morbidity. This review will discuss nutrition recommendations for calories, protein, vitamins and minerals, and enteral and parenteral nutrition support practices.
Current Nutrition Management of Infants With Chronic Lung Disease
Authors: Carlson Susan J.
Published: May 2008

Preterm infants with lung disease present nutrition challenges to health care providers. Malnutrition is common, develops shortly after birth, and may continue into early childhood. Although there are many studies identifying the nutrient deficiencies in infants with chronic lung disease, few randomized trials have explored the effects of nutrition support on the prevention and treatment of chronic lung disease. The purpose of this article is to review current practices and ongoing controversies in the nutrition management of infants with chronic lung disease.
Enteral Access in Mechanically Ventilated Patients
Authors: Guidroz Andrew D. , Chaudhary Ayaz J.
Published: May 2008

The early institution of enteral nutrition is now accepted as the preferred route of feeding in critically ill patients with a functioning gastrointestinal tract. It is particularly important to establish early enteral nutrition in mechanically ventilated patients because of the metabolic demands associated with mechanical ventilation. The options for enteral access in mechanically ventilated patients are reviewed, with an emphasis on those techniques that may be performed at the bedside. The advantages, disadvantages, and complications of the different techniques will be considered.
Effects of Home Parenteral Nutrition on Resting Metabolic Rate: A Case Study
Authors: Ireton‐Jones Carol , Kindle Robbyn
Published: May 2008

Resting metabolic rate (RMR) measurement by indirect calorimetry is often used in acute care; however, indirect calorimetry is rarely performed on patients treated at home with complex therapies such as home parenteral nutrition (HPN). A new handheld indirect calorimeter is now available to measure RMR and oxygen consumption (VO2). This is a case study of a 35‐year‐old female who had her RMR and VO2 measured at rest while receiving cyclic HPN and while off of HPN over a period of 8 days. Results indicate that her RMR was higher while receiving HPN. Measuring RMR in patients receiving HPN may be very beneficial to avoid underfeeding and overfeeding. It will be important for the clinician to note if the patient is receiving HPN at the time of the measurement because RMR may be affected by HPN infusion.
Determining Feeding Tube Location by Gastric and Intestinal pH Values
Authors: Phang Jean S. , Marsh Wallace A. , Barlows Theodore G. , Schwartz Howard I.
Published: May 2008

Background: The purpose of this study was to evaluate a series of pH values of aspirates from feeding tubes to differentiate between gastric and intestinal tube placement. Methods: One hundred ventilator‐supported subjects, with an order for nasoduodenal feeding tube placement were randomly selected. The feeding tube was placed into the stomach, verified by auscultation, and 2 pH measurements were obtained. After the pH measurements were taken, tube location was then verified by fluoroscopy. When the tube was advanced into the small intestine, location was verified by fluoroscopy, and 2 additional pH measurements were obtained. Results: From the selected subjects, both a gastric and intestinal aspirate were obtained from 82 subjects. For the 82 subjects, the mean gastric and intestinal pH values were 4.8 ± 2.3 and 7.1 ± 1.0, respectively. For patients receiving acid‐suppressing agents, these values were 5.0 ± 2.3 and 7.2 ± 1.0, respectively. For subjects not receiving acid‐suppressing agents, these pH values were 4.0 ± 2.5 and 6.7 ± 1.1, respectively. For all patients, using a pH value of 6.5 as a predictor of feeding tube location, the sensitivity and specificity were 0.66 and 0.90. In addition, when an increase in pH ≥1.0 was used as a predictor of location change for all patients, the sensitivity was 0.58. Conclusions: The pH value was a reliable predictor of nasoduodenal tube placement. However, radiographic confirmation of location could not be excluded because of the low sensitivity using pH measurements alone. An increase of ≥1.0 in gastric vs intestinal pH specimens could be useful to determine use of radiography confirmation of tube placement.