bluuebunny/crossref_metadata_2025 huggingface dataset:
Synergy Between Immunosuppressive Therapy and Enteral Nutrition in the Management of Childhood Crohn's Disease
Authors: Heuschkel Robert
Published: May 2008

Induction of a remission in children with Crohn's disease is increasingly successful. However this success is dependent on what measure we use to define “remission.” Achieving a clinical remission is possible in >70% of children with Crohn's disease at diagnosis, while a mucosal or even immunological remission may occur in <50%. The importance of what ‘degree of remission’ should be achieved during maintenance therapy is discussed. Does early aggressive management with immunomodulators or biological agents indeed alter the natural history of the disease, and is it possible to give a prognosis based on either a snap‐shot of endoscopic appearance, or a mucosal cytokine profile? The potential benefits of using a 6–8 week course of exclusive enteral nutrition as an induction therapy in combination with azathioprine/6‐mercaptopurine are discussed. Whole protein formulae are safe and effective at achieving a clinical remission, however they are not a long‐term maintenance strategy. Given the relative safety of these immunosuppressants and their efficacy in children treated at diagnosis, it is now more important than ever to predict which individuals will benefit from use of immunomodulators very early in the disease process. There is brief mention of enteral nutrition as maintenance therapy. Given the very limited data available, it is still not possible to recommend long‐term nutrition supplementation as a maintenance therapy in all children. However, some children may respond to repeated shorter cycles of exclusive enteral nutrition in the absence of other therapeutic options.
Enteral Nutrition and Microflora in Pediatric Crohn's Disease
Authors: Lionetti Paolo , Callegari Maria Luisa , Ferrari Susanna , Cavicchi Maria Chiara , Pozzi Elena , de Martino Maurizio , Morelli Lorenzo
Published: May 2008

Background: Exclusive enteral nutrition (EN) is an established primary therapy for pediatric Crohn's disease (CD). The mechanism of action of such treatment is still conjectural. The aim of the present study was to investigate if EN‐induced remission is associated with modification of the fecal microflora in CD. Methods: Stool samples were collected from 5 healthy children and adolescents over a period of 3 months, and from 9 children and adolescents with active CD. To induce disease remission, children with CD received a course of exclusive EN for 8 weeks with a polymeric formula (Modulen IBD, Nestlè). At the end of the course of exclusive EN, children returned to a free diet but continued to take 40% of the daily caloric intake as polymeric formula. Fecal microflora was analyzed by 16S ribosomal DNA polymerase chain reaction and temperature gradient gel electrophoresis (TGGE) with direct visual comparison of band profiles of PCR products. Results: In 8 of 9 children, the exclusive EN alone induced disease remission. In 1 child, it was necessary to add steroids to the exclusive EN course to achieve remission. In all children with CD, analysis of gel band distribution revealed profound modification of the fecal microflora after exclusive EN. Variations of band distribution corresponding to different bacterial species were observed also in children on partial EN and required time to achieve stability of the band profile. In contrast, control healthy children showed a host‐specific and stable TGGE profile over time. Conclusion: These data suggest that a possible mechanism of action of EN in inducing disease remission in CD is the capacity of modification of gut microflora. Possible explanations of such capacity are both low residue and prebiotic properties of the polymeric liquid formula.
Determinants of Insulin Availability in Parenteral Nutrition Solutions
Authors: Christianson Matthew A. , Schwartz Michael W. , Suzuki Norman
Published: May 2008

Background: Management of hyperglycemia in patients receiving parenteral nutrition (PN) often includes the addition of regular insulin to the PN solution. A literature review has shown insulin availability in such solutions to range from 10% to 95%. This discrepancy in availability may be due to differences in the composition of the PN solution, the final concentration of insulin, or the assay method used to determine insulin concentrations. The purpose of this study was to evaluate insulin recovery from a standard PN solution used at our medical center. Methods: Solutions were manually prepared in our pharmacy according to standard practice. Multivitamins and trace elements were added to 1 of 2 L of solution each day. Each of 3 simulated patients received 2 L of solution per day for 3 consecutive days. Samples from each bottle were drawn at baseline, 1 hour after the start of infusion, and 1 hour before the end of infusion and were subsequently analyzed for immunoreactive insulin levels by radioimmunoassay. Results: Recovery of insulin from solutions containing multivitamins and trace elements was much greater (95%) than from those without (5%). Conclusions: The presence of multivitamins and trace elements is a major determinant of insulin availability in PN solutions. Additional research is necessary to determine the mechanism mediating this effect and to assess its clinical significance.
Carnitine Treatment Improved Quality‐of‐Life Measure in a Sample of Midwestern Hemodialysis Patients
Authors: Steiber Alison L. , Davis Alan T. , Spry Leslie , Strong Jennifer , Buss Mary Lou , Ratkiewicz Michelle M. , Weatherspoon Lorraine J.
Published: May 2008

Background: Previously, we demonstrated that selected groups of hemodialysis patients might be more likely to have abnormalities of carnitine metabolism. The purpose of the present study was to examine the effects of carnitine therapy in these selected groups of hemodialysis patients on quality‐of‐life measures and erythropoietin dose. Methods: This was a double‐blind, randomized, controlled trial, in which 50 hemodialysis patients were treated with either 2 g IV carnitine or placebo. The treatment period was for 24 weeks. Results: Thirty‐four patients (15 in the treatment group) completed the study. The mean age was 69 ± 15 years, 35% were women, and 44% had diabetes. Mean initial plasma total, free, short‐chain acyl and long‐chain acyl carnitine concentrations (μmol/L; mean ± SEM) were 35.9 ± 1.8, 18.2 ± 1.1, 11.6 ± 0.6, and 6.0 ± 0.3, whereas the plasma acyl‐to‐free‐carnitine ratio was 1.02 ± 0.05. With respect to the Medical Outcomes Short Form‐36 (SF‐36), improvements from baseline were noted in the treatment group (n = 13) for role‐physical (33.9± 1.9 to 43.2 ± 3.0, p < .05) and the SF‐36 physical component summary score (36.1 ± 2.7 to 39.7 ± 2.3, p = .09) relative to changes in the control group (n = 14). The erythropoietin dose over the 24‐week period was reduced from baseline in the treatment group relative to the placebo group (–1.62 ± 0.91 vs 1.33± 0.79 units erythropoietin/dry weight/hemoglobin concentration, respectively, p < .05). Conclusions: After 24 weeks of IV carnitine therapy, SF‐36 scores were improved and erythropoietin doses were reduced in hemodialysis patients, relative to the control group.
A Carbohydrate‐Rich Beverage Prior to Surgery Prevents Surgery‐Induced Immunodepression: A Randomized, Controlled, Clinical Trial
Authors: Melis Gerdien C. , van Leeuwen Paul A. M. , von Blomberg‐van der Flier B. Mary E. , Goedhart‐Hiddinga Andrea C. , Uitdehaag Bernard M. J. , van Schijndel Rob J. M. Strack , Wuisman P. I. J. M. , van Bokhorst‐de van der Schueren Marian A. E.
Published: May 2008

Background: Fasting before surgery is still common care in a lot of western hospitals. Overnight fasting can induce postoperative insulin resistance. Insulin resistance has been shown to be related to infectious morbidity. It was shown that postoperative insulin resistance can be attenuated by preoperative intake of a clear carbohydrate‐rich beverage. The aim of this study was to investigate whether preoperative intake of carbohydrate‐rich beverages could postoperatively influence the immune system. Methods: In this randomized, controlled study, we investigated the effect of surgery on the postoperative immune response in 10 preoperatively fasted patients (control) and 2 groups of 10 patients receiving 2 different carbohydrate‐rich beverages preoperatively, by measuring human leukocyte antigen (HLA)‐DR expression on monocytes on the day before and on the day after surgery. Furthermore, we studied perioperative fluid homeostasis and preoperative well‐being of the patients. Results: HLA‐DR expression decreased significantly after surgery in the control group. Patients receiving any of the 2 carbohydrate‐rich beverages did not show this postoperative decrease. Fluid homeostasis was not affected in any of the groups, and well‐being tended to be better in patients receiving carbohydrate‐rich beverages compared with controls. Conclusion: This study suggests that preoperative intake of a carbohydrate‐rich beverage can prevent surgery‐induced immunodepression and thus might reduce the risk of infectious complications.
Enteral Nutrition and Oral Nutrition Supplements: A Review of the Economics Literature
Authors: Pritchard Clive , Duffy Steven , Edington Jackie , Pang Francis
Published: May 2008

Background: We sought to review the economics literature on enteral nutrition (EN) and oral nutrition supplements (ONS) against the background of an ongoing clinical guideline development. Methods: We searched the Health Economic Evaluations Database, the NHS Economic Evaluation Database, and the Cochrane Database of Systematic Reviews. Results: Enteral vs parenteral nutrition was found to be the most common comparison undertaken. The randomized trial evidence suggests that, in some groups of patients, EN is better in terms of clinical endpoints and/or length of hospital stay. This should translate into a lower mean cost for EN, given the reduced daily cost. These studies should be treated with caution because of their small sample size and poor quality. Costing was often crude and poorly reported, tending to focus on the narrow costs of the nutrition supplements. Only 1 study of a nutrition supplement in the community setting was found. Conclusions: There is some evidence to indicate economic advantages of enteral over parenteral nutrition and of immune‐enhancing supplements relative to control diet. There is a lack of well‐designed studies taking a broad view of relevant comparators, costs, and outcomes. The cost‐effectiveness of different forms of nutrition in different patient groups remains to be established.
Antioxidant Supplementation With or Without B‐Group Vitamins After Acute Ischemic Stroke: A Randomized Controlled Trial
Authors: Ullegaddi Rajesh , Powers Hilary J. , Gariballa Salah E.
Published: May 2008

Background: Evidence shows that there is a rapid increase in the production of markers of oxidative damage immediately after acute ischemic stroke and that endogenous antioxidant defenses are rapidly depleted, thus permitting further tissue damage. Several studies point to an antioxidant effect of B‐group vitamins and a pro‐oxidant effect of elevated total plasma homocysteine (tHcy). Methods: To test whether supplementary antioxidants with or without B‐group vitamins during this critical period enhance antioxidant capacity or mitigate oxidative damage, ninety‐six acute ischemic stroke patients within 12 hours of symptom onset were randomly assigned to receive either daily oral 800 IU (727 mg) vitamin E and 500 mg vitamin C (n = 24), or B‐group vitamins (5 mg folic acid, 5 mg vitamin B2, 50 mg vitamin B6, and 0.4 mg of vitamin B12; n = 24), both vitamins together (n = 24), or no supplementation (n = 24) for 14 days. Treatment groups and controls were matched for stroke subtype and age. Blood was obtained before treatment, at day 7, and day 14 for measurements of plasma or blood vitamin status, plasma total antioxidant capacity (TAOC), malondialdehyde (MDA), tHcy and C‐reactive protein (CRP). Results: Supplementation with antioxidant vitamins and B‐group vitamins separately or together significantly increased the plasma concentration of vitamin C, E, pyridoxal phosphate (B6 status), red blood cell folate, and improved a measure of B2 status (red cell glutathione reductase activation coefficient [EGRAC]), compared with the control group. Plasma TAOC increased significantly in the antioxidant treatment groups compared with the nonsignificant decline seen in the control group. tHcy concentrations decreased in subjects who received B‐group vitamins and the control group compared with the rise seen in those who received antioxidants alone. There was a significant reduction in plasma MDA concentration in the 3 treatment groups, in contrast to the increase seen in the control group; however, the changes were most evident in antioxidant groups. CRP concentrations (a marker of tissue inflammation) were significantly lower in the 3 treatment groups compared with the control group. There were no additive or synergistic effects of antioxidants and B‐group vitamins together on any outcome measure. Conclusions: Antioxidants supplementation with or without B‐group vitamins enhances antioxidant capacity, mitigates oxidative damage, and may have an anti‐inflammatory effect immediately postinfarct in stroke disease.
Toxicity of a Soybean Oil Emulsion on Human Lymphocytes and Neutrophils
Authors: Cury‐Boaventura Maria Fernanda , Gorjão Renata , de Lima Thaís Martins , Piva Tatiane Maria , Peres Carmem Maldonado , Soriano Francisco Garcia , Curi Rui
Published: May 2008

Background: The incorporation of lipid emulsions in parenteral diets is a requirement for energy and essential fatty acid supply to critically ill patients. In this study, the toxicity of a lipid emulsion rich (60%) in triacylglycerol of ω‐6 polyunsaturated fatty acids on leukocytes from healthy volunteers was investigated. Methods: Eleven volunteers were recruited, and blood samples were collected before infusion of a soybean oil emulsion, immediately afterwards, and 18 hours later. The cells were studied immediately after isolation and again after 24 hours or 48 hours in culture. The following determinations were made: composition and concentration of fatty acids in plasma, lymphocytes and neutrophils, lymphocyte proliferation, levels of cell viability, DNA fragmentation, phosphatidylserine externalization, mitochondrial depolarization, reactive oxygen species production, and neutral lipid accumulation. Results: Soybean oil emulsion decreased lymphocyte proliferation and provoked neutrophil and lymphocyte apoptosis and necrosis. Evidence is presented herein that soybean oil emulsion is less toxic to neutrophils than to lymphocytes. The mechanism of cell death induced by this oil emulsion was characterized by mitochondrial membrane depolarization and neutral lipid accumulation but did not alter reactive oxygen species production. Conclusions: Soybean oil emulsion given as a single dose of 500 mL promotes lymphocyte and neutrophil death that may enhance the susceptibility of the patients to infections.
Phospholipid Fatty Acid Composition and Diamine Oxidase Activity of Intestinal Mucosa From Rats Treated With Irinotecan Hydrochloride (CPT‐11) under Vegetable Oil–Enriched Diets: Comparison Between Perilla Oil and Corn Oil
Authors: Usami Makoto , Ohata Atsushi , Kishimoto Kazunori , Ohmae Keiko , Aoyama Michiko , Miyoshi Makoto , Fueda Yuri
Published: May 2008

Background: Irinotecan hydrochloride (CPT‐11), a topoisomerase I inhibitor highly effective for various cancers, has its dosage limited by diffuse mucosal damage with increased prostaglandin (PG) E2. However, an analysis of intestinal phospholipid fatty acid composition after CPT‐11 treatment has not been reported. This study aimed to evaluate intestinal phospholipid fatty acid composition in relation to intestinal mucosal integrity and plasma and mucosal PGE2 levels after CPT‐11 treatment. The effect of dietary vegetable oil supplementation, perilla oil vs corn oil, was also evaluated. Methods: Intestinal phospholipid fatty acid composition, PGE2 level, mucosal diamine oxidase (DAO) activity, diarrhea, and blood tests were evaluated in rats injected with CPT‐11 under a conventional diet. The same parameters were compared among 3 different dietary vegetable oil supplementations: perilla oil, corn oil, and a 1:3, respectively, mixture with a semisynthetic diet during 14 days. Results: CPT‐11 treatment caused severe diarrhea, and intestinal mucosal fatty acid composition changed with increased PGE2 level and decreased DAO activity. Decreases in eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and EPA/arachidonic acid (AA) ratio in colonic mucosa were observed. Perilla oil increasedω ‐3 polyunsaturated fatty acids, α‐linolenic acid, EPA, and EPA/AA ratio and decreased plasma PGE2. But the amounts used were not enough to attenuate intestinal damage from CPT‐11 treatment. Conclusions: CPT‐11 induced changes of intestinal mucosal fatty acid composition with increased PGE2 level and decreased intestinal integrity; perilla oil shows the possibility of being able to attenuate those changes.
N‐Acetylcysteine is a Highly Available Precursor for Cysteine in the Neonatal Piglet Receiving Parenteral Nutrition
Authors: Shoveller Anna K. , Brunton Janet A. , Brand Ortrud , Pencharz Paul B. , Ball Ronald O.
Published: May 2008

Background: Cysteine (CYS) is accepted as an indispensable amino acid for infants receiving parenteral nutrition (PN), and CYS is unstable in solution. Thus, developing a method to supply CYS in PN for neonates is needed. N‐acetyl‐l‐cysteine (NAC) is stable in solution and safe for use in humans; therefore, NAC may be a means of supplying parenteral CYS. Methods: We determined the bioavailability of NAC in intravenously (IV)‐fed piglets randomized to 1 of 4 diet treatments, each supplying 0.3 g/kg/d methionine and either 0.2 g/kg/d CYS (CON), 0 NAC (zeroNAC), 0.13 NAC (lowNAC), or 0.27 g/kg/d NAC (highNAC). Piglets (2 days old; 1.8 kg, n = 20) were surgically implanted with femoral and jugular catheters. On day 3 postsurgery, test diets were initiated and continued until day 8. Piglets were weighed daily. Blood was sampled 6 hours before test diet initiation and at 0, 6, 12, 18, 24, 36, 48, 60, 72, 84, 96, 108, and 120 hours. Urine was collected on ice in 24‐hour sample periods. Results: Total mean weight gain was not different between groups; however, average daily gain in the zeroNAC and lowNAC groups declined significantly (p< .05) over the 5‐day treatment period. Nitrogen retention was similar between the CON and highNAC groups, both were higher than the lowNAC group, and the zeroNAC treatment produced the lowest nitrogen retention. NAC percent retention was not different between lowNAC and highNAC and was 85.4% and 82.6%, respectively. Plasma NAC was higher in highNAC than lowNAC (p< .05). Conclusions: These data demonstrate that NAC is available as a precursor for CYS to support growth and protein (nitrogen) accretion in piglets administered a parenteral solution.
Percutaneous Endoscopic Gastrostomy Placement Without Skin Incision: Results of a Randomized Trial
Authors: Sedlack Robert E. , Pochron Nichole L. , Baron Todd H.
Published: May 2008

Background: During percutaneous endoscopic gastrostomy (PEG) placement, skin incision is performed as standard practice. We suspected that this time‐honored principle is unnecessary. Methods: In a prospective, randomized trial, 50 adults undergoing PEG placement were randomized to skin incision omission PEG (IOPEG) and standard PEG (SPEG). Two‐ and 7‐day PEG site evaluations were performed to grade stomal infection, bleeding, pain, and overall satisfaction using a standardized scoring system. Median stomal evaluation scores were compared between groups using a Wilcoxon rank‐sum test. Completion rates were compared using a t‐test. Results: Placement success for the IOPEG and SPEG technique was 22/25 (88%) and 24/25 (96%), respectively (p = NS). Three failed IOPEG attempts required an incision to complete due to increased pull force encountered. One SPEG failed due to inability to transilluminate. Stomal evaluation scores of infection, bleeding, pain, leakage, and patient satisfaction were not significantly different at 2 or 7 days. No serious complications occurred as a result of skin incision omission. Conclusions: Omitting the skin incision does not significantly alter the placement success rate, patient satisfaction, or the rate of stomal complications, thus dispelling the dogma that a skin incision is mandatory for PEG placement and the myth that incisions reduce infectious complications.
Choline Deficiency Is Associated With Increased Risk for Venous Catheter Thrombosis
Authors: Buchman Alan L. , Ament Marvin E. , Jenden Donald J. , Ahn Chul
Published: May 2008

Background: Patients with intestinal failure who require long‐term parenteral nutrition (PN) develop catheter thrombosis as a complication. This patient group may also develop choline deficiency because of a defect in the hepatic transsulfuration pathway in the setting of malabsorption. This study was undertaken to determine whether choline deficiency is a risk factor for development of catheter thrombosis. Methods: Plasma free and phospholipid‐bound choline concentrations were measured in a group of 41 patients that required long‐term PN. Episodes of catheter thrombosis from onset of PN to the time of blood testing were recorded. Results: Sixteen (39%) patients developed catheter thrombosis, and 5 of these had recurrent catheter thrombosis. Plasma free choline was 7.7 ± 2.7 nmol/mL in patients with no history of catheter thrombosis and 6.2 ± 1.7 nmol/mL in patients with previous catheter thrombosis (p = .076 by Wilcoxon rank‐sum test). The partial correlation between plasma free choline concentration and the frequency of clots after controlling for catheter duration was r = –0.33 (p = .038). The relative risk for catheter thrombosis in subjects with a plasma free choline concentration <8 nmol/mL was 10.0, 95% confidence interval (1.134–88.167). Plasma phospholipid‐bound choline concentration was 2191.7 ± 679.0 nmol/mL in patients with previous catheter thrombosis and 2103.3 ± 531.2 nmol/mL in patients without history of catheter thrombosis (p = NS). Conclusion: Choline deficiency is a significant risk factor for development of catheter thrombosis in patients with intestinal failure who require PN.
Age Differences in Fluid Balance and Serum Na+ and K+ Levels After Nasogastric Tube Feeding in Stroke Patients: Elderly vs Nonelderly
Authors: Oh HyunSoo , Seo WhaSook
Published: May 2008

Background: Enteral nutrition support has been commonly used to improve nutrition status in acute stroke patients. The purpose of this study was to examine whether significant alterations in fluid and serum Na+ and K+ levels due to nasogastric tube feeding depended on patient age. Methods: This study was conducted by retrospective review of the medical records of tube‐fed patients with acute brain infarction who had been hospitalized in a university hospital. Results: Rates of overhydration were high before tube feeding in both elderly and nonelderly stroke patients. This overhydration rate became more prevalent after iso‐osmolal tube feeding in the elderly but decreased somewhat in the nonelderly subjects, and this difference in fluid balance after tube feeding between the elderly and nonelderly was statistically significant. Contrary to fluid balance, serum Na+ and K+ concentrations were no different in the elderly and nonelderly patients after tube feeding. Conclusions: Although the results showed that overhydration state was prominent after tube feeding in the elderly, it appeared that there was a very mild clinical impact because the osmolality and serum sodium were not changed in this group. However, more attention to the maintenance of fluid balance in the elderly tube‐fed stroke patients is needed because elderly patients have great difficulty in maintaining a normal fluid balance.
Quantification of Protein Metabolism in Vivo for Skin, Wound, and Muscle in Severe Burn Patients
Authors: Gore Dennis C. , Chinkes David L. , Wolf Steven E. , Sanford Arthur P. , Herndon David N. , Wolfe Robert R.
Published: May 2008

Background: In response to injury, muscle catabolism can be extensive, and in theory, the wound consumes amino acids to support healing. The purpose of this study is to assess a technique by which in vivo protein kinetics of muscle, wound, and normal skin can be quantified in burn‐injured patients. Methods: Study protocol consisting of infusion of d5 phenylalanine; biopsies of skeletal muscle, skin, and donor‐site wound on the leg; quantification of blood flow to total leg, wound, and skin; and sequential blood sampling from the femoral artery and vein. Five‐compartment modeling was used to quantify the rates of protein synthesis, breakdown, and phenylalanine transport between muscle, wound, and skin. Results: The study results demonstrated a net release of phenylalanine from muscle yet a net consumption of phenylalanine by the wound. Compared with skin, the wound had a substantially increased rate of protein synthesis and a reduced rate of protein breakdown (p < .01). Transport rates into and out of muscle were significantly higher than those for wound (p < .01). Conclusions: This novel methodology enables in vivo quantification of the integrated response of muscle, wound, and skin protein/amino acid metabolism and confirms the long‐held theory of a net catabolism of muscle and a net anabolism of wound protein in patients after injury. This methodology can be used to assess the metabolic impact of such measures as nutrition, pharmacologic agents, and surgical procedures.
Clinically Relevant Differences in Accuracy of Enteral Nutrition Feeding Pump Systems
Authors: Tepaske Robert , Binnekade Jan M. , Goedhart Peter T. , Schultz Marcus J. , Vroom Margreeth B. , Mathus‐Vliegen Elisabeth M. H.
Published: May 2008

Background: There are clinically relevant discrepancies between prescribed volumes and delivered volumes of enteral nutrition (EN) in intensive care unit (ICU) patients. Next to EN‐protocol violations due to insufficient care, we hypothesized technical factors to be responsible for this deficit. The aim of this study was to determine the accuracy of EN feeding pump systems frequently used in the ICU. Methods: Thirteen commercially available EN feeding pumps with their own delivery systems were tested in 12 sessions with different EN feeding tubes and EN formulas in a laboratory setting. The reproducibility of the measurements was determined for the 8 best performing EN feeding pump systems. Results: There were clinically important differences between prescribed volumes and delivered volumes of EN in the tested EN feeding pump systems. The deficit in volume ranged from +66 mL (surplus of 66 mL) to –271 mL (deficit of 271 mL) per 24 hours (14% of prescribed volume). Viscosity of test fluids (water/EN feeding formulas) and resistance of test tubes had no influence on the delivered volume by the tested EN feeding pump systems, because differences between prescribed volumes and delivered volumes were consistently found for each system while varying these test settings. Conclusions: Differences between prescribed and delivered EN volumes are caused by the function and construction of EN feeding pump systems. To improve nutrition therapy, the flow rate has to be adjusted or the best‐performing EN feeding pump has to be purchased.
New Parenteral Lipid Emulsions for Clinical Use
Authors: Waitzberg Dan L. , Torrinhas Raquel Susana , Jacintho Thiago Manzoni
Published: May 2008

Routine use of parenteral lipid emulsions (LE) in clinical practice began in 1961, with the development of soybean oil (SO) – based LE. Although clinically safe, experimental reports indicated that SO‐based LE could exert a negative influence on immunological functions. Those findings were related to its absolute and relative excess of ω‐6 polyunsaturated fatty acids (PUFA) and the low amount of ω‐3 PUFA and also to its high PUFA content with an increased peroxidation risk. This motivated the development of new LE basically designed along the reduction of ω‐6 PUFA and the ω‐3 PUFA addition in order to obtain balanced levels of the ω‐6/ω‐3 ratio. The new LE for clinical use (available in Europe and South America) are differentiated by their content in polyunsaturated (ω‐6 and ω‐3), monounsaturated, and saturated fatty acids (FA), as well as FA source of their origin, including soy, coconut, olive, and fish oil. This article presents the new LE nutrition and energy functions but also its biochemical, metabolic, and immunomodulating aspects, according to their FA content. LE at 20% when infused from 1.0 to 2.0 g/kg body weight/day rates, either alone or in association with amino acids and glucose, are safe and well tolerated in routine clinical practice. LE combining SO with medium‐chain triglycerides and/or olive oil have less ω‐6 PUFA and are better metabolized, with less inflammatory and immunosuppressive effects than in relation to pure SO‐based LE. The ω‐3 PUFA used alone or as component of a new and complex LE (soy, MCT, olive and fish oil) has demonstrated anti‐inflammatory and immunomodulatory effects.
Glutamine‐Mediated Attenuation of Cellular Metabolic Dysfunction and Cell Death After Injury Is Dependent on Heat Shock Factor‐1 Expression
Authors: Peng Zhi Yong , Serkova Natalie J. , Kominsky Douglas J. , Brown Jaimi L. , Wischmeyer Paul E.
Published: May 2008

Background:Cellular metabolic dysfunction is associated with occurrence of multiple‐organ failure after critical illness. Glutamine (GLN) attenuates cellular metabolic dysfunction in critical illness models. The mechanism of this protection is unclear. We previously demonstrated that GLN′s benefit in critical illness might be due to enhanced heat shock protein (HSP) expression. We hypothesize that GLN′s attenuation of cellular metabolic dysfunction is dependent on presence of heat shock factor‐1 (HSF‐1).Methods:HSF‐1 wild‐type and knockout mouse embryonic fibroblasts (HSF‐1+/+ and HSF‐1–/–) were used in all experiments. Cells were not treated, or were treated with 8 mmol/L GLN and immediately exposed to heat stress injury (45°C for 45 minutes). Cells were harvested for metabolic analysis by nuclear magnetic resonance (NMR) at 24 hours postinjury. Cell survival was assessed using the MTS assay.Results:GLN treatment in HSF‐1+/+ cells led to significant attenuation of decreases in adenosine triphosphate (ATP)/adenosine diphosphate (ADP) ratio, phosphomonoester/phosphodiester (PME/PDE) ratio, and cell survival observed in non‐GLN‐treated HSF‐1+/+ cells. In HSF‐1–/– cells, the beneficial effect of GLN on preservation of ATP/ADP ratio, PME/PDE proliferation, and cell survival was lost. GLN‐treated HSF‐1–/– cells had a significant increase in extracellular lactate concentrationsvsGLN‐treated HSF+/+ cells.Conclusions:GLN treatment attenuated cellular metabolic dysfunction and improved cell membrane recovery only in HSF‐1+/+ cells. Cellular injury, as measured by lactate release and cell survival assay, was improved by GLN treatment in HSF‐1+/+ cells alone. Thus, GLN′s beneficial effect on cellular metabolic dysfunction and cell survival appears to be dependent on HSF‐1 expression.
Interleukin‐7 Dose‐Dependently Restores Parenteral Nutrition–Induced Gut‐Associated Lymphoid Tissue Cell Loss but Does Not Improve Intestinal Immunoglobulin A Levels
Authors: Fukatsu Kazuhiko , Moriya Tomoyuki , Ikezawa Fumie , Maeshima Yoshinori , Omata Jiro , Yaguchi Yoshihisa , Okamoto Koichi , Mochizuki Hidetaka , Hiraide Hoshio , Hardy Gil
Published: May 2008

Background: Without enteral nutrition, the mass and function of gut‐associated lymphoid tissue (GALT), a center of systemic mucosal immunity, are reduced. Therefore, new therapeutic methods, designed to preserve mucosal immunity during parenteral nutrition (PN), are needed. Our recent study revealed that exogenous interleukin‐7 (IL‐7; 1 μg/kg twice a day) restores the GALT cell mass lost during intravenous (IV) PN but does not improve secretory immunoglobulin A (IgA) levels. Herein, we studied the IL‐7 dose response to determine the optimal IL‐7 dose for recovery of GALT mass and function during IV PN. We hypothesized that a high dose of IL‐7 would increase intestinal IgA levels, as well as GALT cell numbers. Methods: Male mice (n = 42) were randomized to chow, IL‐7‐0, IL‐7‐0.1, IL‐7‐0.33, IL‐7‐1 and IL‐7‐3.3 groups and underwent jugular vein catheter insertion. The IL‐7 groups were fed a standard PN solution and received IV injections of normal saline (IL‐7‐0), 0.1, 0.33, 1, or 3.3 μg/kg of IL‐7 twice a day. The chow group was fed chow ad libitum. After 5 days of treatment, the entire small intestine was harvested and lymphocytes were isolated from Peyer's patches (PPs), intraepithelial (IE) spaces, and the lamina propria (LP). The lymphocytes were counted and phenotypes determined by flow cytometry (αβTCR, γδTCR, CD4, CD8, B cell). IgA levels of small intestinal washings were also examined using ELISA (enzyme‐linked immunoabsorbent assay). Results: IL‐7 dose‐dependently increased total lymphocyte numbers in PPs and the LP. The number of lymphocytes harvested from IE spaces reached a plateau at 1 μg/kg of IL‐7. There were no significant differences in any phenotype percentages at any GALT sites among the groups. IgA levels of intestinal washings were significantly higher in the chow group than in any of the IL‐7 groups, with similar levels in all IL‐7 groups. Conclusions: Exogenous IL‐7 dose‐dependently reverses PN‐induced GALT cell loss, with no major changes in small intestinal IgA levels. IL‐7 treatment during PN appears to have beneficial effects on gut immunity, but other therapeutic methods are needed to restore secretory IgA levels.
Enhancing Patient Safety During Feeding‐Tube Insertion: A Review of More Than 2000 Insertions
Authors: Sorokin Rachel , Gottlieb Jonathan E.
Published: May 2008

Background: An intervention to reduce complications from insertion of small‐bore nasogastric feeding tubes was performed. Methods: This was a Performance Improvement project with the Plan, Do, Study, Act (PDSA) format; interventions occurred in July 2003. Electronic searches of risk management and radiology databases identified feeding‐tube malpositions and complications from January 1, 2001, through December 31, 2004. Chart abstraction and a pre‐ and postintervention comparison were performed. Interventions were adoption of a more compliant feeding tube, direct supervision of residents, technology‐guided insertion, and implementation of explicit policies and procedures. Results: Of all small‐bore nasogastric feeding‐tube placements, 1.3%–2.4% resulted in 50 documented cases of feeding‐tube malpositions during 4 years. Over half of the 50 patients were mechanically ventilated, and only 2 had a normal mental status. There were 13 complications (26% of malpositions), including 2 deaths, which were directly attributed to the feeding‐tube malposition. Only 2 of the 13 complications and none of the misplacements had been recorded in the risk management database; most cases were identified from the search of radiology reports. In the 15‐month postintervention period, no complications were identified. The control chart showed that after the intervention, there was a significant increase in the “number between” tube insertions without complications, confirming the effectiveness of the performance improvement (PI) project. Conclusions: Unassisted feeding tube insertion carries significant risk in vulnerable patients, which can be mitigated. Voluntary reporting appears inadequate to capture complications from feeding tube insertion.
Severe Ataxia, Myelopathy, and Peripheral Neuropathy Due to Acquired Copper Deficiency in a Patient With History of Gastrectomy
Authors: Tan Jeremias C. , Burns David L. , Jones H. Royden
Published: May 2008

Background: In animal studies, copper absorption has been demonstrated to occur in the proximal gut via duodenal enterocytes. Acquired copper deficiency is known as “swayback” in ruminant animals and Menkes' disease in humans. Copper is an essential micronutrient necessary for the hematologic and neurologic systems. Acquired copper deficiency in humans has been described, causing a syndrome similar to the subacute combined degeneration of vitamin B12 deficiency. Methods: This is a single case report. Our patient developed a neurologic constellation of ataxia, myelopathy, and peripheral neuropathy similar to vitamin B12 deficiency many years after gastrectomy for severe peptic ulcer disease. The patient was maintained for decades with enteral feedings via jejunostomy that provided the recommended dietary allowance (RDA) for copper. Results: Copper deficiency was suspected, identified, and treated. Over 3 months of follow‐up, serum copper levels increased from 4 μg/dL to 20 μg/dL (70–150 μg/dL), and ceruloplasmin increased from 6 mg/dL to 8 mg/dL (14–58 mg/dL). During this short time of follow‐up, the patient has had no further progression of his neurologic symptoms. Conclusions: Ataxia and myelopathy secondary to acquired copper deficiency are rare complications of major gastric resection. This is quite similar to the syndrome of vitamin B12 deficiency. Vitamin B12 repletion does not improve symptoms. Bariatric procedures such as gastric bypass surgery result in a similar functional anatomy of the proximal gut and may place more patients at increased risk. Early recognition and therapy with oral or parenteral copper may lead to a decrease in both neurologic and hematologic consequences.
Inflammation as the Key Interface of the Medical and Nutrition Universes: A Provocative Examination of the Future of Clinical Nutrition and Medicine
Authors: Jensen Gordon L.
Published: May 2008

There has been tremendous interest in inflammation by researchers, the medical community, and the lay public. Modulation of injury response is felt to represent a tenuous balance of pro‐ and anti‐inflammatory cytokines. Adverse outcomes may result from severe, sustained, or repeated bouts of inflammation. A critical observation is that nutrition support alone is inadequate to prevent muscle loss during active inflammation. It is necessary to take inflammation into consideration in conducting appropriate nutrition assessment, intervention, and monitoring. A host of medical conditions are actually inflammatory states that have important implications for nutrition care. Multifaceted interventions that may include anti‐inflammatory diets, glycemic control, physical activity, appetite stimulants, anabolic agents, anti‐inflammatory agents, anticytokines, and probiotics, will be necessary to blunt undesirable aspects of inflammatory response to preserve body cell mass and vital organ functions. Nutrition practitioners can seize this opportunity to be a part of the future medical team that brings highly individualized patient care to the bedside.
Metabolic Bone Disease in Patients Receiving Home Parenteral Nutrition: A Canadian Study and Review
Authors: Raman M. , Aghdassi E. , Baun M. , Yeung M. , Fairholm L. , Saqui O. , Allard J. P.
Published: May 2008

Background: Metabolic bone disease (MBD) is a significant complication in patients receiving long‐term home parenteral nutrition (HPN). Pamidronate has been poorly studied in this population. We examine the prevalence and risk factors for MBD and examine changes in bone mineral density (BMD) after pamidronate administration. Methods: First, a chart review of patients receiving HPN for >1 year was performed, and Pearson correlations were used to assess associations between MBD (defined as t score <–1) and risk factors. Second, the effect of IV pamidronate on BMD was studied prospectively in 11 HPN patients. Results were compared using a t‐test. Results: Charts were reviewed in 25 patients (15 F, 10 M): age, 56.9 ± 3.1 years; body mass index (BMI), 21.2± 0.57 kg/m2; months receiving HPN, 113.2 ± 0.09; and days per week receiving HPN, 5.08 ± 0.39. MBD was present in 33% of patients for the spine and hip and in 50% for the femoral neck; 24% had previous fractures. There was a significant negative correlation between the duration of HPN and BMD (r = –0.40) for all measurements. From those patients, 11 received IV pamidronate for a mean of 22.2 ± 5.4 months. At baseline, their mean HPN treatment duration was 10.6 ± 6.3 years. Overall, BMD results showed a trend toward improvement in the mean t score of the spine and hip postpamidronate therapy (pre, –3.1 ± 0.75; post, –2.9 ± 0.69; p = .07). After excluding 2 patients receiving corticosteroids, the mean t score of the spine showed significant improvement (prepamidronate –3.4 ± 0.57 vs post‐pamidronate –3.1 ± 0.65, p = .036). Conclusions: In our HPN population, 76% had MBD and 24% had previous fractures. The results suggest that these patients may benefit from pamidronate. More studies are needed to assess the efficacy of pamidronate.
Does Amount of Protein in Formula Matter for Low‐Birthweight Infants? A Cochrane Systematic Review
Authors: Premji Shahirose , Fenton Tanis , Sauve Reg
Published: May 2008

Background: High protein intake may be associated with negative consequences such as acidosis, uremia, and elevated levels of circulating amino acids (eg, phenylalanine levels). We performed a systematic review of randomized controlled trials to determine whether formula‐fed low‐birthweight infants could tolerate protein intakes ≥3.0 g/kg/d in their initial hospital stay, without adverse consequences. Methods: Randomized controlled trials contrasting levels of protein intakes as low (<3.0 g/kg/d), high (≥3.0 g/kg/d but <4.0 g/kg/d), or very high protein intake (≥4.0 g/kg/d) while other nutrients were held constant, were identified through a systematic search of the literature. Standard methods of the Cochrane Collaboration were used by 2 independent reviewers, with the third reviewer facilitating consensus decision making. Results: A meta‐analysis of 5 randomized trials indicated improved weight gain (weighted mean difference [WMD] 2.36 g/kg/d; 95% confidence interval [CI] 1.31–3.40) and higher nitrogen accretion (WMD 143.7 mg/kg/d; 95% CI 128.7–158.8) with high (≥3.0 g/kg/d but <4.0 g/kg/d) compared with low (< 3.0 g/kg/d) protein intakes while other nutrients were kept constant. No data were available for IQ or Bayley scores at 18 months or later or for very high protein intakes (≥4.0 g/kg/d). No significant differences were seen in rates of necrotizing enterocolitis, sepsis, or diarrhea. Conclusions: Accelerated weight and nitrogen accretion were noted with higher protein intakes in “healthy” formula‐fed low‐birthweight infants. This benefit could not be weighed against the adverse consequences of elevated blood urea nitrogen levels and increased metabolic acidosis and neurodevelopmental abnormalities.
Supplementation of Ω‐3 Fatty Acids in Parenteral Nutrition Beneficially Alters Phospholipid Fatty Acid Pattern
Authors: Senkal Metin , Geier Bruno , Hannemann Martin , Deska Thomas , Linseisen Jakob , Wolfram Günther , Adolph Michael
Published: May 2008

Background: The clinical safety and the uptake of ω‐3 polyunsaturated fatty acids (PUFA) into the serum phospholipids and erythrocyte membranes after administration of fish‐oil‐supplemented parenteral nutrition (PN) was investigated in colorectal surgical patients. Methods: Forty patients undergoing colorectal surgery (n = 40) and with an indication for PN were enrolled in a prospective, double‐blind, randomized study to receive an ω‐3 PUFA‐supplemented 20% lipid emulsion (Lipoplus; B. Braun Melsungen, Melsungen, Germany; test group, n = 19) for 5 days postoperatively. The control group received a standard 20% fat emulsion (Lipofundin MCT/LCT, B. Braun Melsungen, Melsungen, Germany, control group, n = 21). Clinical outcome parameters and safety were assessed by means of adverse events recording clinical parameters and hematologic analyses. The contents of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), as well as arachidonic acid (AA), in phospholipid fractions in plasma and in erythrocytes were analyzed preoperatively, on postoperative days 1, 6, and 10 using liquid gas chromatography. Results: Both fat emulsions were well tolerated, and none of the adverse events was considered to be related to treatment. Postoperative infectious complications occurred in 4 patients of the ω‐3 PUFA group vs 7 patients in the control group. As compared with the control group, the ω‐3 PUFA group had significantly increased levels of EPA in the membranes of the erythrocytes in postoperative day 6 (2.0% ± 0.9% vs 0.8% ± 0.5% fatty acid methyl esters, [FAME]) and postoperative day 10 (2.1% ± 0.8% vs 0.9%± 0.7% FAME, p < .05). Also, the EPA levels in the serum phospholipids were significantly higher than in the control group on the same postoperative days (7.0% ± 2.6% vs 1.3% ± 0.8% and 3.6%± 1.0% vs 1.0% ± 0.4% FAME, p < .05). The DHA levels in the serum phospholipids were significantly higher in theω ‐3 PUFA group compared with the control on postoperative days 6 and 10 (11.8% ± 1.9% vs 8.4% ± 1.5% and 11.2% ± 1.6% vs 8.5% ± 1.4% FAME, p < .05). AA levels were not significantly different in the both groups. Conclusions:Ω ‐3‐fatty‐acids‐supplemented fat emulsions for parenteral administration are safe and very well tolerated. This study demonstrates that parenteral administration of ω‐3‐PUFA‐enriched fat emulsions leads to increased incorporation of EPA and DHA into phospholipids in serum and erythrocytes, whereas AA levels remain unchanged. Thus, postoperative parenteral administration of ω‐3‐PUFA‐enriched lipid emulsions could have an impact on the postoperative inflammatory response after abdominal surgery and could be used in standard postoperative care when PN is indicated.
Alanine‐Glutamine Dipeptide (AGD) Inhibits Expression of Inflammation‐Related Genes in Hemorrhagic Shock
Authors: Yang Rongjie , Tan Xiaoyu , Thomas Ann M. , Steppacher Robert , Qureshi Nilofer , Morrison David C. , Van Way Charles W.
Published: May 2008

Background: Inflammatory factors play an important role in the production of cellular damage after shock and reperfusion. Glutamine has been used to modulate the inflammatory response. Alanine‐glutamine dipeptide (AGD) is a glutamine source. The hypothesis of the present study is that AGD given during resuscitation will suppress postshock expression of messenger ribonucleic acid (mRNA) for tumor necrosis factor (TNF‐α), interleukin‐1 (IL‐1β) and inducible nitric oxide synthase (iNOS). Methods: Male Sprague‐Dawley rats (n = 74, 350 g ± 30 g) were randomly assigned to 5 groups. Under isoflurane anesthesia, the femoral artery and vein were cannulated. Hemorrhagic shock was induced by withdrawing blood through the arterial cannula until the mean arterial pressure (MAP) was 25–30 mm Hg and maintained at the level for 30 minutes with further withdrawals. Resuscitation was carried out by giving 21 mL/kg Ringer's lactate (LR) with or without the administration of AGD (936 mg/kg) and returning the shed blood. Controls were normal (anesthesia only), sham (surgical preparation), and shock (preparation and shock). Rats (n = 45, 9 per group) were killed 30 minutes after completion of resuscitation. Liver samples were collected, and total RNA was isolated for reverse transcription–polymerase chain reaction analysis of mRNA (TNF‐α, IL‐1β, iNOS, and β‐actin). Results: MAP recovered more quickly in the AGD group than in the LR group. Increased expression of liver mRNA for TNF‐α, IL‐1β, and iNOS was seen after hemorrhagic shock and resuscitation. AGD treatment significantly reduced mRNA expression for all 3. Conclusions: AGD modified the expression of genes controlling cytokines and iNOS in the liver. This agent is a potential treatment for hemorrhagic shock.