bluuebunny/crossref_metadata_2025 huggingface dataset:
Persistent Left Superior Vena Cava: Clinical Implications for Central Venous Cannulation
Authors: Schummer Wolfram , Schummer Claudia , Hoffmann Eva , Gerold Matthias
Published: May 2008

In general, persistence of the left superior vena cava (LSVC), the most common anomaly of the venous circulation, is asymptomatic. Diagnosis of a catheter in a persistent LSVC is not straight forward, and a LSVC can create difficulties during central venous and pulmonary artery catheterization. We discuss the differential diagnosis of left‐sided central venous catheters (CVC). Finally a directive is given to prevent dilator‐induced vessel injuries. We report the cannulation of an unsuspected persistent LSVC in two patients. A dilator‐induced vessel injury contributed significantly to the fatal outcome in the first case. On a plain chest X‐ray, a catheter in a LSVC will run down the left mediastinal border and can be confused with other intravascular malpositions and extravascular malpositions. Contrast‐enhanced lateral chest radiograph is an inexpensive and readily available method that can be used to determine exact position.
A Retrospective Review of the Course of Patients With Pancreatitis Discharged on Jejunal Feedings
Authors: Yoder Andrea J. , Parrish Carol Rees , Yeaton Paul
Published: May 2008

Introduction: Although parenteral nutrition (PN) has been the standard nutrition therapy in patients with pancreatitis requiring nutrition support, it is associated with a higher rate of catheter‐related sepsis and gut atrophy. Research suggests enteral nutrition (EN) is possible in patients with pancreatitis without exacerbating symptoms when infused jejunally. The purpose of this study was to review the course of patients with resolving pancreatitis discharged to home on EN. Methods: The medical records of 33 patients with a percutaneous endoscopic gastrostomy tube with jejunal extension (PEG‐J) or nasojejunal tube (NJ) who received home EN were reviewed. The data collected included duration of EN, formula used, goal and maximum tolerated flow rates, anthropometric measures, and gastrointestinal complications. Results: Ninety‐seven percent of patients received a standard polymeric formula providing an average of 1845 ± 421 kcal/d. Forty‐two percent of patients took pancreatic enzyme supplements. Complications occurring in patients included nausea and vomiting (42%), feeding rate intolerance (18%), diarrhea (12%), and PEG site infection (27%). Seventy‐seven percent of patients achieved nutritional goals. Conclusion: Standard polymeric EN seems to be safe and efficacious in the home setting for patients with resolving pancreatitis.
Commentary on “Three Years Clinical Experience With Intestinal Transplantation” and the Nutritional Implications
Authors: Janson Douglas D.
Published: May 2008

Background: After the successful evolution of hepatic transplantation during the last decade, small bowel and multivisceral transplantation remains the sole elusive achievement for the next era of transplant surgeons. Until recently, and for the last thirty years, the results of the sporadic attempts of intestinal transplantation worldwide were discouraging because of unsatisfactory graft and patient survival. The experimental and clinical demonstration of the superior therapeutic efficacy of FK 506, a new immunosuppressive drug, ushered in the current era of small bowel and multivisceral transplantation with initial promising results.

Study Design: Forty‐three consecutive patients with short bowel syndrome, intestinal insufficiency, or malignant tumors with or without associated liver disease, were given intestinal (n = 15), hepatic and intestinal (n = 21), or multivisceral allografts that contained four or more organs (n = 7). Treatment was with FK 506‐based immunosuppression. The ascending and right transverse colon was included with the small intestine in 13 of the 43 grafts, almost evenly distributed between the three groups.

Results: After 6 to 39 months, 30 of the 43 patients are alive, 29 bearing grafts. The most rapid convalescence and resumption of diet, and the highest three‐month patient survival (100%) and graft survival (88%) were with the isolated intestinal procedure. However, this advantage was slowly eroded during the first two postoperative years, in part because the isolated intestine was more prone to rejection. By the end of this time, the best survival rate (86%) was with the multivisceral procedure. With all three operations, most of the patients were able to resume diet and discontinue parenteral alimentation, and in the best instances, the quality of life approached normal. However, the surveillance and intensity of care required for these patients for the first year, and in most instances thereafter, was very high, being far more than required for patients having transplants of the liver, kidney, or heart.

Conclusions: Although intestinal transplantation has gone through the feasibility phase, strategies will be required to increase its practicality. One possibility is to combine intestinal transplantation with contemporaneous autologous bone marrow transplantation.
Relationship Between Feeding Difficulties, Medical Complexity, and Gestational Age
Authors: Burklow Kathleen A. , McGrath Ann M. , Valerius Kristin S. , Rudolph Colin
Published: May 2008

Background: This study examined feeding skills differences in medically complex children born prematurely and full term and sought to determine whether later feeding difficulties within this medically complicated sample were related to medical factors or factors related to preterm status. Methods: A total of 143 pediatric patients referred to an outpatient clinic for feeding, nutrition, or growth problems were compared by their gestational age at birth across a variety of dependent variables related to feeding development and behaviors. Results: Full‐term and preterm children did not demonstrate significant differences in feeding difficulties at first oral feeding. By the time of introduction to solid (cereal) feeding, however, preterm children more often continued to demonstrate difficulty than full‐term children. Regression analyses indicated that medical factors, primarily the need for breathing assistance, accounted for more of the variance than prematurity alone. Conclusions: Medically complex children, especially those with an early need for respiratory support, will benefit from ongoing oral‐motor feeding intervention.
Nutrition Treatment for HIV Wasting: A Prescription for Food as Medicine
Authors: McDermott Ann Yelmokas , Shevitz Abby , Must Aviva , Harris Susan , Roubenoff Ronenn , Gorbach Sherwood
Published: May 2008

Background: The optimal nutrition approach for the promotion of weight gain in HIV‐infected adults with wasting remains unclear. Previous dietary interventions report minimal success and provide inadequate information regarding the counseling approach, contact time, session format, and issues addressed with the subject. The methods we report were incorporated in a 12‐week intervention trial for the reversal of HIV‐wasting. Methods: All subjects involved in the intervention trial for the reversal of HIV‐wasting received weekly, customized, one‐on‐one counseling and an oral nutrition supplement (480 kcal/d with 30 g protein). The nutrition aims were to (1) increase caloric intake to surpass daily energy requirements by 500 kcal/d (suggested caloric intake: 40 to 50 kcal/kg current weight); (2) increase protein intake (1.6 to 1.8 g/kg current weight per day); and (3) identify foods that may exacerbate or curtail side effects associated with HIV. Also assessed were preconceptions, nutrition knowledge level and primary information source, and obstacles to healthy eating. Sessions, conducted by a nutritionist in an interactive, action‐oriented learning approach, ranged from 30 to 60 minutes. Results: At baseline, subjects harbored many misconceptions, reported numerous HIV‐related side effects, and lacked practical nutrition strategies, all of which interfered with weight maintenance and health. The protocol strategies were acceptable to the patients (87% subjects completed all visits), with marked improvements in dietary intake, weight, and body composition, both during and after intervention. Conclusions: We describe a customized nutrition intervention that produces changes in energy intake, maintenance of appropriate protein intake, and the reversal of unintentional weight loss over 5 to 15 months. Sustained improvements occurred across a socioeconomically diverse population, despite persistent disease‐ and medication‐associated side effects.
Effect of Cyclical Intravenous Clodronate Therapy on Bone Mineral Density and Markers of Bone Turnover in Patients Receiving Home Parenteral Nutrition
Authors: Haderslev KV , Tjellesen L , Sorensen HA , Staun M
Published: May 2008

Background: Patients receiving home parenteral nutrition (HPN) because of intestinal failure are at high risk of developing osteoporosis. Objective: We studied the effect of the bisphosphonate clodronate on bone mineral density (BMD) and markers of bone turnover in HPN patients. Design: A 12‐mo, double‐blind, randomized, placebo‐controlled trial was conducted to study the effect of 1500 mg clodronate, given intravenously every 3 mo for 1 y, in 20 HPN patients with a bone mass T score of the hip or lumbar spine of less than −1. The main outcome measure was the difference in the mean percentage change in the BMD of the lumbar spine measured by dual‐energy X‐ray absorptiometry. Secondary outcome measures included changes in the BMD of the hip, forearm, and total body and biochemical markers of bone turnover, ie, serum osteocalcin, urinary pyridinoline, and urinary deoxypyridinoline. Results: The mean (±SEM) BMD of the lumbar spine increased by 0.8 ± 2.0% in the clodronate group and decreased by 1.6 ± 2.0% in the placebo group (P = 0.43). At all secondary skeletal sites (ie, hip, total body, and distal forearm), we observed no changes or small increases in the BMD of the clodronate group. In the clodronate group, biochemical markers of bone resorption decreased significantly (P < 0.05). Conclusions: Clodronate significantly inhibits bone resorption as assessed by changes in biochemical markers of bone turnover. Although the mean BMD increased in the clodronate group, cyclic clodronate therapy failed to increase spinal BMD significantly at 12 mo.
Ins and Outs of Enteral Access. Part 3: Long‐Term Access—Jejunostomy
Authors: Vanek Vincent W.
Published: May 2008

Feeding jejunostomy tubes can be useful in patients with gastroesophageal reflux or a nonfunctioning stomach and can be short‐term, long‐term, or permanent. These tubes can be inserted surgically, endoscopically, radiologically, or laparoscopically. Each of these techniques is described, and their mortality, morbidity, advantages, and disadvantages are compared.
Review of a Potential Role for Zinc Supplementation in Oral Rehydration Solutions
Authors: Matarese Laura E. , Steiger Ezra , Seidner Douglas L.
Published: May 2008

Patients with short bowel syndrome often present with diarrhea and significant fluid and electrolyte abnormalities. Management consists of the use of medication, dietary modification, and oral rehydration solutions. Zinc deficiency has been shown to result in diarrhea. Oral zinc has been used for the management of acute diarrhea primarily in underprivileged children in developing countries. The effectiveness and feasibility of adding zinc to oral rehydration solutions (ORS) to abate and control diarrhea for adult patients with intestinal failure caused by short bowel syndrome has not been studied. Based on studies evaluating the use of oral zinc supplementation in the treatment of acute diarrhea, recommendations are made for the composition of ORS in adults.
Feeding the Hypotensive Patient: Does Enteral Feeding Precipitate or Protect Against Ischemic Bowel?
Authors: McClave Stephen A. , Chang Wei‐Kuo
Published: May 2008

Although the enteral route of enteral feeding is the preferred method of nutrition support for critically ill patients, this important therapeutic strategy is not without risk. In human subjects, the digestion and absorption of nutrients induce typical hemodynamic changes, consisting of an increase in mesenteric blood flow at the expense of reduced systemic blood pressure. On rare occasion when providing aggressive enteral nutrition to critically ill patients, common symptoms of gastrointestinal intolerance may progress to a syndrome of abdominal distention, hypotension, and shock, with the development of small bowel ischemia or necrosis. Although the incidence of small bowel ischemia secondary to enteral feeding is low, the overall clinical outcome is still poor and carries a high mortality rate. Enteral feeding is well tolerated and is probably beneficial in most critically ill patients before and after a period of hypotension. Although enteral nutrition may be used with caution during the period of hypotension, evidence of poor gastrointestinal function (increased nasogastric tube output, unexplained abdominal pain, and abdominal distention), or development of dilated loops of bowel or intramural gas (pneumatosis intestinalis) on radiographic studies should be interpreted as potential indicators of gut ischemia. With progress in our understanding of the pathophysiology, diagnosis, and prevention of ischemic injury to the intestinal mucosa, the strategy of aggressive enteral feeding for critically ill patients may result in a reduction in this major complication and enhanced functional recovery from severe illness.
Increased Adiposity in Female Rhesus Monkeys Exposed to Androgen Excess During Early Gestation
Authors: Eisner JR , Dumesic DA , Kemnitz JW , Colman RJ , Abbott DH
Published: May 2008

Objective: The aim of this study was to investigate the effects of early‐gestational androgen excess on adult body fat distribution in female rhesus monkeys. Methods: Six midreproductive‐aged, adult, female rhesus monkeys that were exposed to androgen excess started during the first one‐third of gestation were pair‐matched to control women by age, body weight, and body mass index. Body composition was determined using somatometrics, dual x‐ray absorptiometry, and computed tomography. Results: Total abdominal and intra‐abdominal fat depots are increased in adult female rhesus monkeys exposed to prenatal androgen excess. Discussion: Early gestational androgen excess in female rhesus monkeys causes a preferential accumulation of total abdominal and intra‐abdominal fat during adulthood. Fat accumulation in these regions is independent of total body adiposity, occurring throughout the spectrum of body mass index in these animals. This study establishes alterations in abdominal adiposity as another consequence of prenatal androgen excess in female rhesus monkeys that may contribute to the impaired insulin secretion observed in these animals during adulthood.
Clinical Applications of l‐Glutamine: Past, Present, and Future
Authors: Wischmeyer Paul E.
Published: May 2008

Objective: This review will attempt to summarize recent clinical data on glutamine's use. It will present the concept of glutamine as a“ drug” or “nutraceutical,” given in addition to standard nutrition support. Key references will be discussed, and clinical recommendations with regard to patients who may benefit and dosing are also provided. Recent Findings: Glutamine, traditionally considered a nonessential amino acid, now is considered “conditionally essential” after critical illness, stress, and injury. States of illness or injury can lead to a significant decrease in plasma levels of glutamine, and when this decrease is severe, it has been correlated with increased mortality. Laboratory data have demonstrated numerous benefits of glutamine in experimental models of critical illness, cancer, and cardiac injury. The mechanism of these protective effects includes attenuated proinflammatory cytokine expression, improved gut barrier function, enhanced ability to mount a stress response, improved immune cell function, and decreased mortality. Over the last 10 years, clinical trials of glutamine supplementation in critical illness, surgical stress, and cancer have shown benefit with regard to mortality, length of stay, and infectious morbidity. However, data demonstrating a lack of benefit with glutamine supplementation in some patients have been presented as well. It appears that dose and route of administration clearly influence the benefit observed from glutamine administration, with high‐dose parenteral glutamine demonstrating an advantage over low‐dose enteral glutamine. Summary: High‐dose or parenteral (> 0.25 to 0.30 g/kg/day IV or ≥30 g/day enterally) glutamine appears to demonstrate the greatest potential for benefit in hospitalized patients. No evidence of harm has been observed in studies conducted to date; thus, further clinical trials using glutamine as a pharmacologic supplement to standard nutrition are warranted.
Adverse Effects From Inappropriate Medication Administration via a Jejunostomy Feeding Tube
Authors: Dickerson Roland N. , Tidwell Angelina C. , Brown Rex O.
Published: May 2008

Numerous complications can arise when administering medications to patients receiving continuous enteral feeding. We report a case of a patient who could not be fed by mouth and was receiving continuous jejunal enteral feeding who had an adverse event associated with inappropriate administration of a medication via his jejunostomy tube. He had taken an extended‐release niacin product before hospitalization for type IIb hyperlipidemia. The patient was inappropriately given a single dose of 750 mg of niacin as the short‐acting tablets that were crushed and administered via the jejunostomy tube. He experienced severe cutaneous flushing, a feeling of warmth, itching, nausea, and emesis. He was noted to have “prickly heat” to the forehead, according to the nursing notes. A discussion of problems and guidelines for medication administration in adult patients receiving continuous tube feeding is provided.
Effect of Acclimation on Resting Energy Expenditure Measurements
Authors: Kobar Shirley , Francis Coni C. , MaWhinney Samantha , Sharp Teresa
Published: May 2008

Background: Development of an acclimation protocol for use when measuring resting energy expenditure (REE) would simplify and standardize data collection. The purpose of this study was to determine if our 2 metabolic carts could be used interchangeably and to determine if excluding the first 3 or 5 minutes of data collected as an acclimation period would significantly improve the coefficients of variation (CVs) for oxygen consumed (VO2) and carbon dioxide produced (VCO2) when performing REE assessments with our metabolic cart systems. Methods: Thirteen healthy, nonsmoking adults ranging in age from 32 to 45 years, with activity levels ranging from sedentary to highly active, participated. Indirect calorimetry was performed twice in the morning after 30 minutes of supine resting. Subjects had fasted for 12 hours, and did not exercise within the last 24 hours. The system order for testing was randomized for the first measurement. When the first measurement was completed, subjects were crossed over for measurement using a second metabolic cart. Results: The CVs for VO2 and VCO2 were significantly lower when excluding the first 3 (VO2, p = .0005), (VCO2, p = .0024) or 5 minutes (VO2, p = .0001, VCO2, p = .0021) of data compared with no exclusions. No significant differences in CVs between the 3‐ and 5‐minute exclusions were found for VO2 (p = .3224) or VCO2 (p = .2255). Conclusions: Clearly, our machines cannot be used interchangeably within a study. An acclimation period improves CVs of VO2 and VCO2. The similarities in CVs led us to adopt a 3‐minute acclimation period for measuring REE.
Principles of Immunology
Authors: Lentz Ashley K. , Feezor Robert J.
Published: May 2008

The immune system, composed of innate and acquired immunity, allows an organism to fight off foreign pathogens. Healthy immunity accomplishes four essential principles: (1) ability to detect and fight off infection; (2) ability to recognize a host's own cells as “self,” thereby protecting them from attack; (3) a memory from previous foreign infections; and (4) ability to limit the response after the pathogen has been removed. In an unaltered state, the intricate network of immunologic organs and cells creates an environment for proper host defense. Without adequate execution of immunologic mechanisms, a host is rendered defenseless against pathogens. Conversely, an unchecked immune response can be self‐destructive. As a result of either of these untoward sequelae, immune dysfunction can elicit disease states in the host. The goal of this review is to elucidate the characteristics of a healthy immune system, focusing on the principles of immunity and the cells that participate in host protection. We also briefly discuss the clinical ramifications of immune dysfunction.
Probiotics As Functional Foods
Authors: Lin David C.
Published: May 2008

Probiotic products have been widely used in Japan and Europe for years. Probiotics are now emerging as an important category of food supplement in the United States. Questions about the biologic nature, available products, claimed health benefits, and safety and regulation of probiotics are important for both consumers and nutrition professionals. Probiotics can be considered functional foods because they provide health benefits beyond the traditional nutrition function. With few exceptions, most probiotic products currently available contain lactic‐acid‐producing bacteria, which mainly belong to the genera Lactobacillus and Bifidobacterium. We reviewed the scientific papers published in major nutrition journals and abstracts available on the PubMed website regarding probiotics. Evidence suggests the following beneficial effects of probiotics: normalization of the intestinal microflora, ability to block the invasion of potential pathogens in the gut, prophylactic or therapeutic treatment for several types of diarrhea, relief of symptoms of irritable bowel syndrome and inflammatory bowel disease, amelioration of lactose intolerance, prevention of colon cancer, modulation of immune function, inhibition of Helicobacter pylori, and possible enhancement of calcium absorption and reduction of blood cholesterol levels. Mechanisms for the above benefits have been proposed, but none has been proven. An adequate level of viable bacteria in a probiotic product and an appropriate daily dose are critical to achieve a health benefit. Because probiotics are not known to be pathogenic and their upper tolerable level is high, they could be promoted as a beneficial food supplement. Currently, no disease‐prevention or therapeutic claim for probiotics is legally allowed.
Electrolyte Disorders Following Oral Sodium Phosphate Administration for Bowel Cleansing in Elderly Patients
Authors: Beloosesky Y , Grinblat J , Weiss A , Grosman B , Gafter U , Chagnac A
Published: May 2008

Background: Oral sodium phosphate is currently used for colon preparation before colonoscopy or barium enema. Sodium phosphate induces hyperphosphatemia, hypocalcemia, and hypokalemia. Elderly patients are at an increased risk for phosphate intoxication because of decreased glomerular filtration rate, medication use, and systemic and gastrointestinal diseases. We investigated these electrolyte disorders and their correlation with creatinine clearance, coexistent diseases, medications, and functional status. Methods: Thirty‐six hospitalized patients were included in the study. On day 1, patients were administered 2 doses of oral sodium phosphate. Venous blood samples for electrolyte determination were obtained at 7 am on days 1, 2 (the procedure day), and 3. Urine samples were obtained from 10 patients. Results: An increase in serum phosphorus level was correlated with a decreased creatinine clearance (R = ‐0.52; p = .001). Hypocalcemia and hypokalemia were present in 21 (58%) and 20 (56%) patients, respectively. Patients with a serum potassium concentration of 3.5 mEq/L or less on day 2 had a lower serum potassium concentration on day 1 vs those with a serum potassium concentration >3.5 mEq/L on day 2 (p = .03). Five (dependent patients) had a serum potassium concentration of 3 mEq/L or less, and 2 had severe diarrhea, necessitating treatment. There were more demented patients with hypokalemia compared with normokalemic patients (p < .05). Urinary fractional excretion of phosphorus tripled on day 2 (p = .01). Potassium and sodium fractional excretion remained unchanged. Conclusions: Sodium phosphate induces serious electrolyte abnormalities in the elderly. The frequency and severity of hypokalemia is due to intestinal potassium loss associated with inadequate renal potassium conservation and is apparently more prevalent in frail patients. Assessment of serum electrolytes, phosphorus, and calcium before sodium phosphate preparation is advised, and in selected patients, postprocedural assessment and correction may be required.
Effect of Fish Oil on Appetite and Other Symptoms in Patients with Advanced Cancer and Anorexia/Cachexia: A Double‐Blind, Placebo‐Controlled Study
Authors: Bruera E , Strasser F , Palmer JL , Willey J , Calder K , Amyotte G , Baracos V
Published: May 2008

Background: To determine whether high doses of fish oil, administered over 2 weeks, improve symptoms in patients with advanced cancer and decreased weight and appetite. Methods: Sixty patients were randomly assigned to fish oil capsules or placebo. Appetite, tiredness, nausea, well‐being, caloric intake, nutritional status, and function were prospectively assessed at days 1 and 14. Results: The baseline weight loss was 16 ± 11 and 16 ± 8kginthe fish oil (n = 30) and placebo (n = 30) group, respectively, whereas the baseline appetite (0 mm = best and 100 mm = worst) was 58 ± 24 mm and 67 ± 19 mm, respectively (p = not significant). The mean daily dose was 10 ± 4 (fish oil group) and 9 ± 3 (placebo group) capsules, which provided 1.8 g of eicosapentaenoic acid and 1.2 g of docosahexaenoic acid in the fish oil group. No significant differences in symptomatic or nutritional parameters were found (p < .05), and there was no correlation between changes in different variables between days 1 and 14 and the fish oil doses. Finally, the majority of the patients were not able to swallow >10 fish oil capsules per day, mainly because of burping and aftertaste. Conclusion: Fish oil did not significantly influence appetite, tiredness, nausea, well‐being, caloric intake, nutritional status, or function after 2 weeks compared with placebo in patients with advanced cancer and loss of both weight and appetite.
Acute Pancreatitis: A Review of Pathophysiology and Nutrition Management
Authors: Russell Mary Krystofiak
Published: May 2008

Acute pancreatitis (AP) is an acute inflammatory process of the pancreas that may involve peripancreatic tissue or remote organs. In its more severe forms, it is a significantly catabolic illness for which specialized nutrition support is required.

This review summarizes the pathophysiology of AP, the severity grading systems used in its evaluation, and general treatment strategies, and reviews the value of enteral tube feeding and parenteral nutrition in supporting the patient with this common disease.
Posttransplant Diabetes Mellitus: Cause, Impact, and Treatment Options
Authors: Obayashi Patricia A. C.
Published: May 2008

The incidence of diabetes mellitus (DM) is increased in adult organ transplant recipients. As many as 30% to 45% of solid organ adult transplant patients have DM before transplantation or develop posttransplant diabetes mellitus (PTDM). Risk factors for PTDM include family history, ethnic or genetic background, insulin resistance, and diabetogenic effects of immunosuppressive medications. Posttransplant hyperglycemia may result in increased platelet aggregation, increased wound infections, dehydration, and loss of lean body mass. More significantly, long‐term complications of DM such as coronary artery disease and peripheral vascular disease may be exacerbated with the use of immunosuppressive medications whose known side effects include hyperglycemia, hyperlipidemia, and hypertension; these effects may lead to premature transplant graft dysfunction. Treatment goals for PTDM reflect those of the American Diabetes Association guidelines; long‐term management is linked with early, patient‐centered education and optimizing minimally diabetogenic immunosuppressive medication regimens. A multidisciplinary team including the patient, family/support people, transplant surgeon, transplant physician, transplant nurse coordinator, transplant social worker, pharmacist, dietitian, and diabetes educator is crucial to long‐term management of PTDM.
Hypoglycemia as a Predictor of Mortality in Hospitalized Elderly Patients
Authors: Kagansky N , Levy S , Rimon E , Cojocaru L , Fridman A , Ozer Z , Knobler H
Published: May 2008

Background: Hypoglycemia during hospitalization occurs in patients with and without diabetes. The aims of this study were to determine the incidence, associated risk factors, and short‐ and long‐term outcome of hypoglycemia among hospitalized elderly patients. Methods: This is a case‐control study conducted at geriatric and medicine departments. All patients 70 years or older with documented hypoglycemia hospitalized within 1 year (n = 281) were compared with a nonhypoglycemic group of 281 elderly, randomly selected patients from the same hospitalized population. Results: Among 5404 patients 70 years or older, 281 (5.2%) had documented hypoglycemia. Compared with the nonhypoglycemic group, we found the following characteristics to be true in the hypoglycemic group: there were more women than men (58% vs 44%; p = .001); sepsis was 10 times more common (p < .001); malignancy was 2.8 times more common (p = .04); the mean serum albumin level was lower (2.8 g/dL vs 3.4 g/dL, p < .001); and the mean serum creatinine and alkaline phosphatase levels were higher (p < .001 for both). Diabetes was known in 42% of the hypoglycemic group and in 31% of the nonhypoglycemic group (p = .03); 70 patients in the hypoglycemic group were taking sulfonylureas or insulin. Multivariate logistic analysis showed that sepsis, albumin level, malignancy, sulfonylurea and insulin treatment, alkaline phosphatase level, female sex, and creatinine level were all independent predictors of developing hypoglycemia. In‐hospital mortality and 3‐month mortality were about twice as high in the hypoglycemic group (p < .001). Multivariate analysis of mortality found that sepsis, low albumin level, and malignancy were independent predictors, whereas hypoglycemia was not. Conclusions: Hypoglycemia was common in elderly hospitalized patients and predicted increased in‐hospital 3‐ and 6‐month cumulative mortality. However, in a multivariate analysis, hypoglycemia was not an independent predictor for mortality, implying that it is only a marker.
Arginine: Mediator or Modulator of Sepsis?
Authors: Zaloga Gary P. , Siddiqui Rafat , Terry Colin , Marik Paul E.
Published: May 2008

Arginine is a conditionally essential amino acid that plays pivotal roles in maintaining body homeostasis. Arginine is a substrate for protein synthesis but can also be metabolized to various bioactive compounds that include nitric oxide, ornithine, polyamines, creatine phosphate, agmatine, and dimethylarginines. Arginine produces physiologic effects via nitric oxide dependent and independent pathways. Nitric oxide is important for the modulation of vascular tone, inflammation, immune function, endothelial function, platelet and leukocyte adherence, and neurotransmission. Nitric oxide modulates many biochemical processes important for the response to sepsis. Arginine, independent of nitric oxide, is important for growth, wound healing, cardiovascular function, immune function, inflammatory responses, energy metabolism, urea cycle function, and other metabolic processes. Arginine supplementation improves outcomes in animals with sepsis, wounds, ischemia‐reperfusion injury, and following thermal injury. Enteral administration of arginine improves endothelial function but has little effect upon hemodynamics during human sepsis. An analysis of clinical studies using enteral formulas with supplemental arginine suggests benefits upon outcome, with no evidence of significant detrimental effects.
Hyperglycemia and Nutrition Support: Theory and Practice
Authors: McCowen Karen C. , Bistrian Bruce R.
Published: May 2008

Hyperglycemia has long been known to portend a worse short‐term prognosis than euglycemia in hospitalized patients. Hyperglycemia reflects illness severity and results in deleterious consequences for certain patient groups. In a surgical intensive care unit population, normalization of morning glucose values using insulin infusions improved mortality vs controls. Until additional studies in other patient groups are reported, practitioners of nutrition support must prevent excessive iatrogenic hyperglycemia, in particular when using parenteral feeding, and should choose aggressive glycemic goals that also avoid hypoglycemia.
Specialized Nutrition Support in the Hospitalized Obese Patient
Authors: Dickerson Roland N.
Published: May 2008

The rising prevalence of obesity in the United States has resulted in concerns regarding the implementation of safe and effective specialized nutrition support in hospitalized obese patients. This review discusses complications associated with the provision of specialized nutrition support for obese patients and emphasizes the scientific basis for and against the provision of hypocaloric, high‐protein parenteral and enteral nutrition support. Because there is a paucity of data concerning enteral nutrition support, some practical aspects of implementing hypocaloric high‐protein enteral nutrition are also given.
The Lived Experience of Home Total Parenteral Nutrition: An Online Qualitative Inquiry With Adults, Children, and Mothers
Authors: Silver Heidi J.
Published: May 2008

Background: The purpose of this study was to access a sample of short‐bowel patients receiving home total parenteral nutrition (HTPN) in their home environment and describe their HTPN experience using qualitative methodology. Methods: Three semistructured, openended, in‐depth interviews were conducted online over a 5‐month period with 6 adults (aged 27 to 45 years) who received HTPN for 2 to 8 years, 3 children (aged 8 to 10 years) receiving HTPN since birth, and the children's mothers. The constant comparison method was used to code and categorize data, inductively develop themes, and create a taxonomy (flow chart) of themes from the data. Credibility of data analysis and themes was established by the prolonged engagement with subjects and subject review of themes identified. Results: Six major themes emerged: affirmation of life, infusion‐related complications, lifestyle adaptations, self‐worth, isolation, and food intake. Within most themes, subjects described similar concerns and reactions. A clear difference occurred within the theme of food intake. Adults reported feeling constantly hungry and challenged with resisting temptation to eat restricted foods. They admitted to lack of consistency in following dietary restrictions and repeated attempts to consume contraindicated foods. Children expressed lack of desire for food and mothers complained of their children's refusal to eat. Conclusions: Using qualitative methods allowed insight into the HTPN experience and depiction of the daily challenges of being total parenteral nutrition–dependent from patients' and caregivers' perspectives. It provides insight into their reactions and behaviors. By gaining this type of awareness and understanding, clinical protocols and services can be planned that are more likely to derive successful outcomes.
Copper Deficiency During Parenteral Nutrition: A Report of Four Pediatric Cases
Authors: Hurwitz Melissa , Garcia Manuel G. , Poole Robert L. , Kerner John A.
Published: May 2008

The standard of care for patients with cholestasis (direct bilirubin ≥2 mg/dL) while receiving parenteral nutrition (PN) solutions is to reduce or discontinue the copper and manganese. The repercussions of this action have not been studied. Two adult case reports document low serum copper levels associated with clinical symptoms of copper deficiency after the removal of copper from their PN solutions. We now describe the first known series of pediatric patients to develop copper deficiency after copper was removed from their PN solutions.
Evaluation of Nutrition Assessment Parameters in the Presence of Human Immunodeficiency Virus Infection
Authors: Earthman Carrie P.
Published: May 2008

Malnutrition, weight loss, and body cell mass (BCM) depletion have long been observed in individuals with HIV infection and acquired immunodeficiency syndrome and are associated with increased morbidity and mortality. Nutritional status may be adversely affected by many factors, including inadequate intake, gastrointestinal disturbances, altered nutrient metabolism, and medication‐related side effects. Increasing numbers of HIV‐infected individuals are exhibiting fat redistribution characterized by any combination of changes including peripheral fat atrophy, visceral or dorsocervical adiposity, or other changes, and these changes have been shown to be associated with increased cardiovascular disease risk. A complete nutrition assessment is key to effective patient management in HIV infection. This review focuses on the evaluation of anthropometry (including BCM and fat redistribution), biochemistries, medication‐related issues, medical/social/dietary histories, and physical examination and clinical findings. A discussion of BCM, its significance as a parameter of nutritional status, and methodological issues concerning its measurement by available technologies is presented in light of current research. Methods for assessing fat redistribution are discussed. Recommendations for biochemical assessment and medical, social, and dietary histories are reviewed. Finally, medication‐related side effects for common antiretroviral therapies and clinical findings that may affect nutritional status are presented. Clearly, nutrition assessment in HIV infection is a complex process involving many factors.
Gastrointestinal Manifestations of AIDS
Authors: Wilcox C. Mel
Published: May 2008

Although gastrointestinal complications have decreased dramatically in patients with acquired immunodeficiency syndrome (AIDS) who received highly active antiretroviral therapy, these disorders still occur in those who do not seek healthcare, those with resistant virus, and those in developing countries where these drugs are not available. Opportunistic infections are the most frequent causes of gastrointestinal disease in patients with AIDS. A practical approach based on the character of the complaints and location of symptoms will help direct the most appropriate evaluation. In most patients, a diagnosis should be sought because effective antimicrobial therapy is available for most infections in these patients. When possible, improvement in immune function forms an integral part of the treatment regimen.
Practical Approach to Metabolic Assessments in the Pediatric Human Immunodeficiency Virus Outpatient Clinic
Authors: Rabbat Jennifer , Borum Peggy R.
Published: May 2008

Background: Metabolic assessment is not a routine part of the care of pediatric HIV‐positive patients in the outpatient setting, although research studies are demonstrating an increasing prevalence of metabolic abnormalities in this population. Addition of metabolic assessments to routine clinic care can be hindered by the perception that collection of the data needed for the assessments will need too much clinic time and too many clinic resources to be practical. Methods: A method to provide metabolic assessments using minimal clinic resources while offering educational opportunities for university students was developed and implemented at the University of Florida Pediatric Immunology and Infectious Diseases weekly clinic. The success rate of metabolic assessment data collection from all clinic patients and the impact of data collection on the flow of clinic activity were monitored for a 12‐month period. Results: The metabolic assessment team interviewed 87% of all patients who came to the 454 clinic during the 12‐month period and performed a complete metabolic assessment for 75% of the HIV‐positive patients interviewed. Addition of metabolic assessments to the routine care of each patient did not result in any noticeable adverse effect on the functionality of the clinic. Conclusions: Addition of metabolic assessments to the routine clinic care of pediatric HIV positive patients can be an educational opportunity for university students and provide the clinic staff with changes in parameters indicative of metabolic abnormalities and without noticeable changes in maintaining the patient schedule at each clinic.
Combination Megestrol Acetate, Oxandrolone, and Dietary Advice Restores Weight in Human Immunodeficiency Virus
Authors: Mwamburi D. Mkaya , Gerrior Jül , Wilson Ira B. , Chang Hong , Scully Ed , Saboori Shiva , Miller Laurel , Forfia Janet , Albrecht Mary , Wanke Christine A.
Published: May 2008

Background: We examined changes in total body weight (TBW) and health‐related quality of life (HRQL) during prolonged combination weight‐gaining therapy and dietary advice in HIV. Design: This was a cohort study of patients initially randomized to single agent therapy for 2 months, megestrol acetate (800 mg daily), or oxandrolone (10 mg twice daily), followed by both agents and dietary advice for 5 months. Methods: Two community health clinics and 1 urban infectious disease clinic were included, as were HIV‐positive adult patients receiving highly active antiretroviral therapy with documented 5% weight loss. TBW and HRQL were measured after 7 months (7 m). Results: Twenty‐nine of 39 participants completed 7 m. The average sample age was 40 years, 75% were male, and 52% were of color at enrollment. Baseline mean TBW and body mass index (BMI) were 62.5 kg and 21 kg/m2, respectively. Net gains in TBW, lean body mass, and fat during the 7 m were 5.3 kg (8.5% of baseline), 2.1 kg, and 3.1 kg, respectively (p < .01 for each). BMI increased to 23.1 kg/m2 (p < .01). Dietary intake increased by 467 kcal/day (p = .03). Physical health improved by 5.7 (100‐point scale, p < .01), and mental health was unchanged (–4.2, p = .11). In multivariable models, female gender (p < .01), lower baseline HIV viral load (p = .03), and increasing age (p< .01) were associated with TBW gain. Injection drug use (p < .01) and higher baseline HIV viral load (p < .01) were associated with reduction in physical health. Conclusions: Prolonged combination therapy with megestrol acetate, oxandrolone, and dietary advice could reverse weight loss and low BMI associated with incomplete viral suppression and improve physical health.
The Validity of Bioelectrical Impedance Models in Clinical Populations
Authors: Buchholz Andrea C. , Bartok Cynthia , Schoeller Dale A.
Published: May 2008

Bioelectrical impedance analysis (BIA) is the most commonly used body composition technique in published studies. Herein we review the theory and assumptions underlying the various BIA and bioelectrical impedance spectroscopy (BIS) models, because these assumptions may be invalidated in clinical populations. Single‐frequency serial BIA and discrete multifrequency BIA may be of limited validity in populations other than healthy, young, euvolemic adults. Both models inaccurately predict total body water (TBW) and extracellular water (ECW) in populations with changes in trunk geometry or fluid compartmentalization, especially at the level of the individual. Single‐frequency parallel BIA may predict body composition with greater accuracy than the serial model. Hand‐to‐hand and leg‐to‐leg BIA models do not accurately predict percent fat mass. BIS may predict ECW, but not TBW, more accurately than single‐frequency BIA. Segmental BIS appears to be sensitive to fluid accumulation in the trunk. In general, bioelectrical impedance technology may be acceptable for determining body composition of groups and for monitoring changes in body composition within individuals over time. Use of the technology to make single measurements in individual patients, however, is not recommended. This has implications in clinical settings, in which measurement of individual patients is important.
Monitoring Energy Metabolism with Indirect Calorimetry: Instruments, Interpretation, and Clinical Application
Authors: Holdy Kalman E.
Published: May 2008

Indirect calorimetry is the best measure to guide calorie administration during nutrition support. This article presents an update of the types of currently available indirect calorimeters and reviews the recent advances that guide the clinical application of indirect calorimetry. The emphasis of this report is placed on issues that the practicing clinician can use to evaluate, interpret, and apply measurements of energy expenditure.
Gastric Feeding as an Extension of an Established Enteral Nutrition Protocol
Authors: Marr Alan B. , McQuiggan Margaret M. , Kozar Rosemary , Moore Frederick A.
Published: May 2008

Background: Indiscriminate gastric feeding in ICU patients imposes unacceptable risks of aspiration. Believing that a subset of ICU patients can be fed safely via the stomach, we have developed a protocol to identify appropriate patients and guide the bedside clinician in how to safely and effectively feed via the stomach. Methods: A literature search was done to identify appropriate medical literature. High grade evidence along with local expert opinions were used to develop a protocol. This protocol has been refined and implemented. Results: Based on perceived risk of aspiration, patients are assigned enteral access (ie, stomach vs. distal postpyloric). Enteral formula is selected based on patient characteristics. It is then advanced by a standard protocol with specific precautions while monitoring for symptoms of intolerance. Management of intolerance is dictated by the type and severity of intolerance. Conclusion: We have implemented a gastric feeding into a subset of our ICU patients. Gastric feeding requires certain precautions but appears to be safe. With more experience and better understanding of the pathogenesis gastroparesis, we believe that most ICU patients should be able to safely feed into the stomach. This is logistically easier than postpyloric feeding and offers physiologic advantages.
The Use of Specialized Enteral Formulas in Pulmonary Disease
Authors: Malone Ainsley M.
Published: May 2008

The relationship between pulmonary disease and nutrition is significant. Malnutrition and its associated adverse pulmonary effects can directly affect outcomes in the individual with pulmonary disease. The use of nutrition support is common for these patients as a supportive or therapeutic measure. Historical reports of adverse respiratory function associated with high parenteral carbohydrate intakes have led to the controversial use of high‐fat enteral products in patients with chronic pulmonary dysfunction. The rationale for using this type of formula is that by providing less carbohydrates, carbon dioxide production will be reduced, respiratory quotient will therefore decrease, and a favorable respiratory outcome will result. In the patient with acute respiratory distress syndrome, an inflammatory state exists in which proinflammatory mediators are produced and affect the course of the disease. An enteral formula with modified lipids designed to modulate eicosanoid production and therefore influence the inflammatory cascade is available. This article reviews the rationale for use of modified enteral formulas in both chronic and acute pulmonary disease, reviews the available studies evaluating the efficacy of these formulas, and provides overall recommendations for the use of specialized enteral formulas in individuals with pulmonary disease.