bluuebunny/crossref_metadata_2025 huggingface dataset:
Urticaria Associated With Parenteral Nutrition
Authors: Scolapio James S. , Ferrone Marcus , Gillham Robert A.
Published: May 2008

We report a 53‐year‐old female patient with short bowel syndrome who developed urticaria after administration of cyclic parenteral nutrition (PN). The urticaria occurred 2 hours into the 12‐hour nocturnal infusion and resolved completely 1 hour after discontinuation of the PN infusion. The urticaria occurred despite removing lipids from the 3‐in‐1 PN solution. The urticaria did not occur when the multivitamin preparation was removed from the PN. Upon rechallenge with a PN solution containing a multivitamin, the urticaria reoccurred. Prick skin testing using the multivitamin in increasing aliquots was negative. Serum tryptase and 12‐hour urinary histamine level during PN infusion containing the multivitamin was unchanged compared with baseline measurements. The patient had no allergic reaction using a similar dose of an oral multivitamin. This case illustrates that allergic reactions from PN infusion may occur and that the multivitamin preparation can be the cause.
Preoperative Immunonutrition: Cost‐Benefit Analysis
Authors: Braga Marco , Gianotti Luca
Published: May 2008

Background: To evaluate whether preoperative immunonutrition might lead to a savings in patient care. Data on resources consumed to treat postoperative complications are scanty, but morbidity costs continue to be a major burden for any health care system. A recent randomized clinical trial carried out in well‐nourished patients with gastrointestinal cancer showed that a 5‐day preoperative oral immunonutrition reduced postoperative morbidity compared with conventional treatment (no supplementation). Methods: The abovementioned trial was the basis for the economic evaluation. In‐hospital related costs of routine surgical care and costs of nutrition were calculated. Estimates of complication costs were based on both resources used for treatment and additional length of hospital stay. Cost comparison and cost‐effectiveness analysis were then carried out. Results: Total cost of nutrition was € 3407 in the conventional group and € 14,729 in the preoperative group. In patients without complication, the cost of in‐hospital routine care was similar in both groups. The mean cost of complication was € 6178 in the conventional group and € 4639 in the preoperative group (p =.05). Total cost of patients with complications was € 535,236 in the conventional group and € 334,148 in the preoperative group. Total costs consumed 93% of the diagnosis‐related‐group (DRG) reimbursement rate in the conventional group and 78% in the preoperative group. Cost‐effectiveness was € 6245 for the conventional group and € 2985 for the preoperative group. Conclusions: The costs of postoperative morbidity consumed a large amount of the DRG reimbursement rate. Preoperative immunonutrition was cost‐effective in our series. (Journal of Parenteral and Enteral Nutrition 29:S57–S61, 2005)
Enteral Nutrition as Primary Therapy in Childhood Crohn's Disease: Control of Intestinal Inflammation and Anabolic Response
Authors: Beattie Robert M.
Published: May 2008

Crohn's disease in childhood is a chronic relapsing and remitting condition that can significantly impact normal growth and development. This influences choice of both initial and ongoing management. The goal of therapy is to induce and maintain remission with minimal side effects. Enteral nutrition is effective in active disease and will induce disease remission in most cases avoiding corticosteroid use. The high frequency of relapse means additional immunosuppressive therapies are usually required but nutrition remains a key priority as part of the subsequent management strategy.
Macronutrients and Bioactive Molecules: Is There a Specific Role in the Management of Inflammatory Bowel Disease?
Authors: Gassull Miquel A. , Mañé Josep , Pedrosa Elisabet , Cabre Eduard
Published: May 2008

The effect of bioactive nutrient molecules on inflammatory response has an archetype in Inflammatory Bowel Disease. The exacerbated inflammatory response in such conditions can be nutritionally modified by 2 ways: changing the response of the host, or changing the composition of the intestinal ecosystem. Host response can be modified by changing the cell structure and function which is nutrient dependent. Nutrient deprivation will lead to a situation where there is not enough building material for cell replacement and the synthesis of mediators (enzymes, hormones, etc). However, this may occur even in a situation where there is no quantitative nutrient deprivation but only qualitative changes. In Inflammatory Bowel Disease, changes in the sources of some nutrients such as lipids or carbohydrates (CHO) can modify the inflammatory response. Lipids, by changing cell membrane composition, may modify the pattern of eicosanoid synthesis, intracellular signal transmission and activation of nuclear transcription factors, which modify the expression of some genes—that is, changing the host response. On the other hand, certain sources of carbohydrates, by undergoing anaerobic bacterial fermentation, drop the pH in the intestinal lumen favoring the growth of certain strains of bacteria which act favorably in maintaining tolerance in the bowel. In addition, as a consequence of CHO fermention, short‐chain fatty acids are produced which, especially butyrate, may act in 2 ways: by providing energy to the epithelial cells, but also as anti‐inflammatory substrate—that is, modifying at least 1 of the mechanisms triggering the inflammatory response enhancement. However, it should not be forgotten that the cellular response to dietary modifications will depend on the individual genome, as has been recently observed. This may explain why some individuals do and others do not show a similar response to dietary interventions.
External Bolster Placement After Percutaneous Endoscopic Gastrostomy Tube Insertion: Is Looser Better?
Authors: DeLegge Mark , DeLegge Rebecca , Brady Courtney
Published: May 2008

Background: Abdominal and gastric wall inflammation, infection, and necrosis after percutaneous endoscopic gastrostomy (PEG) placement is a topic of importance but of limited study. Healing of the abdominal wound after PEG placement is thought to be dependent on a number of factors, including the patient's nutrition status, comorbid disease status, and postprocedural PEG wound care. Another important factor that may influence wound healing is tissue tension and compression. This requires special attention to the correct placement of the external bolster of the PEG tube against the abdominal wall. Methods: We performed a study in mongrel dogs to determine the relevance of tissue compression on PEG‐tube wound healing; 8 mongrel dogs each received 3 separate 24 Fr PEG tubes at 1 endoscopic setting. After PEG placement, the external bolster was placed at 0 cm, 1 cm, or 4 cm from the abdominal wall. Post‐PEG care and enteral feedings were standardized. The dogs were killed at 3 weeks. Results: Partial migration of the PEG internal bolster into the gastric wall occurred in 1 of 8 of the PEG tubes with the external bolster at 0 cm. PEG‐tube‐tract tissue inflammation was worse in the dogs with the external bolster placed at 0 cm. Conclusions: The position of the external bolster in relation to the abdominal wall may be an important factor in the healing of a post–PEG‐tube‐placement tissue tract.
Severe Selenium Deficiency Secondary to Chylous Loss
Authors: de Berranger Eva , Colinet Stéphanie , Michaud Laurent , Cremer Robin , Fourrier Catherine , Brévière George Marie , Turck Dominique , Gottrand Frédéric
Published: May 2008

Selenium deficiency is observed in patients with poor intake. We report the first case of a child with lymphangiomatosis who presented a myopathy associated with severe cardiomyopathy secondary to selenium deficiency due to selenium loss in chylous fluid.
Energy Expenditure in Patients With Nontraumatic Intracranial Hemorrhage
Authors: Esper Dema Halasa , Coplin William M. , Carhuapoma J. Ricardo
Published: May 2008

Background: Patients with intracerebral (ICH), intraventricular (IVH) and subarachnoid hemorrhage (SAH) have increased morbidity and mortality compared with other forms of stroke. We postulate that the systemic inflammatory state triggered by these forms of nontraumatic intracranial hemorrhage (IH) translates into higher nutrition requirements than traditionally assumed. In order to test this hypothesis, we performed a retrospective study comparing the resting energy expenditure (REE) of 14 mechanically ventilated IH patients with the REE of 6 severe traumatic brain injury (sTBI) patients (a disease known to induce an increased metabolic state). Methods: Using nonparametric analysis, we compared 2 contemporary cohorts of patients—IH and sTBI—who required mechanical ventilation and who underwent indirect calorimetry (IC) within 7 days after the ictus. Results: Fourteen patients with nontraumatic IH (IVH, 2; SAH, 9; SAH/ICH, 1; ICH/SAH/IVH, 2) who underwent IC within 7 days from injury were identified; median age: 59 (28–84) years, median admission Glasgow Coma Scale (GCS): 6 (4–9), and median APACHE II: 19.5 (15–28). A control cohort of 6 patients with sTBI was identified; median age: 57.5 (18–80) years, admission GCS: 6.5 (4–8), and APACHE II: 16 (11–31). Sedation was used in 11/14 patients with IH and in 5/6 severe TBI patients. No patient was pharmacologically paralyzed. Median REE was 1810 (1124–2806) and 2238 (1860–2780) kcal/d for the IH and for the sTBI patient cohorts, respectively. Using Wilcoxon signed ranks test, the 2 patient groups were found comparable in regard to baseline clinical variables and disease severity (APACHE II). We did not identify a statistically significant difference in the REE between these 2 cohorts of patients (p = .25). Conclusions: Patients with severe TBI and patients with IH have similar increments in metabolic rate during the initial phase (1 week from onset) of their disease. This information needs to be confirmed in a larger cohort of patients. If reproduced, our results suggest that nontraumatic IH patients are at high risk of inadequate nutrition if their metabolic rate is estimated after conventional nutrition practice.
Chronic Constipation in Overweight Children
Authors: Misra Sudipta , Lee Amy , Gensel Kathy
Published: May 2008

Background: Obesity and functional constipation seem to share a common biopsychosocial model of causation. Though chronic constipation can significantly affect the quality of life of an overweight child, this association has not been highlighted in the literature. The purpose of this study was to compare the proportion of overweight children among children with chronic constipation with a control group of children with normal bowel habits. Methods: Retrospective chart review with a control population. One hundred one consecutive children 5–18 years of age referred to the Subspecialty Clinic for functional constipation were the study group. The control group consisted of 100 consecutive children from the general pediatric practice seen for physicals and minor illnesses. Children with a body mass index (BMI) of >85 percentile from the National Institutes of Health (NIH) 2000 chart were classified as overweight. Results: The control and study groups were statistically comparable in mean age (10.97± 3.83 years and 8.07 ± 2.56 years, respectively) and gender ratio (58 males in each group). Thirty children in the control group and 44 in the study population were overweight (p < .05). Among children with chronic constipation, the group of overweight children was male predominant (70.45% vs 47.36%, p < .05), had increased incidence of psychological/behavioral problems (45.45% vs 22.8%, p < .05), and was more likely to fail treatment (40.9% vs 21.05%, p < .05). There was no significant difference in the clinical profile of constipation, such as mean duration of constipation before presentation, sex ratio, incidence of painful defecation, and soiling and frequency of defecation between these 2 groups. Conclusions: There appears to be an association between chronic severe constipation and being overweight. Children with constipation are more likely to be overweight when compared with controls. Among children with chronic constipation, overweight individuals seem to constitute a distinct clinical group. This group is male predominant, has increased incidence of psychological/behavioral disorders, and is more likely to fail treatment.
The Impact of Needleless Connector Device Design on Central Venous Catheter Occlusion in Children: A Prospective, Controlled Trial
Authors: Schilling Susan , Doellman Darcy , Hutchinson Nancy , Jacobs Brian R.
Published: May 2008

Background: Intraluminal occlusion is common in children with central venous catheters (CVCs). Although multiple factors predispose CVCs to occlusion, reflux of blood is frequently implicated. We hypothesized that use of either a single‐valve or positive‐pressure‐valve needleless connector device would reduce CVC occlusion rates in comparison to a standard device. We further hypothesized that saline would be as effective as heparinized saline flush in preventing occlusion and infection. Methods: CVC lumens were prospectively capped with 1 of 3 needleless connector devices in a 4‐group design. Group 1 lumens were capped with a standard device, group 2 with a single‐valve device, group 3 with a positive‐pressure‐valve device flushed with heparinized saline, and group 4 with a positive‐pressure‐valve device flushed with saline. Data were obtained regarding occlusion and infection rates and user satisfaction. Results: Three hundred sixty children with 599 CVC lumens completed the study. Complete occlusion occurred in 19/150 (12.7%) lumens in group 1 in comparison to 2/150 (1.3%) in group 2, 5/149 (3.4%) in group 3, and 6/150 (4%) in group 4 (p < .05). There was a trend toward a 2‐fold greater infection rate in group 4. User satisfaction was higher in groups 2, 3, and 4 than group 1 (p < .05). Conclusions: CVCs capped with a single‐valve or positive‐pressure‐valve needleless connector device have lower complete catheter occlusion rates than those capped with a standard device. Heparinized saline flush affords no advantages over saline in reducing occlusion rate; however, there was a trend toward lower infection rate with the use of heparinized saline.
The Effect of Hyperglycemic Hyperinsulinemia on Small‐Intestinal Mucosal Protein Synthesis in Patients After Surgical Stress
Authors: Rittler Peter , Schiefer Beatrice , Demmelmair Hans , Koletzko Berthold , Vogeser Michael , Alpers David H. , Jauch Karl‐Walter , Hartl Wolfgang H.
Published: May 2008

Hyperglycemic hyperinsulinemia cannot stimulate intestinal protein synthesis in healthy individuals but does so in conditions characterized by an altered somatotropic axis such as diabetes. Only in a state of growth hormone resistance (high growth hormone but low insulin like growth factor [IGF‐1] concentrations), extra insulin may acutely reverse the impaired, growth‐hormone‐induced IGF‐1 release, thereby exerting anabolic actions at the intestinal tract. Growth hormone resistance can be also found in patients after surgical stress. Therefore, we wanted to test the hypothesis whether hyperglycemic hyperinsulinemia would stimulate ileal protein synthesis in the latter condition. Mass spectrometry techniques (capillary gas chromatography/combustion isotope ratio mass spectrometry) were used to directly determine the incorporation rate of 1‐[13C]‐leucine into ileal mucosal protein. All subjects had an ileostomy, which allowed easy access to the ileal mucosa, and consecutive sampling from the same tissue was performed during continuous isotope infusion (0.16 μmol/kg min). Isotopic enrichments and fractional protein synthesis were determined at baseline (period I) and after a 4‐hour glucose infusion (170 mg/kg/h) or after infusion of saline (control group) (period II). In controls, ileal protein synthesis declined significantly during prolonged isotope infusion (period I: 1.11± 0.14%/h, period II: 0.39 ± 0.13%/h, p < .01). In contrast, ileal protein synthesis remained constant during glucose infusion (period I: 1.32 ± 0.35%/h, period II: 1.33 ± 0.21%/h, n.s. vs period I, but p < .005 vs the corresponding value at the end of period II in the control group). Using the continuous tracer infusion technique, ileal protein synthesis seemingly declines over a short time in control subjects. We found evidence that this artificial decline was due to mass effects of a rapidly turning over mucosa protein pool in which an isotopic plateau was reached during the experiment and of which the size amounted to approximately 4% of the total mixed protein pool. Maintenance of ileal protein synthesis during glucose infusion therefore indicates a rise of ileal protein synthesis in a slowly turning over protein pool. This effect in postsurgical patients would be compatible with the concept of intestinal insulin action to depend on the specific clinical state (eg, growth hormone resistance).
Whole‐Body Protein Metabolism in Chronic Heart Failure: Relationship to Anabolic and Catabolic Hormones
Authors: Toth Michael J. , Matthews Dwight E.
Published: May 2008

Background: Patients with chronic heart failure frequently experience profound wasting during the course of the disease, a condition termed cardiac cachexia. Although protein is the primary structural and functional component of most tissues, few studies have examined the effect of heart failure on protein metabolism. Moreover, no study has assessed the relationship of protein turnover to hormonal alterations thought to promote cachexia. Thus, our goal was to determine if whole‐body protein metabolism is altered in heart failure patients and to assess the relationship of protein kinetics to circulating levels of anabolic and catabolic hormones. Methods:We measured whole‐body protein metabolism using 13C‐leucine, body composition, and circulating anabolic and catabolic hormone levels in 10 patients with chronic heart failure and 11 elderly controls. Results: No differences in leucine rate of appearance, oxidation, or nonoxidative disposal were noted between heart failure patients and controls. However, in a subgroup of patients characterized by increased resting energy expenditure for their metabolic body size (n = 4; ≥20% above that predicted from fat‐free mass), leucine rate of appearance (mean ± SE; 146 ± 6 μmol/min), an index of protein breakdown, tended to be higher compared with patients with normal resting energy expenditure (n = 5; 120 ± 8 μmol/min) and controls (127± 4 μmol/min; p = .06). Alterations in anabolic/catabolic hormone balance did not explain increased protein breakdown in this subgroup, and no correlations were found between hormone levels and protein breakdown in the heart failure group as a whole. In contrast, increased circulating interleukin‐6 soluble receptor (r = 0.829; p < .01) and reduced insulin‐like growth factor‐I (r =–.751; p < .05) levels were related to greater rates of leucine oxidation in heart failure patients. Conclusion: Our results demonstrate that, although increased protein turnover is not a generalized feature of heart failure, there is a subgroup of patients characterized by resting hypermetabolism and increased protein breakdown. Moreover, hormonal alterations related to the heart failure syndrome were related to increased protein oxidation.
Application Criteria of Enteral Nutrition in Patients With Anorexia Nervosa: Correlation Between Clinical and Psychological Data in a“ Lifesaving” Treatment
Authors: Paccagnella Agostino , Mauri Alessandra , Baruffi Carla , Berto Rita , Zago Raffaella , Marcon Maria Lisa , Pizzolato Daniela , Fontana Francesca , Rizzo Lenio , Bisetto Mario , Agostini Silvana , Foscolo Giancarlo
Published: May 2008

Background: Data and research increasingly point to multiple factors in the genesis of eating‐behavior disorders, but the lack of a clear etiological definition prevents a unique therapeutic or prognostic approach from being defined. Therapeutic approaches, as well as scientific research, have separately analyzed the psychological aspects and the clinical‐nutrition aspects without integrating the variables or correlating clinical and psychological data. This work has several goals because it aims at considering the problem from the 2 different perspectives. Psychological and clinical variables are analyzed both separately and together in order to assess (a) the minimal criteria to define a cure as “lifesaving” and submit a patient to artificial nutrition; (b) the kind of implementation artificial nutrition should follow; (c) which indicators of the efficacy of artificial nutrition must be taken into account; (d) the results in nutrition terms that may be obtained during the follow‐up; (e) if artificial nutrition may be used as a therapeutic tool; (f) if there are any psychological effects after artificial nutrition; (g) if there are any effects due to the patients' age; and (h) the correlation between the psychological profile of a patient and the acceptance of the nutrition treatment. Methods: Several psychological and pharmacologic variables, together with clinical and anthropometric data and blood chemical values, were all considered. Conclusions: Besides defining minimal criteria for a “lifesaving” cure and proposing 2 ad hoc scales for the assessment of patients' subjective willingness toward feeding and for the objective measurement of feeding itself, clinical data and correlations with psychological data evidenced the importance of artificial nutrition and specifically of enteral nutrition as a therapeutic tool, allowing us to define the modalities of implementation of enteral nutrition. Results show that, because enteral nutrition did not deteriorate the psychological state of the patients, and was found to be accepted more positively than feeding orally in the most critical initial phase, it should be included in the therapy.
Hyperglycemia During Critical Illness
Authors: Nasraway Stanley A.
Published: May 2008

Background: We sought to review the literature describing the benefits of tight glycemic control in critically ill patients, comparing outcome differences in subgroup populations. Methods: We searched PubMed for relevant literature on the topic of hyperglycemia and its management in the intensive care unit. Results: Overwhelming evidence in both surgical and medical patients conclusively demonstrates that hyperglycemia is a marker of severity of illness and is also an independent determinant of bad outcome, largely from infectious complications. Randomized trial evidence, in conjunction with historically controlled trials, supports the use of intensive insulin therapy and euglycemic control in critically ill patients, with nondiabetics possibly benefiting even more than diabetic patients. Euglycemia is best achieved, and hypoglycemia attenuated, through use of a protocolized approach. Further elaboration as to what threshold range defines euglycemia in patient subpopulations is needed and what pitfalls must be avoided in this practice. Development of continuous blood glucose monitoring has started and will someday be incorporated into routine practice in the same way that continuous electrocardiographic monitoring and pulse oximetry are standards of care in the intensive care unit. Conclusions: Hyperglycemia is a predictor of death and complications in critically ill patients. Early aggregated study results show that control of hyperglycemia improves outcomes. Well‐designed studies involving thousands of patients have started to better elucidate the concomitant promoters of hyperglycemia and to better quantify the benefits from tight glycemic control.
Appearance of Individual Amino Acid Concentrations in Arterial Blood During Steady‐State Infusions of Different Amino Acid Formulations to ICU Patients in Support of Whole‐Body Protein Metabolism
Authors: Iresjö Britt‐Marie , Körner Ulla , Larsson Bo , Henriksson Bengt‐Åke , Lundholm Kent
Published: May 2008

Background: Previous work has demonstrated a relationship between arterial amino acid concentrations and uptake of amino acids across peripheral tissues in healthy volunteers, as well as in chronically and acutely ill patients. The aim of the present study was to evaluate whether different amino acid profiles in commercially available amino acid formulations are translated into significantly different arterial amino acid concentrations presumably high enough to promote protein metabolism in intensive care unit (ICU) patients. Methods: Nonprotein calories (60% glucose: 40% lipid) were simultaneously and constantly infused over 72 hours. Different free amino acid solutions were infused at random to each patient for 24 hours in order to determine the appearance of steady‐state arterial concentrations of individual amino acids. Basal metabolic and nutrition states were defined after a 12‐hour infusion period with glucose in each patient. Healthy volunteers receiving a standardized oral meal served as reference subjects in measurements of venous amino acid concentrations after normal oral food intake. Results: The sum of all amino acids in arterial plasma increased significantly during steady‐state infusions of all the free amino acid solutions vs basal state in ICU patients. Only glutamine, taurine, and tyrosine did not increase at all vs basal state during steady‐state infusions of the 3 formulations. Alanine, arginine, citrulline, glycine, histidine, serine, methionine, phenylalanine, valine, and ornithine showed different concentration among the amino acid solutions during infusions. Healthy volunteers had significantly higher overall concentrations of amino acids in both fasted and fed state compared with ICU patients, which indicates that free amino acid solutions remain a limiting component in artificial nutrition to patients to promote arterial amino acid concentrations in the artificially fed state. Conclusions: It appears important to continue further improvement of composition profile in solutions of free amino acids to promote adequate uptake across organ beds in promotion of protein balance in artificially nourished patients.
Phase Angle From Bioelectrical Impedance Analysis: Population Reference Values by Age, Sex, and Body Mass Index
Authors: Bosy‐Westphal Anja , Danielzik Sandra , Dörhöfer Ralf‐Peter , Later Wiebke , Wiese Sonja , Müller Manfred J.
Published: May 2008

Background: The use of bioelectrical impedance phase angle has been recommended as a prognostic tool in the clinical setting, but published reference data bases are discrepant and incomplete (eg, they do not consider body mass index [BMI], and data are lacking for children). Methods: Phase angle reference values stratified by age, sex, and BMI were generated in a large German data base of 15,605 children and adolescents and 214,732 adults, and the determinants of phase angle values were assessed. The reference values were applied to 3 groups of patients and compared with previously published reference values from the United States and Switzerland. Results: Gender and age were the main determinants of phase angle in adults, with men and younger subjects having higher phase angles. In children and adolescents, age and BMI were the main determinants of phase angle. In normal and overweight adults, phase angle increased with increasing BMI, but there was an inverse association at a BMI >40 kg/m2. In cirrhosis, the prevalence of a low phase angle increased with the state of disease, whereas it was not different between patients with the metabolic syndrome and controls. There are considerable differences between phase angle reference values from different populations. These differences are not explained by age or BMI and may be due to differences between impedance analyzers. Conclusion: The determinants of phase angle differ between adults and children. In adults, the influence of BMI on phase angle depended on the BMI range. The prognostic value of phase angle may differ in different clinical settings. The use of population‐specific and probably impedance‐analyzer‐specific reference values for phase angle is recommended.
The Effect of Glutamine‐Enriched Enteral Nutrition on Intestinal Permeability in Very‐Low‐Birth‐Weight Infants: A Randomized Controlled Trial
Authors: van den Berg Anemone , Fetter Willem P. F. , Westerbeek Elisabeth A. M. , van der Vegt Ina M. , van der Molen Hilda R. A. , van Elburg Ruurd M.
Published: May 2008

Background: Very‐low‐birth‐weight (VLBW) infants are susceptible to glutamine depletion. Glutamine depletion has negative effects on intestinal integrity. The lower infection rate in VLBW infants receiving glutamine‐enriched enteral nutrition may originate from improved intestinal integrity, as reflected by decreased intestinal permeability. The aim of our study was to investigate whether glutamine‐enriched enteral nutrition in VLBW infants enhances the normal decrease in intestinal permeability, as measured by the sugar absorption test (SAT). Methods: In a double‐blind, randomized, placebo‐controlled trial, VLBW infants (gestational age <32 weeks or birth weight <1500 g) received enteral glutamine supplementation (0.3 g/kg/d) or an isonitrogenous placebo supplementation (alanine) between days 3 and 30 of life. Intestinal permeability, determined from the urinary lactulose/mannitol (L/M) ratio after an oral dose of lactulose and mannitol, was assessed at 4 time points: before the start of the study, and at days 7, 14, and 30 of life. Results: At least 2 SATs were performed in 45/52 (86%) and 45/50 (90%) infants in the glutamine‐supplemented and control groups, respectively. Baseline patient and nutrition characteristics were not different between the groups. There was no effect of glutamine‐enriched enteral nutrition on the decrease of the L/M ratio between the start and end of the study (p = .78). In both treatment groups, median urinary lactulose concentrations decreased (p < .001), whereas median urinary mannitol concentrations increased (p = .003). Conclusions: Glutamine‐enriched enteral nutrition does not enhance the postnatal decrease in intestinal permeability in VLBW infants. Any beneficial effect of glutamine may involve other aspects of intestinal integrity; for example, modulation of the intestinal inflammatory response.
The Prognostic Value of Severe Malnutrition in the Development of Nonthyroidal Illness in Head and Neck Cancer Patients
Authors: Siroen M. P. C. , van Bokhorst‐de van der Schueren M. A. E. , Richir M. C. , Sauerwein H. P. , Leemans C. R. , Quak J. J. , van Leeuwen P. A. M.
Published: May 2008

Background: Thyroid hormone metabolism is modulated by starvation and overfeeding but also by dietary composition. Unfortunately, little is known about the effect of malnutrition on disease‐induced nonthyroidal illness (NTI). In this study, we investigated whether the degree of NTI after surgery differed between severely malnourished and well‐fed patients with head and neck cancer. Methods: Plasma levels of the thyroid hormones 3′,5‐triiodothyronine (T3), reverse T3 (rT3), free T4 (FT4), and thyrotropin (TSH) were measured on the first day before the operation and on the first, fourth, and seventh day after the operation in 16 malnourished patients who were admitted for intentional curative surgery of T1–T4 carcinomas of the head and neck. Six well‐fed head and neck cancer patients eligible for surgical treatment served as a control group. Results: In the malnourished group, rT3 showed a significant increase, whereas T3 and FT4 decreased significantly due to the operation. TSH showed no significant change. During the postoperative course, it took 7 days until rT3 and 4 days until T3 and FT4 were restored to their preoperative value. In contrast, well‐fed patients did not develop NTI. Conclusions: This study shows that peri‐ and postoperative rT3, T3, and FT4 levels change significantly in malnourished patients compared with well‐fed patients. Therefore, it can be concluded that nutrition status of patients undergoing major head and neck surgery should be optimized in order to prevent the development of NTI.
Day‐to‐Day Variance in Measurement of Resting Metabolic Rate Using Ventilated‐Hood and Mouthpiece & Nose‐Clip Indirect Calorimetry Systems
Authors: Roffey Darren M. , Byrne Nuala M. , Hills Andrew P.
Published: May 2008

Background: To know if the magnitude of change in resting metabolic rate (RMR) observed during an intervention is meaningful, it is imperative to first identify the variability that occurs within individuals from day to day under normal conditions. The 2 most common systems used to measure RMR involve a ventilated hood or a mouthpiece & nose clip to collect expired gases. The variation in measurement using these 2 approaches has not been systematically compared. Methods: RMR was measured in 10 healthy adults during 5 separate testing sessions within a 2‐week period where usual diet and physical activity were maintained. Each testing session consisted of one measurement of RMR using a ventilated hood system, followed by another using a mouthpiece & nose‐clip system. Results: No significant difference in RMR was evident between measurement sessions using either indirect calorimeter. Oxygen consumption and RMR were significantly higher using the mouthpiece & nose‐clip system. Average within‐individual coefficient of variation for RMR was significantly lower for the ventilated‐hood system. RMR measures were consistently lower using the ventilated‐hood system by an average of 94.5 ± 63.3 kcal. Day‐to‐day variance was between 2% and 4% for both systems. Conclusions: The use of either system is appropriate for assessing RMR in clinical and research settings, but alternating between systems should be undertaken with caution. A change in RMR must be greater than ∼6% (96 kcal/d; 1.2 kcal/kg/d) or∼ 8% (135 kcal/d; 1.7 kcal/kg/d) when using a ventilated‐hood system or a mouthpiece & nose‐clip system, respectively, to observe any meaningful intervention‐related differences within individuals.
Horner's Syndrome After Placement of a Peripherally Inserted Central Catheter
Authors: Links David John Raymond , Crowe Phillip John
Published: May 2008

We describe a delayed case of Horner's syndrome after the use of a peripherally inserted central line. Central vein thrombosis, a well‐recognized complication of central venous access, led to temporary injury to the sympathetic tract in the neck. Presentation of Horner's syndrome with central venous access in place should be further investigated to rule out central vein thrombosis.
Simultaneous Infusion of Glutamine and Branched‐Chain Amino Acids (BCAA) to Septic Rats Does Not Have More Favorable Effect on Protein Synthesis in Muscle, Liver, and Small Intestine Than Separate Infusions
Authors: Holecek Milan , Muthny Tomas , Kovarik Miroslav , Sispera Ludek
Published: May 2008

Background: Glutamine and branched‐chain amino acids (BCAA; valine, leucine, and isoleucine) are used as nutrition supplements in the treatment of proteocatabolic illness. We hypothesized that simultaneous administration of BCAA and glutamine affects protein metabolism more significantly than separate administration. In the present study, we evaluated their effect on protein synthesis in skeletal muscle, liver, and jejunum of septic rats. Methods: Twenty‐four hours after induction of sepsis by subcutaneous injection of turpentine, the rats were infused for 6 hours with 5 mL of 1.75% glutamine, 1.75% BCAA, 1.75% glutamine + BCAA, or saline solution. The control group consisted of intact rats infused with saline. Protein synthesis was measured at the end of infusion by a “flooding method” with [3,4,5‐3H]phenylalanine. Results: In turpentine‐treated animals, we observed a decrease in glutamine concentration in blood plasma and skeletal muscle, a decrease in BCAA concentration in liver and jejunum, and a decrease in protein synthesis in all tissues. Glutamine or glutamine + BCAA infusion increased glutamine concentration in plasma and muscle and stimulated protein synthesis in the liver. The BCAA infusion enhanced concentrations of BCAA in plasma and tissues, but the effect of BCAA on protein synthesis was insignificant. Synergistic effect of simultaneous infusion of glutamine and BCAA on protein synthesis was not observed. Conclusions: We conclude that glutamine infusion to rats with septic injury may significantly improve impaired protein synthesis in the liver and that there is no synergistic effect of glutamine and BCAA infusion on protein synthesis in skeletal muscle, liver, and jejunum.
Impact of Caloric Intake on Parenteral Nutrition–Associated Intestinal Morphology and Mucosal Barrier Function
Authors: Sun Xiaoyi , Spencer Ariel U. , Yang Hua , Haxhija Emir Q. , Teitelbaum Daniel H.
Published: May 2008

Background: Parenteral nutrition (PN) is known to induce villus atrophy, epithelial cell (EC) apoptosis, and increase mucosal permeability. The study hypothesized that increasing amounts of energy delivery to mice would result in the best outcome, with the least effects on the mucosa. Methods: Mice were randomized to enteral controls (saline infusion with ad libitum enteral food) or to 1 of 3 PN groups (with no enteral nutrition): full (100% of daily average energy intake for the mouse), reduced (75% of energy intake) or very low (50% of energy intake). Mice received PN for 7 days. Mucosal morphology, EC apoptosis, and bacterial translocation were assessed. Results: Villus height decreased significantly with decreasing levels of caloric intake and was significantly lower in all PN groups compared with controls. Body weight loss was significantly greater in PN groups vs controls and was greatest in mice with the lowest caloric delivery. A consistent trend toward a higher EC apoptotic index with decreasing caloric intake was observed, and apoptosis in all PN groups exceeded controls (2‐fold). All PN groups demonstrated greater bacterial translocation than controls. Conclusions: PN induces intestinal EC apoptosis and villus and crypt atrophy, even at 100% of predicted energy needs, and such changes increased with greater reduction of energy intake. This study supports a concept that lack of enteral nutrition, rather than absolute caloric levels, is responsible for many of the adverse effects of PN. The study also allows the investigators to better optimize a mouse model of PN delivery.
Effect of Energy Substrates on Protein Degradation in Isolated Small Intestinal Enterocytes From Rats
Authors: Saberi Mohsen T. , Stewart Sarah A. , Annette Myriam , Knowles Andrew L. , Attaix Didier , Samuels Sue E.
Published: May 2008

Background: Nutrients affect small intestinal protein mass and metabolism, but studies on the effect of nutrients on small intestinal protein degradation are very limited due to a lack of a proper method. The objectives of this study were to establish a method to directly estimate protein degradation in isolated enterocytes from rats and to test the effect of energy substrates on protein degradation. Methods: Male Sprague‐Dawley rats (150–200 g, n ≥ 8 per treatment) were used. Cell viability, tyrosine release as an indicator of protein degradation, and the effect of osmolarity, 50 mmol/L glucose, 20 mmol/L β‐hydroxybutyrate, 4.7 mmol/L butyrate, and 30 mmol/L glutamine on protein degradation were measured. Results: The average viability of enterocytes at time 30 minutes was 85.8% (range, 81%–94%). Tyrosine release was linear over the course of experiments, indicating constant protein degradation (R 2 = 0.9943; p < .05). Osmolarity, glucose, and glutamine had no effect on protein degradation in isolated enterocytes. β‐Hydroxybutyrate significantly decreased it (–16%; p < .05), whereas butyrate slightly increased it (+5%; p < .05). Conclusions: A high viability and constant protein degradation indicate a successful establishment of a method to estimate protein degradation in isolated small intestinal enterocytes from rats. The large effect of β‐hydroxybutyrate suggests a potential positive role for ketone bodies to limit the loss of small intestinal protein mass by decreasing protein degradation.
Tolerance and Efficacy of Enteral Nutrition in Traumatic Brain–Injured Patients Induced Into Barbiturate Coma
Authors: Bochicchio Grant V. , Bochicchio Kelly , Nehman Shelley , Casey Colleen , Andrews Penny , Scalea Thomas M.
Published: May 2008

Background: There is a paucity of data evaluating the efficacy of nutrition support in traumatic brain–injured patients induced into barbiturate coma for refractory intracranial hypertension. Our objective was to evaluate the efficacy of enteral nutrition in a select group of trauma patients. Methods: Prospective data were collected on severe traumatic brain–injured patients over a 4‐year period. Patients were stratified by whether or not they were induced into a barbiturate coma. Barbiturate coma was defined as per American Association of Neurological Surgeons (AANS) guidelines. All patients were initially fed via the enteral route via a nasogastric feeding tube. Patients who did not tolerate feedings within 48 hours started receiving prokinetic agents. Feeding tolerance was defined as ability to tolerate enteral feedings with <150 mL of gastric residuals every 6 hours for >72 hours. Results: Fifty‐seven patients were induced into a barbiturate coma. All were victims of blunt‐force trauma. Forty‐two of 57 (74%) patients were men, with a mean age of 37 ± 12 years and a mean injury severity score of 24 ± 10. Thirty‐eight of the 57 (67%) patients had an isolated traumatic brain injury. All 57 patients failed enteral nutrition via the nasogastric route after the first 48 hours of nutrition initiation after barbiturate coma was fully achieved by protocol criteria. Prokinetic agents demonstrated no improvement in feeding tolerance after the subsequent 48–72 hours. Of the 12 patients who had a postpyloric feeding tube placed, only 25% tolerated enteral nutrition for >48 hours. Conclusions: Patients with traumatic brain injury induced into barbiturate coma develop a significant ileus that is refractory to prokinetic agents. Only a marginal improvement is seen when the postpyloric route is obtained. Early parenteral nutrition should be considered in this patient population.
Implementing Feeding Guidelines for NICU Patients <2000 g Results in Less Variability in Nutrition Outcomes
Authors: Street Jennifer L. , Montgomery Dianne , Alder Stephen C. , Lambert Diane K. , Gerstmann Dale R. , Christensen Robert D.
Published: May 2008

Background: We devised a consistent approach to instituting and advancing enteral nutrition among neonatal intensive care unit (NICU) patients<2000 g birth weight. We then assessed variability in feeding‐related outcomes during a period before (period 1) vs after (period 2) implementing these guidelines. Methods: Using data from period 1 vs period 2, we statistically compared the equivalence of variance, focusing on certain feeding‐related outcomes. Specific outcomes we chose to examine were (1) day of life when the first enteral feedings were given, (2) number of days during the entire hospitalization when no feedings were given, (3) number of days parenteral nutrition (PN) was administered, and (4) day of life when feedings of 80 mL/k/d and 100 kcal/k/d enteral were achieved. Results: Fifty‐eight patients <2000 g were admitted to the NICU in period 1, of which 56 survived to discharge home. In period 2, 68 patients<2000 g were admitted and 66 survived to discharge. Demographic features of the patients in periods 1 and 2 did not differ. In both periods, feedings were begun on a median of day 1. However, in period 1 the range was from day 0 to day 24, and in period 2, the range was from day 0 to day 6 (equivalence of variance p < .001). After feedings were initiated, they were withheld for a median of 2 days (range, 0–23) during the remainder of the hospitalization in period 1 vs a median of 1 day (range, 0–12) in period 2 (p < .001). During period 1, PN was used for a median of 10 days (range, 0–72) vs 7 (range, 0–47) in period 2 (p = .001). During period 1, more variability occurred in the day of life when 80 mL/k/d and 100 kcal/k/d were achieved (both p< .001). No differences were seen in necrotizing enterocolitis, intestinal perforation, mortality, or length of hospital stay. Conclusions: Implementing feeding guidelines was associated with significantly less variability in feeding‐related outcomes. We speculate that this is a reflection of better feeding tolerance, which resulted from a more consistent approach to initiating and advancing enteral feedings.
Analysis of Sites of Bacterial Contamination in an Enteral Feeding System
Authors: Mathus‐Vliegen Elisabeth M. H. , Bredius Marjan W. J. , Binnekade Jan M.
Published: May 2008

Background:Contamination of enteral feedings is an often overlooked source for bacterial infection in the intensive care unit. A new 1‐L enteral feeding system with minimal chances of touching critical areas (Nutrison Pack) was compared with routinely used 0.5‐L glass bottle systems.Methods:Patients admitted to intensive care were randomized to Pack or glass bottle feeding systems. Cultures were taken from the delivery sets 5 times during the day and from feeding containers and different sites of the system after 24 hours.Results:Bacteria were present in 3 of 112 glass bottles and in 2 of 95 Pack bags. True bacterial contamination (defined as >102colony‐forming units/mL, with same bacteria also present in the delivery set) was found in none of the Packs with a 12‐h (69 Packs) or a 24‐h (26 Packs) hanging time and in only 1 of the glass bottles with a hanging time of 24 hours, which exceeded the advised hanging time of 8 hours. In contrast, the contamination rate of delivery sets was 48%, with increasing bacterial counts over the day and 4 subsequent days. Bacteria mainly belonged to the group of potentially pathogenic bacteria (Enterobacteriaceae and Pseudomonaceae). They likely originated from throat, lungs, and stomach and grew into and along feeding tubes upwards until they reached the delivery set.Conclusions:Prolonged hanging times of Pack bags were safe with respect to bacterial contamination. However, the bacterial safety of enteral feedings is more likely to be endangered by the endogenous route of contamination rather than exogenous contamination, as high bacterial counts were found in feeding tubes and delivery sets as a result of retrograde growth.
Sutured Securement of Peripherally Inserted Central Catheters Yields Fewer Complications in Pediatric Patients
Authors: Graf Jeanine M. , Newman Christopher D. , McPherson Mona L.
Published: May 2008

Background: Pediatric peripherally inserted central catheters (PICCs) can be secured with tape, sutures, or sutureless securement devices. Despite widespread catheter use, no standardized method of securement has been proven superior. Methods: A prospective randomized trial of catheter securement with either tape or suture was undertaken in pediatric patients hospitalized at a tertiary children's hospital. Patient demographics, catheter dwell time, and all catheter complications were collected. All patients were followed for the entire dwell time of the catheter, including those discharged with lines still in place. Results: Sixty‐six patients completed the study, with 34 children in the suture group and 32 children in the tape group. Patients' ages ranged from 9 months to 19 years. Overall complication rate in our sutured group was 5.8%, and 32.4% in the tape group. Conclusions: In this study of children of varying ages, sutured PICCs were associated with significantly fewer complications than those catheters secured with tape (p = .005). The 3 most common complications included migration, occlusion, and leaking catheters.