bluuebunny/crossref_metadata_2025 huggingface dataset:
A Priori Dietary Ω‐3 Lipid Supplementation Results in Local Pancreatic Macrophage and Pulmonary Inflammatory Response Attenuation in a Model of Experimental Acute Edematous Pancreatitis (AEP)
Authors: Sharif Suhail , Broman Michael , Babcock Tricia , Ong Evan , Jho David , Rudnicki Marek , Helton W. Scott , Espat N. Joseph
Published: May 2008

Background: Acute pancreatitis is often complicated by multiorgan dysfunction, which is postulated to occur in part by macrophage infiltration into the pancreas. Eicosapentaenoic acid (EPA), an ω‐3 fatty acid, is the principal biologic component of fish oil and has clinically and experimentally been demonstrated to be anti‐inflammatory. We hypothesized that dietary EPA supplementation before the induction of pancreatitis would attenuate both Mϕ‐mediated local pancreatic and systemic pulmonary inflammatory response in an in vivo model of acute edematous pancreatitis (AEP). Methods: Male Sprague‐Dawley (SD) rats were pretreated 2 times per day with oral gavage with EPA (ω‐3 fatty acid; 5 mg/kg/dose) or ω‐6 fatty acid control (5 mg/kg/dose) or saline (equal volume) for 2 weeks. AEP was induced in ω‐3, ω‐6, and saline pretreated rats by 5 hourly subcutaneous (SC) injections of cerulein. Pancreas, lung, and serum were harvested 3 hours after the last cerulein injection. Severity of pancreatitis was confirmed by serum amylase and by histopathologic score. Pancreatic macrophage infiltration was assessed by confocal fluorescent microscopy, and pulmonary leukocyte respiratory burst (LRB) analysis was performed on mononuclear cells obtained from bronchioalveolar lavage (BAL). Results: All animals demonstrated acute pancreatitis through hyperamylasemia and histopathologic examination. Confocal analysis demonstrated significantly lower macrophage infiltration, and BAL analysis by flow cytometry demonstrated significantly lower (p < .05) LRB in the ω‐3‐treated group compared with theω ‐6 and the saline pancreatitis group. Conclusions: Attenuation of both pancreatic MΦ inflammatory response and pulmonary leukocyte respiratory burst in AEP by EPA supports further investigation into the potential role for EPA dietary supplementation in the progression of pancreatitis‐associated sequelae.
Olive Oil–Based Lipid Emulsion's Neutral Effects on Neutrophil Functions and Leukocyte–Endothelial Cell Interactions
Authors: Buenestado Amparo , Cortijo Julio , Sanz María‐Jesús , Naim‐Abu‐Nabah Yafa , Martinez‐Losa Magdalena , Mata Manuel , Issekutz Andrew C. , Martí‐Bonmatí Ezequiel , Morcillo Esteban J.
Published: May 2008

Background: Infection remains a drawback of parenteral nutrition (PN), probably related, among other factors, to immunosuppressive effects of its lipid component. Newer preparations may have lesser immunosuppressive impact. This study examines the effects of an olive oil–based lipid emulsion (long‐chain triacylglycerols‐monounsaturated fatty acids [LCT‐MUFA]; ClinOleic) on various functions of human neutrophils in vitro and on rat leukocyte–endothelial cell interactions in vivo compared with LCT (Intralipid) and 50% LCT–50% medium‐chain triacylglycerols (MCT; Lipofundin) mixture. Methods: Neutrophils isolated from healthy donors were incubated with concentrations (0.03–3 mmol/L) of lipid emulsions encompassing clinically relevant levels. In vivo leukocyte recruitment was studied with intravital microscopy within rat mesenteric microcirculation. Results: LCT‐MUFA (3 mmol/L) did not alter the N‐formyl‐Met‐Leu‐Phe (FMLP)‐induced rise in [Ca2+]i, oxidative burst, chemotaxis, and elastase release, whereas LCT‐MCT decreased [Ca2+]i and chemotaxis and increased oxidative burst. FMLP‐induced LTB4 production was augmented by lipid emulsions. Serum‐opsonized zymosan‐induced phagocytosis was unaltered by lipid emulsions. Basal and FMLP‐induced CD11b expression was unaffected by lipid emulsions. Lipopolysaccharide (LPS)‐induced TNF‐α, IL‐1β and IL‐8 mRNA, and protein expression was unaltered by LCT‐MUFA, whereas LCT and LCT‐MCT decreased IL‐1β mRNA and protein. LCT‐MUFA did not alter apoptosis, but LCT increased apoptosis in absence and presence of GM‐CSF. LPS (1 μg/mL)‐induced increase in leukocyte rolling flux, adhesion, and emigration was inhibited by LCT and LCT‐MCT but unaffected in LCT‐MUFA‐treated rats. Immunohistochemistry showed LPS‐induced increase in P‐selectin expression attenuated by LCT and LCT‐MCT but not LCT‐MUFA. Conclusions: LCT‐MUFA showed lower in vitro and in vivo impact on neutrophil function compared with LCT and LCT‐MCT.
Influences of Long‐Term Antibiotic Administration on Peyer's Patch Lymphocytes and Mucosal Immunoglobulin A Levels in a Mouse Model
Authors: Yaguchi Yoshihisa , Fukatsu Kazuhiko , Moriya Tomoyuki , Maeshima Yoshinori , Ikezawa Fumie , Omata Jiro , Ueno Chikara , Okamoto Koichi , Hara Etsuko , Ichikura Takashi , Hiraide Hoshio , Mochizuki Hidetaka , Touger‐Decker Riva E.
Published: May 2008

Background: Long‐term antibiotic administration is sometimes necessary to control bacterial infections during the perioperative period. However, antibiotic administration may alter gut bacterial flora, possibly impairing gut mucosal immunity. We hypothesized that 1 week of subcutaneous (SC) antibiotic injections would affect Peyer's patch (PP) lymphocyte numbers and phenotypes, as well as mucosal immunoglobulin A (IgA) levels. Methods: Sixty‐one male Institute of Cancer Research mice were randomized to CMZ (cefmetazole 100 mg/kg, administered SC twice a day), IPM (imipenem/cilastatin 50 mg/kg × 2), and control (saline 0.1 mL × 2) groups. After 7 days of treatment, the mice were killed and their small intestines removed. Bacterial numbers in the small intestine were determined using sheep blood agar plates under aerobic conditions (n = 21). PP lymphocytes were isolated to determine cell numbers and phenotypes (CD4, CD8,αβ TCR, γδTCR, B220; n = 40). IgA levels in the small intestinal and bronchoalveolar washings were also measured with ELISA. Results: Antibiotic administration decreased both bacterial number and the PP cell yield compared with the control group. There were no significant differences in either phenotype percentages or IgA levels at any mucosal sites among the 3 groups. Conclusions: Long‐term antibiotic treatment reduces PP cell numbers while decreasing bacterial numbers in the small intestine. It may be important to recognize changes in gut mucosal immunity during long‐term antibiotic administration.
Glutamine Attenuation of Cell Death and Inducible Nitric Oxide Synthase Expression Following Inflammatory Cytokine‐Induced Injury Is Dependent on Heat Shock Factor‐1 Expression
Authors: Peng Zhi‐Yong , Hamiel Christine R. , Banerjee Anirban , Wischmeyer Paul E. , Friese Randall S. , Wischmeyer Paul
Published: May 2008

Background: Glutamine (GLN) has been shown to improve outcome after experimental and clinical models of critical illness. Enhanced expression of heat shock protein (HSP) has been hypothesized to be responsible for this protection. The heat shock response has been shown to inhibit inducible nitric oxide synthase (iNOS) gene expression and nitric oxide (NO) production. This study tested the hypothesis that GLN‐mediated activation of the HSP pathway is responsible for improved survival and attenuation of iNOS expression after an inflammatory cytokine–induced injury. Methods: Heat shock factor‐1 (HSF‐1) wild‐type and knockout mouse embryonic fibroblasts (HSF‐1+/+ and HSF‐1–/–) were used in all experiments. Cells were treated with 0 mmol/L or 8 mmol/L GLN and cytomix (tumor necrosis factor‐α, lipopolysaccharide, and interferon‐γ) in a concurrent treatment model once they had reached confluence. Cell viability was assayed with MTS/PMS mixture. Apoptosis and necrosis were assayed via immunohistochemistry. iNOS and HSP‐70 expression were detected via Western blotting. NO production was measured using the Griess reagent. Results: GLN treatment significantly attenuated inflammatory cytokine–induced cell death and apoptosis in HSF‐1+/+ cells vs 0 mmol/L GLN treatment; however, GLN′s cellular protection was lost in HSF‐1–/– cells. GLN supplementation attenuated cytomix‐induced iNOS expression and NO production only in HSF‐1+/+ cells. Further, GLN induced HSP‐70 expression only in HSF‐1+/+ cells. Conclusions: This is the first demonstration that GLN‐mediated cellular protection after inflammatory cytokine injury is due to HSF‐1 expression and cellular capacity to activate an HSP response.
Relative Bioavailability of Carnitine Supplementation in Premature Neonates
Authors: Crill Catherine M. , Christensen Michael L. , Storm Michael C. , Helms Richard A.
Published: May 2008

Background: Carnitine is an important nutrient in the infant diet. We compared total plasma carnitine concentrations in premature neonates supplemented with carnitine via parenteral and enteral nutrition. Methods: This is a post hoc analysis of plasma total carnitine concentrations and carnitine intake in neonates randomized in a previous study to receive 20 mg/kg/d carnitine supplementation over 8 weeks. Neonates received l‐carnitine initially via parenteral nutrition (PN). When neonates were fed enterally, oral supplementation of l‐carnitine was given in divided doses with each feeding. Results: Sixteen neonates (27 ± 2 weeks gestation; 2.9± 1.0 days postnatal age at enrollment; 965.6 ± 279.1 g birth weight) are included. Concentrations were below reference range (31.1–60.5 nmol/mL) at baseline and exceeded reference range from week 1 through the last study period. Concentrations were not different from week 1 (108 ± 49) through weeks 4 (87 ± 34) and 8 (83 ± 31). Carnitine intakes and concentrations were compared in neonates receiving 100% parenteral carnitine at week 1 (n = 6) and 100% enteral carnitine at week 8 (n = 8). Concentrations at week 1 (100.1 ± 27.9) were not different (p = .19) from week 8 (78.6 ± 29.3); an estimate of relative bioavailability was 78.6%. Bioavailability with paired analysis of neonates (n = 5) receiving 100% parenteral carnitine at week 1 and 100% enteral carnitine at week 8 was 83.7% ± 41.2% (30.1%–140.6%). Conclusions: Parenteral and enteral supplementation of 20 mg/kg/d carnitine results in plasma total carnitine concentrations that exceed the reference range. Concentrations are not different between parenteral to enteral supplementation, suggesting that enteral carnitine is well absorbed when given daily in divided doses with enteral feedings.
Oral Rehydration for Viral Gastroenteritis in Adults: A Randomized, Controlled Trial of 3 Solutions
Authors: Rao S. S. C. , Summers R. W. , Rao G. R. S. , Ramana S. , Devi U. , Zimmerman B. , Pratap B. C. V.
Published: May 2008

Background: Pedialyte and Gatorade are advocated for the treatment of dehydration in viral gastroenteritis, but there is limited evidence to support their use. We examine the efficacy, safety, and palatability of Pedialyte, Gatorade, and a New Oral Rehydration Solution (N‐ORS). This was a randomized double‐blind trial conducted in an inpatient, community hospital. Seventy‐five consecutive adult patients (male, 42; female, 33) admitted with viral gastroenteritis were randomized to receive Gatorade, Pedialyte, or N‐ORS for 48 hours. A yogurt/rice diet was allowed ad libitum. Stool and urine output, electrolytes, fluid intake, body weight, hematocrit, and palatability of solutions were measured. Results: Sixty completed the study. Stool frequency, consistency, and body weight improved (p < .001) in all 3 groups, but there was no difference between groups. Likewise, urine output, hematocrit, and correlations between fluid ingested, stool weight, or urine output were similar. At admission and 24 and 48 hours later, hypokalemia was observed in 7, 10, and 8 patients with Gatorade; 3, 2, and 1 with N‐ORS; and 2, 2, and 1 with Pedialyte, respectively. Similarly, hyponatremia was observed in 6, 9, and 3 patients with Gatorade; 5, 3, and 4 with N‐ORS; and 4, 5, and 4 with Pedialyte. Tastewise, Gatorade and N‐ORS were rated higher (p < .05) than Pedialyte. Limitations were a smaller sample size and higher dropout (20%). Conclusions: Gatorade and N‐ORS seem to be as effective as Pedialyte in correcting dehydration and in improving bowel symptoms. All 3 solutions were safe. Unlike other groups, hypokalemia persisted in the Gatorade group. Gatorade and N‐ORS may be effective in the treatment of dehydration associated with mild viral gastroenteritis.
Clonidine Reduces Diarrhea and Sodium Loss in Patients With Proximal Jejunostomy: A Controlled Study
Authors: Buchman Alan L. , Fryer Jon , Wallin Anita , Ahn Chul W. , Polensky Sharon , Zaremba Karen
Published: May 2008

Background: Patients with short bowel syndrome have significant fluid losses. This represents a significant management problem, especially in patients with minimal residual intestine. We determined whether clonidine, anα 2‐adrenergic agonist, is effective in decreasing fecal water and sodium (Na) losses in patients with proximal jejunostomy. Eight parenteral nutrition (PN)–dependent subjects (3 men, 5 women), aged 49.9 ± 10.2 years, with a residual small bowel length of 71.8 ± 152.0 cm that ended in a jejunostomy, were studied. Methods: Subjects were admitted to the North‐western General Clinical Research Center (GCRC) for a 2‐day equilibrium period while receiving a self‐selected 100 g fat diet with protein 1.5 g/kg/d and 30 kcal/kg/d and 1 L/d of oral rehydration solution. A d‐xylose test was performed after an overnight fast. On days 3–5, all stool and urine were collected for volume, weight, fat, nitrogen, energy, sodium, magnesium, potassium, and calcium. Meals were provided in duplicate and the equivalent portions consumed by each patient were analyzed for fluid volume, fat, nitrogen, energy, sodium, magnesium, calcium, and potassium in order to calculate nutrient balances. At the conclusion of the stool and urine collections (day 6), a clonidine (0.3 mg) patch was applied to the shoulder. Subjects were restudied after 1 week. Results: Daily fecal volume and weight were 4.514 ± 1.769 L/d and 4394 ± 1727 g/d, respectively, at baseline. Five subjects were net“ secretors” in that excreted fecal volume exceeded oral intake. Fecal volume decreased by 427 ± 562 mL/d (8.9%, p = .07). Fecal weight decreased by 438 ± 527 g/d (9.4%, p = .05). Urine volume correspondingly increased by 747 ± 1934 mL (18.9%, p = not significant [NS]). The increase in urine output was weakly and negatively correlated with the decrease in fecal volume and weight (r =–0.37 and –0.41, respectively, p = NS). Oral fluid intake decreased slightly from 3.328 ± 1.246 L/d baseline to 3.203± 1.119 L/d with clonidine therapy (–3.8%, p = NS). Fecal Na loss was significantly decreased from baseline (887 ± 996 mg/d, 11.2 ± 12.3%; p = .036). This was not related to decreased oral Na intake, which actually increased from baseline (3.799± 2.271 g/d) to 3.933 ± 1.314 g/d after clonidine therapy (p = NS). No patient developed hypotension. Conclusions: Our results show the transdermal administration of clonidine is associated with a modest but clinically significant decrease in fecal output in patients with short bowel syndrome and high‐output proximal jejunostomy that require chronic parenteral fluid infusion. This is accompanied by decreased fecal Na loss.
Anatomy and Physiology of the Luminal Gut: Enteral Access Implications
Authors: Grant John P.
Published: May 2008

Successful long‐term enteral nutrition requires enteral access that is comfortable and easy to maintain. However, to be successful, the enteral access must also satisfy conditions of gut anatomy and physiology. (Journal of Parenteral and Enteral Nutrition 30:S41‐S46, 2006)
History of Vascular Access
Authors: Dudrick Stanley J.
Published: May 2008

Milestones in the history of the development of vascular access and the subsequent advances in practical clinical applications of the knowledge, techniques, technology, and experience to the beneficial management of a variety of patients are described. The original achievements are presented and briefly discussed primarily, but not exclusively, in relationship to the successful development of parenteral nutrition (PN). Beginning with the discovery of the circulation of blood, landmark events, resulting from astute observations, experimentation, and ingenious technological advances, are summarized or outlined chronologically over the past 4 centuries, with emphasis on the many recent accomplishments of basic and clinical scientists during the past 6 decades. Brief descriptions of several seminal contributions to safe and effective IV access, management, and therapy acknowledge and recognize the historical highlights that have allowed a complex and potentially hazardous therapeutic modality to evolve into a commonly applied useful adjunct to our current inpatient and outpatient armamentarium. A comprehensive list of references documents the highlights of the development of vascular access for the student of history. (Journal of Parenteral and Enteral Nutrition 30:S47‐S56, 2006)
Vascular Access for Home Intravenous Therapy in Children
Authors: Chwals Walter J.
Published: May 2008

This review article describes the vascular access devices available for long‐term vascular access in children, describes the procedures for implanting them and the sites available for this purpose, discusses the complications associated with catheter placement and how to avoid them, and compares the various catheter systems in terms of their advantages and disadvantages. (Journal of Parenteral and Enteral Nutrition 30:S65‐S69, 2006)
Anatomy and Physiology of Venous System Vascular Access: Implications
Authors: Grant John P.
Published: May 2008

Ideal characteristics for long‐term vascular access that can be managed in the home environment include a large vascular lumen in a high‐flow blood system to minimize risks of obstruction and phlebitis, ease of sterile dressing maintenance, patient comfort, and longevity of the access site. Additionally, adaptation to placement at the bedside or in the home, technical ease and safety of placement, and minimal expense would be beneficial. With these considerations, possible anatomical sites would include the external and internal jugular veins, subclavian vein, cephalic vein, basilic vein, femoral vein, right atrial appendage, and translumbar and transhepatic access to the inferior vena cava. Of these, the internal jugular vein, subclavian vein, cephalic vein, basilic vein, and femoral vein would seem best suited for long‐term venous access. (Journal of Parenteral and Enteral Nutrition 30:S7‐S12, 2006)
Evidence‐Based Practice in the Management of Vascular Access Devices for Home Parenteral Nutrition Therapy
Authors: Ryder Marcia
Published: May 2008

Catheter‐related bloodstream infection and catheter occlusion are potential significant complications of parenteral nutrition therapy. The increased incidence and associated morbidity, mortality, increased costs, and qualityof‐life issues experienced with these adverse events necessitate specialized management of vascular access devices. The host coagulation response to biomaterials and the associated development of biofilm on vascular devices are complex phenomena. Multiple interventions are required to prevent access of bacteria to both intraluminal and extraluminal catheter surfaces, and the occurrence of catheter occlusion. The discovery of the biofilm form of microbial life and the associated recalcitrance of biofilm bacteria to antimicrobials has provided insight into the failure of current prevention, diagnostic, and treatment protocols. Critical interventions are presented correlating current evidence with new discoveries in pathogenesis. (Journal of Parenteral and Enteral Nutrition 30:S82‐S93, 2006)
Establishing the Use of Body Mass Index as an Indicator of Nutrition Risk in Children With Cancer
Authors: Nething Joshua , Ringwald‐Smith Karen , Williams Ruth , Hancock Michael L. , Hale Gregory A.
Published: May 2008

Background: The negative health consequences of malnutrition in the pediatric oncology patient are well known. The purpose of this study was to determine the usefulness of body mass index (BMI) for age as a tool to prospectively identify pediatric cancer patients at risk for malnutrition and to determine the BMI percentile that would be required to identify at‐risk patients. Methods: This study was conducted by a retrospective chart review of 1839 newly diagnosed acute lymphoblastic leukemia patients at St. Jude Children's Research Hospital. Those falling below the 10th percentile on any one category of height for age (HFA), weight for age (WFA), or weight for height (WFH) were classified with regard to nutrition risk and compared with those identified as at risk by BMI for age (BFA). The BMI percentiles of the lower 9th–11th percentile patients on the HFA, WFA, and WFH growth charts were averaged in an attempt to determine a useful value to identify nutrition risk. Results: Lack of agreement was found to exist between BFA and HFA in identifying patients at risk for malnutrition, and also between BFA and WFA. Significant agreement was found to exist between BFA and WFH. The BMI percentile required to identify those at risk for malnutrition by the other growth charts would classify too many patients as being at risk for malnutrition to be considered clinically useful. Conclusions: Although research has shown BMI is appropriate to use in the nutrition assessment of children, its usefulness has not been confirmed in the pediatric oncology patient; therefore, further study is warranted. BFA assessment should be included in the nutrition survey of new pediatric oncology patients, along with other parameters, but it cannot be recommended as the sole indicator of nutrition status at this time.
Resting Energy Expenditure During Mechanical Ventilation and Its Relationship With the Type of Lesion
Authors: Raurich Joan Maria , Ibáñez Jordi , Marsé Pere , Riera María , Homar Xavier
Published: May 2008

Background: Resting energy expenditure (REE) of critically ill patients is usually calculated according to basal energy expenditure obtained from Harris‐Benedict equations traditionally corrected by different stress factors, resulting in a variable accuracy for the individual patient. The objective of this study was to investigate whether or not the type of lesion affects the metabolism level of critically ill patients treated with mechanical ventilation. We performed a retrospective study measuring the REE of critically ill patients with 3 different types of lesions (trauma, medical, surgical) who were treated with mechanical ventilation and sedation. Each lesion group of patients was matched with another group, differing in the type of lesion, according to gender, age, and weight. Methods: Eighty‐seven from a database of 175 critically ill patients undergoing indirect calorimetry were necessary for matching. Twenty matched pairs of patients for each of the following different type of lesion were obtained: medical vs surgical, medical vs trauma, and surgical vs trauma. Results: The mean REE difference was 52 kcal/d (95% confidence interval [CI] of –136 –241 kcal/d) for the medical vs surgical group, 5 kcal/d (95% CI –236 –247 kcal/d) for the medical vs trauma group and 43 kcal/d (95% CI of– 132–219 kcal/d) for the surgical vs trauma group. No statistically significant differences between groups were found in the measured REE. We did not find statistically significant differences in the measured REE of patients with and without infection. Conclusions: Critically ill patients with different types of lesion treated with mechanical ventilation have similar measured REE.
Gastric Residual Volume (GRV) and Gastric Contents Measurement by Refractometry
Authors: Chang Wei‐Kuo , McClave Stephen A. , Hsieh Chung‐Bao , Chao You‐Chen
Published: May 2008

Background: Traditional use of gastric residual volumes (GRVs), obtained by aspiration from a nasogastric tube, is inaccurate and cannot differentiate components of the gastric contents (gastric secretion vs delivered formula). The use of refractometry and 3 mathematical equations has been proposed as a method to calculate the formula concentration, GRV, and formula volume. In this paper, we have validated these mathematical equations so that they can be implemented in clinical practice. Methods: Each of 16 patients receiving a nasogastric tube had 50 mL of water followed by 100 mL of dietary formula (Osmolite HN, Abbott Laboratories, Columbus, OH) infused into the stomach. After mixing, gastric content was aspirated for the first Brix value (BV) measurement by refractometry. Then, 50 mL of water was infused into the stomach and a second BV was measured. The procedure of infusion of dietary formula (100 mL) and then water (50 mL) was repeated and followed by subsequent BV measurement. The same procedure was performed in an in vitro experiment. Formula concentration, GRV, and formula volume were calculated from the derived mathematical equations. Results: The formula concentrations, GRVs, and formula volumes calculated by using refractometry and the mathematical equations were close to the true values obtained from both in vivo and in vitro validation experiments. Conclusions: Using this method, measurement of the BV of gastric contents is simple, reproducible, and inexpensive. Refractometry and the derived mathematical equations may be used to measure formula concentration, GRV, and formula volume, and also to serve as a tool for monitoring the gastric contents of patients receiving nasogastric feeding.
Living Long With Short Bowel Syndrome: A Historical Case of Twenty‐Nine Years of Living With Home Parenteral Nutrition
Authors: Fairman Julie , Compher Charlene , Morris Jon , Mullen James L.
Published: May 2008

Background: This paper traces the 29‐year survival of Robert Thomas, who received home parenteral nutrition (PN), and contrasts his oral narrative with the clinical history of PN. Methods: Interviews, chart review, review of the literature, and historical analysis. Results: Bobby Thomas was part of an early group of patients scattered throughout the country who, with their medical team, provided the foundation for more successful survival with home PN. They learned together and taught numerous nutrition support clinicians the intricacies of patient management. The importance of the patient to the teaching function of new and experienced practitioners is highly critical. Patients like Robert Thomas gave practitioners firsthand evidence of both the tenacity of the human spirit and the complexity and difficulties of chronic illness and its treatments. Conclusions: While Bobby struggled with the complications and difficulties that came with the disease and the treatment keeping him alive, his own experiences over 29 years, as told to his medical team during his treatment and to informed interviewers before he died, tell a story that is both intersecting and parallel to the medical history. Pioneering patients like Bobby Thomas confirm the possibility of survival. They also, through their own negotiations to maintain a sense of control, can live lives they themselves help define.
Lactulose Feeding Lowers Cecal Densities of Clostridia in Piglets
Authors: Kien C. Lawrence , Blauwiekel Ruth , Williams Carol H. , Bunn Janice Yanushka , Buddington Randal K.
Published: May 2008

Background: In order to understand the consequences of persistent enteral feeding in patients with carbohydrate malabsorption, we fed piglets lactulose in sufficient dosage to produce osmotic diarrhea or inulin, using a conventional dose, to determine if this prebiotic can modulate the effects of lactulose. Feeding lactulose increases cecal luminal synthesis of butyrate, with inulin having an intermediate effect. Because clostridia may be a major source of colonic butyrate production, we hypothesized that feeding piglets lactulose or inulin would increase cecal densities of clostridia. Methods: Piglets were assigned to 3 formula study groups for 6 days: (1) control, fed only sow milk replacer (n = 12); (2) inulin, inulin supplement (3 g/L; n = 11); and (3) lactulose, lactulose supplement (66.7 g/L; n = 6). Cecal fluid for bacteriological studies was sampled intraoperatively. Results: The wet/dry ratio of the cecal contents (mean ± SEM) was 8.2 ± 0.5, 6.2 ± 0.5, and 18.8 ± 5.5, respectively, in the control, inulin, and lactulose groups (p = .049, Kruskal‐Wallis). There were no differences among the diet groups for cecal densities (106 colony‐forming units [CFU]/g dry wt cecal contents) of total anaerobes, total aerobes, bifidobacteria, or lactobacilli. Densities of clostridia were markedly reduced in the lactulose group (1.14 ± 0.41) vs the control (18.39 ± 4.44; p = .001) or inulin groups (8.87 ± 2.20; p = .04). Conclusions: In piglets, feeding lactulose at a dose known to cause diarrhea reduces cecal densities of clostridia.
Percutaneous Endoscopic Gastrostomy (PEG) Placement in the Overweight and Obese Patient
Authors: McGarr Sean E. , Kirby Donald F.
Published: May 2008

Background: Traditionally, percutaneous endoscopic gastrostomy (PEG) placement in the obese patient has been considered a relative contraindication due to the impedance of gastric transillumination and inability to approximate the abdominal and gastric wall. The aim of this study was to determine the overall success rate, morbidity, and PEG‐related mortality in overweight and obese patients. Methods: Three hundred fifty‐five consecutive patients were retrospectively evaluated over a 1‐year period at the Virginia Commonwealth University Medical Center for postprocedure‐related PEG and PEG/jejunostomy (J) complications. One hundred thirty‐four patients were considered overweight (body mass index [BMI] ≥27 kg/m2). Of those, 80 patients were found to be obese (BMI ≥30 kg/m2) with a BMI ranging 30–63 kg/m2. Results: Gastrostomy placement was successful in 130 of 134 (97%) overweight patients (p < .05). The overall procedure‐related mortality was 0%. The rate of significant complications in overweight and obese patients remained 0% when compared with those patients with a normal BMI. Out of 355 patients, 14 failed to receive a PEG; 3 of these were obese and 1 was overweight. These 4 procedures were aborted due to a paucity of anatomical landmarks and failure to transilluminate the abdominal wall. Conclusions: We believe that PEG placement in the overweight and obese patient can be a technically safe procedure according to our success rate of 100%, with a procedure‐related mortality rate of 0%. In those overweight and obese patients who require specialized long‐term enteral nutrition support, PEG placement should be considered earlier and more frequently.
A Prospective Study of Tube‐ and Feeding‐Related Complications in Patients Receiving Long‐Term Home Enteral Nutrition
Authors: Crosby Jason , Duerksen Donald R.
Published: May 2008

Objectives: Percutaneous endoscopic gastrostomy tubes are frequently inserted to facilitate long‐term enteral nutrition. There are few studies that address long‐term complications related to feeding tubes. The purpose of this study is to examine the long‐term complications related to tube malfunction and the effect these have on health care use. Methods: In this prospective study, 8 patients who were discharged home on long‐term home enteral nutrition completed a diary that listed 17 potential complications related to enteral feeding devices. Subjects completed the diary on a weekly basis, noting which of the potential complications they were experiencing and the intervention related to that complication. Results: The 8 patients were followed for a mean of 10.5 months. Common tube‐site complications included discharge from the tube site, red or tender stoma, and granulation tissue. Mechanical problems related to tubes plugging, breaking, and falling out were also common. Despite having a dedicated nurse and dietitian to follow these patients, unscheduled health care contacts were frequent and averaged 5.4 contacts over the mean follow‐up time of 10.5 months. Conclusions: In patients receiving long‐term home enteral nutrition, tube and tube‐feeding complications are frequent and result in significant health care use. Given the increasing use of long‐term enteral nutrition, strategies and programs must be developed to assist patients and their families in managing these complications.
Nutrition Assessment of Patients With Inflammatory Bowel Disease
Authors: Vagianos Kathy , Bector Savita , McConnell Joseph , Bernstein Charles N.
Published: May 2008

Background: Malnutrition among inflammatory bowel disease (IBD) subjects is well documented in the literature and may arise from factors including inadequate dietary intake, malabsorption, and disease activity. The aims of this present study were to complete a comprehensive nutrition assessment of IBD subjects. Methods: One hundred twenty‐six consecutive adults with IBD completed anthropometric measures, 4‐day food‐record assessments, and biochemical markers of nutrition. Results: A high prevalence of inadequate nutrient consumption was observed: vitamin E (63%), vitamin D (36%), vitamin A (26%), calcium (23%), folate (19%), iron (13%), and vitamin C (11%). Several biochemical deficiencies were also observed. The prevalence of subnormal serum levels was hemoglobin (40%), ferritin (39.2%), vitamin B6 (29%), carotene (23.4%), vitamin B12 (18.4%), vitamin D (17.6%), albumin (17.6%), and zinc (15.2%). Dietary intake was not correlated with serum levels in all instances; there was a highly significant correlation between diet and serum values of vitamin B12, folate, and vitamin B6 for all IBD subjects, independent of disease activity, and for vitamin D among all IBD subjects in remission. Conclusions: Subjects with IBD have a high rate of iron deficiency and anemia, which are most likely not secondary to diet. Supplementing with iron should be warranted only if a true iron deficiency exists. The routine evaluation of serum vitamin B6 and vitamin D levels is recommended. Routine multivitamin supplementation is warranted in IBD in view of numerous dietary and biochemical deficiencies observed among adult IBD subjects. Even if subjects with IBD seem to be well nourished, they may harbor vitamin/mineral deficiencies.
Oral Antibiotics Attenuate Bowel Segment Reversal–Induced Systemic Inflammatory Response and Body Weight Loss in Massively Bowel‐Resected Rats
Authors: Lee Chien‐Hsing , Lo Hui‐Chen , Chou Ming‐Chih , Tsai Huei‐Ru
Published: May 2008

Background: Using a massively bowel‐resected rat model, our previous study demonstrated that small bowel segment reversal stimulates jejunal hyperplasia but may also increase the possibility of bacterial translocation and the elevation of circulating white blood cells and serum interleukin‐6 that may reduce the whole‐body anabolism. The aim of this study is to investigate whether oral antibiotics might attenuate the inflammatory responses and might therefore facilitate the beneficial effects of bowel segment reversal. Methods: Male Wistar rats (∼270 g) underwent a 70% small bowel resection with (REV group) or without (CON group) a 3‐cm small bowel segment reversal, or underwent a sham operation (SHAM group). After surgeries, half of the animals in the REV group were given oral clindamycin plus amoxicillin (50 plus 50 mg/kg/d, ANT group) for 3 weeks. Results: Oral antibiotics administration significantly attenuated the decreases in feeding efficiency (g of body weight/100 kcal diet) and increases in the circulation of white blood cells, serum nitric oxide, and interleukin‐6 (1‐way ANOVA, p < .05), which are associated with bowel segment reversal. In addition, antibiotics significantly increased serum concentrations of insulin‐like growth factor‐I, significantly decreased the total numbers of bacteria in the intestine, and tended to reduce the extent of jejunal hyperplasia in rats with bowel segment reversal. Conclusions: Our results suggest that oral antibiotics may be used as an adjuvant to attenuate the inflammatory responses and to enhance the anabolic responses in massively bowel‐resected patients with bowel segment reversal.
Dietary Gangliosides Enhance In Vitro Glucose Uptake in Weanling Rats
Authors: Drozdowski Laurie A. , Suh Miyoung , Park Eekjoong , Clandinin M. Tom , Thomson Alan B. R.
Published: May 2008

Background: The intestine adapts to environmental stimuli, such as modifications in dietary lipids. Dietary lipids modify brush border membrane (BBM) permeability and nutrient transporter activities. Gangliosides (GANG) are glycolipids present in human milk, but they are present only in low amounts in infant formula. Exogenous GANG are incorporated into cell membranes and increase their permeability. This study was undertaken to determine if feeding a 0.2% GANG‐enriched diet for 2 weeks alters in vitro intestinal sugar absorption in weanling rats compared with an isocaloric control diet or diet enriched with polyunsaturated long‐chain fatty acids. Methods: In vitro uptake of 34–96 mm glucose and fructose and morphological measurements were assessed on intestinal tissue of weanling rats. Western blotting, immunohistochemistry, Northern blotting, and reverse transcription–polymerase chain reaction were performed to determine the mRNA and protein abundance of the sugar transporters SGLT‐1, GLUT2 and GLUT5. Results: Feeding GANG did not alter the rates of animal weight gain or intestinal morphology. GANG did not affect fructose uptake. Depending on the concentration of glucose, GANG increased jejunal uptake of higher concentrations of glucose by approximately 20%–60%. There were no changes in GLUT5 or GLUT2 protein or mRNA abundance. Similarly, there were no changes in SGLT‐1 mRNA and protein abundance, as determined by Northern and Western blotting. However, using immunohistochemistry, SGLT‐1 was lower in GANG than in controls. Conclusions: The results of this study suggest that the enhanced uptake of glucose that results from feeding 0.2% GANG for 2 weeks to weanling rats may be regulated posttranslationally. Clearly any adjustment of the content of GANG in infant formula must be studied carefully.
Misplacement of Percutaneously Inserted Gastrostomy Tube Into the Colon: Report of 6 Cases and Review of the Literature
Authors: Friedmann Reuven , Feldman Helena , Sonnenblick Moshe
Published: May 2008

Background: With the increasing use of percutaneous endoscopic gastrostomy (PEG), rare complications are seen; one of them is misplacement of the tube into the colon. We describe the various clinical pictures and treatment approaches. Methods: Case series from our hospital and case reports from the literature are presented. Symptoms, time interval from symptoms to diagnosis, time elapsed from initial PEG insertion to replacement or to regression, regression of gastrostomy tube to the colon vs colonic placement of reinserted tube, and treatment approaches are evaluated. Results: We identified and studied 6 patients in our hospital who had misplacement of a PEG into the colon. A review of the English literature revealed another 22 adult cases with this complication. Of the total 28 cases, 8 had previous abdominal pathology. Seventeen patients developed symptoms after tube replacement, whereas in 11 the tube had not been changed. Fourteen had diarrhea, 11 presented with fecal discharge in or around the tube, and 3 were asymptomatic. Thirteen showed colocutaneous fistula without residual connection to the stomach. Ten patients were treated surgically and 14 conservatively by removal of the tube. One patient had colonoscopic clipping of the fistula. Conclusions: Gastroenterologists should adhere strictly to cautionary measures to prevent misplacement of PEG into the colon. In patients with PEG feeding, the clinician should suspect misplacement of the tube into the colon when there is recurrent severe diarrhea of undigested food or fecal content in the tube, particularly after tube replacement. Treatment may be conservative in most cases.
Enteral Feeding of a Chemically Defined Diet Preserves Pulmonary Immunity but Not Intestinal Immunity: The Role of Lymphotoxin β Receptor
Authors: Kudsk Kenneth A. , Gomez F. Enrique , Kang Woodae , Ueno Chikara
Published: May 2008

Background: Compared with chow or a complex enteral diet (CED), IV administration of a parenteral nutrition solution (IV‐PN) impairs intestinal and respiratory mucosal immunity, resulting in cellular and immunoglobulin A (IgA) defects in the intestine and impaired respiratory antiviral and antibacterial defenses. PN given intragastrically (IG‐PN) impairs intestinal immunity similar to IV‐PN but preserves antiviral defences and partially preserves antibacterial defenses. Lymphotoxin β receptor (LTβR) is a molecule essential for development and organization of lymphoid tissue. It controls many molecules important in mucosal immune integrity. This study examines effects of route (IV or enteral) and type (PN, CED, or chow) on murine intestine and lung LTβR expression. Methods: Forty‐three mice randomly received IV‐PN (n = 12), IG‐PN (n = 11), IV saline + chow (chow; n = 11), or a CED (n = 9). After 5 days of feeding, intestinal and lung samples were obtained and processed for levels of LTβR by Western blot. Results: IV‐PN significantly reduced intestinal and lung LTβR compared with CED and chow. IG‐PN reduced LTβR levels only in the intestine but preserved lung levels. Conclusions: Route and type of nutrition differentially influence molecular events in the intestinal and respiratory mucosal immune systems. Enteral feeding with any diet (complex or chemically defined) maintains lung LTβR expression, whereas intestinal LTβR levels are maintained only with CEDs (chow and CED). We hypothesize that LTβR is responsible for the observed preservation of respiratory tract immunity with administration of a noncomplex, chemically defined enteral diet, whereas intestinal immunity is compromised with this diet.
Supplementation of Arachidonic Acid Plus Docosahexaenoic Acid in Cirrhotic Patients Awaiting Liver Transplantation: A Preliminary Study
Authors: Pazirandeh Sassan , Ling Pei‐Ra , Ollero Mario , Gordon Fredric , Burns David L. , Bistrian Bruce R.
Published: May 2008

Background: In patients with cirrhotic liver diseases, supplementation of linoleic acid and α‐linolenic acid often does not alter the levels of arachidonic acid (AA), eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA), suggesting the necessity to directly provide these nutrients. Methods: In a double‐blind, placebo‐controlled fashion, 9 cirrhotic patients listed for liver transplantation at Lahey Clinic Center were given daily supplementation with either 10 gel caps containing 500 mg of AA and 1000 mg of DHA (AA/DHA) or 250 mg of linolenic acid (LA) and 125 mg of oleic acid (OA; OA/LA) for 6 weeks. α‐Tocopherol at 200 IU was provided daily. No other dietary prescription was made. Plasma fatty acid profiles were determined in triglyceride and phospholipids fractions. Plasma levels of C‐reactive protein (CRP), tumor necrosis factor (TNF), interleukin 6 (IL‐6), and soluble TNF receptor II (sTNFRII) were also measured. Results: Four patients receiving OA/LA and 5 patients receiving AA/DHA completed the study without evidence of any adverse effects or intolerance. The supplementation of LA, AA, and DHA effectively raised their levels in either one or both plasma lipid fractions in this limited number of subjects. DHA plus AA also lowered 22:4ω‐6, 22:5ω‐6, and 22:5ω‐3, suggesting that DHA reduced the elongation and desaturation of AA and EPA. Conclusions: It is feasible to improve the liver disease–associated deficiency of AA or DHA with modest intakes of AA and DHA. Whether this maneuver will affect the systemic inflammatory responsiveness and ultimately clinical outcome will require a large‐scale and well‐controlled intervention.
Brussels 2007 Roundtable on Metabolism in Sepsis and Multiple Organ Failure
Authors: Herndon David H. , Wernerman Jan
Published: May 2008

At the 2007 International Symposium on Intensive Care and Emergency Medicine (ISICEM) in Brussels, a roundtable conference on “Metabolic Support in Sepsis and Multiple Organ Failure” was held. The roundtable was endorsed by the European Society of Intensive Care Medicine, the Society of Critical Care Medicine, the European Society for Clinical Nutrition and Metabolism, and the American Society for Parenteral and Enteral Nutrition. Metabolic support in intensive care has become an exciting topic in recent years, with improved understanding of the effects of compromised mitochondrial function, studies demonstrating outcome benefits of tight glucose control, new insights into the mechanisms behind insulin resistance, recognition of glutamine and antioxidants as key nutrients, and emerging knowledge concerning the interactions between metabolism and endocrinology. Together, these aspects have generated an increased interest in the importance of metabolism in intensive care medicine, reflected in the programs and abstracts at international congresses of the past few years. This roundtable's participants each gave a presentation within their specific area of expertise, and each was followed by general discussion. Discussions became heated as new concepts and ideas were debated. New data will be discussed in this summary which reveals metabolic and nutrition interventions that could lead to major improvements in clinically relevant outcomes.
Enteral Glutamine During Active Shock Resuscitation Is Safe and Enhances Tolerance of Enteral Feeding
Authors: McQuiggan Margaret , Kozar Rosemary , Sailors R. Matthew , Ahn Chul , McKinley Bruce , Moore Frederick
Published: May 2008

Background: Feeding the hemodynamically unstable patient is increasingly practiced, yet few data exist on its safety. Because enteral glutamine is protective to the gut in experimental models of shock and improves clinical outcomes, it may benefit trauma patients undergoing shock resuscitation and improve tolerance if administered early. This pilot study aimed to evaluate gastrointestinal tolerance and safety of enteral feeding with glutamine, beginning during shock resuscitation in severely injured patients. Methods: In a prospective randomized trial, 20 patients were randomly assigned to either an enteral glutamine group (n = 10) or a control group (n = 10). Patients with severe trauma meeting standardized shock resuscitation criteria received enteral glutamine 0.5 g/kg/d during the first 24 hours of resuscitation and 10 days thereafter. Immune‐enhancing diet began on postinjury day 1, with a target of 25 kcal/kg/d. Control patients received isonitrogenous whey powder plus immune‐enhancing diet. Tolerance (vomiting, nasogastric output, diarrhea, and distention) was assessed throughout the study. Results: Glutamine was well tolerated and no adverse events occurred. Treated patients had significantly fewer instances of high nasogastric output (5 vs 23; p = .010), abdominal distention (3 vs 12; p = .021), and total instances of intolerance (8 vs 42; p = .011). Intensive care unit (ICU) and hospital length of stay were comparable. Control patients required supplemental parenteral nutrition (PN) to meet goals at day 7. Conclusions: Enteral glutamine administered during active shock resuscitation and through the early postinjury period is safe and enhances gastrointestinal tolerance. A large clinical trial is warranted to determine if enteral glutamine administered to the hemodynamically unstable patient can reduce infectious morbidity and mortality.