bluuebunny/crossref_metadata_2025 huggingface dataset:
Managing Nutrition Problems in Transplant Patients
Authors: Perez Richard
Published: May 2008

Patients who undergo organ transplantation receive immunosuppressive drugs in the posttrans‐plant period. All of these drugs influence host metabolic response or alter nutrient intake. One of the most prominent aspects of the posttransplant period is the occurrence of hyperlipidemia, which may require dietary or pharmacologic control. Dietary recommendations for this patient population include limiting carbohydrate intake, restricting caloric intake to maintain ideal body weight, and maintaining a low cholesterol/saturated fat diet.
Treatment of Anorexia With Megestrol Acetate
Authors: Tchekmedyian N. Simon
Published: May 2008

Anorexia and involuntary weight loss are prevalent problems in oncology and AIDS patients. Cytokines are suspected but not proven causes of cachexia. Megestrol acetate has been found to increase appetite, food intake, and weight in randomized, placebo‐controlled trials in patients with advanced malignancies and in patients with AIDS. This hormone derivative probably has both central nervous system and peripheral metabolic effects. No significant effect on survival has been demonstrated in these trials. The optimal dose for appetite enhancement is unknown; we have chosen 320 mg/d as our initial dose. Megestrol acetate is usually well tolerated, and it may be helpful in the symptomatic and palliative therapy of patients with anorexia and weight loss.
Causes of Diarrhea in Tube‐Fed Patients: A Comprehensive Approach to Diagnosis and Management
Authors: Eisenberg Patti G.
Published: May 2008

In the absence of a standard definition for diarrhea, clinicians have developed their own descriptions, such as an increased frequency of stools, an increased quantity of water in the stool, an increased weight of the stool, or a change in the consistency of the stool. The clinician should first determine whether the diarrhea is osmotic or secretory. Diarrhea in patients who receive enteral nutrition is often caused by such conditions as diabetes, malabsorption syndromes, infection, gastrointestinal complications, or concomitant drug therapy instead of the enteral formula. Factors related to the enteral nutrition that may contribute to diarrhea include the composition of the formula, the manner of administration, or bacterial contamination. To ensure that the nutritional requirements of patients are met and the appropriate treatment is administered, all of the possible causes of diarrhea should be considered before discontinuing or reducing the amount of formula delivered.
Detection and Prevention of Central Venous Catheter‐Related Infections
Authors: Kruse James A. , Shah Nipurn J.
Published: May 2008

Infectious complications of central venous catheterization are an important clinical problem. Although systemic infection complicates only a small fraction of cases, the prevalence of catheter‐related sepsis remains high because of the widespread use of these catheters in acutely ill hospitalized patients. The major route of infection is probably by migration of microorganisms from the skin along the outer surface of the catheter and through the subcutaneous catheter tract to the bloodstream. Semi‐quantitative catheter tip cultures have become a standard clinical tool for the evaluation for catheter‐related infection. Despite the use of this technique and a variety of other proposed methods for evaluating catheter colonization and infection, discriminating catheter‐related sepsis from sepsis originating at another site is often difficult. Prevention of these infections is important. There have been many investigations of the factors that contribute to catheter infections. These studies have shown that meticulous attention to sterile technique during catheter insertion and during routine maintenance is critical.
Nutrient Needs of the Preterm Infant
Authors: Rose Joni , Gibbons Kristy , Carlson Susan E. , Koo Winston W.K.
Published: May 2008

Preterm infants exhibit special nutrient needs that differ substantially from other patient populations. Special characteristics include increased energy and protein requirements that must be addressed to prevent tissue catabolism and support growth. The immaturity of some organ systems may also complicate the administration of nutrition support. This article describes important characteristics of enteral and parenteral nutrition as it applies to the preterm infant.
Fiber‐Containing Formula and Needle Catheter Jejunostomies: A Clinical Evaluation
Authors: Collier Paige , Kudsk Kenneth A. , Glezer Jeffrey , Brown Rex O.
Published: May 2008

Despite the high frequency of diarrhea, chemically defined diets have traditionally been used with needle catheter jejunostomies, a common form of postpyloric enteral access, to avoid tube occlusion. We reviewed our experience with 57 patients fed a fiber‐containing diet to determine the incidence of catheter occlusion and diarrhea. Eight catheters temporarily occluded but were reopened and remained patent for an additional 6.3 ± 3.1 days for an overall success rate of 91% (52 of 57). The five remaining occluded catheters were removed after 6.2 ± 1.8 days. Four of the five patients with occluded catheters tolerated gastric feedings, but one required a permanent jejunostomy. Diarrhea occurred in six (10.5%) of the 57 patients given the fiber‐containing formula. We concluded that a fiber‐containing formula can be administered through needle catheter jejunostomies if the catheter is irrigated daily and if no medications are given via the catheter. A fiber‐containing formula may reduce the incidence of diarrhea in jejunostomy‐fed patients compared with patients fed chemically defined diets.
Observations of Hypophosphatemia and Its Management in Nutrition Support
Authors: Sacks Gordon S. , Walker Joe , Dickerson Roland N. , Kudsk Kenneth A. , Brown Rex O.
Published: May 2008

Severe hypophosphatemia is associated with significant morbidity in hospitalized patients. Specialized nutrition support is an important factor that contributes to the development of this metabolic disorder. Current treatment regimens for hypophosphatemia are empiric and often fail to normalize serum phosphorus concentrations in these patients. Patients who develop hypophosphatemia during the administration of specialized nutrition support exhibit increased phosphorus demands and require aggressive replacement therapy.
Invited Review: Enteral Access
Authors: Minard Gayle
Published: May 2008

The enteral route is the preferred method of nutrition support in patients with functional gastrointestinal tracts. Many techniques for obtaining enteral access are available, and the decision regarding which one to use depends on several issues, including anticipated duration of support, aspiration risk, and local expertise. Using laparotomy, laparoscopy, fluoroscopy, or endoscopy, tubes can be placed into the stomach, the duodenum, and the jejunum. Nasogastric and nasoenteric tubes are useful for short‐term supplementation; however, patients needing support for more than 6 weeks may be better served with a more permanent tube. In this review, specific methods for obtaining enteral access are discussed along with their advantages and disadvantages.
Starting a Nutrition Support Team Short‐Term Pain for Long‐Term Gain
Authors: Tougas Jane Grant
Published: May 2008

This article relates the collective wisdom of five nutrition support professionals who share their experience in starting a nutrition support team. These professionals describe how to navigate the administrative— and political—waters, which are often murky and filled with obstacles. In addition, a hospital administrator discloses what CEO types look for when clinicians propose starting up a nutrition support team in their institutions. The upshot: In this rapidly changing environment, nutrition support professionals would do well to hone their political skills and use them to persuade their administrators that nutrition support is indeed a cost‐effective therapy that benefits patients—and that it is best delivered in an interdisciplinary approach.
High Tech Home Care: Surviving and Prospering in a Changing Environment
Authors: Viall Carolyn D. , Crocker Kathleen S. , Hennessy Kathryn A. , Orr Marsha E.
Published: May 2008

Managed care plans are expanding rapidly into new marketplaces. Reimbursement for home infusion therapy, including parenteral and enteral nutrition, is significantly affected under managed care, especially when capitated payment mechanisms are used. Home care companies have experienced downsizing, mergers, acquisitions, and fierce competition in the managed care environment. Clinicians who are entering the home care setting may find that, in addition to clinical expertise, their marketability depends on a set of new skills and abilities in order to prosper in this new environment.
Home Nutrition Support Materials
Authors: Evans Mary Ann , Czopek Shelly
Published: May 2008

The provision of enteral and parenteral nutrition to patients in the home setting continues to be an expanding area of practice throughout the US and Canada. The need for specialized training of patients and family members to safely administer these nutrition therapies at home following hospital discharge also continues to grow. In 1993, written materials designed for this purpose were gathered from institutions throughout the US and listed in a directory of Home Nutrition Support Patient Education Materials1. Many nutrition support teams and health care organizations have been undergoing reorganization and streamlining during the past several years. As a result, resources for the creation and distribution of home nutrition support (HNS) education materials are diminished in many areas. An updated version of this directory has therefore been compiled to facilitate the exchange of these training items between institutions and teams across the country.
Invited Review: Nutrition Support in Pancreatitis
Authors: Marulendra Shivaprasad , Kirby Donald F.
Published: May 2008

Nutrition support in patients with pancreatitis has created a challenge for clinicians. Because the pancreas is normally stimulated by the ingestion of food, particularly fat, patients are often denied oral nutrition. This reduction in the ingestion of food, together with the increased metabolic demands of this disease, often results in a negative energy balance and occasionally undernutrition or malnutrition. This review summarizes the etiologies and methods for staging pancreatitis, the physiology of pancreatic exocrine secretion and the response of the pancreas to different methods of nutrition support. The results of clinical trials, which examine both parenteral and enteral nutrition in animals and humans with this disease, are reviewed. Recommendations for nutrition management of patients with acute and chronic pancreatitis and areas for future research are discussed.
Femoral Catheters Increase Risk of Infection in Total Parenteral Nutrition Patients
Authors: Harden Jaculin L. , Kemp Lisa , Mirtallo Jay
Published: May 2008

Central venous access for the administration of total parenteral nutrition is usually achieved via the subclavian or internal jugular veins. Although a high incidence of complications has been reported with the use of femoral catheters for central venous access, this route has been used when traditional central venous access is contraindicated. We retrospectively reviewed 171 patients who received total parenteral nutrition via a central venous triple‐lumen catheter and compared the rates of infections in femoral vs nonfemoral access. A literature review was performed to identify associated complications of and appropriate indications for femoral catheter use. In the 171 patients studied, 355 triple‐lumen catheters were placed; these included 331 nonfemoral catheters and 24 femoral catheters. Femoral catheters were placed in nine patients. Femoral catheters had a greater incidence of positive tips (42% vs 6.9%, p < .001) and related bacteremia (16.7% vs 1.8%, p = .002) than did nonfemoral catheters. The organisms most commonly isolated from the blood and catheter tips of both catheter access sites were methicillin‐resistant Staphylococcus epidermidis and Candida. The use of femoral catheters for central venous access for total parenteral nutrition administration results in an increased risk of infectious complications.
Decision‐Making for Enteral Feeding Administration: The Why Behind Where and How
Authors: Clevenger Frederick W. , Rodriguez Donna J.
Published: May 2008

Enteral nutrition has become the preferred route of nutrient administration. Because of vigorous attempts to deliver nutrient enterally in expanded patient groups, many different locations for enteral access have been advocated along with a variety of methods related to rate and pattern of delivery. Because all modes of delivery are not compatible with all sites of access and both need to be tailored to specific subsets of patients, confusion can develop regarding where and how enteral nutrients are best delivered and why. In an era when such a high priority has been placed on feeding through the enteral route, a review of the methods and rationale behind the ever‐expanding choices of enteral access is timely.
Advancing Clinical Privileges for Nutrition Support Practitioners: The Dietitian as a Model
Authors: Davis Anne M. , Baker Susan S. , Leary Ruth A.
Published: May 2008

The specialty of nutrition relies heavily on trained practitioners to assess patient nutritional status, define nutritional goals, and recommend therapeutic strategies to achieve those goals. To facilitate the timely delivery of nutrition care, the dietitians at the University of Massachusetts Medical Center expanded clinical privileges. With the support of the Nutrition Department, the multidisciplinary Nutrition Support Service, and the Nutrition Advisory Committee, dietitians write orders for diets, oral and parenteral nutrient supplementation; and custom mix parenteral nutrition solutions, tube feedings, transitional feedings, balance studies, blood glucose monitoring, and home care orders (parenteral and enteral). Dietitians also order laboratory tests such as chemistries, indirect calorimetry, and bone densitometry. Clinical privileges are a permanent part of each dietitian's appointment to the Health Professional Staff and are granted by the Chancellor/Dean of the Medical University.
Obesity: Nutrition Support Practice and Application to Critical Care
Authors: Ireton‐Jones Carol S. , Francis Coni
Published: May 2008

Much controversy exists regarding the nutritional care of obese, hospitalized patients. There is no real agreement among health care professionals in the nutritional support of obese patients. A survey was designed to determine the methods used to provide for the nutritional needs of obese, hospitalized patients. The survey included questions on definition of obesity, equations used to calculate energy and protein needs, and body weight used for calculations. The information received from this survey describes the variability of nutritional care for obese, hospitalized patients. In addition, a review of the current literature is provided regarding the metabolic response of the obese.
Invited Review: A Review of Mechanisms of Wasting in HIV Disease
Authors: Fields‐Gardner Cade
Published: May 2008

According to estimates, between 50% to 90% of patients infected with the Human Immunodeficiency Virus (HIV) will experience some form of malnutrition. The degree and types of malnutrition are attributed to alterations in nutrient intake, absorption, and metabolism. Causes for each of these changes are complex and multifactorial. Research on treatment modalities generally concentrates on a single mechanism and reports varying degrees of short‐term benefit. Appetite stimulation along with special diets, oral supplements, and nonvolitional enteral or parenteral nutrient provision may improve nutrient intake and body weight. Therapies aimed at the rehabilitation and improvement of the pool of functioning protein stores, such as alteration of inflammatory response, restoration of hormonal balance, and exercise are under investigation. Longer term studies will allow researchers to observe effects of therapies on overall body functions. With the development of clinical standards of care, the maintenance and restoration of nutritional status is emerging as the foundation for HIV disease management.
Body Composition and Nutrition Support in Pediatrics: What to Defend and How Soon to Begin
Authors: Cunningham John J.
Published: May 2008

Specialized nutrition support is initiated during hospital care on the assumption that sparing the mobilization of body energy reserves is advantageous to recovery. The combined effects of disease and undernutrition on body cell mass, organ function, immune responsiveness, and wound healing are well documented in adults. Children cannot survive a fast as long as adults because of their lesser stores of energy substrates relative to the rate of energy expenditure. The present contribution attempts to estimate the rates of compositional losses for infants and prepubertal children on the basis of available data and reasonable metabolic assumptions. The lesson that emerges from this exercise is one of a very critical need for the early initiation of nutrition support for infants and children. The analysis suggests that an acute risk of protein depletion exists for children of all ages. Especially for infants, the empirical wisdom that “the absence of evidence is not evidence of absence” should be invoked to support early nutrition intervention. This work is submitted for critical review and revision to establish a consensus on the timeline of pediatric morbidity or mortality from semistarvation or starvation.
Treatment of Anorexia Nervosa With Total Parenteral Nutrition
Authors: Mehler Philip S. , Weiner Kenneth A.
Published: May 2008

Recently, there has been a resurgence of interest and ideas regarding refeeding in anorexia nervosa. Given the severe morbidity, a subpopulation that appears refractory to treatment, and the very high mortality in an otherwise healthy young population, research studies are needed to define optimal treatment regimens. The authors describe their experience with total parenteral nutrition in the treatment of anorexia nervosa.
Formulaic Methods of Estimating Calorie Requirements in Mechanically Ventilated Obese Patients: A Reappraisal
Authors: Amato Paul , Keating Kevin P. , Quercia Robert A. , Karbonic Joann
Published: May 2008

A variety of formulae are used by clinicians to estimate calorie requirements in hospitalized obese patients. Many of these formulae have been validated by determining their correlation to calorie requirements as determined by indirect calorimetry (IC). The use of correlation coefficients (CC) in this manner may be misleading. A more appropriate statistical method, limits of agreement (LA), for comparing clinical measurements has recently been described by Bland and Altman. We obtained a total of 188 IC measurements on 113 obese (>120% IBW), mechanically ventilated patients. These were compared by CC and LA to seven formulaic methods of determining calorie requirements. All formulae correlate significantly with IC. Analysis by LA indicated acceptable bias in several formulae (eg, 21 kcal/kg, Ireton‐Jones obese patients (IJ), Ireton‐Jones ventilatory patients, (VEE); however, the uniform lack of precision demonstrated by all formulae renders their clinical utility questionable.
Taking Your Show on the Road: The Concept of a Mobile Nutrition Support Team
Authors: Orr Marsha
Published: May 2008

Nutrition support teams (NSTS) have been in existence since the 1970s and remain an enduring concept of how nutrition support should be provided. The basic model of a NST who serves one institution has changed little over the past two decades. With the expansion of managed care, development of integrated hospital networks, decreasing inpatient census, and downsizing in hospital staff, a new model for the NST that anticipates and addresses these changes in the healthcare environment is needed. This article presents a model for a NST who is mobile and can function within an integrated system to improve the utilization, management, and quality of specialized nutrition therapy.
Generic Enteral Formulas: A New Idea for the 1990s
Authors: Bell Stacey J. , Stack Jennifer A. , Forse R. Armour , Delfierro Cora , Wade Ellen , Burke Peter
Published: May 2008

Generic equivalent enteral formulas are now commercially available. The purpose of this article is threefold: (1) to define generic equivalents and compare both their nutritional and monetary differences with brand name products, (2) to provide the clinician with factors to consider when evaluating generic formulas— the source and distribution of macronutrients and micro‐nutrients, and patient tolerance, nutritional status and outcome—and (3) to provide information on how to incorporate generic enteral formulas onto an institution's enteral formulary. In today's environment of diminishing health care budgets, generic enteral formulas can play a role in cost containment without sacrificing quality nutritional care.
Bile Salt Inhibits Acid‐Promoting Feeding Tube Occlusion
Authors: Yeoh Don , Zhao Xiao‐Tuan , Sanders Stephanie L. , Elashoff Janet D. , Bonorris George , Lin Henry C.
Published: May 2008

Occlusion of feeding tubes is a common and costly complication of enteral feeding. Although the composition of feeding formulas, the size, design, and material of the feeding tube, and the rate of delivery have been considered as factors that determine the rate of tube occlusion, little information is available on the effect of the luminal content of the gut on tube occlusion. Enteral feeding tubes are placed either in the stomach or postpylorically, in the small intestine. The chemical composition of these regions including acidity and bile salt concentration may vary. Since acidity has been shown to promote tube occlusion and bile salts have detergent‐like properties, these chemical differences in the luminal environment may be important to tube occlusion. To test the idea that bile salt inhibits acid‐promoted occlusion of feeding tubes, in an in vitro study, we compared the time‐to‐complete occlusion of four groups of formula‐filled feeding tubes (six tubes in each group) immersed in an acidic solution (pH 3.0) containing 0 (control), 10, 20, or 40 mM of taurocholate. We found that although 33% of the feeding tubes were occluded within 12 hours in the absence of exposure to bile salt, none were occluded when 20 or 40 mM of taurocholate was added to the acidic solution. After 24 hours, 40 mM of taurocholate inhibited acid‐promoted occlusion of 67% of the feeding tubes. Thus 0 to 40 mM of taurocholate still inhibited acid‐promoted tube occlusion in a dose‐dependent fashion (p<.05). Acidity and the concentration of bile salt may work together, but in opposite directions, as luminal factors that determine the rate of occlusion of feeding tubes.
Invited Review: The Nutrition Screening Initiative: A 5‐Year Perspective
Authors: White Jane V.
Published: May 2008

A history of the goals, activities, and accomplishments of the Nutrition Screening Initiative (NSI) is provided. A commentary on the development and intended use of the NSI's self‐assessment and screening tools is given to facilitate selection of feeding devices for older Americans who need nutrition care. Additional questionnaires and interventions designed to address the needs identified through the NSI's standardized, interdisciplinary approach to the assessment of nutritional risk are described and their use encouraged. Legislative and public policy advocacy is summarized. A systemic approach to the assessment and maintenance of optimal nutritional health in the older population will have a profound effect on health care delivery systems.
Should We Still Use the Harris and Benedict Equations?
Authors: Garrel Dominique R. , Jobin Nathalie , De Jonge Lilian H.M.
Published: May 2008

Resting metabolic rate (RMR) is commonly predicted using the Harris‐Benedict (HB) equations, but an overestimation of 10% to 15% is normally found. More recent studies have proposed equations with a better predictive value. In this study, we explore the relationship between measured RMR and HB in 67 healthy volunteers and in a data set from the literature and compared measured RMR with six more recent equations. Mean differences between RMR and HB were 21%, 12%, 10%, and 4% for the lowest to the highest RMR quartile, respectively, and 20%, 8%, 6%, and ‐4% for Owen's subjects. Among the six recent equations, only the World Health Organization (WHO) equations predicted RMR within 10% in 100% of the cases. Our results suggest that overestimation of RMR by HB is not a homogenous finding but is inversely related to RMR. This may have important implications for predicting RMR in women and in patients with diminished lean body mass. In addition, the WHO equations appear more precise than the HB equations.
Pharmacologic Influence on Nutrition Support Therapy: Use of Propofol in a Patient Receiving Combined Enteral and Parenteral Nutrition Support
Authors: Lowrey Trudy S. , Dunlap Alexander W. , Brown Rex O. , Dickerson Roland N. , Kudsk Kenneth A.
Published: May 2008

Propofol is a lipid‐based sedative that provides 1.1 kcal/mL. Because propofol has rapid onset and quick recovery, it is becoming used widely in critical care units. A 15‐year‐old critically ill pregnant patient received specialized nutrition support concomitantly with propofol infusion for sedation. A serum triglyceride concentration obtained on day 6 of the propofol infusion was 1100 mg/dL with no previous history of hyperlipidemia. Caloric intakes from propofol averaged 1275 kcal/d (range 445 to 2354 kcal/d) over a 5‐day period. Infusion of propofol or any other lipid‐based drug must be monitored closely when given in conjunction with enteral or parenteral nutrition to avoid the pitfalls of overfeeding and hypertriglyceridemia. Enteral and parenteral formulas must be manipulated to provide optimal nutrient intakes while not overfeeding with fat when using increased amounts of lipid‐based drugs.
Pediatric Enteral Access Center: A Multidisciplinary Approach
Authors: Mascarenhas M.R. , Redd D. , Bilodeau J. , Peck S. , Llacouras C.A.
Published: May 2008

The need for enteral access and gastrostomy placement in children has increased dramatically over the past several years. In the following article, we present a case report of a typical patient undergoing evaluation for enteral nutrition and enteral access. Following the case report, we describe our newly formed Pediatric Enteral Access Program including patient selection, the method of gastrostomy placement, risks and benefits, cost analysis, and follow‐up of this ever‐increasing population of children.
Nutrition Management in a Pregnant Comatose Patient
Authors: Wong Miki , Apodaca Christina , Markenson Glenn , Yancey Michael
Published: May 2008

Major intracranial injury or disease during pregnancy resulting in a comatose state presents unique and complex management challenges. Our patient is a 34‐year‐old woman who suffered a closed‐head injury associated with spousal abuse at 22 weeks' gestation. This injury resulted in a large right frontoparietal hematoma that was subsequently evacuated via a right frontotemporal craniotomy 5 days after the injury. She remained in a vegetative state postoperatively. Aggressive nutrition support was provided with enteral feedings through a nasoduodenal feeding tube. Mild oligohydramnios was detected at 30 weeks' gestation and was subsequently determined to be due to preterm premature rupture of membranes. She was managed until 33 weeks' gestation, when signs of chorioamnionitis were noted. She then underwent a primary cesarean delivery and was delivered of an appropriate‐for‐gestational‐age 2150‐g viable male infant. The patient had progressive improvement in her mental status with occupational and physical therapy and was discharged on the 29th postpartum day. This case presents the nutrition and medical challenges of maintaining adequate maternal and fetal health in a pregnant comatose patient.
Clinical Management of Latex Allergy
Authors: Bey Donna , Browne Barry
Published: May 2008

The use of latex gloves in the health care setting dates back to the 1800s, when these products were introduced as a means of preventing the passage of microorganisms to operating room patients.1 Today, fear of human immunodeficiency virus transmission and other blood‐borne diseases has led to implementation of standardized guidelines for glove use for health care professionals. Because of the unique combination of strength, flexibility, and elasticity of natural rubber, latex is typically the material of choice for a variety of medical products, including examination gloves. Unfortunately, routine use of latex in the health care setting may be detrimental to patients and caregivers with a history of natural rubber latex hypersensitivity reactions.
Physicochemical Stability of Two Types of Intravenous Lipid Emulsion as Total Nutrient Admixtures
Authors: Driscoll David F. , Bacon Marc N. , Bistrian Bruce R.
Published: May 2008

Background: Recent data have demonstrated that total nutrient admixtures (TNAs) are unstable when the percentage of fat (PFAT) globules >5 μm in diameter constitute >0.4% of the total fat present and therefore can be considered pharmaceutically unfit for human administration. Methods: We studied five nutritionally balanced TNAs using two different products of different oil composition designed to feed adult patients weighing 40 to 80 kg in 10 kg increments, which were given in final volumes equal to 25 mL/kg. Final concentrations of amino acids, dextrose, and lipids were held constant for each weight level. To provide cationic stress within clinical limits, calcium and magnesium were given in amounts equal to three times the usual daily dose, at 15 mmol each. Five TNAs were made in duplicate and for each product (n = 20) and studied over 5 days. Lipid droplet counts were determined by laser light extinction and conducted at five intervals; immediately after preparation at time 1 (T1), after 4 days at 4°C ± 2°C (T2), and then at 6 (T3), 24 (T4), and 30 (T5) hours during storage at 25°C ± 1°C. At T3, a simulated patient infusion, set at a rate to deliver the entire volume over the next 24 hours, was begun. Samples taken at T3, T4, and T5, equal to 0, 18, and 24 hours, respectively, of the simulated patient infusion, were collected from the terminal infusion port of the IV administration set. Mean particle size (MPS) was determined by dynamic light scatter at T1, T3, and T5. Dependent variable analyses included the PFAT globules > 1.75 and 5 μm and MPS. A repeated‐measure two‐way ANOVA assessing treatment and time was performed. Results: The MCT/LCT‐based TNAs had significantly fewer enlarged fat globules >1.75 μm (p <.0001) and >5 μm (p =.046), and smaller MPS (p <.0001) than TNAs made with the pure LCT emulsion. Of the 20 TNAs studied, 4 demonstrated visible evidence of instability (ie, heavy creaming or free oil), each occurring on day 5 only with the 70‐ and 80‐kg LCT‐based TNAs, and no evidence of instability with admixtures prepared from MCT/LCT lipid emulsions (χ2 analysis: p <.05). Conclusions: Because the final macronutrient concentrations were held constant, the instability seen with the LCT‐based TNAs of higher volumes may result from dilution of the electrolyte concentrations that unfavorably alters the electrical double layer and irreversibly commits the emulsion to an unstable state. The greater physicochemical stability achieved with the MCT/LCT‐based TNAs, in turn, likely results from the smaller lipid droplet sizes, which may be an inherent property of MCTs. (Journal of Parenteral and Enteral Nutrition 24:15–22, 2000)
Decreased In Vitro Fluoroquinolone Concentrations After Admixture With an Enteral Feeding Formulation
Authors: Wright David H. , Pietz Sarah L. , Konstantinides Frank N. , Rotschafer John C.
Published: May 2008

Background: The purpose of this study was to determine if mixing of fluoroquinolones with a common enteral feeding formulation, Ensure (Ross Products Division, Abbott Laboratories, Columbus, OH), would alter the measured in vitro quinolone concentrations over a 24‐hour period. Methods: Tablets of ciprofloxacin (500 mg), levofloxacin (500 mg), and ofloxacin (300 mg) were crushed and mixed with 240 mL of Ensure, water and calcium chloride (500 mg/L), water and magnesium chloride (200 mg/L), water and calcium chloride and magnesium chloride, and water alone. Fluoroquinolone concentrations of the mixtures were measured, via high‐performance liquid chromatography, at baseline and serially over 24 hours. Experiments were performed in duplicate, at three temperatures (5°C, 25°C, and 37°C). Results: Average decreases of 82.5% ± 1.5% for ciprofloxacin, 61.3% ± 5.2% for levofloxacin, and 45.7% ± 10.1% for ofloxacin (mean ± 95% CI) were observed in vitro for Ensure over the two experimental sets at baseline. Serial analysis revealed no further significant change in any of the quinolone concentrations over the remaining 24‐hour period. No significant decrease was noted with the quinolones when mixed in water and calcium, water and magnesium, water and calcium and magnesium, or water alone. This phenomenon appears to be unaffected by time and temperature. Conclusions: These data suggest there is an immediate and significant loss of fluoroquinolone when mixed with Ensure. An explanation for the loss of fluoroquinolone remains unclear. (Journal of Parenteral and Enteral Nutrition 24:42–48, 2000)
Effects of Parenteral Lipid Emulsions With Different Fatty Acid Composition on Immune Cell Functions In Vitro
Authors: Granato Dominique , Blum Stéphanie , Rössle Claudia , Le Boucher Jacques , Malnoë Armand , Dutot Guy
Published: May 2008

Background: Numerous studies suggest that immune function may be compromised by lipid emulsions rich in polyunsaturated fatty acids (PUFAs). In our study, we compared the effect of a new olive oil‐based lipid emulsion (ClinOleic) containing a moderate level of PUFAs, with emulsions based on soybean oil (Intralipid or Ivelip), on immune functions of human cell in vitro. Methods: Peripheral white blood cells were collected from healthy volunteers. Lymphocyte proliferation was evaluated by [3H]‐thymidine incorporation after stimulation with either phytohemagglutinin (PHA) or antibodies against T‐cell specific antigens. Lymphocytes subsets and T‐cell activation markers (CD25 and HLA‐DR) were measured by flow cytometry. The release of cytokines (interleukin [IL]‐2, IL‐1β, and tumor necrosis factor‐ α [TNF‐α]) was measured by enzyme‐linked immunosorbent assay (ELISA), after lymphocytes or monocytes/macrophages stimulation with PHA or lipopolysaccharide (LPS). Results: A significant dose‐dependent inhibition of thymidine incorporation was observed with Intralipid and Ivelip (incorporation down to 39.9% of control, p <.001) whereas ClinOleic showed no inhibitory effect. Activation antigen expression on both CD4+ and CD8+ T‐cells tended to decrease with Intralipid (CD25: ‐53.4% on CD4+ and ‐57.4% on CD8+; HLA‐DR: ‐61.5% on CD4+ and ‐58.5% on CD8+) but not with ClinOleic (from ‐2.9% for CD25 on CD4+ to 16.7% for HLA‐DR on CD4+). Intralipid decreased significantly IL‐2 production (‐39.0%, p <.05) whereas ClinOleic had little effect (‐13.0%, NS). Intralipid and ClinOleic tended to inhibit to a similar extent the release of pro‐inflammatory cytokines (TNF‐α: ‐21.5% and ‐34.8%, IL‐1β: ‐45.1% and ‐40.3%; respectively). Conclusions: Our results suggest that an olive oil‐based lipid emulsion could modulate immune response selectively, maintaining protective immunity and reducing inflammatory response. Olive oil may offer an immunologically neutral alternative to soybean oil for use in parenteral lipid emulsions. (Journal of Parenteral and Enteral Nutrition 24:113–118, 2000)
Enteral Nutrition and Keratinocyte Growth Factor Regulate Expression of Glutathione‐Related Enzyme Messenger RNAs in Rat Intestine
Authors: Jonas Carolyn R. , Farrell Catherine L. , Scully Sheila , Eli Alana , Estívariz Concepción F. , Gu Li H. , Jones Dean P. , Ziegler Thomas R.
Published: May 2008

Background: Malnutrition is associated with increased reactive oxygen species (ROS) formation and depletion of the critical antioxidant glutathione (GSH) in the intestine. The malnutrition‐induced decrease in gut GSH levels is prevented by recombinant keratinocyte growth factor (KGF) administration. We investigated whether enzymes that are induced by oxidants and modulate tissue GSH supply are regulated by enteral nutrients or KGF at the messenger RNA (mRNA) level. Methods: Adult rats were fasted for 3 days alone or fasted for 3 days then refed ad libitum. In a second model, rats were fasted for 3 days and then refed ad libitum or 25% of ad libitum intake with daily intraperitoneal saline or recombinant KGF (5 mg/kg/d) for 3 subsequent days. mRNA levels for γ‐glutamylcysteine synthetase (γ‐GCS), γ‐glutamyl transpeptidase (γ‐GT), glutathione‐S‐transferase Ya‐subunit, gastrointestinal glutathione peroxidase (GI‐GPx), and non‐selenium‐dependent glutathione peroxidase (ns‐GPx) were determined in ileum and colon by ribonuclease protection assay. Results: Fasting increased ileal γ‐GCS, ns‐GPx, and glutathione‐S‐transferase mRNAs (by 36%, 165%, and 130% of controls) and decreased GI‐GPx mRNA (to 55% of controls). In the colon, mRNAs for GSH‐related enzymes were unchanged by fasting or refeeding. Prolonged enteral nutrient restriction (25% refeeding after a 3‐day fast) increased γ‐GCS and glutathione‐S‐transferase mRNAs (by >270% of controls), decreased GI‐GPx mRNA (to <50% of controls) in ileum and colon and increased ns‐GPx mRNA (by 180%) in colon. KGF treatment increased ns‐GPx mRNA in the ileum and colon and glutathione‐S‐transferase mRNA in the colon (by >200% of controls). Conclusions: Enteral nutrient intake regulates GSH‐related enzyme mRNA levels in the intestine, which may contribute to the decrease in mucosal GSH during malnutrition. Increased ns‐GPx and glutathione‐S‐transferase mRNA levels during malnutrition and with KGF administration may increase detoxifying functions in the gut under these conditions. (Journal of Parenteral and Enteral Nutrition 24:67–75, 2000)
Vitamin A Status Modulates Intestinal Adaptation After Partial Small Bowel Resection
Authors: Swartz‐Basile Deborah A. , Rubin Deborah C. , Levin Marc S.
Published: May 2008

Background: Intestinal adaptation after loss of functional small bowel surface area is characterized by cellular hyperplasia and increased absorptive function. Interventions to enhance the adaptive response are needed to decrease the morbidity and mortality associated with short bowel syndrome. Retinoic acid was shown to stimulate crypt cell proliferation in the adapting remnant rat ileum by 6 hours after resection. Thus, vitamin A, which is required for normal epithelial cell proliferation and differentiation and which can modulate programmed cell death, may play an important role in the adapting intestine. On the basis of these observations, the effects of vitamin A deficiency on intestinal morphology, epithelial cell proliferation, and apoptosis in the adapting intestine after resection were investigated. Methods: Weanling male Sprague‐Dawley rats fed either a vitamin A‐deficient or ‐sufficient diet for 58 days underwent 70% proximal small bowel resection. The deficient rats were divided into cohorts that were either maintained on the experimental diet after surgery or replenished with vitamin A 20 hours before surgery and switched to the control diet after surgery. Results: Ten days after resection, vitamin A‐deficient rats exhibited a markedly blunted adaptive response. The adaptive increase in villus height and crypt depth was absent in the deficient rats. However, adaptive increases in crypt cell proliferation were not attenuated by vitamin A deficiency, and there were no differences in apoptotic indices. Conclusions: Vitamin A deficiency inhibits the adaptive response to partial small bowel resection, supporting a role for vitamin A in the adaptive process. Changes in cellular proliferation or programmed cell death are not sufficient to account for this inhibition. This model system will be useful for examining the role of other mechanisms, such as changes in cell‐cell and cell‐extracellular matrix interactions, and rates of epithelial cell migration and cell extrusion. (Journal of Parenteral and Enteral Nutrition 24:81–88, 2000)
Foscarnet‐Induced Electrolyte Abnormalities in a Bone Marrow Transplant Patient Receiving Parenteral Nutrition
Authors: Matarese Laura E. , Speerhas Rex , Seidner Douglas L. , Steiger Ezra
Published: May 2008

Cytomegalovirus (CMV) is a serious complication of immunosuppressed patients receiving bone marrow transplantation. Foscarnet, a pyrophosphate analog, has been used in the treatment of CMV infections. Renal impairment and electrolyte abnormalities are potential adverse reactions associated with the use of foscarnet. We report a case of significant electrolyte changes after initiation of foscarnet in a bone marrow transplant patient receiving parenteral nutrition. (Journal of Parenteral and Enteral Nutrition 24:170–173, 2000)
Semiquantitative Culture of Subcutaneous Segment for Conservative Diagnosis of Intravascular Catheter‐Related Infection
Authors: Fortún Jesús , Perez‐Molina José Antonio , Asensio Angel , Calderón Celia , Casado Jose Luis , Mir Nuria , Moreno Ana , Guerrero A.
Published: May 2008

Background: Sensitivity and negative predictive values of combined surface cultures (skin and hub) are high in the presumptive diagnosis of catheter‐related infection, but specificity and PPVs are poor. The purpose of the study was to evaluate the yield of the semiquantitative culture of the subcutaneous segment in the diagnosis of colonization of the catheter tip without removal of the catheter. Methods: A prospective study was performed in 124 nontunneled central venous catheters that were removed because of suspected infection or the end of therapy. Catheter colonization was considered if >15 colony‐forming units (CFU) in the roll procedure or > 1000 CFU in the quantitative Cleri procedure were recovered from the tip cultures (“gold standard”). Before removing the catheter, a semiquantitative culture of skin surrounding the point of insertion, a semiquantitative culture of the subcutaneous segment (after removing the catheter only 2 cm), a semiquantitative cultures of the hub, and a pareated quantitative blood culture were performed. Receiver operating characteristic curves were calculated to estimate the cutoff points, and a culture was considered positive when CFUs were ≥15, ≥15, and ≥5 for skin, hub, and subcutaneous segment cultures, respectively. Results: Catheter colonization was detected in 51 catheters. The mean duration of catheterization was 14 ± 8 days, and the rates of incidence of tip colonization and bacteremia were 2.9 per 100 catheter days and 1.2 per 100 catheter days, respectively. Sensitivity of skin, subcutaneous, and hub cultures analyzed individually were ≤61%; however, specificity and positive predictive values (PPVs) of subcutaneous segment cultures were significantly higher than skin cultures (94% and 88.5% us 71.6% (p =.001) and 62% (p =.014), respectively). Sensitivity of the combined skin and hub cultures and of the combined subcutaneous segment and hub cultures were similar: 86.2% and 84.3%, respectively; however, specificity and PPVs of this latter combination were significantly higher than former: 82% and 78.1% us 59.7% (p =.008) and 61.9% (p =.07), respectively. The likelihood ratio of a positive test for the combined subcutaneous segment and hub culture was 4.68, and only 2.13 for the combined skin and hub culture. Conclusions: These results indicate that the combined subcutaneous segment and hub culture constitutes an easy, effective procedure for the conservative diagnosis of catheter colonization. (Journal of Parenteral and Enteral Nutrition 24:210–214, 2000)
Spontaneous Transpyloric Migration of a Ballooned Nasojejunal Tube: A Randomized Controlled Trial
Authors: Cohen Leon D. , Alexander David J. , Catto Jim , Mannion R.
Published: May 2008

Background: Spontaneous transpyloric migration of a simple nasojejunal tube (NJT) can be expected in only one‐third of insertions. Guidance of the tube by radio‐logic or endoscopic maneuvers is usually required. We believed that locating a 5‐mL balloon near the tip of an NJT on which natural peristalsis could act would improve the rate of spontaneous transpyloric migration and facilitate small bowel propagation. Methods: Thirty healthy volunteers were randomly assigned to have an inflated or noninflated, ballooned NJT fashioned from a modified 9F Hickman line catheter inserted. The pH of aspirates was measured hourly and the final location of the tube assessed by gastrografin contrast abdominal x‐ray (AXR) at the end of 6 hours, at which time the tube was removed. Results: After 6 hours, spontaneous transpyloric migration occurred in 86.6% of the ballooned and 66.6% of the nonballooned tubes. The final disposition of the ballooned tubes was: stomach, 2 (13.3%); duodenum, 1 (6.7%); and small bowel, 12 (80%). The final disposition of the nonballooned tubes was: stomach, 5 (33%), NS; duodenum, 9 (60%), p <.05; and small bowel, 1 (6.7%), p <.05. Conclusions: Ballooned NJT have a higher rate of spontaneous transpyloric migration and are significantly more likely to achieve an optimal small bowel location. (Journal of Parenteral and Enteral Nutrition 24:240–243, 2000)
Individual Neuropeptides Regulate Gut‐Associated Lymphoid Tissue Integrity, Intestinal Immunoglobulin A Levels, and Respiratory Antibacterial Immunity
Authors: Hanna M. Keith , Zarzaur Ben L. , Fukatsu Kazuhiko , Chance DeWitt R. , Renegar Kathryn B. , Sherrell Christopher , Wu Yong , Kudsk Kenneth A.
Published: May 2008

Background: Total parenteral nutrition (TPN) leads to atrophy of the gut‐associated lymphoid tissue (GALT) and a significant decrease in intestinal immunoglobulin A (IgA) levels, a major constituent of mucosal immunity. Bombesin (BBS) prevents TPN‐induced GALT atrophy and maintains intestinal IgA levels. BBS, a neuropeptide analogous to gastrin‐releasing peptide in humans, stimulates the release of other gut neuropeptides including cholecystokinin (CCK), gastrin, and neurotensin (NT). This study investigates the ability of CCK, gastrin, or NT to individually prevent TPN‐induced GALT atrophy and preserve respiratory immunity. Methods: Experiment 1: Male mice were randomly assigned to receive chow, TPN, TPN plus CCK, TPN plus gastrin, or TPN plus NT. After 5 days of feeding, Peyer's patches (PP) from the proximal and distal small bowel were harvested and analyzed for cell yields. PP cells were also analyzed for GALT cell type. Small bowel IgA levels were measured by enzyme‐linked immunosorbent assay (ELISA). Experiment 2: Mice were randomly assigned to receive either liposomes containing Pseudomonas antigen or liposomes without antigen. After 10 days, mice were randomly assigned to the same five treatment groups, fed for 5 days, and then given intratracheal Pseudomonas. Mortality was assessed after 48 hours. Results: Experiment 1: GALT cell reductions due to IV‐TPN were greater in the distal than proximal small bowel. All three neuropeptides prevented most TPN‐induced GALT atrophy due mainly to the maintenance of the B‐cell and T‐cell populations in the PP of the distal bowel. Intestinal IgA levels were significantly higher in the animals treated with neuropeptides than animals treated with TPN only; however, these IgA levels were not maintained at levels observed in chow‐fed animals. Experiment 2: Immunization resulted in significantly lower mortality in animals fed chow, TPN plus CCK, and TPN plus gastrin. TPN alone and TPN plus NT resulted in loss of immunity and mortality rate at comparable levels to unimmunized animals. Conclusions: Supplementation of IV‐TPN with CCK, gastrin, and NT prevents GALT atrophy, primarily in the distal bowel. Intestinal IgA levels improve but not to normal levels. CCK and gastrin reversed IV—TPN—induced effects on antibacterial pneumonia in immunized animals while NT did not. (Journal of Parenteral and Enteral Nutrition 24:261–269, 2000)