bluuebunny/crossref_metadata_2025 huggingface dataset:
Induction of a Catabolic State in Rats by Dexamethasone: Dose or Time Dependency?
Authors: Minet‐Quinard Régine , Moinard Christophe , Walrand Stéphane , Villié Françoise , Normand Bernadette , Vasson Marie‐Paule , Chopineau Jean , Cynober Luc
Published: May 2008

Background: Daily injections of dexamethasone (DEX) given to adult rats are a recognized but nonstandardized model of stress. The aim of this work was to establish a reproducible and accurate model of stress in adult rats by chronic injection of DEX in order to standardize it. For this purpose, the effect of the duration of treatment and the effect of DEX dose were tested. To help understand the mechanisms of the catabolic effect of DEX, the study was extended to the metabolism of glutamine (GLN). In experiment 1, 60 male Sprague‐Dawley rats (3 months old) were divided into 8 groups of 6 rats: groups G3, G5, G7, and G9 received 1.50 mg/kg/d of DEX by intraperitoneal (IP) injection for 3, 5, 7, or 9 days, respectively. Groups G3PF, G5PF, G7PF, or G9PF were pair‐fed to groups G3, G5, G7, or Gg, respectively. Group AL (n = 12) was healthy rats fed ad libitum. Results: In treated rats, nitrogen balance reached its lowest value at day 5. After 9 days treatment by DEX, the catabolic state was reduced. An increase in GLN‐synthetase activity and a decrease in muscle GLN content were related to DEX per se not to DEX‐induced anorexia. In experiment 2, 25 rats were divided into 5 groups of 5 animals. Groups G0.75, G1.50, and G2.50 received 0.75, 1.50, and 2.50 mg/kg/d, respectively, of DEX by IP injection for 5 days. Group PF was pair‐fed to group G2.50 and group AL was control rats. Results: DEX induced a decrease in nitrogen balance that was dose‐independent. GLN‐synthetase activity was increased maximally in gastrocnemius by 0.75 mg/kg. Conclusions: Five days of treatment by DEX and a dose of 0.75 mg/kg/d induced a marked catabolic state. (Journal of Parenteral and Enteral Nutrition 24:30–36, 2000)
Incidence of Gastroesophageal Reflux and Aspiration in Mechanically Ventilated Patients Using Small‐Bore Nasogastric Tubes
Authors: Ibáñez Jordi , Peñafiel Albert , Marsé Pere , Jordá Ricard , Raurich Joan Maria , Mata Felix
Published: May 2008

Background: Use of a large‐bore nasogastric tube (NGT) and patient position are considered key factors in promoting gastroesophageal reflux (GER) and pulmonary aspiration in critically ill patients. The objective of this study was to determine the incidence of GER and pulmonary aspiration of gastric contents in mechanically ventilated (MV) patients using small‐bore NGTs. Methods: We studied 30 patients on mechanical ventilation for acute respiratory failure who tolerated enteral nutrition through a small‐bore NGT. Patients were randomly assigned to a group with (n = 16) or without (n = 14) a small‐bore NGT and were maintained in a semirecumbent position during the study. GER and aspiration of gastric contents were assessed by a radio‐isotopic technique. Scans were done 24 hours after technetium‐99m administration (n = 30). In 9 patients a dynamic scintigraphy was performed immediately after colloid administration, and samples of blood and tracheal and oropharyngeal secretions were obtained basally, 30 minutes, and 24 hours after technetium administration and analyzed for radioactivity using a gamma counter. Results: Both groups were similar in age, underlying diagnosis, number of days of mechanical ventilation at the day of study, and mortality. There were no GER reaching the oropharynx and aspiration of gastric contents in both groups. Conclusions: GER and aspiration of gastric contents were not detected in MV patients using small‐bore NGTs and may be a simple measure to prevent ventilator‐associated pneumonia. (Journal of Parenteral and Enteral Nutrition 24:103–106, 2000)
With Medium‐Chain Triglycerides, Higher and Faster Oxygen Radical Production by Stimulated Polymorphonuclear Leukocytes Occurs
Authors: Kruimel Joanna W. , Naber Anton H. , Curfs Jo H. , Wenker Mira A. , Jansen Jan B.
Published: May 2008

Background: Parenteral lipid emulsions are suspected of suppressing the immune function. However, study results are contradictory and mainly concern the conventional long‐chain triglyceride emulsions. Methods: Polymorphonuclear leukocytes were preincubated with parenteral lipid emulsions. The influence of the lipid emulsions on the production of oxygen radicals by these stimulated leukocytes was studied by measuring chemiluminescence. Three different parenteral lipid emulsions were tested: long‐chain triglycerides, a physical mixture of medium‐ and long‐chain triglycerides, and structured triglycerides. Structured triglycerides consist of triglycerides where the medium‐ and long‐chain fatty acids are attached to the same glycerol molecule. Results: Stimulated polymorphonuclear leukocytes preincubated with the physical mixture of medium‐ and long‐chain triglycerides showed higher levels of oxygen radicals (p <.005) and faster production of oxygen radicals (p <.005) compared with polymorphonuclear leukocytes preincubated with long‐chain triglycerides or structured triglycerides. Additional studies indicated that differences in results of various lipid emulsions were not caused by differences in emulsifier. The overall production of oxygen radicals was significantly lower after preincubation with the three lipid emulsions compared with controls without lipid emulsion. Conclusions: A physical mixture of medium‐ and long‐chain triglycerides induced faster production of oxygen radicals, resulting in higher levels of oxygen radicals, compared with long‐chain triglycerides or structured triglycerides. This can be detrimental in cases where oxygen radicals play either a pathogenic role or a beneficial one, such as when rapid phagocytosis and killing of bacteria is needed. The observed lower production of oxygen radicals by polymorphonuclear leukocytes in the presence of parenteral lipid emulsions may result in immunosuppression by these lipids. (Journal of Parenteral and Enteral Nutrition 24:107–112, 2000)
Managing the Obese Patient After Bariatric Surgery: A Case Report of Severe Malnutrition and Review of the Literature
Authors: Kushner Robert
Published: May 2008

Surgery is now considered to be the most effective treatment for reducing weight and maintaining weight loss in patients with clinically severe obesity. Although the jejuno‐ileal bypass has been abandoned, the vertical banded gastroplasty (VBG) and Roux‐en‐Y gastric bypass (RYGB) operations are now commonly performed. A third operation, the bilio‐pancreatic diversion (BPD), is performed less frequently. The RYGB and BPD procedures cause predictable selective micronutrient deficiencies that can be avoided by early supplementation. Surgical complications from all of these procedures may result in more severe forms of malnutrition. This article is intended to familiarize the nutrition support specialist with the anatomic and physiologic changes produced by these procedures, the resulting nutritional deficiencies and recommended supplementation, and the manifestations of severe malnutrition caused by complications. A case of severe malnutrition after RYGB surgery is reported for illustration. (Journal of Parenteral and Enteral Nutrition 24:126–132, 2000)
Effect of Oral Genistein and Isoflavone‐Free Diet on Cecal Flora and Bacterial Translocation in Antibiotic‐Treated Mice
Authors: Wells Carol L. , Jechorek Robert P. , Erlandsen Stanley L.
Published: May 2008

Background: There are several reports indicating that the isoflavone genistein may augment the integrity of the intestinal epithelial barrier as well inhibit bacterial internalization by cultured enterocytes. We speculated that oral genistein might enhance the integrity of the intestinal epithelial barrier as monitored by the extraintestinal dissemination of intestinal bacteria. Methods: Mice were treated with oral antibiotics to induce cecal bacterial overgrowth accompanied by bacterial translocation of antibiotic‐resistant enterobacteria, especially Escherichia coli. These mice were divided into separate groups that included chow‐fed mice orally inoculated either with saline, vehicle, or genistein, and mice fed isoflavone‐free diet and orally inoculated with either saline, vehicle, or genistein. Intestinal bacterial overgrowth was monitored by quantitative culture of excised ceca and bacterial translocation was monitored by quantitative culture of draining mesenteric lymph nodes. Results: Mice fed the isoflavone‐free diet had decreased populations of cecal bacteria compared with chow‐fed mice, and bacterial translocation was reduced in chow‐fed mice compared with mice fed isoflavone‐free diet. However, bacterial translocation was similar in mice given oral genistein compared with appropriate control mice. Conclusions: Oral genistein had no noticeable effect on bacterial translocation in this model. However, the isoflavone‐free diet had an antibacterial effect on cecal flora, and the isoflavone‐free diet was associated with decreased numbers of cecal bacteria and decreased incidence of bacterial translocation. (Journal of Parenteral and Enteral Nutrition 24:56–60, 2000)
Nutritional Treatment for Acquired Immunodeficiency Virus‐Associated Wasting Using β‐Hydroxy β‐Methylbutyrate, Glutamine, and Arginine: A Randomized, Double‐Blind, Placebo‐Controlled Study
Authors: Clark Robert H. , Feleke Getachew , Din Mehraj , Yasmin Tabassum , Singh Gurpreet , Khan Faroque A. , Rathmacher John A.
Published: May 2008

Background: The current study was designed to examine whether a combination of three nutrients, consisting of β‐hydroxy‐β‐methylbutyrate (HMB), a metabolite of leucine, L‐glutamine (Gln) and L‐arginine (Arg), each of which has been previously shown to slow muscle proteolysis, could synergistically alter the course of muscle wasting in patients with established acquired immunodeficiency syndrome (AIDS). Methods: Sixty‐eight human immunodeficiency virus (HIV)‐infected patients with a documented weight loss of at least 5% in the previous 3 months were recruited from the HIV clinic at Nassau County Medical Center. The subjects were randomly assigned in a double‐blind fashion to receive either placebo containing maltodextrin or the nutrient mixture (HMB/Arg/Gln) containing 3 g HMB, 14 g L‐glutamine, and 14 g L‐arginine given in two divided doses daily for 8 weeks. Body weights (BW) were recorded weekly and lean body mass (LBM) and fat mass (FM) were measured by air displacement plethysmography and by a single computerized tomography (CT) slice through the thigh at 0, 4, and 8 weeks. Results: Forty‐three subjects completed the 8‐week protocol, (placebo, n = 21; HMB/Arg/Gln, n = 22). At 8 weeks, the subjects consuming the HMB/Arg/Gln mixture gained 3.0 ± 0.5 kg of BW while those supplemented with the placebo gained 0.37 ± 0.84 kg (p =.009). The BW gain in the HMB/Arg/Gln‐treated subjects was predominantly LBM (2.55 ± 0.75 kg) compared with the placebo‐supplemented subjects who lost lean mass (‐0.70 ± 0.69 kg, p =.003). No significant change in FM gain was observed (0.43 ± 0.83 kg for the group receiving HMB/Arg/Gln and 1.07 ± 0.64 kg for the group receiving the placebo, p >.20). Similar percentage changes in muscle mass and fat mass were observed with CT scans. Immune status was also improved as evident by an increase in CD3 and CD8 cells and a decrease in the HIV viral load with HMB/Arg/Gln supplementation. Conclusions: The data indicate that the HMB/Arg/Gln mixture can markedly alter the course of lean tissue loss in patients with AIDS‐associated wasting. (Journal of Parenteral and Enteral Nutrition 24:133–139, 2000)
Substrate Oxidation in Patients with Cirrhosis: Comparison with Other Nutritional Markers
Authors: Scolapio James S. , Bowen Jennifer , Stoner Gary , Tarrosa Vilia
Published: May 2008

Background: Malnutrition in patients with hepatic cirrhosis is associated with abnormal fuel metabolism marked by reduced glucose oxidation and increased lipid oxidation. A low respiratory quotient (R/Q) indicates reduced glucose and increased lipid oxidation. The aim of this study was to determine if there is an association between substrate oxidation, using indirect calorimetry, and other markers of malnutrition in patients with cirrhosis awaiting liver transplantation. Methods: Indirect calorimetry (MedGraphics) was used to determine resting energy expenditure and R/Q after an overnight fast. Anthropometric measurements including tricep skinfold thickness (TSF) and midarm muscle circumference (MAMC) were performed and expressed as a percentage of standard values. A 24‐hour urinary creatinine excretion was collected to calculate creatinine height index (CHI) and serum albumin. A subjective global assessment (SGA) score was completed on each patient by a dietitian and physician. Spearman rank correlation was used for statistical comparison of R/Q to other nutritional markers. Results: Fifteen patients (7 men, 8 women; mean age, 52 years) were studied. Mean values include: body mass index (BMI) 27.7 kg/m2 ± 7.3, R/Q 0.78 ± 0.04, serum albumin 2.97 g/dL ± 0.56, TSF 71% ± 27%, MAMC 85% ± 13%, CHI 75% ± 18%, and SGA median score A. There was a significant correlation (p <.05) between R/Q and serum albumin, CHI, and SGA score. There was a greater than 90% correlation of SGA estimation by a physician and dietitian. Conclusions: There is good correlation between R/Q values and serum albumin, CHI, and SGA score. BMI and anthropometric measurements may suggest normal nutrition when, in fact, indirect calorimetry (R/Q) suggests changes consistent with abnormal fuel metabolism and poor nutrition. R/Q can be a useful adjunct in the nutrition assessment of patients with hepatic cirrhosis. (Journal of Parenteral and Enteral Nutrition 24:150‐153, 2000)
Treatment of Esophageal Crohn's Disease by Enteral Feeding via Percutaneous Endoscopic Gastrostomy
Authors: Thomas Tabitha S. , Berto Eva , Scribano Maria L. , Middleton Stephen J. , Hunter John O.
Published: May 2008

Background: Crohn's disease of the esophagus is rare, and medical treatment often ineffective. Complications such as abscess and fistula may arise, and the morbidity of surgery is high. Methods: Two cases of refractory esophageal Crohn's disease were confirmed by endoscopy and biopsy. Percutaneous endoscopic gastrostomies (PEGs) were inserted and used for enteral nutrition for 9 and 1 month, respectively. Results: The PEGs were well tolerated. Symptoms subsided rapidly, and later gastroscopies confirmed healing of the esophageal ulcers. No complications occurred, and the gastrostomy sites closed quickly after removal of the tubes, with minimal scarring. Conclusions: Enteral feeding via PEG appears to be safe and well tolerated and may be of great value in the management not only of esophageal Crohn's disease but also of refractory disease at other sites. (Journal of Parenteral and Enteral Nutrition 24:176–179, 2000)
pH and Concentration of Bilirubin in Feeding Tube Aspirates As Predictors of Tube Placement NA Metheny, BJ Stewart, L Smith, et al. Nursing Research 48(4):189–196, 1999
Authors: Zimmaro Bliss Donna
Published: May 2008

In this study, the investigators determined whether the concentration of bilirubin obtained from aspirates of newly inserted feeding tubes improved the ability of pH alone to predict feeding tube location. An algorithm to predict feeding tube location was developed. Aspirates of gastrointestinal fluid from adult, acutely ill patients who had nasogastric (n = 209) or nasointestinal (n = 228) small‐bore feeding tubes (8‐F or 10‐F) inserted were obtained within 5 minutes of radiographs confirming feeding tube placement. Patients were excluded if antacids or tube feedings had been administered within 4 hours preceding sample collection, any medications were administered orally or via feeding tube within 1 hour preceding sample collection, samples were grossly bloody, or if patients had a history of gastric surgery or trauma. Tracheobronchial secretions (n = 125) were obtained by suctioning patients who had an artificial airway; 24 pleural samples were obtained at the time of thoracenteses, and 1 sample was obtained from a feeding tube inadvertently positioned into the right mainstem bronchus. Approximately two‐thirds of the patients were receiving H2 ‐receptor antagonists. The pH and bilirubin concentration of samples were measured using standard methods and compared with the radiographs of feeding tube location.

Mean pH levels in the intestine (7.35 ± 0.6) and lung (7.73 ± 0.4) were significantly higher than in the stomach (3.9 ±.15). Mean bilirubin levels in the stomach (1.28 ± 0.25 and lung (.08 ±.02) were significantly lower than in the intestine (12.73 ±.91 mg/dL). To develop the predictive algorithm, the pH and bilirubin values were dichotomized by visually inspecting the overlap of the data distributions and mean differences by tube sites. A pH of 5 or less and bilirubin less than 5 mg/dL successfully identified more than two‐thirds of the 209 feeding tubes radiographically confirmed as being in the stomach. Misclassification of 53 of the gastric feeding tubes as respiratory cases by this category was attributed to the effects of acid‐inhibiting medications. Thirteen of the gastric tubes were misclassified as being in the intestine, most likely due to acid‐inhibiting agents and reflux of intestinal fluid into the stomach. A pH greater than 5 and bilirubin of 5 or more correctly identified three‐fourths of the 228 tubes in the intestine. Fifty‐four of the intestinal tubes were misclassified as respiratory cases due to lower than expected bilirubin levels. A pH of less than 5 and bilirubin less than 5 mg/dL correctly classified 100% of the 150 respiratory cases. Approximately one‐fourth of the 437 gastrointestinal tube placements were misclassified as respiratory cases by this category. Use of the algorithm was estimated to reduce the number of x‐rays to exclude respiratory placements in 28% of the cases.
Promotion of a Favorable Gut Flora in Inflammatory Bowel Disease
Authors: Kennedy R.J. , Kirk S.J. , Gardiner K.R.
Published: May 2008

Recent evidence suggests that the composition of colonic flora plays a role in intestinal inflammation in inflammatory bowel disease (IBO). This review examines the evidence that altering the concentrations of colonic bacteria might benefit patients with this condition. (Journal of Parenteral and Enteral Nutrition 24:189–195, 2000)
Glutamine‐Enriched Total Parenteral Nutrition Maintains Intestinal Interleukin‐4 and Mucosal Immunoglobulin A Levels
Authors: Kudsk Kenneth A. , Wu Yong , Fukatsu Kazuhiko , Zarzaur Ben L. , Johnson Cheryl D. , Wang Roger , Hanna M. Keith
Published: May 2008

Background: Total parenteral nutrition (TPN) prevents progressive malnutrition but fails to maintain intestinal gut‐associated lymphoid tissue (GALT) or established respiratory antiviral or antibacterial mucosal immunity. Our previous work demonstrated that decreases in intestinal immunoglobulin A (IgA) were associated with decreases in Th2‐type IgA‐stimulating cytokines, interleukin (IL)‐4 and IL‐10. Because glutamine supplementation of TPN partially preserves respiratory defenses and normalizes GALT, we investigated the ability of parenteral glutamine to normalize respiratory and intestinal IgA levels and measured Th2 cytokines in intestinal homogenates. Methods: Animals were cannulated and randomly assigned to receive chow (n = 17), TPN (n = 18), or an isonitrogenous, isocaloric TPN solution formulated by removing the appropriate amount of amino acids and replacing them with 2% glutamine (n = 18) for 5 days. Respiratory tract and intestinal washings were obtained for IgA and the intestine homogenized and analyzed for IL‐4 and IL‐10. Results: TPN decreased intestinal and respiratory IgA in association with decreases in intestinal IL‐4 and IL‐10 compared with chow‐fed animals. Glutamine significantly improved respiratory and intestinal IgA levels, significantly improved IL‐4 compared with TPN animals, and maintained IL‐10 levels midway between chow‐fed and TPN animals. Conclusions: Glutamine‐enriched TPN preserved both extraintestinal and intestinal IgA levels and had a normalizing effect on Th2‐type IgA‐stimulating cytokines. (Journal of Parenteral and Enteral Nutrition 24:270 ‐275, 2000)
Analysis of Intestinal Adaptation Gene Expression by cDNA Expression Arrays
Authors: Erwin Christopher R. , Falcone Richard A. , Stern Lawrence E. , Kemp Christopher J. , Warner Brad W.
Published: May 2008

Background: As a tool for determining gene expression on a genomic scale, cDNA microarrays are a promising new technology that can be applied to the study of complex physiologic processes. The objective of this study was to characterize the expression of individual genes and patterns of gene expression that might provide insight into the mechanism of intestinal adaptation after massive small bowel resection. Methods: Male ICR mice underwent a 50% proximal small bowel resection (SBR) or sham operation. After 3 days, the remnant ileum was harvested, weighed, and RNA extracted. Changes in gene expression were detected utilizing Clontech Atlas mouse cDNA expression arrays. Some of these changes were confirmed by reverse transcriptase‐polymerase chain reactions (RT‐PCR) and Northern blots. Results: Analysis of these cDNA arrays revealed changes in the expression of multiple genes, including those involved in cell cycle regulation, apoptosis, DNA synthesis, and transcriptional regulation. The patterns of expression were consistent with the increased cell proliferation and apoptosis observed during intestinal adaptation. A large number of genes not previously associated with intestinal adaptation were identified. Conclusions: This technology may facilitate the elucidation of the intricate cellular mechanisms underlying intestinal adaptation. (Journal of Parenteral and Enteral Nutrition 24:311–316, 2000)
Phagocytosis and Killing of Candida albicans by Human Neutrophils After Exposure to Structurally Different Lipid Emulsions
Authors: Wanten Geert J. , Curfs Jo H. , Meis Jacques F. , Naber Anton H.
Published: May 2008

Background: To test the hypothesis that structurally different lipid emulsions have distinct immune‐modulating properties, we analyzed the elimination of Candida albicans by neutrophils after exposure to various emulsions. Methods: Neutrophils from 8 volunteers were incubated in physiologic 5 mmol/L emulsions containing long‐chain‐(LCT), medium‐chain‐ (MCT), mixed LCT/MCT‐, α‐tocopherol‐enriched LCT/MCT (LCT/MCT‐E), or structured lipids (SL). After washing, the neutrophils were incubated with C. albicans. Phagocytosis was measured as the number of yeast‐associated neutrophils relative to the total neutrophil count. Killing was expressed as the percentage of Candida survival relative to the initial yeast cell count. Results: No significant differences in yeast‐neutrophil association could be demonstrated after neutrophil incubation in various lipid emulsions or medium, after correction for non‐specific adhesion. However, although Candida survival after 1 hour incubation with non‐lipid‐exposed neutrophils amounted to 53% ± 11% and was not influenced by LCT (60% ± 11%), LCT/MCT (78% ± 7%), LCT/MCT‐E (72% ± 12%), and SL (67% ± 6%), pure MCT (70% ± 13%) significantly impaired the killing capacity of neutrophils. Conclusions: The decreased killing capacity of neutrophils after exposure to medium‐chain fatty acid‐containing emulsions and the absence of this effect with LCT suggest that lipid emulsions influence the elimination of C. albicans depending on the triglyceride chain length. (Journal of Parenteral and Enteral Nutrition 25: 9–13, 2001)
Effect of Growth Hormone on Intestinal Na+/Glucose Cotransporter Activity
Authors: Tavakkolizadeh Ali , Shen K. Robert , Jasleen Jasleen , Soybel David I. , Jacobs Danny O. , Zinner Michael J. , Ashley Stanley W. , Whang Edward E.
Published: May 2008

Background: Growth hormone (GH) has been used alone or as part of a defined regimen in the treatment of patients with short bowel syndrome; however its mode of action remains unclear. Growth hormone has been shown to increase amino acid, water, and electrolyte absorption from the small intestine. The acute effect of growth hormone on intestinal sugar transport has not been described previously. Methods: Mucosal preparations of rat jejunum were mounted in the Ussing chamber. Growth hormone (2 × 10−6 M or 8 × 10−6 M) or vehicle was added to the serosal chamber 1, 3, or 5 hours later. Twenty or 40 minutes after growth hormone addition, 30 mmol/L 3‐O‐methylglucose was added to both chambers, and the change in short‐circuit current (ΔI sc) was recorded. In separate experiments, tissues were pretreated with phloridzin, an inhibitor of Na+/glucose cotransport, before the addition of 3‐O‐methylglucose. In the final set of experiments, kinetic studies were performed. Results: GH did not induce any alterations in baseline electrical parameters. Only tissues left in the chambers for 5 hours, but not 1 or 3 hours, before GH treatment displayed a greater 3–0‐methylglucose‐induced ΔI sc than controls (p <.05). The increase in I sc induced by 3‐O‐methylglucose was 100% phloridzin‐inhibitable. Kinetic analysis showed that growth hormone administration is associated with an increase in Na+/glucose cotransporter maximal velocity (Vmax) but no significant change in carrier affinity for substrate (Km). Conclusions: Growth hormone increases intestinal sugar transport, but only in tissue that has not been exposed to endogenous GH for over 3 hours. (Journal of Parenteral and Enteral Nutrition 25:18–22, 2001)
Verbal and Visual Memory Improve After Choline Supplementation in Long‐Term Total Parenteral Nutrition: A Pilot Study
Authors: Buchman Alan L. , Sohel Mir , Brown Meredith , Jenden Donald J. , Ahn Chul , Roch Margaret , Brawley Tora L.
Published: May 2008

Background: Previous investigations have demonstrated that choline deficiency, manifested in low plasma‐free choline concentration and hepatic injury, may develop in patients who require long‐term total parenteral nutrition (TPN). Preliminary studies have suggested lecithin or choline supplementation might lead to improved visual memory in the elderly and reverse abnormal neuropsychological development in children. We sought to determine if choline‐supplemented TPN would lead to improvement in neuropsychological test scores in a group of adult, choline‐deficient outpatients receiving TPN. Methods: Eleven subjects (8 males, 3 females) who received nightly TPN for more than 80% of their nutritional needs for at least 12 weeks before entry in the study were enrolled. Exclusion criteria included active drug abuse, mental retardation, cerebral vascular accident, head trauma, hemodialysis or peritoneal dialysis, (prothrombin time [PT] >2× control), or acquired immune deficiency syndrome (AIDS). Patients were randomly assigned to receive their usual TPN regimen (n = 6, aged 34.0 ± 12.6 years) over a 12‐hour nightly infusion or their usual TPN regimen plus choline chloride (2 g) (n = 5, aged 37.3 ± 7.3 years). The following neuropsychological tests were administered at baseline and after 24 weeks of choline supplementation (or placebo): Weschler Adult Intelligence Scale‐Revised (WAIS‐R, intellectual functioning), Weschler Memory Scale‐Revised (WMS‐R, two subtests, verbal and visual memory), Rey‐Osterrieth Complex Figure Test (visuospatial functioning and perceptual organization), Controlled Oral Word Association Test (verbal fluency), Grooved Pegboard (manual dexterity and motor speed), California Verbal Learning Test (CVLT, rote verbal learning ability), and Trail Making Parts A & B (visual scanning, psychomotor speed and set shifting). Scores were reported in terms of standard scores including z scores and percentile ranks. Mean absolute changes in raw scores were compared between groups using the Wilcoxon rank sum test, where p values <.05 constituted statistical significance. Results: Significant improvements were found in the delayed visual recall of the WMS‐R (7.0 ± 2.7 vs ‐.33 ± 5.7, p =.028), and borderline improvements in the List B subset of the CVLT (1.0 ± 0.8 vs ‐2.0 ± 2.4, p =.06) and the Trails A test (‐3.8 ± 8.1 vs 3.7 ± 4.5 seconds, p =.067). No other statistically significant changes were seen. Conclusions: This pilot study indicates both verbal and visual memory may be impaired in patients who require long‐term TPN and both may be improved with choline supplementation. (Journal of Parenteral and Enteral Nutrition 25:30–35, 2001)
Percutaneous Placement of an Intercostal Central Venous Catheter for Chronic Hyperalimentation Guided by Transhepatic Venography
Authors: Solomon Brian A. , Solomon Jeffrey , Shlansky‐Goldberg Richard
Published: May 2008

Background and Methods: Increased utilization of central venous catheters for hyperalimentation has caused a rise in the incidence of central venous complications including occlusions and stenoses. When this occurs, the continued use of these catheters becomes more difficult. We describe a technique for catheter placement in a patient requiring access for total parenteral nutrition who had extensive central venous occlusion involving both internal jugular veins, both subclavian veins, and the infrorenal inferior vena cava (IVC). Results: A percutaneous transhepatic venous catheter had been placed in a patient with inferior vena caval, subclavian, and internal jugular venous occlusions. The Hickman catheter functioned well until the patient developed fungal sepsis and a large fibrin sheath around the catheter tip creating the need for a new access site. Placement of ar intercostal venous catheter was performed using transhepatie venography to map patent collateral veins and microcatheters to access an intercostal route for Hickman placement. Conclusions: Patients who require long‐term central venous access often develop stenotic and occlusive complications in the centra venous circulation. Individualized, unique and innovative routes to the central venous circulation must often be utilized to maintain venous access in these patients. Transhepatic venous mapping and microcatheter techniques aid in the finding of alternative sites in these patients with difficult access prob lems. (Journal of Parenteral and Enteral Nutrition 25:42–44, 2001
Comparison of Gastrointestinal Tolerance to Two Enteral Feeding Protocols in Critically III Patients: A Prospective, Randomized Controlled Trial
Authors: Pinilla Jaime C. , Samphire John , Arnold Christopher , Liyan Liu  , Thiessen Brenda
Published: May 2008

Background : The purpose of this study was to compare gastrointestinal tolerance to two enteral feeding protocols in critically ill patients. Methods: A prospective, randomized controlled trial, that involved 96 consecutive patients expected to stay in the intensive care unit for ≥3 days and who had no contraindications to enteral feeding. The patients were randomized to either the current protocol (group I; gastric residual volume threshold, 150 mL, optional prokinetic) or proposed feeding protocol (group II; gastric residual volume threshold 250 mL, mandatory prokinetic). Gastrointestinal intolerance was recorded as episodes of high gastric residual volume, emesis, or diarrhea. The time to reach the goal rate of feeding and the percentage of nutritional requirements received during the study period were also recorded. Results: Nineteen of 36 patients (19/36 = 0.53) in group I had one or more episodes of high gastric residual volume, compared with 10 of 44 patients (10/44 = 0.23) in group II (p <.005). There was no statistical difference between the two protocols with regards to emesis, diarrhea, or the total episodes of intolerance. The patients in group II reached their goal rates on average in 15 hours and received 76% of their nutritional requirements, compared with 22 hours and 70% in group I; however, these differences were not statistically significant. Conclusions: The incidence of enteral feeding intolerance was reduced by using a gastric residual volume of 250 mL along with the mandatory use of prokinetics. The study showed a trend of improved enteral nutrition provision and reduced the time to reach the goal rate in group II. These improvements support the adoption of the proposed feeding protocol for critically ill patients. (journal of Parenteral and Enteral Nutrition 25:81–86, 2001)
Weight Gain and Cardiovascular Risk After Organ Transplantation
Authors: Baum Charles L.
Published: May 2008

Organ transplantation has become a common and effective approach to the management of patients with organ failure. The improvement in long‐term survival has resulted in the emergence of cardiovascular disease as the primary cause of death in renal transplant patients and a significant complication in other organ recipients. A number of factors explain this trend, including a high incidence of hypertension, posttransplant diabetes, hyperlipidemia, and obesity risk factors that are mediated by direct effects of immunosuppressive medications. Weight gain posttransplant affects ~50% of patients and represents a significant problem because of the potential synergism between obesity and immunosuppressive medication‐induced effects on cardiovascular disease risk factor development. This review discusses the incidence and implications of cardiovascular disease risk factors in organ transplant recipients, strategies for clinical management, and future research directions. (Journal of Parenteral and Enteral Nutrition 25:114–119, 2001)
Influence of Tacrolimus and Prednisone on Serum Lipids After Liver Transplantation
Authors: Scolapio James S. , Bowen Jennifer , Lukens Frank J. , Ukleja Andrzej , Atkinson Elizabeth
Published: May 2008

Background:Hyperlipidemia after orthotopic liver transplant is thought to be the result of the immunosuppression therapy given postoperatively. The purpose of this study was to evaluate serum lipid levels pretransplant, 4 months, and 12 months posttransplant.Methods:A retrospective chart review of 50 patients after liver transplantation was completed. Pretransplant serum lipid levels (triglyceride, cholesterol, and high‐density lipoprotein [HDL]) were compared with values at 4 months and 12 months posttransplantation. Pretransplant serum lipid levels were compared using one factor analysis of variance (ANOVA) model. Values between the viral, alcohol, and cholestatic groups were compared using two‐factor ANOVA model.Results:Of the 50 patients (22 females, 28 males) with a mean age of 52 years (range, 16 to 69 years), all 50 had completed their 12‐month follow‐up at the time of this study. The etiology of liver disease included: viral hepatitis (21), alcohol (8), primary biliary cirrhosis and sclerosing cholangitis (7), and others (14). The protocol for immunosuppression included tacrolimus and prednisone. Mean serum triglyceride levels included: 134 mg/dL pretransplant, 155 mg/dL at 4 months, and 169 mg/dL at 12 months posttransplant (p =.117). Mean total serum cholesterol levels included: 174 mg/dL pretransplant, 165 mg/dL at 4 months, and 163 mg/dL at 12 months posttransplant (p =.654). Mean HDL levels included: 39 mg/dL pretransplant, 45 mg/dL at 4 months and 44 mg/dL at 12 months posttransplant (p =.032). There was not a significant difference in serum lipids between the different categories of liver diseases.Conclusions:Although a significant positive effect was observed with HDL, the present data show that total serum cholesterol and triglyceride did not change significantly over time after orthotopic transplantation. This is most likely related to the type of immunosuppressive therapy given posthepatic transplantation.(Journal of Parenteral and Enteral Nutrition25:148–151, 2001)
Metabolic Effects of Arginine Addition to the Enteral Feeding of Critically III Patients
Authors: Preiser Jean‐Charles , Berré Jacques , Van Gossum André , Cynober Luc , Vray Bernard , Carpentier Yvon , Vincent Jean‐Louis
Published: May 2008

Background: Some studies have suggested that the addition of arginine to enteral feeding solutions may improve outcome in critically ill patients, but the mechanism is incompletely explained. In particular, the availability and utilization of arginine administered enterally is not well defined. Methods: This prospective, randomized, double‐blind, placebo‐controlled study performed in a Department of Medicosurgical Intensive Care included 51 patients likely requiring long‐term enteral feeding. Thirty‐seven patients (57 ± 7 years, SAPS II 33 ± 6) completed the 7‐day study, of whom 20 received the formula enriched with free arginine (6.3 g/L) and 17 received an isocaloric and isonitrogenous control solution. Arginine absorption was assessed from plasma arginine concentrations in serial samples. Three pathways of arginine utilization were explored: (1) the production of nitric oxide, assessed by the plasma concentration of nitrite/nitrate (NOx) and citrulline, and 24‐hour urinary excretion of NOx; (2) the protein turnover, estimated by the phenylalanine concentrations; and (3) the activity of arginase, reflected by the ornithine concentration. Results: The plasma concentrations of arginine and ornithine increased in the group fed with the enriched formula (from 55 ± 9 μmol/L to 102 ± 9 μmol/L and from 57 ± 7 to 135 ± 11 μmol/L, respectively, p <.05), but not with the control formula. There was no difference between groups in either NO production or phenylalanine concentration. Conclusions: Supplemental arginine in enteral feeding is readily absorbed, and mainly metabolized into ornithine, presumably by the arginase enzyme. (Journal of Parenteral and Enteral Nutrition 25:182–187, 2001)
Sites of Conditional Essential Fatty Acid Deficiency in End Stage Liver Disease
Authors: Burke Peter A. , Pei Ra. Ling  , Forse Robert A. , Lewis David W. , Jenkins Roger , Bistrian Bruce R.
Published: May 2008

Background: End stage liver disease (ESLD) is a devastating illness. Its protean manifestations involve many different aspects of disturbed hepatic function. One consequence of ESLD is a decrease in plasma levels of very long chain polyunsaturated fatty acids (VL‐PUFAs), particularly arachidonic acid (AA) and docosahexaenoic acid (DHA), the former important for eicosanoid metabolism and the latter for retinal and brain membrane structure. The purpose of this study was to define the VL‐PUFA changes in liver disease by comparing plasma and tissue levels of VL‐PUFAs in controls to patients with ESLD. Methods: Fatty acid profiles from plasma, red blood cell (RBC) membranes, muscle, liver, and fat tissue from ESLD patients undergoing liver transplants were measured and compared with control patients undergoing elective liver resection. Results: Fatty acid profiles from plasma and RBC membranes showed significant decreases in AA and DHA levels in patients with ESLD compared with controls. However, there were no significant differences in tissue fatty acid composition between ESLD patients and controls. Conclusions: ESLD affects the liver's ability to maintain circulating levels of AA and DHA, and thereby presumably RBC membrane levels. However, solid tissues appear not to be affected by ESLD. Although the mechanism for these changes remains to be defined, it is consistent with hepatic impairment of elongation and desaturation to produce VL‐PUFA for transport. The present results also suggest that dietary interventions to include preformed VL‐PUFA rather than their precursors, linoleic and alpha linolenic acid, would be needed to normalize plasma VL‐PUFA levels in patients with ESLD. (journal of Parenteral and Enteral Nutrition 25:188–193, 2001)
Oral Arginine Improves Blood Pressure in Renal Transplant and Hemodialysis Patients
Authors: Kelly Burnett S. , Alexander J. Wesley , Dreyer Dorothea , Greenberg Norman A. , Erickson Ann , Whiting James F. , Ogle Cora K. , Babcock George F. , First M. Roy
Published: May 2008

Background: Hypertension in kidney transplant (KT) patients may result from attenuated whole‐body nitric oxide (NO) content and abnormal NO‐mediated vasodilation. Increasing NO bioavailability with L‐arginine (ARG) could theoretically restore the NO‐mediated vasodilatory response and lower blood pressure. Methods: In a prospective pilot study, 6 normotensive volunteers and 10 KT patients received oral supplements of ARG (9.0 g/d) for 9 days, then 18.0 g/d for 9 more days. Six hemodialysis (HD) and 4 peritoneal dialysis patients received the same dose for 14 days. Five KT patients received 30 mL/d of canola oil (CanO) in addition to ARG. Systolic (SBP) and diastolic (DBP) blood pressure, creatinine clearance (CCr), and serum creatinine (Cr) were measured at baseline, day 9, and day 18. In a subsequent study, 20 hypertensive KT patients with stable but abnormal renal function were randomized in a crossover study to start ARG‐only or ARG+CanO supplements for two 2‐month periods with an intervening month of no supplementation. SBP, DBP, CCr, and Cr were measured monthly for 7 months. Results: In the pilot study, ARG reduced the SBP in HD patients from 171.5 ± 7.5 mmHg (baseline) to 142.8 ± 8.3 mmHg (p =.028). In the crossover study, SBP was reduced from baseline (155.9 ± 5.0 mmHg), after the first 2 months (143.2 ± 3.2 mmHg; p =.03) and subsequent 2 months (143.3 ± 2.5 mmHg; p =.014) of supplementation. DBP was also reduced after supplementation in both studies. CanO had no effect on blood pressure. Renal function did not change. Conclusions: Oral preparations of ARG (±CanO) were well tolerated for up to 60 consecutive days and had favorable effects on SBP and DBP in hypertensive KT and HD patients. (Journal of Parenteral and Enteral Nutrition 25:194–202, 2001)
Outcome of Patients Treated with Home Enteral Nutrition
Authors: Schneider Stéphane M. , Raina Claire , Pugliese Pascal , Pouget Isabelle , Rampal Patrick , Hébuterne Xavier
Published: May 2008

Background: The aims of this study were to prospectively analyze the 1‐month mortality and long‐term outcome of home enteral nutrition (HEN) patients in order to determine the benefits of this treatment. Methods: Between 1990 and 1996, 417 patients, aged 64 ± 25 years, were discharged on HEN and followed up until December 31, 1998, when outcome was assessed, which allowed us to determine survival probabilities and conditions associated with survival. Results: The mean duration of HEN was 242 ± 494 days, with a 24‐ to 103‐month follow‐up. Probabilities of being alive at 1 month, 1 year, and 5 years were 80%, 41.7%, and 25%, respectively. Factors associated with death were dementia, neurologic disease, head and neck cancer, AIDS, and age over 70 years. A total of 5.5% of patients remained dependent on HEN, 32.6% resumed full oral nutrition, 20.2% of patients died during the first month on HEN, and 35% died after more than 1 month on HEN (219 ± 257 days). A total of 6.7% of patients stopped HEN for other reasons. Conclusions: HEN provides well‐tolerated long‐term nutritional support in many patients. However, because of their likelihood of being old and the nature of the underlying disease, these patients as a group tend to have a modest prognosis. This calls for the determination of more accurate selection criteria, and the measurement of the impact of HEN on quality of life. (Journal of Parenteral and Enteral Nutrition 25:203–209, 2001)
Choline Deficiency Causes Reversible Hepatic Abnormalities in Patients Receiving Parenteral Nutrition: Proof of a Human Choline Requirement: A Placebo‐Controlled Trial
Authors: Buchman Alan L. , Ament Marvin E. , Sohel Mir , Dubin Mark , Jenden Donald J. , Roch Margaret , Pownall Henry , Farley William , Awal Mohammed , Ahn Chul
Published: May 2008

Background: Previous studies have shown that plasma free choline concentrations are significantly decreased in many long‐term home total parenteral nutrition (TPN) patients. Furthermore, low choline status has been associated with both hepatic morphologic and hepatic aminotransferase abnormalities. A preliminary pilot study suggested choline‐supplemented TPN may be useful in reversal of these hepatic abnormalities. Methods: Fifteen patients (10 M, 5 F) who had required TPN for >80% of their nutritional needs were randomized to receive their usual TPN (n = 8), or TPN to which 2 g choline chloride had been added (n = 7) for 24 weeks. Baseline demographic data were similar between groups. Patients had CT scans of the liver and spleen, and blood for plasma free and phospholipid‐bound choline, alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase, gamma glutamyl transferase (GGT), bilirubin, serum lipids, complete blood count (CBC), and chemistry profile obtained at baseline, and weeks 2, 4, 6, 12, 16, 20, 24, and 34. CT scans were analyzed for Hounsfield unit (HU) densities. Results: There were no significant differences in any measured parameters after 2 weeks. However, at 4 weeks, a significant difference in liver HU between groups was observed (13.3 ± 5.0 HU [choline] vs 5.8 ± 5.2 HU [placebo], p =.04). This significant trend continued through week 24. Recurrent hepatic steatosis and decreased HU were observed at week 34, 10 weeks after choline supplementation had been discontinued. A significant increase in the liver‐spleen differential HU was also observed in the choline group (10.6 ± 6.2 HU [choline] vs 1.3 ± 3.3 HU [placebo], p =.01). Serum ALT decreased significantly (p =.01 to.05) in the choline group vs placebo at weeks 6,12, 20, and 24. Serum AST was significantly decreased in the choline group by week 24 (p =.02). The serum alkaline phosphatase was significantly reduced in the choline group at weeks 2, 12, 20, 24, and 34 (p =.02 to 0.07). Total bilirubin was normal in these patients and remained unchanged during the study. Serum GGT tended to decrease more in the choline group, but the greater decrease was not statistically significant. Conclusions: Choline deficiency is a significant contributor to the development of TPN‐associated liver disease. The data suggest choline is a required nutrient for long‐term home TPN patients. (Journal of Parenteral and Enteral Nutrition 25:260–268, 2001)
Metastasis of Head and Neck Carcinoma to the Site of Percutaneous Endoscopic Gastrostomy: Case Report and Literature Review
Authors: Sinclair J. Jefferds , Scolapio James S. , Stark Mark E. , Hinder Ronald A.
Published: May 2008

Background: Patients with head and neck cancer often need a percutaneous endoscopic gastrostomy to provide adequate nutrition because of inability to swallow after tumor radiation therapy. However, metastasis of the original tumor to the gastrostomy exit site may occur. Methods: We describe the case of a 61‐year‐old man with stage III (T2 N1) squamous cell carcinoma of the tongue in whom a PEG tube was placed to circumvent anticipated difficulties in swallowing after radiation therapy. We also compare this case with similar cases in the literature. Results: Soreness and erythema near the gastrostomy site reported by the patient were diagnosed as cellulitis, and two courses of antibiotic treatment were prescribed. However, a biopsy showed that the original squamous cell carcinoma had metastasized to the gastrostomy exit site. The “pull” method of tube placement had been used in this patient and in all 19 cases of metastasis reported in the literature. Conclusions: Metastatic cancer should be considered in patients with head and neck cancer who have unexplained skin changes at the gastrostomy site. Our experience with this case and review of the literature indicate that, in patients with head and neck cancer, “pull” procedures for placement of gastrostomy tubes may induce metastasis by direct implantation of tumor cells because of contact between the gastrostomy tube and tumor cells. Methods of tube insertion that avoid such contact are preferred. (Journal of Parenteral and Enteral Nutrition 25:282–285, 2001)