bluuebunny/crossref_metadata_2025 huggingface dataset:
Comparison of Two Systems of Measuring Energy Expenditure
Authors: Stewart Christina L. , Goody Cynthia M. , Branson Richard
Published: May 2008

Background: Health care professionals typically use resting metabolic rate (RMR) via indirect calorimetry to determine a person's energy expenditure. Traditional indirect calorimetry measurements involve an expensive, cumbersome piece of equipment that requires careful calibration. The recent development of a handheld indirect calorimeter makes it easier to measure RMR. The purpose of this study was to compare simultaneous measurements of RMR with handheld and traditional indirect calorimeters. Methods: Healthy, free‐living subjects (n = 50) age 18 years and older were tested simultaneously with both indirect calorimeters. All subjects breathed through the handheld device using a mouthpiece while wearing noseclips to prevent leaks. The handheld indirect calorimetry device was placed inside a canopy. The exhaled gas from the handheld was positioned directly over the inlet to the port delivering gases to the traditional device's mixing chamber. The canopy facilitated the simultaneous collection of all expired gases into the traditional device. During the measurement, oxygen consumption and RMR were continuously recorded on a personal computer.Results: Mean oxygen consumption and RMR did not significantly differ between the two devices, with a mean difference of 0.58± 15.33 mL/min (p = .790) and 4.66 ± 113.39 kcal/day (p = .773) and an absolute difference of 12.3 ± 8.99 mL/min and 86.58 ± 72.32 kcal/day, respectively. Correlation coefficients for oxygen consumption and RMR were 0.945 and 0.941, respectively. Conclusions: No significant difference was found between the measurements of indirect calorimetry with the MedGem (HealtheTech, Golden, CO) device compared with the DeltaTrac device (Datex‐Ohmeda, Madison, WI). These findings suggest that the handheld indirect calorimeter may provide an accurate measure of oxygen consumption and RMR measurements for spontaneously breathing subjects.
The Effect of Severe Undernutrition and Subsequent Refeeding on Whole‐Body Metabolism and Protein Synthesis in Human Subjects
Authors: Winter T. A. , O'Keefe S. J. , Callanan M. , Marks T.
Published: May 2008

Background: To determine the consequences of severe undernutrition and refeeding on whole‐body metabolism and protein synthesis. Methods: Respiratory quotient (RQ), resting energy expenditure (REE), and whole‐body protein synthesis (WBPS) were assessed in undernourished patients, with anorexia nervosa (n = 8) or with coexistent disease (n = 17). Results were compared with 17 healthy controls. Six anorexic patients and 13 disease patients consented to study after nutrition support. Results: Mean body mass index was 12.46 ± 0.53 kg/m2 in the anorexia patients and 13.81 ± 0.40 kg/m2 in the disease patients (controls 23.71 ± 0.72 kg/m2; p < .001). Compared with controls, RQ was similar in anorexia patients (0.85 ± 0.05 vs 0.90 ± 0.05) but lower in the disease patients (0.76 ± 0.03 vs 0.90± 0.05; p = .02). REE was lower in the patients (anorexia 1058± 134.0 kcal/d, disease 1189 ± 101.4 kcal/d vs 1828± 89.76 kcal/d; p < .001); however, expressed as kcal/kg/d, it was higher (anorexia 32.17 ± 4.25, disease 31.30 ± 2.14 vs 25.07 ± 1.00; p < .05). WBPS was lower in the patients (anorexia 140.9 ± 10.54 g/d, disease 119.8 ± 8.57 g/d vs 305.0 ± 21.64 g/d; p < .001); however, when expressed as g/kg/d, the anorexia patients were similar to controls, whereas the disease patients were lower (3.11 ± 0.24 vs 4.27 ± 0.32; p < .05). Refeeding increased RQ in the disease patients (0.84 ± 0.03 vs 0.76 ± 0.03; p < .05), and normalized REE (anorexia 27.65 ± 3.05 kcal/kg/d, disease 28.90 ± 1.85 kcal/kg/d). WBPS increased in the disease patients (173.6 ± 16.38 g/d vs 116.5 ± 10.15 g/d; p < .01). Conclusions: Undernutrition is associated with increased REE (kcal/kg/d). Reduction in RQ and protein synthesis (g/kg/d) was evident in those patients with coexistent disease. Refeeding resulted in normalization of RQ, REE (kcal/kg/d), and protein synthesis (g/kg/d).
Celiac Disease Unmasked After Pancreaticoduodenectomy
Authors: Stone Christian D. , Klein Samuel , McDoniel Karen , Davidson Nicholas O. , Prakash Chandra , Strasberg Steven M.
Published: May 2008

A report of profound diarrhea, weight loss, and malnutrition secondary to celiac disease that manifested after pancreaticoduodenectomy (Whipple surgery). The patient had no prior diarrhea or other symptoms of celiac disease and the diagnosis was unsuspected for months. A review of this underappreciated presentation of celiac disease is provided.
Parenteral Nutrition–Associated Cholestasis in Neonates: Multivariate Analysis of the Potential Protective Effect of Taurine
Authors: Spencer Ariel U. , Yu Sunkyung , Tracy Thomas F. , Aouthmany Moustafa M. , Llanos Adolfo , Brown Morton B. , Brown Marilyn , Shulman Robert J. , Hirschl Ronald B. , DeRusso Patricia A. , Cox Jean , Dahlgren Jacqueline , Strouse Peter J. , Groner Jonathan I. , Teitelbaum Daniel H.
Published: May 2008

Background: Neonates receiving parenteral nutrition (PN) are at risk for PN‐associated cholestasis (PNAC); however, no preventive factors for PNAC have been clearly identified. Despite reports suggesting that taurine may prevent PNAC in neonates, such an effect of taurine has not yet been definitively demonstrated. We determined whether taurine supplementation reduces the incidence of PNAC in premature or critically ill neonates. Methods: This study was part of a prospective, randomized, multi‐institutional trial designed to assess cholecystokinin vs placebo as a potential preventive therapy of PNAC. Taurine supplementation of PN varied between institutions. The presence or absence of taurine in PN was analyzed by multivariate analysis, with a primary outcome measure of serum conjugated bilirubin (CB) as a measure of PNAC. Results: Taurine reduced PNAC in premature infants (estimated maximum CB [95% confidence interval] 0.50 mg/dL [–0.17 to 1.18] for those receiving taurine, vs 3.45 mg/dL [1.79–5.11] for neonates not receiving taurine, approaching significance, p = .07). Taurine significantly reduced PNAC in infants with necrotizing enterocolitis (NEC; estimated maximum CB 4.04 mg/dL [2.85–5.23], NEC infants receiving taurine, vs 8.29 mg/dL [5.61–10.96], NEC infants not receiving taurine, p < .01). There were too few neonates with surgical anomalies to evaluate the effect of taurine in this group. Conclusions: Within specific subgroups of neonatal patients, taurine supplementation does offer a very significant degree of protection against PNAC. Patients with NEC or severe prematurity are most likely to benefit substantially from taurine supplementation.
Latent Copper Deficiency in Patients Receiving Low‐Copper Enteral Nutrition for a Prolonged Period
Authors: Ito Yuki , Ando Tetsuo , Nabeshima Toshitaka
Published: May 2008

Background: Copper deficiency has been reported in patients supported with long‐term enteral nutrition. Occasionally, this leads to anemia and leukopenia. There is no detailed report relating to the onset time of copper deficiency and how the symptoms develop. This report describes the relation between copper deficiency symptoms and duration of enteral nutrition. Methods: The study included 55 patients, with 82 measurements, at the neurologic ward of Nagoya Daini Red Cross Hospital. The mean age was 71± 11 years. The daily average dosage of energy was 938 kcal/d. A commercial nutrient for enteral administration that contains 0.13 mg/1000 mL copper was used. Baseline measures on individual patients were taken every month. Blood was collected at 8 am before and after the start of enteral nutrition. Levels of copper, zinc, ceruloplasmin, hemoglobin, and white blood cells were measured. Results: The serum level of copper in the patients was 94.0–181.0 μg/dL before the start of enteral nutrition. The level of serum copper remained within the normal range for about 3 months. The level of serum copper in the patients decreased gradually and was less than the normal level after 3 months, with the exception of 1 patient. The serum level of copper in the patients was 3.0–123.0μ g/dL 3 months after the start of enteral nutrition. The levels of serum copper were below normal in 25 cases out of 82 measurements. However, the number of patients with symptoms of copper deficiency was only 2. Copper deficiency symptoms appeared at 41 and 77 months, the average being 59 months. Conclusions: Almost all patients showed a latent copper deficiency about 3 months after the start of enteral nutrition. However, only a few patients developed overt symptoms of copper deficiency.
Effects of Hypercaloric Feeding on Nutrition Status and Carbon Dioxide Production in Patients With Long‐Term Mechanical Ventilation
Authors: Lo Hui‐Chen , Lin Ching‐Hsiung , Tsai Ling‐Jang
Published: May 2008

Background: To clarify clinical arguments regarding nutrition support in patients with long‐term mechanical ventilation, we investigated the effects of hypercaloric feeding on nutrition status and carbon dioxide production. Methods: Twenty‐eight mechanically ventilated, clinically stable patients with nasogastric tube feeding were recruited and randomly divided into the control and hypercaloric groups, which were provided with 1.2‐ and 1.8‐fold of resting energy expenditure (REE), respectively. The arterial and venous blood samples were collected, the anthropometric measurements were determined, the serum concentrations of nutrition‐related proteins were measured, and the parameters on the ventilator and indirect calorimeter were recorded on weeks 0, 2, and 4. Results: There were no significant changes in anthropometric measurements, blood gas tensions, and REE between the control and hypercaloric groups during the experimental period (mixed model with repeated measures analysis, p < .05). After adjusted for values on week 0 and time, patients with hypercaloric feeding had significantly increased levels in white blood cells, hemoglobin, and hematocrit. However, the control group had significantly decreased and the hypercaloric group had significantly increased serum concentrations of prealbumin and transferrin, rate of carbon dioxide production, and respiratory quotient (RQ) from week 0 to week 4. Conclusion: Our results suggest that 4 weeks of hypercaloric feeding may significantly increase the production of carbon dioxide but may not significantly alter the clinical outcomes in patients with long‐term mechanical ventilation. The adverse effects of hypercaloric feeding may easily be overlooked, and the appropriateness of nutrition support should be carefully monitored in patients with mechanical ventilation.
Reducing Costs and Patient Morbidity in the Enterally Fed Intensive Care Unit Patient
Authors: Farber Mitchell S. , Moses Julia , Korn Margaret
Published: May 2008

Background: Critically ill patients are at high risk for nosocomial infections and resultant organ dysfunction and death. These patients typically have protracted intensive care unit (ICU) courses and consume increasingly limited resources. Enteral nutrition with specific immune‐modulating components has been previously shown to improve outcomes in select populations of patients, but results have been mixed in critically ill patients. Impact 1.5 (Novartis Nutrition, Minneapolis, MN) is a commercially available enteral formula containing ingredients known to improve several parameters of immune function. We hypothesized that administration of Impact 1.5 tube feedings would reduce the incidence of nosocomial infection and ICU resources in critically ill patients admitted to the ICU for severe trauma, burns, or sepsis insults. Methods: The Impact 1.5 group (n = 17) was compared with a historical cohort of ICU patients (n = 21) of similar illness severity that received a standard high‐energy enteral formula. The incidence of nosocomial infections and mortality, and the consumption of multiple ICU resources were examined. A cost analysis based on these results was then performed to determine the cost effectiveness of this proprietary immunonutrition enteral formula. Results: A pronounced reduction in nosocomial pneumonia (12% vs 52%, p<.01) was identified, with consequent trends toward a reduction in duration of mechanical ventilation and ICU length of stay. Urinary tract infections that may have less influence on ICU resources were increased in the Impact 1.5 group. No difference in mortality was identified, despite the inclusion of patients with severe sepsis in the study group. According to the average number of ICU days required for each study cohort, the Impact 1.5 group led to a cost savings of at least $193,350.00. Conclusions: ICU patients with significant illness severity experienced a decrease in the incidence of an important nosocomial infection that is commonly associated with increased use of ICU resources and length of stay. This decrease in patient morbidity led to substantial cost savings despite the small size of our study trial. (Journal of Parenteral and Enteral Nutrition 29:S62–S69, 2005)
Is the Use of Specialized Nutritional Formulations a Cost‐Effective Strategy? A National Database Evaluation
Authors: Strickland Adrien , Brogan Anita , Krauss Janis , Martindale Robert , Cresci Gail
Published: May 2008

Background: We apply currently published clinical outcomes data to length of stay and hospital cost to determine the potential economic benefit associated with the use of specialized nutritional formulations in elective surgical, trauma, and medical patients. Although the use of immune‐modulating formulations has repeatedly shown favorable clinical outcomes, including decreased complications (both infectious and noninfectious), length of stay (both ICU and total days), and ventilator days, the cost‐effectiveness of nutritional modulation of the immune response in a US‐based population has not previously been explored. Methods: Data for the current study were obtained from a large national database with 126 member hospitals and data from over 1 million patients. Data extracted from the database included patient type (surgical, medical, and trauma) and subservice, whether the hospital stay was “complicated” or “uncomplicated” (as determined by diagnosis‐related groups and International Classification of Diseases, Ninth Revision coding), mean length of stay, mean cost, and incremental cost per complication experienced. The clinical outcomes measures from 3 major peer‐reviewed studies were then applied to the cost data in order to determine the cost savings associated with the use of specialized nutritional formulations in each of the patient populations. Additionally, cost data were segmented by region of the United States (New England, mid‐Atlantic, South, Midwest, Southwest, and West) and by primary focus of the health care facility (academic, indigent care, large community) to enable more meaningful cost comparisons. Results: For the medical patient population, according to the published rate of 51% decrease in risk of infectious complications and a decreased length of hospital stay of 9.7 days, net cost savings (after accounting for the increased costs of administering immune modulating formula) is $2066. The same calculations were done for surgical and trauma patients, with $688 and $308 net cost savings per patient, respectively. These figures assume a base infection rate of 5%. Expected cost savings vary markedly for deviations in base infection rate and slightly for differences in facility type or region of the country. Conclusions: This study demonstrates that specialized nutritional formulations are a cost‐effective way for hospitals to improve clinical outcomes while reducing resource consumption and total cost. These benefits are observable in all patient types, all facility types, and all regions of the United States. (Journal of Parenteral and Enteral Nutrition 29:S81–S91, 2005)
Economic Study in Surgical Patients of a New Model of Nutrition Therapy Integrating Hospital and Home vs the Conventional Hospital Model
Authors: Baxter Yara Carnevalli , Dias Maria Carolina G. , Maculevicius Janete , Cecconello Ivan , Cotteleng Bernard , Waitzberg Dan Linetzky
Published: May 2008

Background: Dehospitalization is a trend in the health sector justified by humanitarian and socials aspects for the patient and relatives. From the financing institutions’ perspective, whether government or third party, the positive results arise from an optimization of hospital bed use and favorable cost‐benefit ratio. The “integrated home‐hospital” model was created with the purpose of optimization of resources without detriment to the patients’ nutritional care. The objective of this study was an economic evaluation regarding nutrition therapy of the integrated hospital‐home model in comparison with an exclusively hospital model. Methods: A retrospective controlled study, paired (age, sex, disease, and surgical procedure), was performed on 56 digestive surgery patients divided into 2 groups: study (SG; n= 30) and control (CG; n= 26). The data collected included total expenses with hospitalization, nutritional benefits, minimization cost analysis, cost‐effectiveness ratio analysis, cost‐benefit ratio analysis, hospital length of stay, and hospital‐bed optimization. Results: The patients from the SG achieved the same nutritional benefits as those in the CG, but with expenses 3 times lower (median Brazil Reals (R)$3237.18 vs R$8647.93; p<.05). The new model resulted in economic benefit to the institution, as shown by the cost‐effectiveness ratio, mainly resulting from the savings of the days of hospitalization avoided. The cost‐benefit ratio showed an important savings per patient for the institution (US $3100). Conclusions: The home‐hospital model also reduced length of hospital stay 2.7 times and optimized the hospital bed usage, as it promoted higher hospital‐bed rotation (3 times greater). (Journal of Parenteral and Enterai Nutrition 29:S96‐S105, 2005)
Enteral Nutrition in the Management of Crohn's Disease
Authors: Griffiths Anne M.
Published: May 2008

Exclusive feeding of defined formula diets has been used successfully as an alternative to corticosteroid treatment of active Crohn's disease, but the mechanism of efficacy remains conjectural. Recognition that polymorphisms in the NOD2/CARD15 gene confer susceptibility to Crohn's disease has increased appreciation of the interactions between the innate immune system and enteric bacteria, which lead to chronic intestinal inflammation. The 2 major goals of this workshop are: first, in light of current understanding of pathogenesis, to examine possible mechanisms of action of enteral nutrition as primary therapy; and second, to make evidence‐based recommendations concerning its use in the new era of biologic therapies, when mucosal healing has become a realistic goal. Factors influencing efficacy, including duration, location of intestinal inflammation, and formula composition require consideration.
Feeding an Elemental Diet vs a Milk‐Based Formula Does Not Decrease Intestinal Mucosal Growth in Infant Pigs
Authors: Stoll Barbara , Price Pamela T. , Reeds Peter J. , Chang Xiaoyan , Henry Josef F. , van Goudoever Johannes B. , Holst Jens J. , Burrin Douglas G.
Published: May 2008

Background: We previously showed that the level of enteral nutrient intake determines the rate of intestinal growth in piglets. Our objective was to determine whether providing enteral nutrition in the form of elemental nutrients (glucose, amino acids, lipid [ED]) rather than cow's milk formula (lactose, protein, lipid [FORM]) reduces small intestinal growth and lactase activity. Methods: Three‐week‐old piglets were fed either ED (n = 7) intragastrically or FORM (n = 6) orally for 6 days. Results: Intestinal protein and DNA masses, villus height, and crypt depth were not different in ED and FORM pigs. Crypt cell proliferation, measured by in vivo bromodeoxyuridine labeling, was significantly (p < .05) higher (+37%) in ED than in FORM pigs. Rates of mucosal protein synthesis (%/d), measured by in vivo 2H‐leucine incorporation, were higher (p < .05) in ED than FORM (147 vs 89) pigs. Circulating concentrations (pmol/L) of the intestinotrophic peptide, glucagon‐like peptide‐2 (GLP‐2), were also higher (p < .05) in ED than in FORM (148 vs 87) pigs. The mean lactase‐specific activity (μmol/min/g) in proximal and distal segments was higher (p < .05) in FORM than in ED (124 vs 58) pigs. Conclusions: We conclude that intestinal mucosal growth and villus morphology are similar in pigs fed ED and FORM, despite higher cell proliferation and protein synthesis rates and lower lactase activity with ED. This implies that elemental diets may be as trophic as polymeric formulas to simultaneously provide nutrition and a stimulus for intestinal growth during bowel rest.
IV Hypertonic Glucose Stimulates the Exocrine Pancreas in Rat
Authors: Fan Bo‐Guang , Andrén‐Sandberg Åke
Published: May 2008

Background: Pancreatic atrophy and dysfunction resulting from parenteral nutrition (PN) may be explained by several mechanisms; one of the important factors is the nutrient in the circulation, which affects the pancreatic growth and secretion. The effect of nutrients on the pancreatic exocrine still has controversies. The aim of the present study is to better understand the effect of IV glucose on the exocrine pancreas stimulated by cholecystokinin during the parenterally fed condition. Methods: Two mixed solutions consisting of 30% and 50% glucose, respectively, were used. Thirty male Sprague‐Dawley rats were randomly divided into 5 groups, including a control group; a freely fed group received cholecystokinin; 2 groups were infused with 30% and 50% glucose, and a group was infused with 50% glucose with cholecystokinin. The body weight and pancreatic contents were measured after 10 days. Results: The body weight in all groups was increased but lower than in the freely fed rats. IV glucose caused a decrease in the pancreatic weight, the amount of the pancreatic protein and DNA, and the level of amylase but elevated the level of trypsin in all treated groups. The enzymes were elevated after infusion of cholecystokinin with glucose, but they were lower than in freely fed animals with cholecystokinin. Compared with 30% glucose, 50% glucose elevated the level of amylase but did not affect the level of trypsin. Conclusions: IV glucose results in atrophy of the exocrine pancreas, elevates the amylase in pancreas, but suppresses the stimulatory effect of cholecystokinin on the exocrine pancreas.
Metabolic Mechanisms of Stress Hyperglycemia
Authors: Mechanick Jeffrey I.
Published: May 2008

Stress hyperglycemia has gained the attention of virtually every physician who encounters critically ill patients, with the emergence of clinical data supporting tight glycemic control and intensive insulinization for optimal outcome. In order to effectively manage stress hyperglycemia, newer theories of critical illness and the interactions of the brain, neuroendocrine axis, and immune system need to be explored. Nonlinear physiologic processes, glucose allostasis, immune‐neuroendocrine axis activation, and molecular mechanisms of insulin receptor signal transduction contribute to a novel model of stress hyperglycemia. In chronic critical illness, allostatic overload leads to a plurality of organ‐system derangements and eventually death. Intervention not only involves insulinization according to neurofuzzy logic but also targeting more proximate events with cognitive/behavioral therapy and hypothalamic releasing factors.
Insulin Therapy and In‐Hospital Mortality in Critically Ill Patients: Systematic Review and Meta‐analysis of Randomized Controlled Trials
Authors: Pittas Anastassios G. , Siegel Richard D. , Lau Joseph
Published: May 2008

Background: Hyperglycemia is common in critically ill hospitalized patients and has been associated with adverse outcomes, including increased mortality. In this review, we examine the effect of insulin therapy on mortality in critically ill patients. Methods: We updated our previous systematic review and meta‐analysis to include recently published trials that report data on the effect of insulin therapy initiated during hospitalization on mortality in adult patients with a critical illness. We also include a short primer on the methods of systematic reviews and meta‐analyses, outlining the specific steps and challenges of this methodology. We performed an electronic search in the English language of MEDLINE and the Cochrane Controlled Clinical Trials Register and a hand search of key journals and relevant review articles for randomized controlled trials that reported mortality data on critically ill hospitalized adult patients treated with insulin (regardless of method of administration). Results: We identified 38 relevant studies that entered the analysis. We found that therapy with insulin in adult patients hospitalized for a critical illness, other than hyperglycemic crises, may decrease mortality in certain groups of patients. The beneficial effect of insulin was evident in the surgical intensive care unit (relative risk [RR], 0.58; confidence interval [CI], 0.22–0.62) and in patients with diabetes (RR, 0.76; CI, 0.62–0.92). There was a trend toward benefit in patients with acute myocardial infarction (RR, 0.89; CI, 0.76–1.03). Targeting euglycemia appears to be the main determinant of the benefit of insulin therapy (RR, 0.73; CI, 0.57–0.94). Conclusions: Insulin therapy in adult patients hospitalized for a critical illness, other than hyperglycemic crises, may decrease mortality in certain groups of patients.
Glutamine Supplementation Increases Postprandial Energy Expenditure and Fat Oxidation in Humans
Authors: Iwashita Soh , Mikus Catherine , Baier Shawn , Flakoll Paul J.
Published: May 2008

Background: Glutamine interacts with insulin‐mediated glucose disposal, which is a component of the increase in energy expenditure (EE) after a meal. The study aim was to examine if glutamine supplementation alters postmeal nutrient oxidation. Methods: Ten healthy young adults consumed a mixed meal (6.5 kcal/kg, 14%:22%:64% = protein:fat:carbohydrate) containing either glutamine (GLN:1.05 kcal/kg) or an isocaloric amino acid mixture (alanine: glycine:serine = 2:1:0.5; CON). GLN and CON treatments were administered on separate days in random order for each subject. EE, nonprotein respiratory quotient (RQ), and fat and carbohydrate oxidation rates were assessed using indirect calorimetry for 30 minutes before and for 360 minutes after meal ingestion. Results: Premeal EE and RQ were similar between treatments. The increase in EE above basal during both early (0–180 minutes) and late (180–360 minutes) postmeal phases was greater in GLN than in CON (p < .05), resulting in postmeal EE being 49% greater during the total postmeal phase (p < .05). Net change of carbohydrate oxidation was 38% higher during the early phase with GLN (p < .05), whereas it was 71% lower during the later phase (p < .05). GLN enhanced fat oxidation by ∼42 kcal compared with CON during the late phase (p < .05). Conclusions: Glutamine supplementation with a mixed meal alters nutrient metabolism to increase postmeal EE by increasing carbohydrate oxidation during the early postmeal phase and fat oxidation during the late postmeal phase. Consideration must be given to the potential that these postprandial changes in EE are related to glutamine‐mediated changes in insulin action and consequently glucose disposal.
Hypertaurinemia in Bile Duct–Ligated Rats After Surgery: The Effect of Gut Endotoxin Restriction on Organ Fluxes and Oxidative Status
Authors: Houdijk Alexander P. J. , Oosterling Steven J. , Siroen Michiel P. C. , de Jong Sigrid , Richir M. , Rijssenbeek Astrid L. , Teerlink Tom , van Leeuwen Paul A. M.
Published: May 2008

Surgery in obstructive jaundice is associated with complications related to gut‐derived endotoxemia. The organs involved in these complications, including liver, kidneys, and gut, are important in the metabolism of taurine, which is implicated in bile acid conjugation and has antioxidative effects. Taurine organ metabolism and liver oxidative status were studied in bile duct–ligated rats (BDL) after laparotomy. Oral cholestyramine treatment inhibits gut‐derived endotoxemia and was used to evaluate the role of endotoxin. In BDL rats, postoperative plasma taurine levels were higher compared with SHAM (p < .0001). Cholestyramine treatment reduced plasma taurine in BDL rats (p < .005), but levels remained higher compared with SHAM groups (p < .0001). In contrast to a liver uptake of taurine in SHAM rats, a release from livers of BDL rats was found (p < .005). Cholestyramine treatment in BDL rats resulted in a liver uptake of taurine (p < .05 vs BDL). A higher uptake of taurine by the kidneys was found in both BDL animals after surgery and SHAM controls (p < .005); however, cholestyramine had no effect. A release of taurine from the gut was found in the SHAM groups, which was reversed in both BDL groups (p < .01). Cholestyramine lowered the elevated levels of hepatic enzymes in BDL rats (ALT and AST: p < .05). Total liver glutathione levels were lower in BDL rats (p < .0001) compared with SHAM groups, and cholestyramine significantly attenuated this decrease (p < .01). Liver malondialdehyde levels were higher in BDL rats compared with SHAM (p < .01), whereas cholestyramine completely prevented this increase in lipid peroxidation (p < .0001). Hypertaurinemia in BDL rats after surgery is most likely explained by reduced bile acid conjugation and hepatocellular leakage. Cholestyramine treatment reduced hepatocellular damage by inhibiting gut‐derived endotoxemia, and reversed the release of taurine from the jaundiced liver into an uptake and consequently lowered plasma taurine levels. This uptake may contribute to the improved antioxidant status in cholestyramine‐treated BDL rats.
Successful Long‐Term Jejunostomy Feedings in Relapsing Pancreatitis: A Case Report
Authors: Sanchez‐Fermin Patricia , Ukleja Andrew , Cruz‐Correa Marcia
Published: May 2008

Relapsing pancreatitis is characterized by repeated episodes of acute inflammation of the pancreas, with either a localized or a systemic organic response that may progress to chronic pancreatitis. Enteral jejunal feedings have been shown to be effective in the management of acute pancreatitis, but long‐term use of jejunal feedings as treatment of relapsing pancreatitis has not been reported. We describe the case of a young patient treated with long‐term jejunal feedings to induce remission and prevent recurrence of acute relapsing pancreatitis. An 18‐year‐old Hispanic man had well‐documented recurrent episodes of acute pancreatitis. Multiple studies were performed as part of the diagnostic workup of the patient's relapsing pancreatitis, including endoscopic ultrasound, endoscopic retrograde cholangiopancreatography with biliary sphincterotomy, and laparoscopic cholecystectomy. Despite medical therapy, endoscopic and surgical procedures, the patient continued having episodes of pancreatitis on a monthly basis, with over 13 distinct documented episodes of pancreatitis during a 15‐month period. A jejunostomy tube was inserted surgically, and long‐term jejunal feedings were instituted, with excellent control of the patient's symptoms. There was only 1 episode of pancreatitis in the ensuing 24 months associated with the resumption of oral feedings and a weight gain of 20 pounds during this time period. Chronic jejunal feedings seem to be an effective alternative for treatment and prevention of acute relapsing pancreatitis. To our knowledge, this is the first report of long‐term enteral feedings in acute relapsing pancreatitis.
Parenteral Nutrition Safe Practices: Results of the 2003 American Society for Parenteral and Enteral Nutrition Survey*
Authors: Seres David , Sacks Gordon S. , Pedersen Craig A. , Canada Todd W. , Johnson Deborah , Kumpf Vanessa , Guenter Peggi , Petersen Craig , Mirtallo Jay
Published: May 2008

Background: The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) recently published a revision of its “Safe Practices for Parenteral Nutrition” guidelines. Because there is a paucity of published scientific evidence to support good practices related to ordering, compounding, and administering parenteral nutrition (PN), a survey was performed in the process of the revision to gain insight into the discrepancies between reported practices and previous guidelines. Methods: A web‐based survey consisting of 45 questions was conducted (n = 651) June 1–30, 2003. Respondents were queried about primary practice setting, professional background, processes for writing PN orders, computer order entry of PN orders, problems with PN orders, and adverse events related to PN. Results: There were 651 survey responses, 90% of which were from hospital‐based practitioners. Almost 75% of responders processed between 0 and 20 PN orders per day. Overall, physicians (78%) were responsible for writing PN orders, but dietitians and pharmacists had significant involvement. PN base components were most often ordered as percentage final concentration after admixture (eg, 20% dextrose), which is inconsistent with safe practice guidelines of ordering by total amount per day (eg, 200 g/day). There was no consistent method for ordering PN electrolytes. Approximately 45% of responders reported adverse events directly related to PN that required intervention. Of these events, 25% caused temporary or permanent harm, and 4.8% resulted in a near‐death event or death. Conclusions: Although the survey found consistency in PN practices for many areas queried, significant variation exists in the manner by which PN is ordered and labeled.
Crocetin Inhibits mRNA Expression for Tumor Necrosis Factor‐α, Interleukin‐1β, and Inducible Nitric Oxide Synthase in Hemorrhagic Shock
Authors: Yang Rongjie , Tan Xiaoyu , Thomas Ann M. , Shen Jing , Qureshi Nilofer , Morrison David C. , Van Way Charles W.
Published: May 2008

Background: Inflammatory factors play an important role in cellular damage after shock and resuscitation. Crocetin, a saffron‐derived carotenoid, has been shown to improve postshock recovery of cellular adenosine triphosphate (ATP) and to increase overall survival in an experimental model of hemorrhagic shock. The hypothesis of the present study is that treatment with crocetin at the beginning of resuscitation suppresses subsequent expression of messenger ribonucleic acid (mRNA) for tumor necrosis factor (TNF‐α), interleukin‐1 (IL‐1β) and inducible nitric oxide synthase (iNOS). Methods: Male Sprague‐Dawley rats (n = 45, 350 ± 30 g) were randomly assigned to 5 groups of 9 animals each. After anesthesia with isoflurane, the femoral artery and vein were surgically cannulated. Hemorrhagic shock was induced by withdrawing blood through the arterial cannula until the mean arterial pressure (MAP) was 25–30 mm Hg and maintained at the level for 30 minutes with further withdrawals. Resuscitation was carried out by giving 21 mL/kg Ringer's lactate (LR) and returning the shed blood, with or without the initial administration of crocetin (2 mg/kg). Controls were normal (anesthesia only), sham (surgical preparation), and shock (preparation and shock). Rats were killed 30 minutes after completion of resuscitation. Liver samples were collected for reverse transcription‐polymerase chain reaction (RT‐PCR) analysis of mRNA (TNF‐α, IL‐1β, iNOS, and β‐actin). Results: Liver mRNA expression for TNF‐α, IL‐1β, and iNOS was found in more animals in the shock and shock‐plus‐resuscitation groups than in the sham control group. The group resuscitated from shock with crocetin had mRNA expression for TNF‐α, IL‐1β, and iNOS in fewer animals than either of the other shock groups and was no different from the sham control group. Conclusions: Crocetin modified the hepatic mRNA expression of cytokines and iNOS in a shock model. This agent continues to show promise as a potential treatment for hemorrhagic shock.
Effects of Preoperative Flavonoid Supplementation on Different Organ Functions in Rats
Authors: van Hoorn Danny E. C. , Nijveldt Robert J. , Boelens Petra G. , Hofman Zandrie , van Leeuwen Paul A. M. , van Norren Klaske
Published: May 2008

Background: Previously it has been reported that preoperative feeding preserves heart function in rats after intestinal ischemia‐reperfusion. To further improve postoperative organ function, bioactive nutrition compounds were selected in vitro against the xanthine oxidase radical cascade, an enzyme suggested to play a key role in the induction of single‐ or multiple‐organ dysfunction. Methods: Flavonoids were selected in vitro for their capacity to (1) inhibit xanthine oxidase, (2) scavenge superoxide, and (3) scavenge peroxylradicals. The most bioactive flavonoids were added to the preoperative nutrition to study their effect on postintestinal ischemia‐reperfusion organ function. Results: A combination of flavonoids selected on basis of effective flavonoid xanthine oxidase inhibition and superoxide scavenging resulted in increased superoxide scavenging. In vivo, the selected flavonoid mixture significantly lowered postischemic intestinal apoptosis and intestinal oxidative stress indicated by malondialdehyde concentration when compared with ischemia‐reperfusion fasted and sham‐fasted animals. Moreover, this flavonoid mixture significantly lowered plasma creatinine and urea concentration, both indicating a better postoperative kidney function. Furthermore, oxidative stress measured as this flavonoid mixture when compared with control significantly lowered plasma malondialdehyde concentration in fed rats. Conclusions: Coadministration of bioactive flavonoid mixture to preoperative nutrition, in contrast to fasting, attenuates ischemia‐reperfusion injury by preserving kidney function in the rat and decreasing apoptosis in the intestine.
Albumin Infusion After Reperfusion Prevents Gut Ischemia‐Reperfusion‐Induced Gut‐Associated Lymphoid Tissue Atrophy
Authors: Ikezawa Fumie , Fukatsu Kazuhiko , Moriya Tomoyuki , Maeshima Yoshinori , Okamoto Koichi , Hara Etsuko , Hiraide Hoshio , Compher Charlene W.
Published: May 2008

Background: Our recent study clarified that gut ischemia‐reperfusion (I/R) causes gut‐associated lymphoid tissue (GALT) mass atrophy, a possible mechanism for increased morbidity of infectious complications after severe surgical insults. Because albumin administration reportedly reduces hemorrhagic shock–induced lung injury, we hypothesized that albumin treatment prevents GALT atrophy due to gut I/R. Methods: Male mice (n = 37) were randomized to albumin, normal saline, and sham groups. All groups underwent jugular vein catheter insertion. The albumin and normal saline groups underwent 75‐minute occlusion of the superior mesenteric artery. During gut ischemia, all mice received normal saline infusions at 1.0 mL/h. The albumin group was given 5% bovine serum albumin in normal saline at 1.0 mL/h for 60 minutes after reperfusion, whereas the normal saline group received 0.9% sodium chloride at 1.0 mL/h. The sham group underwent laparotomy only. Mice were killed on day 1 or 7, and the entire small intestine was harvested. GALT lymphocytes were isolated and counted. Their phenotypes (αβTCR, γδTCR, CD4, CD8, B220) were determined by flow cytometry. Results: On day 1, the gut I/R groups showed significantly lower total lymphocyte and B cell numbers in Peyer's patches and the lamina propria than the sham group. However, the albumin infusion partially but significantly restored these cell numbers. On day 7, there were no significant differences in any of the parameters measured among the 3 groups. Conclusions: Albumin infusion after a gut ischemic insult may maintain gut immunity by preventing GALT atrophy.
Growth Hormone Favorably Affects Bone Turnover and Bone Mineral Density in Patients With Short Bowel Syndrome Undergoing Intestinal Rehabilitation
Authors: Tangpricha Vin , Luo Menghua , Fernández‐Estívariz Concepción , Gu Li H. , Bazargan Niloofar , Klapproth Jan‐Michael , Sitaraman Shanthi V. , Galloway John R. , Leader Lorraine M. , Ziegler Thomas R.
Published: May 2008

Background: Patients with short bowel syndrome (SBS) have a high prevalence of metabolic bone disease due to nutrient malabsorption and potential effects of parenteral nutrition (PN). Human growth hormone (hGH) has been shown in some studies to have anabolic effects on bone, but hGH effects on bone in patients with SBS are unknown. Methods: Adults with PN‐dependent SBS underwent a 7‐day period of baseline studies while receiving usual oral diet and PN and then began receiving modified diets designed to improve nutrient absorption and daily oral calcium/vitamin D supplements (1500 mg elemental calcium and 600 IU vitamin D, respectively). Subjects were randomized to receive in a double‐blind manner either subcutaneous (sc) saline placebo as the control or hGH (0.1 mg/kg/d for 3 weeks, then 0.1 mg/kg 3 days a week for 8 subsequent weeks). Open‐label hGH was given from week 13 to week 24 in subjects who required PN after completion of the 12‐week double‐blind phase. Markers of bone turnover (serum osteocalcin and urinary N‐telopeptide [NTX]), vitamin D nutriture (serum calcium, 25‐hydroxyvitamin D [25‐OH D] and parathyroid hormone [PTH] concentrations), and intestinal calcium absorption were measured at baseline and at weeks 4 and 12. Dual x‐ray absorptiometry (DXA) of the hip and spine was performed to determine bone mineral density (BMD) at baseline and weeks 12 and 24. Results: The majority of subjects in each group exhibited evidence of vitamin D deficiency at baseline (25‐OH D levels <30 ng/mL; 78% and 79% of control and hGH‐treated subjects, respectively). Subjects treated with hGH demonstrated a significant increase from baseline in serum osteocalcin levels at 12 weeks (+62%; p < .05). The levels of NTX were increased over time in the hGH‐treated group; however, this did not reach statistical significance. Both NTX and osteocalcin remained unchanged in control subjects. BMD of the spine and total hip was unchanged in subjects treated with placebo or hGH at 24 weeks. However, femoral neck BMD was slightly but significantly decreased in the placebo group at this time point but remained unchanged from baseline in the hGH‐treated subjects. Conclusions: hGH therapy significantly increased markers of bone turnover during the initial 3 months of therapy and stabilized femoral neck bone mass over a 6‐month period in patients with severe SBS undergoing intestinal rehabilitation.
Isolated Orthotopic Liver Transplantation for Parenteral Nutrition–Associated Liver Injury
Authors: Barshes Neal R. , Carter Beth A. , Karpen Saul J. , O'Mahony Christine A. , Goss John A.
Published: May 2008

Background: Mild liver dysfunction is common after prolonged use of parenteral nutrition (PN), but end‐stage liver failure occurs only rarely. Few treatment options other than combined liver‐intestine transplantation exist for patients with liver failure associated with PN use, however. Herein, we report the results of a cohort of patients undergoing isolated orthotopic liver transplantation (OLT) for PN‐associated liver injury. Methods: A retrospective cohort study of 80 patients (73 pediatric patients and 7 adults) who have undergone isolated OLT for PN‐associated liver injury as the primary indication for transplantation was performed. Results: At the time of OLT, the mean total serum bilirubin was 19.5 mg/dL and the mean serum albumin level was 2.9 mg/dL. Severe hepatic encephalopathy was seen in 5%, spontaneous bacterial peritonitis was seen in 6.3%, and respiratory failure requiring mechanical ventilation was seen in 14% of patients at the time of OLT. Overall 1‐ and 5‐year survival rates were 72% and 52%, respectively, with infection being the most common cause of death after OLT. Retransplantation was required in 25% of patients, and the 5‐year posttransplant patient survival rate only reached 35% in these cases. Conclusions: Patients with end‐stage liver disease associated with PN administration often have very severe liver disease, multiple comorbidities, and poor prognosis by the time they are listed for OLT. Nonetheless, isolated OLT is associated with good long‐term survival and should be considered for selected patients with combined intestine‐liver failure.
Peptide YY (PYY) Is Increased in Elderly Patients With Femoral Neck Fractures: A Prospective Cohort Study
Authors: Nematy Mohsen , Powell Chris A. , Brynes Audrey E. , Pearse Michael , Patterson Michael , Ghatei Mohammad A. , Bloom Steve R. , Frost Gary S.
Published: May 2008

Background: Peptide YY (PYY), a gut peptide, has recently been shown to inhibit appetite. The role of this peptide in elderly nutritionally‐compromised patients with femoral neck fracture (FNF) has not been investigated. In this study, we investigated the longitudinal pattern of PYY levels during hospital stay and investigated the postprandial PYY response to a standard meal in patients with FNF and matched controls. Methods: Fasting plasma concentrations of the PYY were measured on days 1, 4, 7, 14, 21 and 28 or on discharge from the hospital in 17 white patients with FNF. On the second week of stay, 13 patients with FNF consumed a standard breakfast following an overnight fasting. One fasting sample and one 45‐minute postmeal sample were collected. A control group was made up of 17 matched healthy elderly patients. Results: PYY concentrations were increased significantly over the length of hospital stay. Results of the test breakfast suggested a significant and exaggerated post‐prandial PYY response, despite a smaller energy intake being consumed. Conclusions: This study shows PYY concentrations are increased during hospitalization and their post‐prandial release exaggerated in this group of vulnerable patients, and suggests a role in the etiology of reduced appetite in this patient group.
Enteral Access in Home Care
Authors: DeLegge Mark H.
Published: May 2008

Enteral nutrition is the delivery of nutrients through the gastrointestinal tract. For those patients who cannot or will not swallow, an enteral access device (EAD) is required. Some of these devices can be passed through the oral or nasal cavity into the stomach or small bowel. Alternatively, the devices can be percutaneously placed by an endoscopist or a radiologist into the stomach or small bowel. Knowledge of the appropriate use of these devices, the appropriate maintenance management of these devices, and the appropriate treatment of EAD‐related complications is essential for the clinician to understand in order to provide effective nutrition therapy. (Journal of Parenteral and Enteral Nutrition 30:S13‐S20, 2006)
Use of Parenteral Nutrition in Patients Receiving Isolated Kidney or Simultaneous Pancreas/Kidney Transplantation
Authors: Sacks Gordon S. , Aguilar‐Nascimento Jose E. , Kudsk Kenneth A.
Published: May 2008

Background: There is little information available on the use of parenteral nutrition (PN) in patients after a kidney (KID) or simultaneous pancreas‐kidney (SPK) transplantation. This study examined the indications and use of PN in these patients. Methods: Retrospective study of 25 patients (12M/13F; mean age: 51 ± 11 years old) receiving PN after KID or SPK transplantation. Patients were divided in 2 groups according to the number of PN days (group A = <7 days and group B = >7 days). Results: Overall mortality was 16% (group A: 0/7; group B: 4/18). Postoperative ileus (n = 7), intestinal fistula (n = 5), and nausea/vomiting (n = 4) were the most common indications for PN. Functional disorders accounted for 56% (14/25) of the indications for PN. Factors differentiating group A (7/25; median = 5 [4–6] days) from group B (18/25; median =9 [7–31] days) included a significantly higher preoperative serum albumin, SPK transplantation for the first time, and diagnosis of ileus as the indication for PN initiation. Conclusions: Functional disorders of the digestive tract are the primary reason for initiation of PN in isolated KID and SPK transplantation patients. Well‐nourished patients undergoing their first SPK transplantation who develop postoperative ileus usually do not need nutrition intervention.