bluuebunny/crossref_metadata_2025 huggingface dataset:
Effects of prebiotics on the immune response to vaccination in the elderly
Authors: Bunout D , Hirsch S , de la Maza MP , Munoz C , Haschke F , Steenhout P , Klassen P , Barrera G , Gattas V , Petermann M
Published: May 2008

BACKGROUND: Prebiotics stimulate the growth of bifidogenic bacteria in the gut. The aim of this work was to assess the effects of a prebiotic mixture on the immune response in healthy elderly people. METHODS: Healthy free‐living elderly people (age, > or = 70 years), receiving a nutritional supplement that provided 1.6 MJ, 15 g of protein, and 50% of vitamin daily reference values per day, were randomly assigned to receive a prebiotic mixture (6 g/d of a 70% raftilose and 30% raftiline mixture) or placebo (6 g of maltodextrin powder) for 28 weeks. At week 2 of the study, all subjects were vaccinated with influenza and pneumococcal vaccines. At weeks 0, 2, and 8 of the study, serum total proteins, albumin, immunoglobulins, saliva secretory immunoglobulin A (IgA), and serum titers of influenza A and B and pneumococcal antibodies were measured. At week 8, cultured peripheral monocyte cell secretion of interleukin‐4, interferon‐gamma, and lymphocyte proliferation, stimulated with phytohemagglutinin and influenza antigen, were measured. RESULTS: Sixty‐six subjects were considered eligible for the study, and 43 (20 receiving prebiotics and 23 receiving placebo) were considered for final analyses on a per protocol basis. No changes in serum proteins, albumin, immunoglobulins, and secretory IgA were observed. Antibodies against influenza B and pneumococcus increased significantly from weeks 0 to 8, with no significant differences between groups. Antibodies against influenza A did not increase. No effects of prebiotics on interleukin‐4 and interferon‐gamma secretion by cultured monocytes were observed. CONCLUSIONS: No immunological effects of prebiotics were observed in this study.
Contribution of the raw material to the aluminum contamination in parenterals
Authors: Bohrer D , do Nascimento PC , Binotto R , Becker E , Pomblum S
Published: May 2008

BACKGROUND: The extent of aluminum contamination in parenteral nutrition solutions was measured in 35 different commercial products, including amino acids, electrolytes, glucose, lipids, vitamins trace elements, and albumin. The extent of aluminum contamination in substances used as raw material for preparation of parenterals was also measured. Chemicals from different manufacturers and of different quality grades were analyzed individually. METHODS: The measurements were done by atomic absorption spectrometry. RESULTS: The results showed that the same product might have different aluminum content depending on the manufacturer, either for commercial formulations or substances. The highest contaminated chemicals included cystine, NaOH, vitamin C, biotin, gluconate, and Fe and Cr salts. The lowest contaminated chemicals included lipids, apolar amino acids, glucose, HCI, acetic acid, KCl, NaCl, and heparin. Among commercial products, the major contamination rates appeared in calcium gluconate, followed by trace elements, some vitamins, bicarbonate, phosphates salts, and heparin. CONCLUSIONS: Comparing the aluminum in commercial products and substances, it can be concluded that the contamination may occur in parenterals because aluminum is present naturally in the chemicals. However, when the composition and concentration of the parenteral solution are considered, the contamination of calcium gluconate, trace elements, some vitamins, phosphates, bicarbonate, and heparin cannot be related only to the raw substances. The aluminum level present in these commercial formulations is too high to come only from the substances; therefore, it is possible that one of the steps of the manufacturing procedure is responsible for elevating the contamination of these products.
Increased resting energy expenditure in patients with end‐stage renal disease
Authors: Neyra R , Chen KY , Sun M , Shyr Y , Hakim RM , Ikizler TA
Published: May 2008

BACKGROUND: Protein‐calorie malnutrition is a significant problem for patients with end‐stage renal disease. Increased resting energy expenditure may be an important contributing factor. We postulate that resting energy expen diture in the different stages of renal disease and treatments may be different. METHODS: Resting energy expenditure was measured using a whole‐room indirect calorimeter (metabolic chamber) along with nutritional parameters and body composition after 12‐hour fasting in 15 patients with advanced chronic renal failure patients, 15 patients on chronic hemodialysis, and 10 patients on peritoneal dialysis. Patients on hemodialysis were assessed on a non‐dialysis day. A 2‐day dietary recall was used to assess energy intake. RESULTS: Resting energy expenditure, adjusted for fat‐free mass, was similar in patients on hemodialysis and peritoneal dialysis but significantly higher than in patients with chronic renal failure (p <.05). Resting energy expenditure in all patients were generally higher (10% to 20%) than predicted values using standard equations derived in normal and obese populations, whereas daily energy intake was less (26% to 34%) than energy expenditure for all groups, adjusted for light daily activity. CONCLUSIONS: End‐stage renal disease patients displayed increases in resting energy expenditure over the predicted values derived using normal populations. Resting energy expenditure was significantly higher in patients receiving dialysis, regardless of the modality, than patients with chronic renal failure. Daily energy intake was substantially less than required in all patient groups studied, suggesting that patients with renal failure could develop protein‐calorie malnutrition because of increased resting energy expenditure, which is exacerbated by dialysis.
3–0 methylglucose absorption in vivo correlates with nutrient absorption and intestinal surface area in experimental short bowel syndrome
Authors: Martin GR , Meddings JB , Sigalet DL
Published: May 2008

BACKGROUND: Inert carbohydrate probes are widely used to study intestinal permeability and examine the passive uptake of markers. This study examined the use of quantifying 3–0 methylglucose (3–0 MG) absorption as a marker of intestinal surface area and active nutrient transport capability. METHODS: Using a rat model, varying degrees of short bowel syndrome (SBS) were induced: sham operation (intestinal transection only), 50% resection (R50), 75% resection (R75), and 90% resection (R90; n = 6 to 8 in each group). Animals were pair fed, and over days 5 and 6 postoperation, a balance study was done to quantify absorption of dietary fat, protein, and carbohydrate. On day 7, animals were gavaged with the test solution containing 3–0 MG, lactulose, and mannitol, followed by a 16‐hour urine collection. Urine recovery of probes was quantified using high‐performance liquid chromotography. Animals were then killed, and the gross and microscopic intestinal morphology was determined. RESULTS: As expected, increased resection resulted in reduced absorption of dietary nutrients and 3–0 MG, which reached significance in the R90 resected animals. 3–0 MG absorption was significantly correlated with intestinal surface area and the absorption of dietary protein and fat (p <.01 for all comparisons). Interestingly, 3–0 MG absorption was not significantly correlated with the absorption of dietary carbohydrate. CONCLUSIONS: 3–0 MG absorption is a useful marker of functional intestinal surface area and of the absorption of dietary fat and protein in experimental SBS. 3–0 MG may be a useful marker of nutrient absorptive capacity in patients with SBS; further study is indicated.
Effect of enteral feeding with eicosapentaenoic acid, gamma‐linolenic acid, and antioxidants on antioxidant status in patients with acute respiratory distress syndrome
Authors: Nelson JL , DeMichele SJ , Pacht ER , Wennberg AK
Published: May 2008

BACKGROUND: We previously showed that enteral feeding of a diet containing eicosapentaenoic acid, gamma‐linolenic acid, and elevated antioxidants improved clinical outcomes compared with a control diet in acute respiratory distress syndrome (ARDS) patients. It has been suggested that oxidative stress may overwhelm endogenous antioxidant levels and allow free radicals to further damage lung tissue. Therefore, we determined whether these ARDS patients were under oxidative stress and whether the experimental diet could improve antioxidant status. METHODS: Ninety‐eight ARDS patients received either the experimental or control diet (minimum of 75% of basal energy expenditure x 1.3) for at least 4 to 7 days. Total radical antioxidant potential (TRAP), lipid peroxide levels (LPO), and plasma antioxidant concentrations were determined at baseline and study days 4 and 7. Sixty‐two normal individuals were assessed for reference values. RESULTS: At baseline, ARDS patients had significantly lower plasma beta‐carotene, retinol, and alpha‐tocopherol, lower TRAP, and higher LPO values compared with normals. After 4 days of feeding, beta‐carotene and alpha‐tocopherol levels were normalized and significantly increased in the experimental group compared with controls. TRAP and LPO were not significantly different between groups and study day 4 and 7 values were not different from baseline values. Retinol levels increased equally in both groups. CONCLUSIONS: Before treatment, ARDS patients were found to be in a state of oxidative stress and had reduced levels of antioxidants. Although enteral nutrition with the experimental diet for at least 4 to 7 days did not reduce oxidative stress as measured, it did restore plasma levels of beta‐carotene and alpha‐tocopherol to normal or higher levels and appeared to protect ARDS patients from further lipid peroxidation.
New Food and Drug Administration requirements for inclusion of vitamin K in adult parenteral multivitamins
Authors: Helphingstine CJ , Bistrian BR
Published: May 2008

The newly amended requirements by the Food and Drug Administration (FDA) for an effective adult parenteral multivitamin drug product increase the amounts of vitamins B1, B6, C, and folic acid currently in the product to better meet estimated needs, and specifies the inclusion of 150 microg of vitamin K. Infuvite Adult Multiple Vitamins for Infusion is the first adult parenteral multivitamin product to meet the revised FDA requirements. The inclusion of vitamin K in adult parenteral multivitamin products is intended to afford patients a consistent daily supply of vitamin K approximating usual levels of intake. This is a change to clinical practice in the United States, where vitamin K has not been included in adult parenteral vitamin preparations, and physicians prescribe vitamin K separately. The reformulation of adult parenteral multivitamins required by the FDA raises questions about the potential impact that inclusion of vitamin K will have on patient management. One clinical practice change is that patients on parenteral nutrition receiving Infuvite Adult should no longer need weekly subcutaneous (SC) or intramuscular (IM) vitamin K injections. In addition, the consistent and modest level of vitamin K provided by the reformulated adult parenteral multivitamins may make it easier for physicians to maintain the desired level of hypoprothrombinemia (low levels of prothrombin) in those patients also on anticoagulant therapy with warfarin. However, for physicians accustomed to administering vitamin K separately, it is important to highlight that it may be more difficult to titrate anticoagulant therapy, especially among patients receiving dual feeding or vitamin K from another source. If marketed globally, these clinical practice issues may be more pronounced outside of the United States, where dual feeding is common, and patients may receive vitamin K from other sources.
History of parenteral nutrition
Authors: Vinnars E , Wilmore D
Published: May 2008

A survey is given of the development of parenteral nutrition with the beginning of William Harvey's fantastic discovery of the circulation to today's discussion of what is an optimal regime of parenteral nutrition. The important and different steps of development during the 17th and 19th centuries are discussed. The modern steps during the last century leading to the concept we have today of parenteral nutrition is mentioned, with reference to all pioneers all over the world. Glucose, protein hydrolysates and crystalline amino acids, development of safe fat emulsions, and the current concepts of parenteral nutrition and future considerations are discussed.
Glutamine administration during total parenteral nutrition protects liver adenosine nucleotides during and after subsequent hemorrhagic shock
Authors: Dhar A , Kujath S , Van Way CW
Published: May 2008

BACKGROUND: Glutamine supplementation of total parenteral nutrition (TPN) in stressed patients has been advocated. To determine whether glutamine supplementation affects the host response to conditions of stress, animals were given TPN with or without glutamine for 7 days. They were then subjected to the acute stress of hemorrhagic shock, which results in marked loss of hepatic adenosine triphosphate (ATP) and adenosine diphosphate (ADP), with accumulation of adenosine monophosphate (AMP) and the metabolites adenosine, inosine, hypoxanthine, and xanthine. This loss of ATP and accumulation of metabolites contributes to subsequent tissue damage. The hypothesis of the study was that glutamine supplementation would significantly improve restoration of hepatic adenosine nucleotides before and after hemorrhagic shock. METHODS: Sprague‐Dawley rats were given TPN for 7 days. One half of the animals (n = 8) received TPN supplemented with glutamine, while one half received TPN with an isonitrogenous mixture of alanine and glycine. Animals were subjected to hemorrhagic shock for 30 minutes and then resuscitated using only heparinized shed blood. Liver biopsies were taken pre‐ and post‐shock, and at 30 and 60 minutes after resuscitation. ATP, ADP, AMP, and their metabolites were measured using gradient high‐performance liquid chromatography. RESULTS: After 7 days of TPN, baseline values of ATP, ADP, AMP, and metabolites were similar between the 2 groups before the initiation of shock. Glutamine‐treated animals manifested a 40% decrease in ATP level immediately after shock and recovered to 90% of baseline within 60 minutes. By contrast, the control animals manifested a 66% decrease in ATP level after the shock period and recovered only to 60% of baseline at 1 hour postresuscitation. Similar changes were observed in ADP levels and were accompanied by corresponding changes in AMP and adenosine metabolites, all of which rose during shock and fell after resuscitation. CONCLUSIONS: Glutamine supplementation significantly protected the liver from tissue damage caused by hemorrhagic shock. ATP levels remained higher during shock and recovered more rapidly after resuscitation. Glutamine supplementation may help to protect cellular energy stores in the stressed organism and may offer opportunities for therapeutic intervention during and after stress.
Long‐term effects of early postnatal food restriction on growth hormone secretion in rats
Authors: Houdijk ME , Engelbregt MT , Popp‐Snijders C , Delemarre van der Waal HA
Published: May 2008

BACKGROUND: Malnutrition in early life retards growth permanently in both humans and rats, but the underlying mechanism is unclear. The purpose of this study was to test the hypothesis that early postnatal food restriction induces long‐term changes in the growth hormone‐insulin‐like growth factor I (GH‐IGF‐I) axis. METHODS: We examined the effect of increasing litter size to 20 during lactation [food restriction (FR)] on growth and spontaneous GH secretion and serum IGF‐I levels in 14‐ to 15‐week‐old rats. RESULTS: No catch up in body weight (BW; p <.05), total length (TTL; p <.001), or tail length (TL; females, p <.02; males, p <.001) was observed in the adult female and male FR rats. Spontaneous 6‐hour rat GH (rGH) secretory profiles showed significantly increased (p <.05) mean baseline rGH plasma concentrations in the male adult FR versus control (CON) rats (38.0 +/‐ 3.6 versus 26.4 +/‐ 2.5 ng/mL). Serum IGF‐I levels in the male adult FR rat were significantly (p <.01) reduced (751.3 +/‐ 50.3 versus 985 +/‐ 55.5 ng/mL) compared with male controls. rGH secretory pattern in the adult female FR rat and serum IGF‐I concentrations were not different from female controls. CONCLUSIONS: FR during lactation leads to incomplete catch‐up growth in adult female and male rats. In the adult male FR rat, increased baseline rGH secretion and reduced serum IGF‐I concentrations might explain the slow growth.
Total parenteral nutrition, an ally in the management of patients with intestinal failure and malnutrition: a long‐term view
Authors: Spencer CT , Compher CW
Published: May 2008

Dr. Jonathan Rhoads played a key role in the development of parenteral nutrition, a feeding method used today for the same clinical conditions as during Rhoads’ time: intestinal failure and severe malnutrition. Specific indications for parenteral nutrition use over time and Dr. Rhoads’ personal contributions are addressed in this paper.
Compounding TPN admixtures: then and now
Authors: Driscoll DF
Published: May 2008

Compounding TPN admixtures has significantly developed since the first clinical reports by Dr. Dudrick and colleagues from the University of Pennsylvania approximately 35 years ago. Today, the responsibility for the compounding of sage parenteral nutrition admixtures for patients incapable of oral or enteral nutrition primarily rests with the pharmacy department. Although others may influence the desirable components to be contained therin, no one is more qualified to deal with the physicochemical issues and aseptic technique compounding requirements than a registered pharmacist. In fact, the United States Pharmacopeia (USP), the official drug compendium in the US since 1906, has published Chapter 797 entitled “Pharmaceutical Compounding‐‐Sterile Preparations”, enforceable by the FDA, and makes clear the role of the pharmacist in the compounding of safe parenteral admixtures. Ultimately, after careful pharmaceutical review of the final formulation, the composition of the final admixture for infusion will be determined based on the ability to safely compound the prescribed additives in the desired quantities of a specified volume of sterile fluid. There will always be instances, where, for example the patient's needs cannot be safely met through the TPN admixture, primarily because of stability, compatibility and/or sterility issues. When this occurs, suitable alternative methods of delivering the additives in question must be sought so as not to compromise the safety issues of the final TPN infusion. Although there have been many advances in the development of nutritional additives, compounding devices, and containers, significant safety issues continue to arise necessitating further modification of paretneral nutrition protocols. ASPEN, through periodic reviews of tis published guidelines, such as the 1998 Safe Practices for Parenteral Nutrition Formulations, is in a key position to keep nutrition support clinicians abreast of the central issues affecting the safety of TPN therapy.(Journal of Parenteral and Enteral Nutrition
Central venous catheter occlusion: a prospective, controlled trial examining the impact of a positive‐pressure valve device
Authors: Jacobs BR , Schilling S , Doellman D , Hutchinson N , Rickey M , Nelson S
Published: May 2008

BACKGROUND: Central venous catheter (CVC) occlusion occurs frequently in children. This problem is often associated with disruption of intravascular therapy and monitoring. Multiple factors may predispose to catheter occlusion, but reflux of blood into the catheter lumen is a common factor. We hypothesized that use of a positive pressure valve device would reduce the incidence of catheter occlusion. METHODS: In phase I of this sequential study design, newly placed CVCs were capped with a standard device. In Phase II, CVCs were capped with a positive‐pressure valve device. Data collected included patient demographics, type of catheter, infusate, catheter duration, and complications. Partial and complete catheter occlusions were delineated. A user satisfaction survey was conducted. RESULTS: There were 153 children (mean age 48.0 +/‐ 7.7 months) with 312 CVC lumens enrolled in the study. Mean catheter duration was 9.4 +/‐ 0.9 days. There were fewer complete occlusions in CVCs capped with the positive pressure valve device than with the standard device [6/161 (3.7%) vs 18/151 (11.9%) occlusions, respectively; p =.012)]. There were no significant differences in partial occlusions, phlebitis, or catheter‐related bloodstream infection between the 2 groups. CONCLUSIONS: CVCs with a positive‐pressure valve cap device have a lower incidence of complete catheter occlusion than those with a standard cap device.
Supplementation with a combination of beta‐hydroxy‐beta‐methylbutyrate (HMB), arginine, and glutamine is safe and could improve hematological parameters
Authors: Rathmacher JA , Nissen S , Panton L , Clark RH , May PE , Barber AE , D'Olimpio J , Abumrad NN
Published: May 2008

BACKGROUND: Combining the amino acids arginine and glutamine with the leucine metabolite beta‐hydroxy‐beta‐methylbutyrate (HMB) has been shown to reverse lean tissue loss in cancer and acquired immunodeficiency syndrome (AIDS) patients. Although each of these nutrients has been shown to be safe, the safety of this mixture has not been reported. Three double‐blind studies examined the safety of the combination of HMB, arginine and glutamine on blood chemistries, hematology, emotional profile, and adverse events. METHODS: Study 1 was conducted in healthy adult males (n = 34), study 2 was in HIV patients with AIDS‐associated weight loss (n = 43), and study 3 was in cancer patients with wasting (n = 32). Volunteers were assigned to either a placebo or a mixture of 3 g HMB, 14 g arginine, and 14 g glutamine per day. RESULTS: Across the 3 studies, HMB, arginine, and glutamine supplementation was not associated with any adverse indicators of health. The only significant changes noted were positive indicators of health status. HMB, arginine, and glutamine supplementation was associated with an improvement in emotional profile (p =.05), a decreased feeling of weakness (p =.03), and increased red blood cells, hemoglobin, hematocrit, lymphocytes, and eosinophils (p <.05) when compared with placebo‐supplemented subjects. Blood creatinine levels were not changed. However, blood urea nitrogen increased (p =.01) with HMB, arginine, and glutamine supplementation, which was possibly caused by the additional nitrogen consumed or to the fact that ureagenesis is influenced by arginine and glutamine supplementation. CONCLUSION: These results show that HMB, arginine, and glutamine can be safely used to treat muscle wasting associated with AIDS and cancer.
Sodium polystyrene sulfonate used to reduce the potassium content of a high‐protein enteral formula: a quantitative analysis
Authors: Rivard AL , Raup SM , Beilman GJ
Published: May 2008

BACKGROUND: Sodium polystyrene sulfonate (Kayexalate) commonly is used in treating hyperkalemia. As a cation exchange resin, it also can be used to reduce the potassium content of enteral nutrition formulas. This study evaluates the use of Kayexalate to reduce potassium in one high‐protein enteral formula and describes the quantitative analysis of the product. METHODS: Sodium polystyrene sulfonate and enteral formula were mixed into a slurry and allowed to settle, and then the supernatant was decanted off and tested as samples. Three sample concentrations were analyzed: a control not subjected to potassium reduction, 0.5 g of Kayexalate per mEq K+ sample, and a 1 g/mEq K+ sample. Of these samples, moisture, lipid, protein, carbohydrate, ash, and mineral content were obtained. RESULTS: Compared with the control, the percentage decrease of potassium ranged from 25% to 36%, depending on the concentration of Kayexalate. A significant increase of 324% in sodium concentration was found in the 1.0 g/mEq K+ sample. Although there was no change in magnesium content, a slight increase in phosphorus, iron, and zinc was evident. CONCLUSIONS: The treatment of an enteral formula with sodium polystyrene sulfonate significantly increases its sodium content, with a modest decrease in potassium content. Clinicians using this method in clinical practice should be aware of the increase in sodium content.
Endotoxin and cytokine released during parenteral nutrition
Authors: Zheng YJ , Tam YK , Coutts RT
Published: May 2008

BACKGROUND: Apart from its benefits, parenteral nutrition (PN)‐related complications have been reported. Studies have shown that PN could alter cytochrome P450 (CYP) activity. One of the possible mechanisms is through cytokine and nitrite release, which is triggered by endotoxin. The purpose of this study is to investigate the potential release of endotoxin, cytokines, and nitrite during PN. METHODS: Rats were randomly assigned into either (a) the PN group, which received continuous PN infusion only; or (b) the control group, which received normal chow with saline infusion. The infusions were administered continuously for 7 days, and then blood was collected and microsomes were prepared from the excised livers. RESULTS: Endotoxin levels in the PN group were significantly higher in portal vein but not in inferior vena cava when compared with those of the controls. TNF‐alpha and IL‐6 levels were significantly higher in the PN group (p <.05). However, IL‐1 beta levels were not significantly different in the 2 groups (p >.05). The nitrite levels, the end product of nitric oxide formation, were found to be almost 2 times higher after PN (p <.05). CONCLUSIONS: It is confirmed that a 7‐day infusion treatment of PN in rat may be linked to bacterial translocation, which leads to increased levels of endotoxin. This increase could trigger cytokine release, which could down regulate CYP activities.
Education and evidence are needed to improve neonatal parenteral nutrition practice
Authors: Ahmed M , Irwin S , Tuthill DP
Published: May 2008

BACKGROUND: Parenteral nutrition (PN) is an essential component of neonatal care for those infants who are unable to tolerate adequate enteral feeding. Its use is not without complications such as biochemical derangements, sepsis, thrombosis, extravasation of fluid, and death. Such complications can be reduced by meticulous management of PN in response to biochemical abnormalities, nutrition teams, policies to reduce sepsis, and staff training to be more aware of pericardial and pleural effusions. We ascertained the current practices in PN administration and management of complications in all neonatal units with 6 or more intensive care cots in England, Scotland, and Wales. METHODS: Telephone survey of middle grade doctors (Specialist Registrars) working in all 57 neonatal units was conducted using a standard questionnaire. The questions were focused around practical issues and problems that are commonly encountered with PN practice, including composition, complications, and nutrition support. RESULTS: A response was obtained from 95% of the units contacted and a wide range of practices observed. Thirty‐three percent of units delay protein (nitrogen) until > 48 hours after birth. Lipid infusions are stopped in proven or suspected sepsis in just over half of all units. In hyperglycemic preterm infants, 25 units decrease their glucose infusion, 21 commence insulin, and 8 have no policy. Two thirds of middle grade doctors had no idea of the amount of protein or nitrogen to prescribe for these infants, and only one‐third involve a pharmacist in the PN prescribing. CONCLUSIONS: There is a diverse practice and knowledge with a concerning lack of education in nutrition among the middle grade doctors in England, Scotland, and Wales. The management of common complications such as sepsis and hyperglycemia are highly variable. Improved staff training and production of unified evidence‐based guidelines need urgent consideration.
Nutrition support in Brazil: past, present, and future perspectives
Authors: Waitzberg DL , Campos AC
Published: May 2008

The history of nutrition support in Brazil is parallel to its development in the world. Inspired by the publications of the surgical group headed by Professor Rhoads at the University of Pennsylvania, a group of Brazilian physicians pioneered the beginning of parenteral nutrition (PN) therapy. The Brazilian Society of Parenteral and Enteral Nutrition (SBNPE) was officially founded in 1975. Soon, scientific contributions started to appear, reflected by articles in the Journal of Parenteral and Enteral Nutrition and other journals and by books. In many states of Brazil, nutrition support services were created to carry out scientific and educational activities. The relationship with the American Society of Parenteral and Enteral Nutrition was fundamental in the development of clinical nutrition in Brazil because of the strong scientific exchange between the United States and Brazil. However, after the stimulating initial launching, momentum slowed because of the lack of medical awareness and inadequate reimbursement. In Brazil, the federal government is responsible for the majority of health care, but enteral nutrition was not reimbursed. In response to this situation, a study in 4000 hospitalized patients was undertaken in Brazil. It was reported that nearly half of them presented with malnutrition, and > 12% had severe malnutrition. These alarming results were decisive in persuading the Brazilian government to begin reimbursement for enteral nutrition. Today, Brazilian hospitals that assist public health system patients receive reimbursement for enteral nutrition. However, it is required to have an officially registered nutrition support team and a certified and approved facility for enteral feeding preparation. Considering that low nutrition prescription in Brazil could be the result of lack of nutrition education (not required in most medical schools), the SBNPE participated in the creation of 2 very effective, practical, and dynamic courses for the basic teaching of clinical nutrition. These courses were created by the Latin American Federation of Parenteral and Enteral Nutrition: the TNT (Total Nutrition Therapy) Course and the CINC Course (Interdisciplinary Course in Clinical Nutrition). These 2 courses are available to members of all Latin American countries and are regularly offered by the SBNPE to its members all over Brazil. Altogether, > 4000 physicians, dietitians, nurses, and pharmacists have been introduced to the basic principles and practice of clinical nutrition. It is clear that the outstanding ideas of Professors Rhoads, Dudrick, and Wilmore and other collaborators from this group in the field of clinical nutrition have grown and flourished in Brazil.
Feasibility and safety of needle catheter jejunostomy for enteral nutrition in surgically treated severe acute pancreatitis
Authors: Weimann A , Braunert M , Muller T , Bley T , Wiedemann B
Published: May 2008

BACKGROUND: The role of the gut in the development of septic complications and promising clinical results have led to a shift from the parenteral to the enteral route for nutrition support of patients with acute pancreatitis. In patients undergoing surgery for severe necrotizing pancreatitis, the application of a needle catheter jejunostomy might be useful. However, there is a shortage of clinical data on its feasibility and possible harmful effect. METHODS: Between January 1999 and December 2002, 13 patients were operated for severe acute necrotizing pancreatitis. At the time of surgery, needle catheter jejunostomy was performed using a standard technique. Enteral nutrition was initiated without a strict protocol by feeding small amounts of a standard diet and carefully monitoring patient tolerance. As long as necessary, patients were also fed parenterally in order to achieve target caloric goals. RESULTS: No major tube‐ or feeding‐related complications were observed. A single case of tube dislodgement caused by manipulation during relaparotomy for lavage occurred and was rectified during the same operation. CONCLUSIONS: In patients undergoing surgery for severe acute pancreatitis, needle catheter jejunostomy for long‐term enteral nutrition can be applied with no additional risk.
Selenium concentrations in pancreatic juice of patients with chronic pancreatitis
Authors: Scolapio JS , Raimondo M , Woodward TA , Wallace MB
Published: May 2008

BACKGROUND: Free radicals have been implicated as an important mediator in the pathogenesis of tissue injury. Experimental animal models would suggest selenium deficiency contributes to the pathogenesis of chronic pancreatitis (CP). In clinical studies, low plasma selenium levels have been reported in patients with CP. To the best of our knowledge, selenium levels have not been measured in pancreatic juice. METHODS: Twenty‐seven patients with chronic intermittent upper quadrant abdominal pain were studied. The diagnosis of CP was made by endoscopic retrograde cholangiopancreatography. Patients were allowed to eat an ad libitum western diet. None of the patients was taking selenium supplements. Patients underwent upper endoscopy with routine conscious sedation. Secretin (0.2 microg/kg) was given i.v. immediately before intubation. Pancreatic juice collected from the duodenum was immediately frozen in liquid nitrogen and stored at ‐80 degrees C until the assay was performed. Selenium levels of the pancreatic juice were determined using the inductively coupled plasma‐mass spectrometry method. RESULTS: Twelve patients had an abnormal pancreatogram. The gender and median age in controls and CP were 11 females and 4 males (54 years, range 32–78) and 7 females and 5 males (56 years, range 37–79), respectively. The etiology of CP was alcohol and idiopathic. The median selenium concentration in controls was 4 microg/mL (range, 2–11.5) and in CP 4.5 microg/mL (range, 2–16). There was not a statistically significant difference between the 2 groups (p = not significant). CONCLUSIONS: The pancreatic juice concentration of selenium is similar in patients with CP compared with age matched controls. Our results would therefore suggest that the effects of selenium on pancreatic injury might be systemic rather than local tissue effect.
Dexamethasone plus glucagon‐like peptide 2 given to lactating rat dams has a late effect on intestinal lipid uptake in the weanling offspring
Authors: Iordache C , Drozdowski L , Clandinin T , Wild G , Todd Z , Thomson AB
Published: May 2008

BACKGROUND: Glucagon‐like peptide 2 (GLP‐2) has a trophic effect on the intestine and enhances intestinal absorption in adult animals, but its effect in young rats is unknown. Glucocorticosteroids accelerate the ontogeny of the intestine, and in adult animals they increase the uptake of sugars and lipids. We hypothesized that GLP‐2 and dexamethasone (DEX), when administrated to lactating rat dams, will enhance lipid uptake in the suckling and weanling offspring. METHODS: Eight nursing rats were treated during lactation, 19 to 21 days, with GLP‐2 (0.1 microg/g/d subcutaneously [s.c.]), DEX (0.128 microg/g/d s.c.), GLP‐2 + DEX (GLP‐2 0.1 microg/g/d s.c. plus DEX 0.128 microg/g/d s.c.), or placebo. Half of the offspring (“sucklings”) were killed at 19 to 21 days of age, and half were killed 4 weeks later (“weanlings”). The rate of intestinal uptake of fatty acids (12:0, lauric; 16:0, palmitic; 18:0, stearic; 18:1, oleic; 18:2, linoleic; and 18:3, linolenic) and cholesterol were assessed using an in vitro ring technique. RESULTS: GLP‐2 and DEX resulted in loss of body weight in sucklings, which was prevented by giving the combination GLP‐2 + DEX. The jejunal atrophy in sucklings given DEX was prevented by giving GLP‐2 + DEX, but GLP‐2 + DEX did not prevent the decline in jejunal and ileal villous height and crypt depth observed in weanlings given DEX. GLP‐2 had little effect on lipid uptake in sucklings, whereas DEX or GLP‐2 + DEX increased the uptake of lipids. In contrast, in weanlings there was malabsorption of several lipids with GLP‐2 or GLP‐2 + DEX, but not with DEX. Lipid uptake was lower in weanlings than in sucklings, and this age‐associated decline was not altered by GLP‐2 or DEX. CONCLUSIONS: The loss of body weight and the jejunal atrophy induced by DEX in sucklings is prevented by adding GLP‐2. Giving DEX or GLP‐2 + DEX to lactating mothers enhances lipid uptake in their suckling offspring. In marked contrast, a month after lactating dams were given GLP‐2 or GLP‐2 + DEX, there was reduced lipid absorption in the postweaning animals. Thus, giving GLP‐2 + DEX during lactation may be useful to enhance lipid uptake in the suckling offspring, without adverse effects on body weight or intestinal characteristics. However, the late effects of this treatment on lipid absorption were of concern, and could be potentially deleterious to the nutritional well‐being of the animal.
Assessing the Metabolic and Clinical Consequences of Early Enteral Feeding in the Malnourished Patient
Authors: Flesher Mary E. , Archer Katharine A. , Leslie Barbara D. , McCollom Robert A. , Martinka Grzegorz P.
Published: May 2008

Background: It is often thought that enteral feeding should be initiated slowly in those who are severely malnourished. This descriptive study examined the effect of an enteral feeding protocol on the typical metabolic consequences seen in refeeding syndrome. Methods: A retrospective chart review was conducted on 51 patients who had been placed on hospital‐wide enteral feeding and electrolyte replacement protocols over a 9‐month period to determine whether there were any negative clinical consequences to early feeding. Results: Goal feeding rate was achieved within 17.6 ± 8.7 hours. Forty patients (80%) developed depletions in phosphate, magnesium, or potassium after initiation of enteral feeding, including 93% of those deemed “at risk” and 74% of those“ not at risk.” All patients received electrolyte replacement according to protocols, and no patients showed any negative clinical effect. Conclusions: This study showed that malnourished patients at risk for refeeding syndrome can be fed early without observed negative clinical consequences. An electrolyte replacement protocol may be an effective means of minimizing the electrolyte imbalances associated with early feeding. It also demonstrated the significance of applying such protocols to all patients requiring enteral support, as current methods of assessing “risk” for refeeding syndrome may be inadequate.
Implementation of a Nutrition Support Protocol Increases the Proportion of Mechanically Ventilated Patients Reaching Enteral Nutrition Targets in the Adult Intensive Care Unit
Authors: Mackenzie Shannon L. , Zygun David A. , Whitmore Bev L. , Doig Christopher J. , Hameed Syed Morad
Published: May 2008

Background: Despite the evidence that enteral feeding reduces morbidity in critically ill patients and is preferred to parenteral nutrition, the delivery of enteral nutrition (EN) is often inadequate. The purpose of this study was to determine whether implementation of an evidence‐based nutrition support (NS) protocol could improve EN delivery. Methods: An NS protocol incorporating available scientific evidence; data from a retrospective survey of 30 intensive care unit (ICU) patients; and input from dietitians, intensive care physicians, surgeons, nurses, and pharmacists was developed. The impact of this protocol was evaluated prospectively in 123 consecutive adult patients admitted to a multisystem ICU who were eligible for EN. Results: The percentage of patients who received at least 80% of their estimated energy requirements during their ICU stay increased from 20% before implementation of the NS protocol to 60% after implementation (p < .001). After adjusting for confounders, those in the postimplementation group received significantly more kcal/kg/d than the preimplementation group (3.71 kcal/kg/d; 95% confidence interval, 1.64 to 5.78; p = .001). Parenteral nutrition kcal/kg/d use was reduced in the postimplementation group (1.6 vs 13%, p = .02). There was no difference in time to initiation of enteral nutrition between groups (1.76 days preprotocol vs 1.44 days postprotocol implementation, p = .9). Conclusions: The development and use of an evidence‐based NS protocol improved the proportion of enterally fed ICU patients meeting their calculated nutrition requirements.
Glycemia Influences on Glucose Metabolism in Sepsis During Hyperinsulinemic Clamp
Authors: Rusavy Zdenek , Macdonald Ian A. , Sramek Vladimir , Lacigova Silvie , Tesinsky Pavel , Novak Ivan
Published: May 2008

Background: We investigated glucose metabolism in septic patients during hyperglycemic clamps and compared the different levels of insulinemia and glycemia. Methods: In 10 non‐diabetic stable septic patients on mechanical ventilation with baseline glycemia >6mmol/L and continuous insulin infusion, 3 steps of hyperinsulinemic clamp were performed after 8 hours without caloric intake. In step 1, the targets were insulinemia of 250 mIU/L and glycemia of 5mmol/L; in step 2, insulinemia of 250 mIU/L and glycemia of 10 mmol/L; in step 3, insulinemia of 1250 mIU/L and glycemia of 5 mmol/L. Glucose uptake was calculated as the amount of glucose per time needed to maintain the target level of glycemia. Glucose oxidation was calculated from indirect calorimetry and urinary nitrogen losses. Values are provided as means ± SD. A two‐way analysis of variance and Scheffe's method were used for statistical analysis and p < .05 was considered significant. Results: At step 1, glucose uptake was lower than at step 2 (3.8 ± 2.48 mg/kg/min and 7.9 ± 3.45 mg/kg/min, respectively; p < .001). Glucose oxidation was also lower at step 1 (2.6 ± 0.98 and 4.2 ± 1.85 mg/kg/min, respectively; p< .01). Glucose storage was low at step 1 (0.7 ± 1.39) and increased at step 2 (3.5 ± 2.18; p < .05). In step 3, glucose uptake was 7.0 ± 2.1, oxidation was 3.6 ± 1.37, and storage was 2.9± 2.79. There was no significant difference in all these parameters between steps 2 and 3. Energy expenditure between steps 1, 2 and 3 did not change (2294 + 307.42, 2334 + 341.53, and 2342 + 426.67 kcal/day, respectively). Alanine in plasma dropped significantly (p < .05): 10 mmol/L (311 ± 55.88 mmol/L) at glycemia compared with 5 mmol/L (390± 76 umol/L) at insulinemia 250 mIU/L. It did not differ significantly from the values obtained at glycemia 5 mmol/L and insulinemia 1250 mIU/L (348± 70.68 mmol/L). Even if the level of cytokines in sepsis was higher, there was no correlation between the insulin level in plasma (250 and 1250 mIU/L), glycemia (5 and 10 mmol/L) and cytokine level (IL‐1β, IL‐2, IL‐6, IL‐8 and TNFα). Conclusion: At insulinemia 250 mIU/L, a glucose level of 10 mmol/L seems to increase glucose uptake, oxidation, and storage compared with glycemia 5 mmol/L. This glucose uptake and oxidation at glycemia 10 mmol/L is comparable with the effect of extremely high insulinemia (1250 mIU/L) clamped at glycemia 5 mmol/L. A higher level of blood glucose or a high level of insulinemia significantly increases glucose uptake but not energy expenditure.
Outcomes in a Pediatric Intensive Care Unit Before and After the Implementation of a Nutrition Support Team
Authors: Gurgueira Gisele Limongeli , Leite Heitor Pons , de Aguiar Carrazedo Taddei José Augusto , de Carvalho Werther Brunow
Published: May 2008

Background: We evaluated the effect of parenteral nutrition (PN) and enteral nutrition (EN) on in–pediatric intensive care unit (PICU) mortality before and after a continuous education program in nutrition support that leads to implementation of a nutrition support team (NST). Methods: We used a historical cohort study of infants hospitalized for >72 hours at the PICU from 1992 to 2003. Five periods were selected (P1 to P5), considering the modifications incorporated into the program: P1, without intervention; P2, basic themes and original articles discussion; P3, clinical and nursing staff participation; P4, clinical visits; P5, NST. The samples were compared in terms of sex, age, admitting service (ie, medical vs surgical), prognostic index of mortality, length of stay (LOS), duration of mechanical ventilation, in‐PICU mortality rate, and percentage of time receiving EN and PN for each patient. Bi‐ and multivariate analyses were performed. Statistical significance was set at 0.05 level. Results: Progressive increase was observed in EN use (p = .0001), median values for which were 25% in P1 and rose to 67% by P5 in medical patients; there was no significant difference in surgical patients. A reduction was observed in PN use; in P1 medians were 73% and 69% for medical and surgical patients respectively, and decreased to 0% in P5 for both groups (p = .0001). There was significant reduction in‐PICU mortality rate during P4 and P5 among medical patients (p < .001). The risk of death was 83% lower in patients that received EN for >50% of LOS (odds ratio, 0.17; confidence interval, 0.066–0.412; p = .000). Conclusions: The program motivated an increase in EN and a decrease in PN use, mainly after implementation of NST and reduced in‐PICU mortality rate.
Evolution of Fatty Acid Profile and Lipid Oxidation During Enteral Formula Storage
Authors: Rufián‐Henares José Ángel , Guerra‐Hernández Eduardo , García‐Villanova Belen
Published: May 2008

Background: Enteral formulas can be stored for up to 2 years. Fat oxidation during storage can lead to the loss of nutritive value and generation of toxic products such as lipid peroxides. Methods: Two standard enteral formulas were stored for short periods at high temperatures (1–4 weeks at 32–55°C) or for long periods at low temperatures (12–36 weeks at 4°C, 20°C, or 30°C). The present study included the assessment of lipid oxidation by measuring related fluorescent compounds and the evolution of fatty acids profile. Results: Enteral formula fat was oxidized under all assayed conditions, including storage at 4°C. The loss of essential fatty acids (linoleic and linolenic acids) was always higher when time and temperature were increased. The ω6/ω3 ratio was increased by storage from 5.6 to 7.8, which could exacerbate the inflammatory response in critically ill patients. Fluorescence intensity increased with time and temperature of storage and was correlated with the decrease in essential fatty acids (lineal correlation between –0.9416 and –0.9996). Conclusions: Enteral formula fat was oxidized during storage, leading to a loss of nutritional value. These formulas should be stored under refrigeration to minimize this loss. Finally, fluorescence measurement proved to be a fast and easy method to assess fat oxidation status.