bluuebunny/crossref_metadata_2025 huggingface dataset:
Transverse Witzel‐T‐Tube Feeding Jejunostomy
Authors: Schwaitzberg S.D. , Sable David B.
Published: May 2008

Background: In patients prone to recurrent aspiration, a feeding jejunostomy is only performed to ensure adequate nutrition. A popular method for placement of the jejunostomy tube is the Witzel procedure, employing a sersosal tunnel on the antimesenteric border. The Witzel procedure, however, frequently suffers from the complication of tube dislodgement and obstruction due to narrowing of the intestinal lumen. Methods: To minimize the complications associated with the standard Witzel method, we modified the procedure wherein a T‐tube is substituted for a standard French rubber catheter, and transversely sutured to the mesenteric border. We believe that the placement of the Witzel line in the transverse plane minimizes the risk of obstruction, and substitution of a T‐tube for a standard French catheter should reduce the incidence of tube dislodgement. Results: The Transverse Witzel T‐tube feeding jejunostomy has been performed successfully in 30 patients without any complications of tube dislodgement or leaks, and no tube to date has been difficult to remove. Length of tube use has ranged from 1 to 6 months, and no postoperative complications have been observed in this group. Conclusions: The Transverse Witzel T‐tube jejunostomy is an effective and rapid technique for placement of a feeding tube. No serious complications have been observed, and the complication of tube dislodgement appears to be decreased compared to the standard Witzel procedure. (Journal of Parenteral and Enteral Nutrition 19:326–327, 1995)
The Effect on Energy and Nitrogen Metabolism by Continuous, Bolus, or Sequential Infusion of a Defined Total Parenteral Nutrition Formulation in Patients After Major Surgical Procedures
Authors: Sandstrom Rolf , Hyltander Anders , Korner Ulla , Lundholm Kent
Published: May 2008

Background: The role of IV infusion kinetics to explain nutrition efficiency was investigated in patients after major surgical procedures. Methods: IV nutrition was provided as three different infusion kinetic regimens in a randomized fashion. All patients received nonprotein calories (100% of predicted preoperative REE, 60% D‐glucose, 40% fat) and amino acid nitrogen (0.2 g N/d). Group A: Nutrition was provided by sequential infusion with combined fat and amino acids during daytime and glucose alone during nighttime (“sequential infusion”). Group B: Patients received 24‐hour combined infusion with fat, amino acids, and glucose (all in one mixture) (“continuous infusion”). Group C: Nutrition was provided by bolus infusions during 1 hour followed by 2 hours without any infusion (“bolus infusion”). Results: The daily energy balance was negative in all groups (‐318 ± 25 kcal/d, sequential infusion; ‐368 ± 25 kcal/d continuous infusion; ‐292 ± 20 kcal/d, bolus infusion). Significantly different excretion patterns of nitrogen in urine occurred among the groups despite an almost identical provision of nitrogen. Continuously infused patients retained nitrogen significantly better (‐0.2 ± 0.6 g/d) compared with sequentially (‐3.4 ± 1.0 g/d) and bolus‐infused patients (‐2.8 ± 0.3 g/d) (p <.01), whereas their cumulative urinary glucose excretion was significantly larger. Continuously infused patients were in cumulative nitrogen balance during the entire postoperative period, whereas the other groups were in a significantly negative nitrogen balance. Urinary 3‐methylhistidine excretion was similar in all groups. Conclusions: The breakdown of muscle proteins was not sensitive to alterations in nutrient and substrate supply. Thus improved nitrogen retention reflected entirely improved synthesis. “All‐in‐one” IV nutrition with prolonged infusion periods is at present the most favorable regimen considering both the nutritional efficiency and its metabolic load on the organism after major surgery. (journal of Parenteral and Enteral Nutrition 19:333—340, 1995)
Nutrition Support Affects the Distribution and Organ Uptake of Cachectin/ Tumor Necrosis Factor in Rats
Authors: Keith Mary E. , Norwich Kenneth H. , Jeejeebhoy Khursheed N.
Published: May 2008

Background: We have previously observed a potentiation of the metabolic response to cachectin/tumor necrosis factor (TNF) by total parenteral nutrition (TPN) but not in anorexic orally fed animals. We hypothesized that nutritional status might affect TNF clearance kinetics. Methods: We compared the clearance of a bolus of labeled TNF in TPN‐fed animals given sufficient nutrients to grow called weight‐gaining rats (WGR) with those given 50% of the WGR called weight‐losing rats (WLR) and with orally fed rats (OFR). Data were analyzed using a two‐compartment open system model and by linear systems analysis. Results: The data from both types of analysis indicated that although metabolic clearance was similar, WGR had a slower fractional TNF clearance rate (FCR) as well as a larger volume of distribution than WLR or OFR. Further analysis showed that an increased proportion of the total mass of TNF resided in a plasma‐associated compartment in WGR compared with WLR and OFR. In addition, WGR had reduced uptake of labeled TNF by the kidney. Conclusion: The data suggest that nutrition support influences either the distribution of TNF or the FCR, resulting in a greater retention in the plasma‐associated compartment with intact absolute removal rates. This study has important implications concerning the type of nutrition support provided to the critically ill patient because our data suggest that clinical states with increased circulating TNF levels may be adversely affected by currently available nutritional practices. (journal of Parenteral and Enteral Nutrition 19:341–350, 1995)
How Effective Is Enteral Nutrition in Inducing Clinical Remission in Active Crohn's Disease? A Meta‐Analysis of the Randomized Clinical Trials
Authors: Fernández‐Bañares Fernando , Cabré Eduard , Esteve‐Comas Maria , Gassull Miquel A.
Published: May 2008

Background: The purpose of the study was to evaluate, using meta‐analysis techniques, whether enteral nutrition is effective in inducing clinical remission in active Crohn's disease. Methods: Randomized trials either comparing enteral nutrition with steroids or comparing elemental (amino acid‐based) with nonelemental diets were selected using MEDLINE (1984 to 1994), reference lists from published articles, reviews, and abstracts from major gastrointestinal meetings. Sixteen studies fulfilled the inclusion criteria (four published as abstracts). Crude rates for induction of remission were collected on an intention‐to‐treat basis by three independent observers. Each study was given a quality score, based on predetermined criteria. Results: The pooled odds ratio (OR) for all type of enteral diets compared with steroid therapy was 0.35 (95% CI, 0.23 to 0.53). This result was similar for the best studies (by quality score) combined, for trials using tube feeding combined, and when noncompliant patients were withdrawn. Further subgroup analyses were conducted on the basis of the type of diet administered. Peptide‐based diets were significantly inferior to steroids (pooled OR, 0.32; CI, 0.20 to 0.52). There was a trend to lower remission rate after elemental diets than after steroids (pooled OR, 0.44; CI 0.17 to 1.12). On the other hand, pooled OR for whole protein‐based diets compared with elemental diets was 1.28 (CI, 0.40 to 4.02). Conclusions: Data available to date show that steroids are better than enteral nutrition to induce remission in active Crohn's disease. These results are more evident when peptide‐based diets are administered, but they are not conclusive when either elemental or whole protein‐based diets are used. (journal of Parenteral and Enteral Nutrition 19:356–364, 1995)
Structured Triglycerides Were Well Tolerated and Induced Increased Whole Body Fat Oxidation Compared With Long‐Chain Triglycerides in Postoperative Patients
Authors: Sandström Rolf , Hyltander Anders , Korner Ulla , Lundholm Kent
Published: May 2008

Background: It has been proposed, on the basis of animal experiments, that medium‐chain triglycerides (MCT) may exert more favorable effects on whole body metabolism of injured animals than long‐chain triglycerides (LCT). Therefore, the present study was designed to evaluate whether structured triglycerides are associated with increased whole body fat oxidation without promotion of ketogenesis in postoperative patients. Methods: A structured lipid emulsion (73403 Pharmacia, Sweden) containing medium‐ and long‐chain fatty acids, esterified randomly to glycerol in a triglyceride structure, was used. Whole body fat oxidation was determined by indirect calorimetry in the postoperative period. Patients were randomized to receive structured lipids 1 day followed by LCT (Intralipid, Pharmacia) the next day or vice versa during 6 postoperative days. In part 1 of the study patients received fat at 1.0 g/kg per day in the presence of 80% of the basal requirement of nonprotein calories. In part 2 patients received fat at 1.5 g/kg per day in the presence of 120% of the nonprotein caloric requirement. Amino acids were always provided at 0.15 g N/kg per day. Results: Structured lipids were not associated with any side effects, were rapidly cleared from the plasma compartment, and were rapidly oxidized without any significant hyperlipidemia or ketosis. Provision of structured lipids in the presence of excess of nonprotein calories (part 2) caused a significantly higher whole body fat oxidation (2.4 ± 0.05 g/kg per day) compared with LCT provision (1.9 ± 0.06 g/kg per day) (p <.0001) examined in the same patients. Conclusions: The results demonstrated for the first time in man that provision of structured triglycerides were associated with increased whole body fat oxidation in stressed postoperative patients, which is in line with the original metabolic and biochemical concept for structured triglycerides. The study provided evidence to support that structured lipids may represent a next generation of IV fat emulsions that may be clinically advantageous compared with conventional LCT emulsions in certain clinical conditions. (journal of Parenteral and Enteral Nutrition 19:381—386, 1995)
The Effects of Light Exposure on the In Vitro Hepatic Response to an Amino Acid—Vitamin Solution
Authors: Shattuck Karen E. , Bhatia Jatinder , Grinnell Chali , Rassin David K.
Published: May 2008

Background: Administration of parenteral nutrition (PN) that has been irradiated with light is associated with hepatic dysfunction in rats in vivo. Using the isolated perfused rat liver, we report the in vitro hepatic response to a light‐exposed amino acid‐vitamin (AAV) solution, compared with a light‐protected solution. Methods: The amino acid‐vitamin solution (3 g Aminosyn and 2.5 mL MVI‐12 added to buffer) was placed under a lamp in a beaker that was covered completely with foil (light‐protected) or with a transparent wrap (light‐exposed) for 24 hours before liver perfusion. Livers from adult male rats were isolated and perfused with buffer for 30 minutes, with the AAV solution for 60 minutes, and again with buffer for 30 minutes. Results: Infusion with the AAV solution resulted in decreases in bile flow rates. Compared with light‐protected groups, light‐exposure was associated with significantly lower bile flow rates, significant increases in biliary concentrations of oxidized glutathione (GSSG), and significantly decreased biliary concentrations of free amino acids, including the glutathione precursors glutamate and glycine. Conclusions: Perfusion of the isolated rat liver with an AAV solution that has been irradiated with light for 24 hours results in a decrease in bile flow rates and an increase in biliary GSSG concentrations, suggesting oxidant stress. Consideration should be given to protecting solutions from light in the clinical setting. (Journal of Parenteral and Enteral Nutrition 19:398–402, 1995)
Does the Use of Hydrochloric Acid Damage Silicone Rubber Central Venous Catheters?
Authors: Shulman Robert J. , Barrish James P. , Hicks M. John
Published: May 2008

Background: Hydrochloric acid (HCl) is commonly used to clear obstructions in central venous catheters (CVC). Methods: To determine if HCl adversely affects the integrity of a CVC we infused 0.1 N HCl daily into CVC in vitro. At weekly intervals sections of the CVC were removed and examined using scanning electron microscopy. Results: Over 8 weeks, no damage to the CVC was visible. Conclusions: HCl administration poses no threat to the structural integrity of a CVC. (Journal of Parenteral and Enteral Nutrition 19:407–409, 1995)
Increase in Lumbar Spine Bone Mineral Content in Patients on Long‐Term Parenteral Nutrition Without Vitamin D Supplementation
Authors: Verhage Albert H. , Cheong Wei K. , Allard Johane P. , Jeejeebhoy Khursheed N.
Published: May 2008

Background: We had previously shown that short‐term withdrawal of vitamin D in patients with metabolic bone disease complicating home parenteral nutrition (HPN) corrected osteomalacia. We therefore conducted a prospective study of the effect of long term withdrawal of vitamin D in patients on home parenteral nutrition. Methods: Baseline measurements of bone mineral content, serum levels of calcium, phosphorus, parathormone, 25‐OH and 1,25 (OH)2 D; urinary calcium; and bone mineral density were measured. Then all parenteral vitamin D was withdrawn and the above parameters were followed for a mean of 4.5 years. Results: Lumbar spine bone mineral content (LSBMC) was 0.79 ± 0.06 g/cm2 at the start of the study, well below the reference value, 1.16 ± 0.13 g/cm2. Parathyroid hormone (PTH) (0.48 ± 0.24 pmol/L) and 1,25‐(OH)2D levels (22.8 ± 7.9 pmol/L) were low and 25‐hydroxyvitaniin D levels were normal (33.3 ± 5.5 nmol/L) before removing vitandn D from the HPN solutions. After withdrawal of vitamin D for 4.5 ± 0.2 years LSBMC increased from 0.79 ± 0.06 to 0.93 0.07 g/cm2 (p < 0.005). Calcium phosphorus, magnesium and 25‐hydroxyvitamin D did not change significantly, 1,25(OH)2D, and PTH levels became normal after withdrawal of vitamin D. Conclusions: In selected patients with depressed PTH levels, long‐term withdrawal of vitamin D during HPN increases LSBMC and levels of PTH and 1,25(OH)2D. There is no reduction of the mean level of 25‐hydroxyvitamin D. (Journal of Parenteral and Enteral Nutrition 19:431–436, 1995)
Glutamine Supplementation of Enteral Nutrition: Impact on Whole Body Protein Kinetics and Glucose Metabolism in Critically Ill Patients
Authors: Long Calvin L. , Nelson Karl M. , Dirienzo Douglas B. , Weis Jeffery K. , Stahl Richard D. , Broussard Toby D. , Theus William L. , Clark J. Allen , Pinson Terry W. , Geiger John W. , Laws Henry L. , Blakemore William S. , Carraway Robert P.
Published: May 2008

Background: Glutamine‐supplemented parenteral nutrition has been reported to attenuate the early postoperative reduction in intracellular glutamine and improve protein synthesis and nitrogen balance. We investigated the effect of an enteral formula on protein and glucose kinetics and nitrogen balance in trauma patients. Methods: The enteral formula (AlitraQ) provided a mean intake of 0.35 g of glutamine/kg body weight per day to 16 trauma patients and was compared with an isonitrogenous formula that provided a mean of 0.05 g of glutamine/kg body weight per day in 14 trauma patients. After 3 days of feeding, protein kinetics were measured using a 4‐hour prime‐continuous infusion Of L‐[1‐13C]leucine. Glucose kinetics were measured during the same time interval using prime‐continuous infusion of [U‐14C]‐ and [6‐3H]glucose. Results: Nitrogen balance was not significantly different in the two groups. There were no significant differences in protein turnover, synthesis, and breakdown between the two groups. There were no significant differences in glucose turnover, oxidation, recycling, and percent Of VCO2 from glucose oxidation between the two groups. Conclusions: Glutamine‐enriched enteral formulas are well tolerated by the severely injured patient but provide no additional nutritional advantage compared with standard enteral formulas during the first 3 days of feeding immediately after trauma. (Journal of Parenteral and Enteral Nutrition 19:470–476, 1995)
Pharmacokinetic Analysis of Dodecanedioic Acid in Humans From Bolus Data
Authors: Bertuzzi Alessandro , Mingrone Geltrude , Gandolfi Alberto , Greco Aldo Virgilio , Salinari Serenella
Published: May 2008

Background: Excretion and tissue uptake of dodecanedioic acid (C12), a proposed alternative fuel substrate, was investigated in humans by bolus experiments. Methods: Seven overnight‐fasting healthy male volunteers received IV a bolus (1 g) of C12. Blood samples were collected after C12 administration at intervals of 15 minutes, and C12 serum concentration was measured by high‐performance liquid chromatography. C12 excretion in 24‐hour urine was measured. Binding of C12 in human serum was determined in separate equilibrium dialysis experiments by means of an isotopic compound (disodic salt of (1,12)14C‐dodecanedioic acid). A two‐compartment model was used for describing C12 kinetics. Results: The excreted amount of C12 in 24‐hour urine was found to be, on the average, 1.62% of administered dose. The apparent number of binding sites per albumin molecule was 3.1 ± 0.2 (estimate ± SE) with an affinity constant of 6.4 ± 1.8 mM−1. The distribution volume of central compartment was 5.56 ± 3.13 L and that of peripheral compartment was 87.4 ± 30.4 L. The rate constant of exchange between compartments was 4.60 ± 3.50 L/min, that of urinary excretion 25.6 ± 15.5 mL/min, and that of tissue uptake 2.17 ± 0.86 L/min. Conclusions: These results are promising for C12 utilization in parenteral nutrition, because C12 elimination in urine is low whereas tissue uptake appears to be rather efficient. (Journal of Parenteral and Enteral Nutrition 19:498–501, 1995)
Complications of Long Arm‐Catheters: A Randomized Trial of Central vs Peripheral Tip Location
Authors: Kearns Patrick J. , Coleman Steven , Wehner John H.
Published: May 2008

Background: This two‐part study initially evaluated complications associated with catheters inserted via upper extremity veins. The second prospective phase compared thrombotic risk of peripheral catheter tips vs a central vein terminus. Methods: Patients from public institutions with infectious diseases were observed throughout their inpatient and outpatient use of IV catheters. Seventy‐two and 39 patients enrolled in phase 1 and phase 2, respectively. Phase 1 consisted of prospective observations and analysis of complications and associated risk factors. Phase 2 randomized patients to a catheter tip location in the superior vena cava or the axillosubclavian‐innominate vein and compared the incidence of thrombosis, phlebitis, and infection. Results: In phase 1, there was an increased risk of thrombosis with peripheral tip localization (61% vs 16%, p <.05). Phase 2 confirmed increased thrombosis with tips in the axillosubclavian‐innominate vein compared with the superior vena cava (60% vs 21%, p <.05) with an improved survival for central tip catheters (p <.02). Catheters associated with thrombosis were more likely to become infected (r = 0.48, p <.02). Conclusions: The experience supports use of the long arm catheter as an effective device for parenteral therapy. A novel method for placing these catheters makes most patients candidates for this approach. Placing a long arm‐catheter's tip in the central venous circulation reduces the risk of thrombosis. A high incidence of tip misdirection indicates a need for radiographic confirmation before use. (Journal of Parenteral and Enteral Nutrition 20:20–24, 1996)
Impact of the Nutritional Regimen on Protein Catabolism and Nitrogen Balance in Patients With Acute Renal Failure
Authors: Macias William L. , Alaka Karla J. , Murphy Mary H. , Miller Michael E. , Clark William R. , Mueller Bruce A.
Published: May 2008

Background: Patients with acute renal failure are in substantial negative nitrogen balance as a result of their extremely high protein catabolic rates. We prospectively evaluated a series of patients with acute renal failure managed with continuous venovenous hemofiltration to determine which nutritional and nonnutritional variables might influence protein catabolism and nitrogen balance. Methods: Forty consecutive patients (aged 52 ± 20 years; mean ± SD) were monitored for 357 treatment days (average treatment duration 8.9 ± 8.6 days). All data (including nutritional regimen, laboratory values, APACHE II score, administered blood products, hemofiltration parameters, and medications) were collected daily. Results: For all patients, the mean normalized protein catabolic rate was 1.4 ± 0.5 g/kg per day. The rate did not differ between those who received nutrition support and those who did not. The net nitrogen deficit was less in those patients receiving nutrition support (‐6.0 ± 5.2 vs ‐14.0 ± 5.6 g N/d; p =.02). Using regression techniques (adjusted for the within‐person correlation and the previous day's normalized protein catabolic rate), the level of protein and energy provision and the interaction between protein and energy provision were predictive of the normalized protein catabolic rate. Predicted values, using this equation, suggest that at low protein administration rates (< 1 g/kg per day), increasing energy provision may reduce the protein catabolism. However, at this level of protein provision, patients remain in negative nitrogen balance. At protein administration rates necessary to achieve nitrogen balance (~1.5 to 1.8 g/kg per day), protein catabolism may increase. Providing relatively low levels of energy may diminish the magnitude of this increase. Conclusion: These results suggest that the optimal nutritional regimen for patients with acute renal failure may require a high‐protein (~1.5 to 1.8 g/kg per day) and a relatively low‐energy (~25 to 35 kcal/kg per day) content. (Journal of Parenteral and Enteral Nutrition 20:56–62, 1996)
Segmental Small Bowel Transplantation in the Rat: Comparison of Lipid Absorption Between Jejunal and Ileal Grafts
Authors: Kiyozaki Hirokazu , Kobayashi Eiji , Toyama Nobuyuki , Miyata Michio
Published: May 2008

Background: From the immunological point of view, it is very important to evaluate the efficacy of segmental small bowel transplantation and to determine which part of the intestine, jejunum, or ileum should be used. In the present study, we investigated the absorptive function of the transplanted jejunum and ileum in the rat. Methods: Syngeneic segmental small bowel transplantation (jejunal or ileal grafting) was performed. After surgery, body weight and fecal fat excretions were measured. In addition, bile acid concentration in bile juice was measured, and the response of both serum lipase and bile flow rate after oleic acid stimulation was evaluated. Recanalization of the lymphatic vessels was investigated by lymphangiography. Results: There was no significant difference in body weight change between normal controls, jejunum‐transplanted rats, and ileum‐transplanted rats. In short gut rats, however, body weight was significantly impaired. Fecal fat excretion in short gut rats was the highest in the four groups, and it was significantly lower in ileal grafts than in jejunal grafts. Ileum‐transplanted rats also showed a significantly higher bile acid concentration in bile juice than jejunum‐transplanted rats. After oleic acid stimulation, serum lipase responded better in ileal transplants than in jejunal transplants, but the bile flow rate did not show significant change in either group. Recanalization of the lymphatic vessels was established on the 28th postoperative day. Conclusions: These results clearly show that ileal transplantation is more conducive to lipid absorption than jejunal transplantation. (Journal of Parenteral and Enteral Nutrition 20:67–70, 1996)
Fatal Microvascular Pulmonary Emboli From Precipitation of a Total Nutrient Admixture Solution
Authors: Hill Steven E. , Heldman Leslie S. , Goo Elwin D.H. , Whippo Paul E. , Perkinson Joseph C.
Published: May 2008

Background: Paroxysmal respiratory failure and death occurred in two young adult females with pelvic infections. Autopsy revealed an amorphous material containing calcium obstructing the pulmonary microvasculature of each patient. Both patients received an identical total nutrient admixture (TNA) solution before their deaths. Methods: Infusion of TNA into an animal model was undertaken in an effort to reproduce the clinical effect. Laboratory investigation was also performed to isolate a precipitate and identify the factors contributing to precipitation. Results: A nonvisible precipitate containing calcium, phosphorus, and organic material was isolated from the TNA solution. Infusion of the formulation into healthy pigs resulted in sudden death within 4 hours. Alteration of the amino acid component, mix sequence, agitation technique, and mixing container influenced precipitate formation. Conclusion: Pulmonary embolization of a precipitate containing calcium phosphate resulted in the death of two patients. The pH of the amino acid component, transient elevation of calcium and phosphorus concentrations during mixing, and the lack of agitation during automated preparation of the formulation were identified as the etiologic factors producing the fatal precipitate. (Journal of Parenteral and Enteral Nutrition 20:81–87, 1996)
Perioperative Nutritional Support in Patients Undergoing Hepatectomy for Hepatocellular Carcinoma FAN ST, Lo CM, LAI ECS, ET AL: N Engl J Med 331:1547–1552, 1994
Authors: Ziegler Thomas R.
Published: May 2008

This prospective, randomized, controlled trial from the University of Hong Kong evaluated the efficacy of perioperative parenteral nutrition (PN) in patients requiring hepatectomy for primary hepatocellular carcinoma. From September 1990 through June 1993, 150 consecutive patients with resectable hepatocellular carcinoma were randomly assigned to receive either perioperative PN (n=75), in addition to usual oral diet, or to no additional therapy (oral diet alone without PN; n=75). Excluding patients with metastatic disease, a total of 64 patients in the perioperative PN group (39 with associated cirrhosis, 18 with chronic active hepatitis, and 7 without associated liver disease) were compared to 60 control patients (33 with cirrhosis, 12 with chronic active hepatitis and 15 with no associated liver disease).
An Evaluation of the Safety of Mixed Micelles in Healthy Subjects
Authors: Ballinger A.B. , Forget D. , Le Brun A. , Farthing M.J.G.
Published: May 2008

Background: Fat and water soluble vitamins are an essential part of IV nutrition (IVN). However, they are unstable in solution and may adhere to the bags and tubing containing the IVN. This study has examined the safety and side‐effect profile of mixed micelles (mixed bile‐salt lecithin micelles) used to solubilize water and fat soluble vitamins for IV administration. Methods: Two groups of six healthy male subjects received either placebo or mixed micelles daily for 5 days by IV infusion in a randomized crossover design with a 9‐day washout period separating the two treatment periods. Results: Infusion of mixed micelles resulted in a significant increase in serum glycocholic acid from a median of 26.5 μg/dL (interquartile range 18 to 38) to 115 μg/dL (70 to 155) postinfusion. Glycocholic acid may have a lytic effect on cell membranes; however, in this study there was no evidence of hemolysis or increase in serum transaminases during mixed micelle infusion. There was no increase in reported side effects during mixed micelle infusion compared with placebo. Conclusion: Mixed micelles can be used safely for the solubilization of fat‐ and water‐soluble vitamins and drugs that are to administered by IV injection. (Journal of Parenteral and Enteral Nutrition 20:110–112, 1996)
Case Management in Home Total Parenteral Nutrition: A Cost‐Identification Analysis
Authors: Curtas Susan , Hariri Reza , Steiger Ezra
Published: May 2008

Background: Home parenteral nutrition (HPN) requires intensive medical case management by practitioners with expertise in the provision of nutrition support. There is expenditure of considerable time and resources for management of these patients not covered by any of the traditional reimbursement mechanisms. The costs associated with this unreimbursed input and follow‐up are most often borne by the Nutrition Support Team or individual practitioners. Reimbursement by home care agencies to physicians for management of patients after discharge cannot be done because this may be construed as a “kick‐back” for referral of patients to particular home care agencies. Methods: Time and costs associated with management of HPN patients after discharge from the hospital were assessed using a cost‐identification analysis of 24 different factors. Daily activity logs were kept by the Nutrition Support Team members over a 2‐week period. Costs of space and furnishings were calculated. Results: On average, a total of 25 h/d was spent by members of the Nutrition Support Team on our HPN patients. Variable activities accounted for 5640.1 hours of time with fixed support at 890.3 hours. This computes to a total annual personnel cost of $168,482 ($1982 per patient). If costs of furnishings and space are also included, the overall cost of all resources was $175,989 per year or $2070 per patient. Conclusion: Significant and currently nonreimbursed costs are involved in HPN patient management. These costs are most often absorbed by the Nutrition Support Team and should be considered when evaluating total costs of HPN. (Journal of Parenteral and Enteral Nutrition 20:113–119, 1996)
Isocaloric Glutamine‐Free Diet and the Morphology and Function of Rat Small Intestine
Authors: Horvath K. , Jami M. , Hill I.D. , Papadimitriou J.C. , Magder Laurence S. , Chanasongcram S.
Published: May 2008

Background: The importance of L‐glutamine as metabolic fuel for enterocytes and its role in prevention of mucosal atrophy during total parenteral nutrition is well documented. No data are available to date that document whether a glutamine‐free complete enteral diet, requiring full energy expenditure for hydrolysis and absorption, is associated with changes in the morphology and function of the small intestine. Our aim was to examine the effect of such a diet during a 4‐week period on the morphology and function of the small intestine of rats. Methods: Three isocaloric solid rat food, containing 0%, 4%, and 8% of glutamate, respectively, were fed to three groups of rats. On the 7th and 28th days the morphology of the jejunum, the subcellular structure of enterocytes on transmission electron microscopy, enzyme activities, blood, and muscle glutamine were examined and compared in the three groups. Results: The rats on the glutamine‐free diet had significantly lower mucosal wet weight, protein and DNA content, and number of intraepithelial lymphocytes on the 7th day, whereas the number of mitoses in the Lieberkuhn's crypts was significantly less on the 28th day. The height of the enterocytes and villi was 20% higher on average in the glutamine‐free group. Electron microscopy revealed either early (swelling of cristae) or terminal (swelling of matrix) mitochondrial degenerative changes, homogenization of apical cytoplasm, and degeneration and fragmentation of microvilli with loss of their rootlets. The Na+,K+‐ATPase activity was markedly decreased in the glutamine‐free group compared with that of the other groups, most likely because of a diminished energy supply. Among brush border membrane enzymes, lactase activity decreased markedly (p <.05) in the first week. The glutamine‐free diet resulted in an increase of the lung glutamine synthetase activity and decrease in muscle glutamine content by the 28th day of the diet. Conclusions: Our study shows for the first time that a complete enteral diet, deficient only in glutamine, is associated with significant early morphologic and functional changes in the small intestine. The precise effect on intracellular events and the time of onset of these changes needs to be clarified in the future. (Journal of Parenteral and Enteral Nutrition 20:128–134, 1996)
Effects of Xylitol on Urea Synthesis in Normal Humans: Relation to Glucagon
Authors: Hamberg Ole , Almdal Thomas Peter
Published: May 2008

Background: Xylitol exerts a nitrogen‐sparing effect in stress catabolic states with hyperglucagonemia, but the mechanism(s) is unknown. We examined the effects of xylitol on urea synthesis during physiologic glucagon concentrations and during hyperglucagonemia. Methods: Urea synthesis was measured independently of blood amino acid concentration by means of functional hepatic nitrogen clearance (FHNC) (ie, the linear slope of the relation between urea synthesis rate and blood α‐amino nitrogen concentration during infusion of alanine). FHNC was measured on four separate occasions in each of seven healthy subjects: during constant infusion of alanine alone, alanine superimposed on a constant infusion of xylitol (blood xylitol 1 mmol/L), alanine superimposed on infusion of glucagon, and alanine superimposed on infusions of xylitol and glucagon. Results: During alanine infusion alone, plasma glucagon rose to ‐170 ng/L, and FHNC was (mean ± sem) 27.9 ± 1.3 L/h. Xylitol did not affect plasma glucagon and only moderately reduced FHNC to 24.3 ± 1.0 L/h (p <.05). Glucagon infusion increased plasma glucagon to ‐450 ng/L and FHNC twofold to 50.9 ± 6.2 L/h; this increase was totally prevented by the addition of xylitol that reduced FHNC to 27.4 ± 2.6 L/h (p <.01). Conclusions: The results show that xylitol only inhibited FHNC minimally during spontaneous glucagon levels. In contrast, xylitol completely inhibits the increase in FHNC by glucagon. This suggests that the mechanism whereby xylitol reduces nitrogen loss in stress catabolic conditions with hyperglucagonemia involves an effect on liver metabolism. The mechanism is unknown but may be related to depletion of hepatocyte adenine nucleotides. (Journal of Parenteral and Enteral Nutrition 20:139–144, 1996)
Duodenojejunal Motility After Oral and Enteral Nutrition in Humans: A Comparative Study
Authors: Riachi Ghassan , Ducrotte Philippe , Guedon Claire , Bouteloup Corinne , Denis Philippe , Colin Raymond , Lerebours Eric
Published: May 2008

Background: Small bowel motility during enteral nutriton (EN) remains poorly known. Our aim was to compare, in six healthy volunteers, the duodenojejunal motor patterns after a 750‐kcal meal either ingested or infused intraduodenally at two different infusion rates: 2 kcal/min for 6 hours (6‐hour EN) or 1 kcal/min for 12 hours (12‐hour EN). Methods: In each volunteer, the three manometric studies were carried out in a random order with an interval of ≥ 1 week between each recording. Number of phase III (PIIIs), their characteristics, number of waves (NW), and area under the curve (AUC) were determined. Results: PIIIs were interrupted by each type of nutrition in every volunteer. In five of six during 6‐hour EN and in six of six during 12‐hour EN, the first PIII returned before the end of EN. The mean duration of the fed pattern was similar in the three studies. During the interruption of PIIIs after oral meal, duodenojejunal motility was characterized by uninterrupted random contractions. By contrast, in four of six during the 6‐hour EN and in five of six during 12‐hour EN, it was organized as regular short bursts of contractions separated by motor quiescence. In all studies during the disruption of PIIIs, NW and AUC values decreased progressively with time and were higher at the jejunum level than in the duodenum (p <.001). However, at each level of recording, NW and AUC values were similar in the three types of feeding. After the return of PIIIs, the number, duration, and propagation velocity of PIIIs, NW, and AUC values were similar in the three studies. Conclusions: EN interrupts PIIIS, but, in most cases, PIIIs reappear before the end of EN. During the interruption of PIIIs, the organization of the contractions is qualitatively different from the fed pattern observed after oral feeding. For the same caloric value of the meal, the quantitative duodenojejunal motor response is not affected by the infusion rate, and the more important jejunal, rather than duodenal motor response found after an oral meal, is observed during EN. During EN, after the return of PIIIs, despite the persistence of a nutrient infusion into the duodenum, the small bowel motor patterns are not qualitatively or quantitatively different from those recorded in fasting subjects. (journal of Parenteral and Enteral Nutrition 20:150–155, 1996)
Histologic Development of the Sheath That Forms Around Long‐Term Implanted Central Venous Catheters
Authors: O'Farrell Laura , Griffith James W. , Lang C. Max
Published: May 2008

Background: Chronically implanted catheters often become covered with a thin, white adherent covering of tissue that has been referred to as a fibrin sheath. This tissue often interferes with catheter function. Methods: To chronicle the development of this sheath, rats were implanted with silicone rubber central venous catheters. Five rats were euthanized at 3, 7, and 60 days postimplantation so that gross necropsy and histology could be performed on the catheterized vessels. Results: The coating that developed around the external portion of the catheter started as a dark red thrombus containing fibrin and progressed into vascularized, fibrous connective tissue. Conclusions: The translucent to white sheath that forms around chronically implanted catheters is not composed of fibrin and is therefore not likely to be dissolved by fibrinolytic agents such as urokinase, streptokinase, or tissue plasminogen activator. (Journal of Parenteral and Enteral Nutrition 20:156–158, 1996)
Adhesive Mucous Gel Layer and Mucus Release as Intestinal Barrier in Rats
Authors: Boshi Yasuhiko , Nezu Rchiro , Li Cui  , Kai Chen  , Khan Jesmine , Yoshida Hiroshi , Sando Kinya , Kamata Shinkichi , Takagi Yoji , Okada Akira
Published: May 2008

Background: Although it has been reported that total parenteral nutrition induces an increased intestinal permeability and a decreased mucous gel layer covering the intestinal epithelium, the role of mucous gel on intestinal permeability has not been well understood. We examined the in vivo effects of N‐acetyl cysteine (NAC) as mucolytic agent and colchicine as suppressant of the mucus production on the intestinal transmission of fluorescein isothiocyanate dextran 70,000 (FITC‐dextran). Methods: Rats were divided into four groups. In each group, FITC‐dextran (750 mg/kg) with or without NAC (3000 mg/kg) was injected into the small intestinal lumen 3 hours after intraperitoneal injection of saline or colchicine (Col, 10 mg/kg). Thirty minutes after injection of FITC‐dextran, blood samples were taken from portal vein to analyze plasma fluorescein concentration by fluorescence spectrometry. Samples of small intestine were sectioned in a cryostat for fluorescence microscopy, and the identical sections were stained by periodic acid‐Schiff reaction. Results: Plasma FITC‐dextran level in NAC group was higher than that in control group (p<.01), that in Col+NAC group was higher than that in Col group (p <.01) and that in Col + NAC group was higher than that in NAC group (p <.05). The spaces between villi were filled with mucous gel in the control and Col groups, whereas those were not entirely filled with mucous gel in NAC and Col + NAC groups. FITC‐dextran and mucous gel showed complementary distribution in all rats. The villous interstitial edema was recognized in NAC group and the villi were disrupted in Col + NAC group. Conclusions: These results suggest that intestinal permeability is possibly affected not only by the mucous gel covering the intestinal epithelium but also by mucus release from goblet cells of the small intestine. (Journal of Parenteral and Enteral Nutrition 20:98–104, 1996)
Glycemic Response to Dietary Supplements in Cystic Fibrosis is Dependent on the Carbohydrate Content of the Formula
Authors: Milla Carlos , Doherty Leah , Raatz Susan , Schwarzenberg Sarah Jane , Regelmann Warren , Moran Antoinette
Published: May 2008

Background: Enteral formula feedings are frequently prescribed to cystic fibrosis (CF) patients to boost caloric intake. A substantial number of these patients are glucose intolerant and have severe respiratory compromise. Methods: To determine the effect of the carbohydrate content on glucose tolerance and respiratory function in glucose‐intolerant CF patients with poor lung function, we examined the response to bolus feedings of five dietary supplements: a high‐fat formula developed in our Clinical Research Center (CRC), Pulmocare, a high‐carbohydrate formula developed in our CRC, Ensure Plus, and sugar‐free Scandishake. Results: Glucose excursion in response to the formulas with the lowest carbohydrate content was significantly less than that found in response to formulas with higher carbohydrate content. Insulin levels were also markedly lower in response to the low‐carbohydrate high‐fat formulas. Glucose excursion, expressed as a percent of the response to the CRC high‐fat formula, was 111% ± 12% for Pulmocare (p = NS), 202% ± 34% for Ensure Plus (p <.01), 227% ± 37% for CRC high carbohydrate (p =.001), and 357% ± 33% for sugar‐free Scandishake (p <.001). CO2 production, O2 consumption, minute ventilation, and respiratory rate increased modestly but not significantly in response to all formulas. No significant differences were found between the formulas in regards to these parameters. There were no subjective complaints of dyspnea during any of the five studies. Conclusion: The carbohydrate content of liquid dietary supplements appears to be an important determinant of hyperglycemia in glucose‐intolerant adult CF patients. (Jouynal of Parenteral and Enteral Nutrition 20:182–186, 1996)
Rapid Diagnosis of Catheter‐Related Sepsis Using the Acridine Orange Leukocyte Cytospin Test and an Endoluminal Brush
Authors: Tighe Mark J. , Kite Peter , Thomas Daniel , Fawley Warren N. , Mcmahon Michael J.
Published: May 2008

Background: In neonates, the acridine orange leukocyte cytospin (AOLC) test has been found to be a highly sensitive test for the detection of infected IV catheters in situ, which provides a result in less than 1 hour. Preliminary data suggested that the AOLC test was of limited value in adults. We report here a modification of the test for adult patients with indwelling central venous catheters. Methods: A prospective study was performed on two groups of 50 adult patients with suspected sepsis and a central venous catheter. The AOLC test was carried out after the clinical decision to remove the catheter had been made. In group 1 patients, a blood sample was withdrawn from the catheter for the AOLC test. In the patients in group 2, an endoluminal brush was used to “sweep” the catheter before the collection of the blood sample. Results of the AOLC test were compared with culture of the removed catheter tip. Results: From the catheters in group 1 (no brush), 17 catheter tips were found to be infected, but the AOLC was positive in only two patients (12%). In group 2 (brush), 18 tips were infected, and the AOLC test was positive in 15 patients (83%). The use of the endoluminal brush significantly improved the yield of the AOLC test (p <.O1) to levels reported in neonates. The AOLC test produced no false positives in either group. Conclusion: When used independently, the AOLC test was not sensitive enough to detect catheter‐related sepsis. However, in combination with an endoluminal brush, the AOLC test was much more sensitive and has the potential to provide a simple, rapid, and accurate diagnostic test for catheter‐related sepsis, which does not require removal of the catheter. (Journal of Parenteral and Enteral Nutrition 20: 215–218, 1996)
In Vivo Crypt Surface Hyperproliferation Is Decreased by Butyrate and Increased by Deoxycholate in Normal Rat Colon: Associated In Vivo Effects on c‐Fos and c‐Jun Expression
Authors: Velázquez Omaida C. , Dongying Zhou  , Seto Renée W. , Jabbar Abdul , Choi Julie , Lederer Howard M. , Rombeau John L.
Published: May 2008

Background: Studies on colon carcinogenesis suggest that the short‐chain fatty acid butyrate may be protective, whereas the secondary bile acid deoxycholate may promote tumor development. Crypt surface hyperproliferation is regarded as a biomarker of colon cancer risk and can be modulated in vitro by the differentiation inducer butyrate and the tumor promoter deoxycholate. We hypothesized that butyrate decreases and deoxycholate increases crypt surface proliferation in vivo and that these effects are mediated by changes in the expression of the protooncogenes c‐Fos and c‐Jun, which are known to regulate proliferation and differentiation. Methods: Twenty‐five adult Sprague‐Dawley rats underwent colonic isolation and 24‐hour intraluminal instillation of 10 mmol/L sodium chloride, 10 mmol/ L sodium butyrate, or 10 mmol/L sodium deoxycholate. Proliferation of the whole crypt and five crypt compartments from base to surface was assessed by proliferating cell nuclear antigen immunohistochemistry. The ϕh value, an index of “premalignant” hyperproliferation, was calculated as the ratio of labeled cells in the two surface compartments divided by the labeled cells in the entire crypt. Expression of c‐Fos and c‐Jun was evaluated by Western blot. Results: Crypt surface proliferation and the ϕh value were significantly decreased by butyrate and increased by deoxycholate. Butyrate increased colonic expression of c‐Jun, whereas deoxycholate significantly induced c‐Fos. Conclusions: The in vivo effects on surface proliferation are consistent with a potential tumor‐promoting role for butyrate and a promotive role for deoxycholate in colon carcinogenesis. The concurrently observed effects on colonic c‐Jun and c‐Fos expression represent a novel finding and suggest that direct or indirect modulation of protooncogene expression may be the mechanism by which these dietary byproducts regulate proliferation in vivo. (Journal of Parenteral and Enteral Nutrition 20:243–250, 1996)
Short‐Chain Fatty Acid‐Supplemented Total Parenteral Nutrition Improves Nonspecific Immunity After Intestinal Resection in Rats
Authors: Pratt Vera C. , Tappenden Kelly A. , McBurney Michael I. , Field Catherine J.
Published: May 2008

Background: Total parenteral nutrition (TPN) alters both specific and nonspecific immune functions, resulting in immunosuppression. Short‐chain fatty acids have been shown to improve the adaptive responses of the gut after surgery. The following study investigates the effects of adding short‐chain fatty acids to TPN on the immune system after an 80% small bowel resection. Methods: Rats (237 ± 3 g) were infused with either TPN (n = 25) or TPN supplemented with short‐chain fatty acids (n = 26) for 3 or 7 days. Hematologic analysis was performed on peripheral blood and splenocytes were isolated to characterize cell phenotypes, natural killer cell cytotoxicity and to estimate proliferative response. Results: The relative percent of T (CD3+) cells increased (p <.05) and the relative percent of macrophages decreased (p <.001, n = 13) in the spleens of the 3‐day TPN‐fed rats. By day 7, these differences disappeared. The natural killer cells from rats that were supplemented with short‐chain fatty acids had higher (p <.0001) cytotoxic activity than the TPN groups at day 3. Mitogenic response did not differ between groups but were depressed compared with sham‐treated rats. By day 7, rats on standard TPN had larger (p <.0001) spleens than all other groups. This group also had a higher total white blood cell count because of increased numbers of macrophages and neutrophils (p <.02). Conclusion: Short‐chain fatty acids improve components of nonspecific immune responses and may be beneficial in reducing certain aspects of TPNassociated immunosuppression after major surgery. (Journal of Parenteral and Enteral Nutrition 20:264–271, 1996)