bluuebunny/crossref_metadata_2025 huggingface dataset:
Low Carbohydrate Diets, Pro: Time to Rethink Our Current Strategies
Authors: Bloch Abby S.
Published: May 2008

Obesity‐attributable medical expenditures in the United States are estimated at $75 billion annually, half of which are financed by Medicare and Medicaid. In 2002, the estimated 80,000 bariatric surgical procedures cost between $15,000 to $30,000 per patient. It is now believed that poor diet and physical inactivity may soon overtake tobacco as the leading cause of death. These findings, along with escalating health care costs and an aging population, are compelling reasons for US health care and public health systems to create more effective preventive approaches than have been used to date to reverse this epidemic. According to current trends, obesity will become the #1 cause of death by 2005, with the toll surpassing 500,000 deaths a year, rivaling the annual deaths from cancer. Conditions of overweight and obesity are associated with diabetes, hypertension, hypercholesterolemia, asthma, arthritis, and poor health status. The successful experiences by many individuals who have limited their carbohydrate intake and mounting scientific studies supporting low‐ or controlled‐carbohydrate diets' physiologic and metabolic action warrant a closer look at this dietary regimen as a potentially viable option to current conventional approaches. For individuals with high serum triglyceride and low high‐density lipoprotein (HDL) levels, truncal obesity, or insulin resistance (metabolic syndrome or hyperinsulinemia), reducing carbohydrate intake has been shown to improve these parameters without adverse clinical effects. Studies are beginning to validate the benefit of controlling carbohydrate intake for individuals with type 2 diabetes. The controlled‐carbohydrate regimen could be a viable alternative dietary approach for weight management used by clinicians managing patients who are failing with conventional approaches. This can be achieved by either restricting carbohydrates initially and then adding back healthy carbohydrate choices until the individual's carbohydrate threshold is achieved or by eliminating carbohydrate foods one at a time from the diet until carbohydrates are limited enough to achieve weight loss and improve clinical parameters. One diet approach does not fit all patients. Some individuals might do best on a very‐low‐fat, high‐carbohydrate diet, whereas others may respond to lowering carbohydrate intake. Identifying specific needs and health conditions of each individual is key to successful application of the best approach and management for long‐term success of weight loss in conjunction with improved health.
Low‐Carbohydrate Diets, Con: The Mythical Phoenix or Credible Science?
Authors: Kushner Robert F.
Published: May 2008

Low‐carbohydrate diets are based on an alternative theory of obesity where dietary carbohydrate, particularly unprocessed sugars, causes hyperinsulinemia, leading to insulin resistance, obesity, and cardiovascular disease. In this model, carbohydrate is viewed as a “metabolic poison” and therefore is limited in the diet. This article systematically reviews and refutes the 6 major physiologic claims made by proponents of low‐carbohydrate diets. Any benefits or advantages resulting from these diets must therefore be derived from factors other than those stated by the alternative theory.
Protein and Energy Depletion in Chronic Hemodialysis Patients: Clinical Applicability of Diagnostic Tools
Authors: Kamimura M. A. , Majchrzak K. M. , Cuppari L. , Pupim L. B.
Published: May 2008

Protein and energy depletion states are common and associated with increased morbidity and mortality in chronic hemodialysis (CHD) patients. Therefore, proper use of diagnostic tools to assess depleted states in CHD patients is critical. Assessment of protein and energy status can be done by an array of methodologies that include simple estimates of the visceral and somatic pools of protein to more refined techniques to measure protein and energy balance. The nutritional and metabolic derangements in the CHD population are highly complex and can be confounded by multiple comorbidities and fluid shifts between body compartments. Therefore, assessment of protein and energy status in CHD patients requires a wide range of methodologies that not only identify depleted states but also monitor nutrition therapy and predict clinical outcome. Most important, these methods require cautious and individualized interpretation in order to minimize the interference of comorbid conditions frequently observed in the CHD population. Currently, there is not a single method that can be considered the gold standard for assessment of protein and energy status in CHD patients. Therefore, a combination of methods is recommended. In this review, we describe available methods to assess protein and energy status, with special considerations pertaining to CHD patients.
Metabolic and Nutritional Aspects of Acute Renal Failure in Critically Ill Patients Requiring Continuous Renal Replacement Therapy
Authors: Wooley Jennifer A. , Btaiche Imad F. , Good Kelley L.
Published: May 2008

Acute renal failure (ARF) is rarely an isolated process but is often a complication of underlying conditions such as sepsis, trauma, and multiple‐organ failure in critically ill patients. As such, concomitant clinical conditions significantly affect patient outcome. Poor nutritional status is a major factor in increasing patients' morbidity and mortality. Malnutrition in ARF patients is caused by hypercatabolism and hypermetabolism that parallel the severity of illness. When dialytic intervention is indicated, continuous renal replacement therapy (CRRT) is a commonly used alternative to intermittent hemodialysis because it is well tolerated by hemodynamically unstable patients. This paper reviews the metabolic and nutritional alterations associated with ARF and provides recommendations regarding the nutritional, fluid, electrolyte, micronutrient, and acid‐base management of these patients. The basic principles of CRRT are addressed, along with their nutritional implications in critically ill patients. A patient case is presented to illustrate the clinical application of topics covered within the paper.
Levocarnitine and Dialysis: A Review
Authors: Schreiber Brian
Published: May 2008

Among the various metabolic abnormalities documented in dialysis patients are abnormalities related to the metabolism of fatty acids. Aberrant fatty‐acid metabolism has been associated with the promotion of free‐radical production, insulin resistance, and cellular apoptosis. These processes have been identified as important contributors to the morbidity experienced by dialysis patients. There is evidence that levocarnitine supplementation can modify the deleterious effects of defective fattyacid metabolism. Patients receiving hemodialysis and, to a lesser degree, peritoneal dialysis have been shown to be carnitine deficient, as manifested by reduced levels of plasma free carnitine and an increase in the acyl:free carnitine ratio. Cardiac and skeletal muscles are particularly dependent on fatty‐acid metabolism for the generation of energy. A number of clinical abnormalities have been correlated with a low plasma carnitine status in dialysis patients. Clinical trials have examined the efficacy of levocarnitine therapy in a number of conditions common in dialysis patients, including skeletal‐muscle weakness and fatigue, cardiomyopathy, dialysis‐related hypotension, hyperlipidemia, and anemia poorly responsive to recombinant human erythropoietin therapy (rHuEPO). This review examines the evidence for carnitine deficiency in patients requiring dialysis, and documents the results of relevant clinical trials of levocarnitine therapy in this population. Consensus recommendations by expert panels are summarized and contrasted with present guidelines for access to levocarnitine therapy by dialysis patients.
Comparison of Urine Urea Nitrogen Collection Times in Critically Ill Patients
Authors: Graves Caran , Saffle Jeffrey , Morris Stephen
Published: May 2008

Twenty‐four‐hour urine urea nitrogen (UUN) collections are used to assess nitrogen loss in critically ill patients but are often difficult to obtain accurately. This prospective study compared 6‐ and 12‐hour UUN collections with 24‐hour UUN collections in critically ill patients receiving continuous nutrition support. ICU patients admitted from September 1999 through January 2003 who had UUN collections as part of routine care were recruited into the study. Patients were not receiving oral diets, were receiving continuous parenteral or enteral nutrition, and had indwelling urinary catheters. We excluded patients with hepatic or renal failure. Urine samples were collected every 6 hours starting at 6:00 am and kept refrigerated until the 24‐hour collection was complete. Samples were analyzed using an automated urease enzymatic reaction. Samples were multiplied by a factor of 4 (6‐hour samples) or 2 (12‐hour samples) to estimate 24‐hour totals and then compared with actual 24‐hour totals. Twenty‐four patients (18 men) completed the study; 21 patients had 6‐hour samples (84 samples), and 24 patients had 12‐hour samples (24 samples). Estimated 24‐hour UUN from 6‐hour (14.7–15.7 g/d) and 12‐hour (15.2 g/d) samples did not differ significantly (p > .5) from actual 24‐hour totals (15.1 g/d). Shortened UUN collection times may be used to estimate 24‐hour nitrogen losses in critically ill patients receiving continuous nutrition support.
Surrogate Nutrition Markers, Malnutrition, and Adequacy of Nutrition Support
Authors: Seres David S.
Published: May 2008

Surrogate nutrition markers are used to assess adequacy of nourishment and to define malnutrition despite evidence that fails to link nourishment, surrogate markers, and outcomes. Markers such as serum levels of albumin, prealbumin, transferrin, and IGF‐1 and delayed hypersensitivity and total lymphocyte count may be valid to help stratify risk. However, it is not appropriate to consider these as markers of adequacy of nourishment in the sick patient.
Nutrients and Wound Healing: Still Searching for the Magic Bullet
Authors: Thompson Cheryl , Fuhrman M. Patricia
Published: May 2008

Clinicians in nearly all practice areas are confronted with the challenges associated with delayed and impaired wound healing. Although nutrition plays a critical role in the healing process, controversy exists regarding the optimal nutrition regimen. This article reviews literature related to nutrition interventions that facilitate wound healing. The limitations of the research that forms the scientific basis of many nutrition recommendations are also examined. The limited availability of rigorously performed clinical studies to develop evidence‐based guidelines for nutrition support in wound care emphasizes the need for further research and underscores the importance of individualizing the nutrition care plan for each patient.
The Beneficial Effects of Antioxidant Supplementation in Enteral Feeding in Critically Ill Patients: A Prospective, Randomized, Double‐Blind, Placebo‐Controlled Trial
Authors: Crimi E , Liguori A , Condorelli M , Cioffi M , Astuto M , Bontempo P
Published: May 2008

We investigated whether intervention with antioxidant vitamins C and E in enteral feeding influenced oxidative stress and clinical outcome in critically ill patients. Two‐hundred sixteen patients expected to require at least 10 days of enteral feeding completed the study. One‐hundred five patients received enteral feeding supplemented with antioxidants, and 111 control patients received an isocaloric formula. Plasma lipoperoxidation (by thiobarbituric acid reactive substances [TBARS] and prostaglandin F2α isoprostane levels), low‐density lipoprotein (LDL) oxidizability, and LDL tocopherol content were determined at baseline and at the end of the 10‐day period. The clinical 28‐day outcome was also assessed. Plasma TBARS and isoprostanes were 5.33 ± 1.26 nM/mL and 312 ± 68 pg/mL, respectively, before treatment and 2.42 ± 0.61 nM/mL and 198± 42 pg/mL after intervention (p < .01 for both comparisons). Antioxidants improved LDL resistance to oxidative stress by approximately 30% (the lag time before treatment was 87 ± 23 minutes and was 118 ± 20 minutes after treatment; p < .04). There was a significantly reduced 28‐day mortality after antioxidant intervention (45.7% in the antioxidant group and 67.5% in the regular‐feeding group; p < .05). Isoprostanes may provide a sensitive biochemical marker for dose selection in studies involving antioxidants.
The Cancer Cachexia Syndrome: A Review of Metabolic and Clinical Manifestations
Authors: Esper Dema Halasa , Harb Wael A.
Published: May 2008

The progressive deterioration in nutrition status frequently seen in cancer patients is often referred to as cancer cachexia. Unlike starvation, in which fat stores from adipose are depleted and protein is spared from skeletal muscle, neither fat nor protein is spared in cachexia. Cachexia affects nearly half of cancer patients, causing the clinical manifestations of anorexia, muscle wasting, weight loss, early satiety, fatigue, and impaired immune response. Cachexia does not only impede the response to chemotherapy but also is a major cause of morbidity and mortality. According to clinical studies, increasing caloric intake does not necessarily reverse cachexia. The pathophysiology of cachexia involves more complex mechanisms than simply caloric deficiency. The process appears to be mediated by circulating catabolic factors, either secreted by the tumor alone or in concert with host‐derived factors, such as tumor necrosis factor‐α (TNF‐α), interleukins (IL‐1 and IL‐6), interferon (IFN‐y), and leukemia inhibitory factor (LIF). The successful reversal of this process will require in‐depth knowledge of the mechanisms involved, which will then enable the development of effective pharmacologic interventions that may not only improve quality of life, but more importantly, improve survival among cancer patients.
A Multidisciplinary Review of Nutrition Considerations in the Pediatric Oncology Population: A Perspective From Children's Oncology Group
Authors: Ladas Elena J. , Sacks Nancy , Meacham Lillian , Henry Dave , Enriquez Lori , Lowry Genevieve , Hawkes Ria , Dadd Gaye , Rogers Paul
Published: May 2008

Over the past few decades, great progress has been made in the survival rates of childhood cancer. As survival rates have improved, there has been an increased focus on supportive care. Nutrition is a supportive‐care modality that has been associated with improved tolerance to chemotherapy, improved survival, increased quality of life, and decreased risk of infection in children undergoing anticancer therapy. Guidelines and assessment criteria have been proposed for the nutrition management of a child with cancer; however, there is no consistent use of criteria among institutions treating children with cancer. This review will present the current evidence and standards of practice incorporating aspects of nutrition, nursing, pharmacology, and psychosocial challenges to consider in the nutrition management of a child with cancer. Recommendations for clinical practice are presented.
The Role of Dietary Factors in Cancer Prevention: Beyond Fruits and Vegetables
Authors: Williams Mark T. , Hord Norman G.
Published: May 2008

Cancer, a disease resulting from dysregulated cell growth control, is caused by an interaction of dietary, genetic, and environmental risk factors. Dietary factors, including physical activity, may contribute to approximately one‐third of all cancers. This meta‐review summarizes dietary factor and cancer risk associations and makes specific dietary recommendations to reduce risk of specific cancers. The evidence supporting specific dietary recommendations to reduce the risk of cancer is heterogeneous in its strength and consistency. Prospective epidemiologic studies have provided strong evidence supporting regular physical activity and minimal adult weight gain to lower risk of colorectal and breast cancer. The strongest evidence linking specific foods to decrease risk of certain cancers includes the consumption of fruits and vegetables and whole grains. Secondary prevention trials and observational prospective epidemiologic studies have demonstrated the efficacy of a Mediterranean‐type dietary pattern to decrease risk of both cancer and cardiovascular diseases. We recommend the adoption of dietary patterns emphasizing regular physical activity, fruits and vegetables, whole grains, legumes, nuts, seeds, and low‐fat dairy products to all people at risk for cancer and cardiovascular disease. These recommendations may be incorporated into enjoyable cultural food patterns as exemplified by Mediterranean‐type diets. The preparation and enjoyment of meals in a convivial atmosphere is a vital component of lifestyles to prevent chronic diseases such as cancer and certain cardiovascular diseases.
Adjusted Body Weight, Pro: Evidence to Support the Use of Adjusted Body Weight in Calculating Calorie Requirements
Authors: Krenitsky Joe
Published: May 2008

The optimal nutrition regimen for obese hospitalized patients remains controversial, and clinicians use a variety of different methods for estimating needs of obese patients who require nutrition support. Adjusted body weight has been proposed as one method to improve the accuracy of predictive equations when calculating calorie expenditure of obese patients. Although adjusted body weight has been criticized as a “nonscientific method,” several studies have investigated the accuracy of adjusted body weight calculations and found it comparable or superior to several prediction equations. This article will summarize the results and discuss the limitations of data from studies regarding calculations for obese hospitalized patients. The use of adjusted body weight is discussed in the context of what is clinically significant in calculations of energy expenditure and in light of the limitations of current outcome data.
Immunonutrition and Upper Gastrointestinal Surgery: What Really Matters
Authors: Sax Harry C.
Published: May 2008

Patients with upper gastrointestinal cancer or other surgical diseases are at high risk for both mechanical and infectious complications. The disease process itself places these patients at increased risk for malnutrition, with subsequent postoperative complications. Because these surgeries are semielective, a period of time is available to optimize the patient's condition. There are several trials that suggest preoperative immunonutrition supplementation improves outcomes and is cost‐effective by reducing complications. However, the most important choice a patient or clinician can make may well be by whom and where the surgery is performed.
Adherence to Nutrition Supplements Among Patients With a Fall‐Related Lower Limb Fracture
Authors: Miller Michelle D. , Daniels Lynne A. , Bannerman Elaine , Crotty Maria
Published: May 2008

Background: The purpose of this study was to provide a detailed evaluation of adherence to nutrition supplements by patients with a lower limb fracture. Methods: These descriptive data are from 49 nutritionally“ at‐risk” patients aged 70+ years admitted to the hospital after a fall‐related lower limb fracture and allocated to receive supplementation as part of a randomized, controlled trial. Supplementation commenced on day 7 and continued for 42 days. Prescribed volumes aimed to meet 45% of individually estimated theoretical energy requirements to meet the shortfall between literature estimates of energy intake and requirements. The supplement was administered by nursing staff on medication rounds in the acute or residential care settings and supervised through thrice‐weekly home visits postdischarge. Results: Median daily percent of the prescribed volume of nutrition supplement consumed averaged over the 42 days was 67% (interquartile range [IQR], 31–89, n = 49). There was no difference in adherence for gender, accommodation, cognition, or whether the supplement was self‐administered or supervised. Twenty‐three participants took some supplement every day, and a further 12 missed <5 days. For these 35 “nonrefusers,” adherence was 82% (IQR, 65–93), and they lost on average 0.7% (SD, 4.0%) of baseline weight over the 6 weeks of supplementation compared with a loss of 5.5% (SD, 5.4%) in the “refusers” (n = 14, 29%), p = .003. Conclusions: We achieved better volume and energy consumption than previous studies of hip fracture patients but still failed to meet target supplement volumes prescribed to meet 45% of theoretical energy requirements. Clinicians should consider alternative methods of feeding such as a nasogastric tube, particularly in those patients where adherence to oral nutrition supplements is poor and dietary intake alone is insufficient to meet estimated energy requirements.
Gastrostomy Tube Placement Outcomes: Comparison of Surgical, Endoscopic, and Laparoscopic Methods
Authors: Bankhead Robin Rago , Fisher Carol A. , Rolandelli Rolando H.
Published: May 2008

Background: Advances in percutaneous endoscopic gastrostomy (PEG) and laparoscopic (LAP) techniques now allow for less invasive placement of gastrostomy tubes. This study compared morbidities and feeding outcomes of these procedures with standard surgical (OPEN) insertion. Methods: Gastrostomy tubes placed in the operating room by the PEG, LAP, and OPEN methods were compared for insertion times, tube insertion and maintenance complications, enteral feeding complications, and feeding start days. Patients with concomitant intra‐abdominal procedures were excluded. Patients were followed for 6 days after tube placement. Results: A total of 91 catheters (PEG = 23, LAP = 39, OPEN = 29) were inserted in the operating room for indications of ventilator‐dependent respiratory failure (45), dysphagia (30), head and neck cancer (9), and decreased mental status (7). No patients were fed on the day of the procedure. Insertion times were significantly longer (p < .05) in the OPEN technique (68 minutes) vs LAP (48 minutes) and PEG (30 minutes). Insertion complications occurred in the LAP and PEG cohorts (3 failed LAP, 1 failed PEG), and maintenance complications were higher in the LAP group, including 1 episode each of cellulitis, bleeding, and serous drainage. Twenty enteral feeding complications in 17 patients occurred in all groups (9 in LAP vs 6 in PEG and 5 in OPEN), and included emesis (6), high residual (5), diarrhea (3), ileus (3), nausea (2), and pain after feeding (1). Overall complications were significantly lower in the PEG (7) and OPEN (5) groups compared with the LAP group (15). Feeding start day was significantly delayed in the OPEN technique (2.1 days vs 1.7 in PEG and 1.5 in LAP); however, no difference was found in days to goal among groups (4.4–4.8 days). Conclusions: PEG should be the procedure of choice for placement of gastrostomy tubes. If PEG is contraindicated, then OPEN technique may be best due to fewer complications, although insertion time is longer than the LAP technique.
Understanding Clinical Issues in Postoperative Nutrition After Pancreaticoduodenectomy
Authors: Zgodzinski Witold , Dekoj Thomas , Espat N. Joseph
Published: May 2008

Postoperative nutrition support for patients undergoing pancreaticoduodenectomy (Whipple's procedure) may be complicated due to gastrointestinal tract dysfunction (gastroparesis, dumping, and malabsorption) subsequent to the procedure. Clinical management of these patients may be adversely affected by procedure‐specific knowledge deficits (method of gastrointestinal [GI] reconstruction), common and expected surgical complications, and the available route for alimentation. It is the aim of this report to provide the reader with an overview of the procedure, common postoperative nutrition issues, and available interventions.
Adding Dietary Green Beans Resolves the Diarrhea Associated With Bowel Surgery in Neonates: A Case Study
Authors: Drenckpohl Douglas , Hocker James , Shareef Maliha , Vegunta Ravindra , Colgan Cheryl
Published: May 2008

Feeding intolerance is a common problem in infants who have had multiple or extensive resections of their small bowel. Chronic malabsorption and diarrhea are common side effects that inhibit the advancement of enteral feedings and prolong dependence on parenteral nutrition (PN). Poor growth, recurrent central line infections, cholestasis, and osteopenia are well‐known complications associated with long‐term PN dependency. It has been shown that, in adults with short bowel syndrome, providing dietary fiber can improve tolerance to enteral feeding. There are no published studies that have addressed the influence of dietary fiber on feeding intolerance in infants after bowel resections. The ensuing case studies illustrate the positive outcomes of fiber use in infants with diarrhea secondary to small bowel resections.
Diagnosis and Management of Adult Patients With Chronic Intestinal Pseudoobstruction
Authors: Sutton Dwight H. , Harrell Steven P. , Wo John M.
Published: May 2008

Chronic intestinal pseudoobstruction (CIP) is a motility syndrome that presents with symptoms and signs of intestinal obstruction and radiographic evidence of dilated bowels, but no anatomic obstruction can be found. It primarily is a disorder of small bowel motility, but it can occur anywhere in the gastrointestinal tract. This review will focus on the diagnosis and treatment of adult patients with CIP. The clinical presentation of CIP is variable, and its incidence is rare. It is a disorder with a multitude of etiologies, many of which are poorly understood. To properly manage the patient, clinicians should be aware of the various symptoms, signs, and systemic diseases that are associated with CIP. Diagnostic studies are needed to confirm the diagnosis, identify the etiology, and search for coexisting motility dysfunction. The management goals of CIP are to restore proper nutrition and fluid balance, relieve symptoms, improve intestinal motility, and treat complications.
Nutrition Aspects of Gastroparesis and Therapies for Drug‐Refractory Patients
Authors: Abell Thomas L. , Malinowski Scott , Minocha Anil
Published: May 2008

Gastroparesis, broadly defined as disordered gastric emptying, is a commonly encountered clinical problem. Nutrition problems frequently occur in gastroparesis, primarily due to inadequate oral intake but also due to losses from vomiting or diarrhea. Treatment of gastroparesis may include dietary modification with or without medication. Some patients require supplementation with either enteral or parenteral nutrition for survival. However, many patients with gastroparesis are drug‐refractory and invariably do not do well with enteral or parenteral access. Historically, these patients have been without effective therapeutic options. The development of gastrointestinal electrical stimulation has allowed many with drug‐refractory gastroparesis to be treated successfully. Enteric electrical stimulation for gastroparesis often corrects many of the nutrition abnormalities, along with improving symptoms and quality of life and reducing costs; for some categories of patients, it may improve survival rates.
Nutrition Support Teams: An Evidence‐Based Practice
Authors: Schneider Philip J.
Published: May 2008

With the development of specialized nutrition support, an interdisciplinary approach was essential to translating this medical breakthrough from the laboratory to the bedside. As this new innovation was adopted, interdisciplinary nutrition support teams were created to optimize the effectiveness and safety of this therapy. The impact of standardization and the use of an interdisciplinary team to provide specialized nutrition support have been shown to improve outcomes and safety and to have a positive financial impact on healthcare institutions. Yet many hospitals do not have nutrition support teams, and the numbers that do may have decreased. To be effective, nutrition support teams need to practice at an evidence‐based level and measure their performance. Nutrition support teams include many of the components of the healthcare delivery system that are advocated for the future, and nutrition support teams should be encouraged as the preferred system of providing specialized nutrition support.
The Use of Advance Care Planning to Guide Decisions About Artificial Nutrition and Hydration
Authors: Gillick Muriel R.
Published: May 2008

Advance care planning is important to ensure that patients, when competent, can influence the kind of medical care they receive if they lose decision‐making capacity. Because decisions by surrogates to forgo nutrition support remain controversial, specific inclusion of artificial nutrition and hydration as a part of advance care planning has taken on growing importance. This article reviews the choices about artificial nutrition and hydration that are possible using conventional advance directives such as the living will, the instructional directive, values histories, and combination directives. It summarizes the legal basis for such documents. It also describes the ways that physicians' orders to limit treatment can help implement decisions about the use of artificial nutrition and hydration. Finally, it stresses the importance of clarifying with patients and families the risks and benefits of nutrition support in a variety of common situations such as advanced dementia and metastatic cancer as an essential prerequisite to meaningful advance care planning.
Bridging the Continuum: Nutrition Support in Palliative and Hospice Care
Authors: Fuhrman M. Patricia , Herrmann Virginia M.
Published: May 2008

Clinicians and patients in today's technically focused healthcare environment are often faced with decisions of what should be done vs what could be done. The decision to provide or not provide nutrition support during palliative care and hospice care requires an understanding of and respect for patient wishes, an appreciation for the expectations of the patient and family, and open and effective communication. There can be confusion and disagreement concerning what nutrition therapies should be continued and which ones stopped. These decisions can be facilitated by answering the question: When do the burdens of nutrition support outweigh the benefit to the patient? The patient, family members, and healthcare providers should openly discuss and agree upon the goals of nutrition support during palliative care and hospice care.
Energy Expenditure in Children With Severe Head Injury: Lack of Agreement Between Measured and Estimated Energy Expenditure
Authors: Havalad Suresh , Quaid Maureen A. , Sapiega Vytautas
Published: May 2008

Background: The purpose of this study was to test the hypotheses that estimates of resting energy expenditure (REE) vary significantly from measured energy expenditure in a population of head‐injured children and are not accurate for use in determining nutrition needs in this population. Methods: This is a retrospective study of 30 children with severe head injury, with Glasgow Coma Scale (GCS) score of <8 and needing mechanical ventilation. Measured REE was obtained using indirect calorimetry. Estimated REEs were calculated using Harris‐Benedict, World Health Organization (WHO), Schofield, and White formulas. Severity of illness was calculated using Pediatric Risk of Mortality (PRISM) score. Agreement between measured REE and estimated REE was tested using the Bland‐Altman method. Correlation coefficient between PRISM score and measured REE was calculated using Spearman test. Results: More than half of the estimates of REE differed from measured REE by >10%. Significant disagreement between estimated REE and measured REE was demonstrated using the Bland‐Altman method. There was no correlation between severity of illness and measured REE to explain the inaccuracies of REE estimates. Conclusion: Energy expenditure in critically ill children cannot be estimated accurately; hence, nutrition for critically ill children with head injury should be provided according to measurement of REE to avoid the consequences of overfeeding or malnutrition.
A Randomized Study Comparing the Effects of a Low‐Carbohydrate Diet and a Conventional Diet on Lipoprotein Subfractions and C‐reactive Protein Levels in Patients With Severe Obesity
Authors: Moretti Laura , Canada Todd
Published: May 2008

Purpose: To compare the effects of a low‐carbohydrate diet and a conventional (fat‐ and calorie‐restricted) diet on lipoprotein subfractions and inflammation in severely obese subjects. Methods: We compared changes in lipoprotein subfractions and C‐reactive protein levels in 78 severely obese subjects, including 86% with either diabetes or metabolic syndrome, who were randomly assigned to either a low‐carbohydrate or conventional diet for 6 months. Results: Subjects on a low‐carbohydrate diet experienced a greater decrease in large very low‐density lipoprotein (VLDL) levels (difference =–0.26 mg/dL, p = .03) but more frequently developed detectable chylomicrons (44% vs 22%, p = .04). Both diet groups experienced similar decreases in the number of low‐density lipoprotein (LDL) particles (difference = –30 nmol/L, p = .74) and increases in large high‐density lipoprotein (HDL) concentrations (difference = 0.70 mg/dL, p = .63). Overall, C‐reactive protein levels decreased modestly in both diet groups. However, patients with a high‐risk baseline level (>3 mg/dL, n = 48) experienced a greater decrease in C‐reactive protein levels on a low‐carbohydrate diet (adjusted difference = –2 mg/dL, p = .005), independent of weight loss. Conclusions: In this 6‐month study involving severely obese subjects, we found an overall favorable effect of a low‐carbohydrate diet on lipoprotein subfractions and on inflammation in high‐risk subjects. Both diets had similar effects on LDL and HDL subfractions. (Am J Med. 2004;117:398–405.)
Dietary Folate and Vitamin B12 Intake and Cognitive Decline Among Community‐Dwelling Older Persons
Authors: Carney Erin , Canada Todd
Published: May 2008

Background: Deficiencies in folate and vitamin B12 have been associated with neurodegenerative disease. Objective: To examine the association between rates of age‐related cognitive change and dietary intakes of folate and vitamin B12. Design: Prospective study performed from 1993 to 2002. Setting: Geographically defined biracial community in Chicago, Ill. Participants: A total of 3718 residents, 65 years and older, who completed 2 to 3 cognitive assessments and a food frequency questionnaire. Main outcome measure: Change in cognitive function measured at baseline and 3‐year and 6‐year follow‐ups, using the average z score of 4 tests: the East Boston Tests of immediate and delayed recall, the Mini‐Mental State Examination, and the Symbol Digit Modalities Test. Results: High folate intake was associated with a faster rate of cognitive decline in mixed models adjusted for multiple risk factors. The rate of cognitive decline among persons in the top fifth of total folate intake (median, 742 μg/d) was more than twice that of those in the lowest fifth of intake (median, 186 μg/d), a statistically significant difference of 0.02 standardized unit per year (p = .002). A faster rate of cognitive decline was also associated with high folate intake from food (p for trend = .04) and with folate vitamin supplementation of> 400 μg/d compared with nonusers (β = –.03, p < .001). High total B12 intake was associated with slower cognitive decline only among the oldest participants. Conclusions: High intake of folate may be associated with cognitive decline in older persons. These unexpected findings call for further study of the cognitive implications of high levels of dietary folate in older populations. (Arch Neurol. 2005;62:641–645.)
Ω‐3 Fatty Acids for the Prevention of Atrial Fibrillation After Coronary Artery Bypass Surgery: A Randomized, Controlled Trial
Authors: Hoang Anh , Canada Todd
Published: May 2008

Objectives: The aim of this study was to assess the efficacy of preoperative and postoperative treatment with ω‐3 polyunsaturated fatty acids (PUFAs) in preventing the occurrence of atrial fibrillation (AF) after coronary artery bypass graft surgery (CABG). Background: Postoperative AF is a common complication of CABG. There is growing clinical evidence that PUFAs have cardiac antiarrhythmic effects. Methods: A total of 160 patients were prospectively randomized to a control group (81 patients, 13 female, 64.9 ± 9.1 years) or PUFAs 2 g/day (79 patients, 11 female, 66.2 ± 8.0 years) for at least 5 days before elective CABG and until the day of discharge from the hospital. The primary end point was the development of AF in the postoperative period. The secondary end point was the hospital length of stay after surgery. All end points were independently adjudicated by 2 cardiologists blinded to treatment assignment. Results: The clinical and surgical characteristics of the patients in the 2 groups were similar. Postoperative AF developed in 27 patients of the control group (33.3%) and in 12 patients of the PUFAs group (15.2%) (p = .013). There was no significant difference in the incidence of nonfatal postoperative complications, and postoperative mortality was similar in the PUFAs‐treated patients (1.3%) vs controls (2.5%). After CABG, the PUFAs patients were hospitalized for significantly fewer days than controls (7.3 ± 2.1 days vs 8.2 ± 2.6 days, p = .017). Conclusions: This study first demonstrates that PUFA administration during hospitalization in patients undergoing CABG substantially reduced the incidence of postoperative AF (54.4%) and was associated with a shorter hospital stay. (J Am Coll Cardiol. 2005;45:1723–1728.)
Parenteral Nutrition‐Associated Cholestasis Related to Parental Care
Authors: Wu Peggy A. , Kerner John A. , Berquist William E.
Published: May 2008

Parenteral nutrition‐associated cholestasis (PNAC) is a complication not uncommon in the pediatric population. In severe cases, patients require a liver transplant. To our knowledge, we report the only case of PNAC with end‐stage liver failure in a child with short bowel syndrome that resolved with a change in caretaker. Until his care was transferred from his abusive parents, he was frequently admitted for infection and sepsis. His liver function vastly improved from aspartate aminotransferase (AST) 3139 units/L, conjugated bilirubin 25.9 mg/dL to AST 47 units/L, direct bilirubin 0.3 mg/dL under the care of his attentive foster mother, and a liver transplant was no longer necessary. Bacterial infection and sepsis are risk factors correlated with patients with PNAC requiring liver transplant. Prevention of infection by a good caregiver may be a means to reduce the incidence of PNAC.
Is Tube Feeding an Option in Patients With Liver Disease?
Authors: Crippin Jeffrey S.
Published: May 2008

Tube feeding in patients with liver disease is often approached with trepidation because of fears of bleeding with tube placement due to the presence of esophageal varices or coagulopathy. However, the amount of published data supporting these fears is limited. This manuscript examines the issues surrounding tube feedings in patients with liver disease.
Structured Triglyceride Emulsions in Parenteral Nutrition
Authors: Chambrier C. , Lauverjat M. , Bouletreau P.
Published: May 2008

Over the past 3 decades, various concepts for IV fat emulsions (IVFE) have been developed. A randomized, structured‐lipid emulsion based on an old technology has recently become available. This structured‐lipid emulsion is produced by mixing medium‐chain triglycerides and long‐chain triglycerides, then allowing hydrolysis to form free fatty acids, followed by random transesterification of the fatty acids into mixed triglyceride molecules. Studies in animals have shown an improvement in nitrogen balance with the use of these lipid emulsions. Only 8 human clinical studies with these products have been performed. The results of these human clinical studies have been less promising than the animal studies; however, an improvement in nitrogen balance and lipid metabolism exceeds results associated with infusion of long‐chain triglycerides (LCT) or a physical mixture of long‐chain triglycerides and medium‐chain triglycerides (LCT‐MCT). Structured‐lipid emulsion seems to induce less elevation in serum liver function values compared with standard IVFEs. In addition, structured‐lipid emulsions have no detrimental effect on the reticuloendothelial system. Further studies are necessary in order to recommend the use of structured‐lipid emulsions. The clinical community hopes that chemically defined structured triglycerides will make it possible to determine the distribution of specific fatty acids on a specific position on the glycerol core and therefore obtain specific activity for a specific clinical situation.
An Overview of Tube Feeding: From Ancient Times to the Future
Authors: Chernoff Ronni
Published: May 2008

The history of enteral feeding goes back about 3500 years to the ancient Greeks and Egyptians, who infused nutrient solutions into the rectum to treat various bowel disorders. Over the centuries, experimentation and research have contributed to a greater understanding of nutrient requirements; methods to more accurately access the gastrointestinal tract; development of new materials to use in equipment, tubes, and containers; and the digestion, absorption, and use of macro‐ and micronutrients. It is notable that while advances were made in one area, progress was being made in another. For example, while enteral access and feeding techniques were being developed, essential amino acids were identified. When new information came together, rapid changes opened up the applications for enteral feeding in new directions, sometimes in unexpected ways such as diets designed for the space program, leading to the use of elemental diets as a therapeutic modality.
Modular Protein Supplements and Their Application to Long‐Term Care
Authors: Castellanos Victoria Hammer , Litchford Mary D. , Campbell Wayne W.
Published: May 2008

Modular protein supplements are added to either the diet or enteral formula to increase the protein or amino acid intakes of people who are nutritionally compromised. Protein supplements are aggressively marketed to long‐term care clinicians because protein energy malnutrition and wounds are a common problem in this care setting. It can be challenging for clinicians to distinguish one product from another and to determine the best product for a specific application or nutrition care goal. Modular protein products can be sorted into 4 categories: (1) protein concentrates derived from a complete protein such as milk, soy, or eggs; (2) protein concentrates derived from collagen, either alone or in combination with a complete protein; (3) doses of 1 or more dispensable (nonessential) amino acids; and (4) hybrids of the complete or collagen‐based proteins and amino acid dose. Modular protein supplements are generally provided either as a substrate for protein synthesis or as a source of 1 or more amino acids that may be conditionally indispensable (conditionally essential) under certain disease conditions. This review provides guidelines for the use of modular protein supplements according to their intended physiologic function and the assessment and nutrition care goals of the long‐term care resident.
Nutrition Status of Patients During Hospitalization, Tehran, Iran
Authors: Hosseini Saeed , Amirkalali Bahareh , Nayebi Neda , Heshmat Ramin , Larijani Bagher
Published: May 2008

Background: We assessed the nutrition status of patients on admission and monitored changes during hospitalization at Shariatri Educational Hospital, Tehran, Iran. Methods: One hundred fifty‐six randomly selected patients from 9 different wards were assessed. Body mass index (BMI) and body composition (based on bioelectrical impedance) were measured on admission and discharge. A questionnaire was also completed to evaluate general physical, psychological, and living status of the patients. Medical records were audited to identify when nutrition consultation, nutrition support, and nutrition‐related laboratory factors (serum levels of total lymphocyte count [TLC] and albumin) were ordered. Frequency and paired t‐test were used to analyze data. Results: Undernutrition (BMI <18.5 kg/m2) was present in 5.7% of the patients on admission, and severe undernutrition (BMI <16 kg/m2) existed in 0.6%. When discharged, 11% of patients were undernourished, and the prevalence of severe undernutrition increased to 1.3%. Average body weight and BMI decreased significantly during hospitalization (p < .001). Body composition analysis showed a significant reduction in body protein mass (p < .001). During hospitalization, body water percentile decreased and body fat percentile increased but not significantly. Only 1 patient was supported with parenteral nutrition (PN) and 1 with enteral nutrition. Orders for nutrition consultation were present in 1.9%, TLC levels in 10.8%, and serum albumin levels in 7% of the patient medical records surveyed. Conclusions: Undernutrition increased in patients during hospitalization. According to the low rate of nutrition‐related orders, one potential cause of worsening nutrition status may be inadequate medical staff awareness about the importance of nutrition in hospitalized patients.
The History of Nonsurgical Enteral Tube Feeding Access
Authors: Cresci Gail , Mellinger John
Published: May 2008

Specialized nutrition support, particularly enteral feeding, has been used for centuries. Technologic advancements have affected the provision of enteral feeding. Feeding solutions and devices, as well as the techniques to place the feeding devices, have evolved. This article reviews the history of bedside placement methods for short‐term enteral access devices.
Erythromycin Dose of 70 mg Accelerates Gastric Emptying as Effectively as 200 mg in the Critically Ill
Authors: Kolnik Lyle , Ferrone Marcus
Published: May 2008

Objective: To compare the effectiveness of 70‐mg and 200‐mg doses of IV erythromycin in improving gastric emptying in critically ill patients. Design: Gastric emptying was measured on consecutive days; day 1 (pretreatment), day 2 (posttreatment) after an IV infusion of either 70 or 200 mg erythromycin or saline placebo (0.9%), in a randomized double‐blind fashion. Setting: Mixed medical/surgical intensive care unit, tertiary referral. Patients and Participants: Thirty‐five randomly selected, mechanically ventilated, enterally fed critically ill patients (median APACHE II score 19 on admission). Interventions: On day 2, either 70 or 200 mg erythromycin or saline was administered IV over 20 min. Measurements and Results: Gastric emptying was measured using the [13C]octanoic acid breath test. The gastric emptying coefficient (GEC) and half‐emptying time (t½) were calculated from the area under the 13CO2‐recovery curve. Pretreatment gastric emptying measurements were similar in all 3 patient groups. Treatment with both doses of erythromycin significantly reduced the gastric t½: 70 mg, 98 min (IQR 88–112); 200 mg, 86 min (75–104); vs placebo, 122 min (102–190) (p < .05). The GEC was higher with both doses of erythromycin: 70 mg, 3.8 (3.3–4.0); 200 mg, 4.0 (3.6–4.2); vs placebo, 2.9 (2.5–3.7) (p < .05). There was no difference in gastric emptying posttreatment between the 2 doses of erythromycin. The effect of erythromycin was greatest in patients with delayed gastric emptying. Conclusions: Treatment with 70 and 200 mg IV erythromycin is equally effective in accelerating gastric emptying in the critically ill.
Micronutrient Assessment in Long‐Term Home Parenteral Nutrition Patients
Authors: Fuhrman M. Patricia
Published: May 2008

Assessment of micronutrient status of patients requiring long‐term parenteral nutrition (PN) continues to be a challenge for clinicians. The scientific literature primarily consists of small studies and case reports. There are no evidence‐based guidelines available. Clinicians rely on clinical assessment according to the patient's disease process, medication regimen, physical examination, and history of nutrient intake to determine existence or risk of micronutrient deficiency and toxicity. This paper will examine current scientific evidence and existing recommendations for the micronutrient assessment and management of patients requiring long‐term PN.