bluuebunny/crossref_metadata_2025 huggingface dataset:
Energy Expenditure Assessment and Validation After Acute Spinal Cord Injury
Authors: Barco Kathy T. , Smith Rochelle A. , Peerless Joel R. , Plaisier Brian R. , Chima Cinda S.
Published: May 2008

Background: This study was designed to determine the applicability of the Harris Benedict (HB) equation in predicting energy requirements after acute spinal cord injury (SCI) and to evaluate the accuracy of a 30‐minute energy expenditure measurement to determine 24‐hour requirements. Prealbumin (PAB) was monitored weekly to assess the patient's response to the nutrition support regimen. Methods: Patients with acute isolated SCI requiring mechanical ventilation were studied for 4 weeks postinjury. Predicted energy expenditure was estimated using a modified HB equation (HBEE). The protein goal was 2.0 g/kg or 0.23 g nitrogen/kg admission body weight/day. Nutrition support was initiated within 48 hours if medically feasible. Indirect calorimetry was performed weekly to obtain 24‐hour measured total energy expenditure (MTEE) and measured resting energy expenditure (MREE) values. Respiratory quotient, PAB levels, urinary urea nitrogen (UUN), and calculated nitrogen balance were evaluated weekly. Results: Eleven tetraplegic men with a mean age of 32 ± 8 years were studied. Mean MTEE equaled 95% to 100% HBEE. Mean MREE was not significantly different from the mean MTEE. There was a significant correlation between mean predicted and measured 24‐hour energy expenditure for each data point. Mean UUN excretion ranged from 22.3 to 28.5 g/d that resulted in a mean negative nitrogen balance for all 4 weeks. PAB improved significantly over the 4‐week study period (p< .001). Conclusions: There was a strong correlation between HBEE and MTEE. A brief REE measurement is adequate to determine daily calorie requirements. Visceral protein synthesis can be achieved despite a negative nitrogen balance.
Early Postoperative Oral Feeding After Colectomy: An Analysis of Factors That May Predict Failure
Authors: Petrelli NJ , Cheng C , Driscoll D , Rodriguez‐Bigas MA
Published: May 2008

Background: Previous studies have shown that early postoperative oral feeding is feasible. Traditionally patients were fed when flatus or defecation documented the return of bowel function. This study was undertaken to determine factors that may preclude early feeding. Methods: One hundred four successive patients underwent colorectal surgery from October 1999 to January 2001. Eighty‐nine patients started an oral dieteither on postoperative day 1 or 2. Their clinical outcomes were recorded prospectively. Fifteen of the 104 patients were excluded for small‐bowel resection (5 patients), perioperative complications (5 patients), prior radiation (3 patients), and small‐bowel obstruction (2 patients). A failure in postoperative feeding consisted of nausea, vomiting, or readmission. Results: The mean age of our cohort was 65 years (range, 28 to 87 years). There were 45 male and 44 female patients. The mean postoperative hospital stay was 6 days (range, 3 to 13 days). The median American Society of Anesthesiology score was II (range, I‐IV). The types of resection performed were right colectomy (27 patients), low anterior resection (26 patients), sigmoid resection (11 patients), abdominoperineal resection (8 patients), formation or closure of colostomy (7 patients), posterior pelvic exenteration (4 patients), total colectomy (3 patients), left colectomy (2 patients), and transverse colectomy (1 patient). Sixty‐five patients (73%) tolerated early oral feeding. Of the 24 patients that did not, 16 had nausea or emesis, and 8 required readmission for postoperative complications (small‐bowel obstruction [4 patients], wound dehiscence [1 patient], abdominal pain [1 patient], and anastomotic leak [2 patients]). Univariate analysis revealed that the use of volume expanders contributed to intolerance of early feeding. On multivariate analysis, blood loss during the operation was the only factor contributing to failure of early postoperative oral feeding. Conclusions: Early oral feeding is safe and feasible for postcolectomy patients with a history of colorectal neoplasms.
Improvement in Nutritional Parameters After Initiation of Chronic Hemodialysis
Authors: Pupim LB , Kent P , Caglar K
Published: May 2008

Protein‐calorie malnutrition is highly preventable in patients with chronic renal failure and on chronic dialysis therapy. Longitudinal studies evaluating nutritional outcomes after the initiation of chronic dialysis therapy in incident dialysis patients are limited. Methods: This prospective cohort study evaluated time‐dependent changes in several well‐defined markers of nutritional status before and after initiation of chronic hemodialysis therapy. Fifty incident hemodialysis (HD) patients (60% men, 38% white, 32% with insulin‐dependent diabetes mellitus) were studied. Multiple nutritional markers, including biochemical parameters and analysis of body composition, were assessed before the initial outpatient chronic HD treatment and every 3 months thereafter for 12 months. Results: At baseline, nutritional markers correlated well with each other. After the initiation of HD therapy, there were marked improvements in most nutritional parameters, including serum albumin, serum prealbumin, normalized protein catabolic rate, fat mass, reactance, and phase angle (P < 0.05 for all). Improvements in nutritional parameters were influenced by baseline nutritional status, ie, baseline nutritional parameters were predictors of their end‐of‐study value. Conclusion: Initiation of chronic HD therapy is associated with improvements in most nutritional markers. Nutritional benefits of increased solute clearance provided by the initiation of chronic dialysis therapy prevail over its potential catabolic effects. However, the extent of improvement was dependent on nutritional status at the time of initiation of dialysis therapy, which remained an important determinant of subsequent nutritional improvements during the first year of treatment.
Branched‐Chain Amino Acids in Patients With Hepatic Encephalopathy
Authors: Btaiche Imad F.
Published: May 2008

Hospitalized patients with hepatic insufficiency often suffer from severe catabolic states and are in urgent need of nutrition support during their acute illness. Protein intolerance, however, remains a significant problem with respect to the provision of adequate nutrition, either enterally or parenterally. The following report is an anecdotal series of 63 consecutive patients in a large urban hospital treated prospectively with nutrition support using a prototype high branched‐chain amino acid solution (FO80) given by technique of total parenteral nutrition (TPN) by the subclavian or internal jugular route with hypertonic dextrose. Sixty‐three patients, of which 42 had chronic liver disease (cirrhosis) with acute decompensation and 17 with acute hepatic injury and four with hepatorenal syndrome, are the subject of this report. All required IV nutrition support and were either intolerant to commercially available parenteral nutrition solutions or were in hepatic encephalopathy at the time they were initially seen. The cirrhotic patients had been hospitalized for a mean of 14.5 ± 1.9 days before therapy, had a mean bilirubin of 13 mg/100 mL, and had been in coma for 4.8 ± 0.7 days despite standard therapy. Patients with acute hepatitis had been in the hospital for 16.2 ± 4.1 day before therapy, had a mean bilirubin of 25 mg/100 mL, and had been in coma 5.2 ± 1.6 days before therapy. Routine tests of liver function, blood chemistries, amino acids, EEGs, and complex neurologic testing including Reitan trailmaking tests were used in the evaluation of these patients. Up to 120 g of synthetic amino acid solution with hypertonic dextrose was tolerated in these patients with improvement noted in encephalopathy of at least one grade in 87% of the patients with cirrhosis and 75% of the patients with hepatitis. Nitrogen balance was achieved when 75 to 80 g of synthetic amino acids were administered. Survival was 45% in the cirrhotic group and 47% in the acute hepatitis group. Encephalopathy appeared to correlate with individual amino acids differentially in the various groups and with the ratio between the aromatic and the branched‐chain amino acids. Ammonia did not correlate with either the degree of encephalopathy or improvement therefrom. In 24 patients therapy for hepatic encephalopathy was limited to infusion of the branched‐chain enriched amino acid solution only, with wake‐up in 66% of this group. The results strongly suggest that in protein intolerant patients requiring nutrition support, infusion with branched‐chain enriched amino acid solutions is well tolerated with either no worsening of or improvement in hepatic encephalopathy coincident with the achievement of nitrogen equilibrium and adequate nutrition support.
Altered Drug Disposition in Obesity and After Bariatric Surgery
Authors: Malone Margaret
Published: May 2008

The purpose of this review is to evaluate the effect of obesity and gastric bypass on drug disposition. A Medline search was conducted of literature from 1980 onward. All types of literature were included because of the limited data published on this subject. Very few prospective randomized controlled studies are available that have evaluated changes in drug pharmacokinetics and pharmacodynamics in patients who have a body mass index (BMI) >40 kg/m2 or who have undergone gastric restrictive surgery. Dosing recommendations have been based on general pharmacokinetic principles where specific drug data have not been assessed. Given the increasing prevalence of overweight and obesity in the population, studies that evaluate the impact of obesity on drug disposition, especially related to drugs released in the past 10 years, should be conducted.
Overview of Considerations for the Pediatric Patient Receiving Home Parenteral and Enteral Nutrition
Authors: Vanderhoof Jon A. , Young Rosemary J.
Published: May 2008

Pediatric home nutrition support is a common practice used to provide children with impaired gastrointestinal function and their caregivers a therapeutic environment for the delivery of needed nutrition for proper growth and development. Specialized teams and equipment are now available to make this a successful experience for all involved. This paper will review items specific to the care of infants and children receiving both enteral and parenteral nutrition.
Effect of a Computerized Alert on the Management of Hypokalemia in Hospitalized Patients
Authors: Paltiel O , Gordon L , Berg D , Israeli A
Published: May 2008

BACKGROUND: Electrolyte abnormalities, including hypokalemia, are frequently encountered among hospitalized patients. Their management, when carefully audited, reveals major shortcomings. OBJECTIVE: To evaluate the effect of a computerized alert on the management of severe hypokalemia in hospitalized patients. METHODS: All patients who experienced severe hypokalemia (serum potassium levels <3.0 mEq/L) during their hospitalization at Hadassah Medical Center (a 1000‐bed teaching institution on 2 campuses in Jerusalem, Israel) were included in the study. The study intervention was a computerized alert consisting of a flashing screen or printed warning for patients with serum potassium levels below 3.0 mEq/L, visible whenever an individual patient's or entire ward's results were accessed on any hospital computer. Using a previously validated computerized audit technique, we analyzed the management of hypokalemia 6 months before and 6 months after implementation of the alert intervention. RESULTS: Comparing outcomes before and after the intervention, nonmeasurement of a subsequent serum potassium level after an initial low value decreased by 36.1% (P = .08). Failure to correct the serum potassium level to above 3.5 mEq/L during the hospitalization decreased by 28.6% (P = .02). Discharge from the hospital with a subnormal serum potassium level decreased by 17.2% (P = .06). CONCLUSIONS: A computerized alert system improved the management of hypokalemia in a tertiary care hospital. This was achieved at minimal cost and with no evidence of harm. The computerized audit based on a laboratory information system is an efficient tool for evaluating this intervention.
Randomized, Prospective Trial of Antioxidant Supplementation in Critically Ill Surgical Patients
Authors: Nathens AB , Neff MJ , Jurkovich GJ
Published: May 2008

OBJECTIVE: To determine the effectiveness of early, routine antioxidant supplementation using α‐tocopherol and ascorbic acid in reducing the rate of pulmonary morbidity and organ dysfunction in critically ill surgical patients. SUMMARY BACKGROUND DATA: Oxidative stress has been associated with the development of the acute respiratory distress syndrome (ARDS) and organ failure through direct tissue injury and activation of genes integral to the inflammatory response. In addition, depletion of endogenous antioxidants has been associated with an increased risk of nosocomial infections. The authors postulated that antioxidant supplementation in critically ill surgical patients may reduce the incidence of ARDS, pneumonia, and organ dysfunction. METHODS: This randomized, prospective study was conducted to compare outcomes in patients receiving antioxidant supplementation (α‐tocopherol and ascorbate) vs those receiving standard care. The primary endpoint for analysis was pulmonary morbidity (a composite measure of ARDS and nosocomial pneumonia). Secondary endpoints included the development of multiple‐organ failure, duration of mechanical ventilation, length of ICU stay, and mortality. RESULTS: Five hundred ninety‐five patients were enrolled and analyzed, 91% of whom were victims of trauma. The relative risk of pulmonary morbidity was 0.81 (95% confidence interval 0.60 to 1.1) in patients receiving antioxidant supplementation. Multiple‐organ failure was significantly less likely to occur in patients receiving antioxidants than in patients receiving standard care, with a relative risk of 0.43 (95% confidence interval 0.19 to 0.96). Patients randomized to antioxidant supplementation also had a shorter duration of mechanical ventilation and length of ICU stay. CONCLUSIONS: The early administration of antioxidant supplementation using α‐tocopherol and ascorbic acid reduces the incidence of organ failure and shortens ICU length of stay in this cohort of critically ill surgical patients.
Refeeding Syndrome in Hospitalized Pediatric Patients
Authors: Dunn Rebecca L. , Stettler Nicolas , Mascarenhas Maria R.
Published: May 2008

Refeeding syndrome has been well documented over the years, primarily through case reports and literature reviews. Awareness of refeeding syndrome is crucial in preventing the occurrence of, and the metabolic and physiologic complications associated with, aggressive nutrition support in malnourished populations. Once compromised patients have been identified to be at risk of refeeding syndrome, nutrition rehabilitation should be cautiously initiated. We have found a lack of clinical validation for instituting nutrition support in high‐risk pediatric patients who may develop refeeding syndrome. The purposes of our investigation were to determine the incidence of refeeding syndrome in pediatric hospitalized patients beginning on parenteral nutrition and to determine how consistently the Department of Clinical Nutrition standards of care for screening and prevention were followed at our institution.
Maintaining Mucosal Immunity During Parenteral Feeding with Surrogates to Enteral Nutrition
Authors: Sacks Gordon S. , Kudsk Kenneth A.
Published: May 2008

Pneumonia and intra‐abdominal abscesses are significantly lower in trauma patients receiving enteral feeding compared with those receiving parenteral feeding. Extensive experimental evidence suggests that this is related to maintenance of the mucosal‐associated lymphoid tissue, which provides immunologic protection for both the gastrointestinal and respiratory tracts against microbial flora and infectious pathogens. This system is exquisitely sensitive to the route and type of nutrition delivery that affects its functional effectiveness. Although parenteral nutrition decreases the effectiveness of this extraintestinal mucosal immunity, specialty nutrients like glutamine and neuropeptides such as gastrin‐releasing peptide and cholecystokinin are capable of preventing some of the immune defects associated with parenteral nutrition. This review examines the mechanisms associated with the mucosal immunity and role of both glutamine and neuropeptides in normalizing defects induced by parenteral feeding. Based upon evolving data, specific nutrients and products of the enteric nervous system show promise as adjuncts to parenteral feeding that are capable of maintaining immune function in patients unable to be fed via the gastrointestinal tract.
A Practical Guideline for Calculating Parenteral Nutrition Cycles
Authors: Longhurst Chris , Naumovski Louie , Garcia‐Careaga Manuel , Kerner John
Published: May 2008

Background: Both physiologic and psychological reasons for cycling total parenteral nutrition (TPN) have been well established. Despite widespread acceptance of this practice, the only previously published method for calculating TPN cycle rates is inherently flawed. Methods: A mathematical formula was derived to facilitate reliable calculation of cyclic TPN flow rates as a function of total volume and cycle time. A publicly accessible website was subsequently developed to expedite rapid determination of TPN cycles. Results: A fail‐safe method of calculating TPN cycle flow rates can be expressed as F = V/(4T‐10), where F is equal to the basal flow rate (mL/h), T is equal to the desired cycle time (hours), and V is equal to the total volume of TPN (mL) to be delivered in 24 hours. The basal flow rate and twice the basal flow rate are used for the first and last 2 hours of the TPN cycle, and the remainder of the cycle runs at 4 times the basal flow rate. TPN cycles may be easily calculated online using this formula at http://peds.stanford.edu/tpn.html. Conclusions: We have developed a fail‐safe method of calculating TPN cycle flow rates that will consistently deliver the desired volume and have made an online implementation of this formula publicly available.
The Pathophysiology of Pancreatitis
Authors: Khokhar Asim S. , Seidner Douglas L.
Published: May 2008

The pancreas is an exocrine and endocrine gland that is required for normal digestion and metabolism of proteins, carbohydrates, and fats. Acute pancreatitis (AP) is an inflammatory process of the pancreas that involves peripancreatic tissues and remote organs. Mild AP occurs in 80% of patients requiring hospitalization and severe AP occurs in the other 20%. Chronic pancreatitis (CP) is an inflammatory disorder that causes anatomic changes, including infiltration of chronic inflammatory cells and fibrosis of the pancreas. This review discusses biochemical and histologic features of pancreatic injury in AP and CP and some of the important clinical sequelae associated with these abnormalities.
Enteral Nutrition in Acute Pancreatitis: A Survey of Practices in Canadian Intensive Care Units
Authors: Greenwood Jan K. , Lovelace Heather Y. , McClave Stephen A.
Published: May 2008

Introduction: Enteral nutrition (EN) is becoming the standard of care for the artificial nutrition support of the patient with severe acute pancreatitis. This study was designed to describe nutrition support practices for acute pancreatitis in Canadian intensive care units (ICUs) and to identify any barriers to the provision of EN in this patient population. Methods: After an initial letter of invitation, a survey was sent to all Canadian ICUs with a census of ≥8 beds. At each center, the critical care dietitian was asked 13 questions about usual practice of providing nutrition support to critically ill patients with acute pancreatitis. Results: Out of 62 ICUs successfully contacted through the initial letter that met entry criteria, responses were obtained from 54 (87%). EN was provided to patients with pancreatitis routinely in 13% (7/54) of units, occasionally in 72% (39/54), and never in 15% (8/54) of the ICUs. Technical difficulty obtaining small bowel access, reported by 38 units (72%), and lack of physician support for EN, as noted in 25 units (47%), were identified as the most common barriers to EN in this population. Enteral access was most commonly obtained via the nasojejunal route. The time frame from ICU admission to initiation of EN (when provided) differed widely between centers, varying from up to 24 hours to 48 hours in 22 units (48% of 46 ICUs), 3 to 5 days in 19 units (41%), and >5 days in 5 units (11%). Supplemental parenteral nutrition (PN) was commonly added to EN, routinely at 8 centers (18% of 45 ICUs) and only occasionally in another 20 units (44%). The duration of supplemental PN when used in conjunction with EN was <7 days in 83% (24/29) of the ICUs. When EN was not initiated, PN was used in all but one ICU. Conclusion: Although EN is being commonly provided to patients with acute pancreatitis, PN use remains prominent in many ICUs across Canada. Technical difficulty obtaining small bowel access and lack of physician support seem to be the most common barriers impeding use of EN.
Unraveling the Mystery of Pain in Chronic Pancreatitis
Authors: Rothley Betsy
Published: May 2008

Over 95% of patients with chronic pancreatitis have intractable abdominal pain. The etiology of the pain remains unclear and is considered multifocal. Treating pain associated with chronic pancreatitis requires a comprehensive approach. This care model encompasses interventional, medical, and adjuvant therapies for both pain and symptom management. Maximizing pain and symptom management in patients with chronic pancreatitis results in timely discharges from the hospital, fewer readmissions, and overall decrease in emergency department visitations. Proper assessment and management of pain and symptoms in patients with chronic pancreatitis improves overall quality of life.
A Rational Use of Immune Enhancing Diets: When Should We Use Dietary Arginine Supplementation?
Authors: Ochoa Juan B. , Makarenkova Valeriya , Bansal Vishal
Published: May 2008

Controversies in any arena of human activity often result in the polarization of the individuals involved into 2 opposing camps. Controversy about the use of immune‐enhancing diets (IEDs) is no exception. On one hand, some groups are proposing indiscriminate use of IEDs, whereas others have created guidelines advocating that their use should be banned for the critically ill. At stake is an emerging paradigm: that dietary manipulation of the immune system is possible and may become an important adjunct to other therapies, thus helping prevent or treat multiple diseases for millions worldwide. Under these circumstances, extremist claims of miraculous benefits or inappropriate assertions of evil can only delay the emergence of a nascent science. This paper is therefore a plea for moderation from both camps, lest we cause irreparable damage to our clinical practices and potential injury to individual patients.

IEDs all contain arginine. However, they also contain other substances such as ω‐3 fatty acids, and nucleotides. The use of all these nutrients together into commercial IEDs without adequate evaluation of their individual effects has prevented the development of mechanistic hypotheses of action. Despite this, IEDs have been tested extensively, allowing the development of guidelines for their use. IEDs should be used for surgical patients, especially those undergoing elective surgery. IEDs show no benefit and indeed can potentially harm patients with sepsis, especially in the nonsurgical group, and should not be used outside of research protocols. Advances in basic research have helped us understand mechanisms of how arginine contained in IEDs may help surgical patients but may be deleterious in patients with sepsis. A review of the basic mechanisms of action of arginine on the immune system is enclosed in this paper and should serve as a basis for the development of scientific principles that guide clinical use of IEDs.
Indications for Administration of Parenteral Nutrition in Adults
Authors: Braunschweig Carol , Liang HuiFang , Sheean Patricia
Published: May 2008

Background: Who benefits from parenteral nutrition (PN) has been the subject of much debate and 4 recent meta‐analyses. Methods: We reviewed the 4 meta‐analyses that examined the prospective, randomized, clinical trials (PRCT) that compared PN with no nutrition support (standard care) for design, study population, outcomes evaluated, and results. Results: Overall, a total of 113 PRCT were included in the 4 meta‐analyses; however, only 4 studies were included in all of them. Despite the differences in populations studied and outcomes evaluated, some similarities emerged: (1) PN does not affect mortality; (2) PN does not reduce complications in normally nourished patients; (3) in malnourished patients, PN demonstrated a trend for reduced infections and complication rates; and (4) PN reduced postoperative complications in patients having surgery for cancer of the esophagus or stomach. Conclusion: PN does not appear to be beneficial for most hospitalized patients. Among those with malnutrition or with upper gastrointestinal cancer, benefits may exist; however, these were influenced by quality of the study and year of publication.
Nutrition Support in the Morbidly Obese, Critically Ill Patient
Authors: McGinnis Carol , Fischer Janet , Larson Georgia
Published: May 2008

Nutrition support in the critically ill patient is challenging but is even more difficult in a morbidly obese patient. This case report chronicles the care of a 6‐foot‐tall, 256‐kg male (body mass index 76.5 kg/m2) who spent over a month in the intensive care unit for respiratory failure, sepsis, and acute renal failure. Parenteral nutrition was provided throughout his critical care course. One of the major difficulties encountered was determining his nutritional needs. A hypocaloric nutritional regimen was used, along with moderate protein provisions. Numerous electrolyte imbalances occurred, including hypercalcemia that did not resolve by eliminating calcium from the parenteral nutrition solution. Enteral nutrition was desired but was not used initially because of a need for vasopressors, a diagnosis of pancreatitis, difficulty in documenting feeding tube placement because of diagnostic limitations secondary to the patient's large size, and concern about managing stools. Eventually, oral intake and supplemental enteral feeding were initiated. Nutrition support team members worked closely with the interdisciplinary care team to develop strategies to manage the nutritional problems related to his obesity. A discussion of the various nutritional issues encountered in the care of this patient is provided. Reasonable nutritional status was achieved, but this case reflects some of the challenges encountered in caring for the nutritional needs of select patient populations in clinical practice and the need for increased research and guidelines in this area.
Ethical Issues in Nutrition and Human Immunodeficiency Virus
Authors: Maillet Julie O'Sullivan , Vyas Alpa , Rodrigues Jocelyn
Published: May 2008

Ethical dilemmas often arise in the provision of healthcare. In view of the advances in human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) medical management since the late 1990s, many of the challenges and ethical dilemmas encountered by healthcare professionals have changed from terminal or end‐of‐life issues to long‐term management issues. This article presents 5 case scenarios on common ethical issues faced by those providing nutrition care to people living with HIV/AIDS and addresses key questions to ask in the ethical deliberative process. Ethical dilemmas surrounding the use of complementary and alternative medicine, providing aggressive nutrition support, dealing with third‐party payers for supplement reimbursement, and managing patients with mental health disorders and substance abuse issues are discussed, with possible solutions presented from an ethics point of view.
Pediatric Assessment Scale for Severe Feeding Problems: Validity and Reliability of a New Scale for Tube‐Fed Children
Authors: Crist William , Dobbelsteyn Cindy , Brousseau Anne Marie , Napier‐Phillips Anne
Published: May 2008

Background: This study reports data on the validity and reliability of a new parent report measure, the Pediatric Assessment Scale for Severe Feeding Prob‐ lems, designed to assess progress in the development of oral eating skills for children who need prolonged tube feeding. Methods: The questionnaire was completed by parents of 3 groups of children. The first group consisted of 17 children who received all of their nutrition by tube feedings, a second group of 30 children who were oral eaters but required supplementation by tube feedings, and a third group of 27 children who were referred for feeding difficulties but were not receiving any tube feed‐ ing. A subset of parents from each group completed the measure a second time approximately 2 to 4 weeks after completing the initial questionnaire in order to examine the reliability of the measure. Results: The mean scores (scale of 0 to 66) on the measure were 7.3 for completely tube‐fed children, 30.0 for partially tube‐fed children, and 46.8 for referred, non–tube‐fed children. The correlation between first and second administration of the measure was .98. Conclusions: The validity and reliability of the Pediatric Assessment Scale for Severe Feeding Problems appears to be adequate. The new measure should allow clinicians to better rate initial severity of feeding difficul‐ ties and to track the progress of children as they advance from being totally tube‐fed to completely orally fed.
Massive Gastric Dilation and Necrosis in Anorexia Nervosa: Cause or Effect?
Authors: Lo David Y. , Yen Julia L. , Jones Michael P.
Published: May 2008

A 26‐year‐old female with a diagnosis of anorexia nervosa was admitted and found to have massive gastric dilation and gastric necrosis. Imaging studies suggested the possibility of superior mesenteric artery (SMA) syndrome. She was successfully managed with prompt gastric decompression and was able to resume oral nutrition. Gastric dilation and necrosis may be seen in anorexia nervosa as either an independent event or an SMA syndrome. The SMA syndrome may also be present as either an incidental finding or a true pathophysiologic entity. Finally, significant foregut dysfunction may be mistaken for an eating disorder. Although there is clearly an association between gastric dilation, the SMA syn‐ drome, and eating disorders, cause and consequence may not always be straightforward. Prompt recognition and conservative management are advocated in the absence of abdominal catastrophe.
Correlation Between Ammonia Levels and the Severity of Hepatic Encephalopathy
Authors: Ong JP , Aggarwal A , Krieger D , Easley KA , Karafa MT , Van Lente F , Arroliga AC , Mullen KD
Published: May 2008

Background: Because the correlation between ammonia levels and the severity of hepatic encephalopathy remains controversial, we prospectively evaluated the correlation in 121 consecutive patients with cirrhosis. Methods: The diagno‐ sis of hepatic encephalopathy was based on clinical criteria, and the severity of hepatic encephalopathy was based on the West Haven Criteria for grading of mental status. Arterial and venous blood samples were obtained from each patient. Four types of ammonia measurements were analyzed: arterial and venous total ammonia, and arterial and venous partial pressure of ammonia. Spearman rank correlations (r s) were calculated. Results: Of the 121 patients, 30 (25%) had grade 0 encephalopathy (no signs or symptoms), 27 (22%) had grade 1, 23 (19%) had grade 2, 28 (23%) had grade 3, and 13 (11%) had grade 4 (the most severe signs and symptoms). Each of the four measures of ammonia increased with the severity of hepatic encephalopathy: arterial total ammonia (r s =0.61, p ≤ .001), venous total ammonia (r s =0.56, p ≤ .001), arterial partial pressure of ammonia (r s =0.55, p ≤ .001), and venous partial pressure of ammonia (r s =0.52, p≤ .001).

Conclusions: Ammonia levels correlate with the severity of hepatic encephalopathy. Venous sampling is adequate for ammo‐ nia measurement. There appears to be no additional advantage of measuring the partial pressure of ammonia compared with total ammonia levels.
Percentage of Weight Loss as a Predictor of Surgical Risk: From the Time of Hiram Studley to Today
Authors: Parekh Neha R. , Steiger Ezra
Published: May 2008

Hiram Studley's 1936 article of research was the first publication to present a connection between preoperative weight loss and adverse postoperative outcome. Almost 70 years later, weight loss remains one of the most prominently used tools to assess nutritional status and predict surgical risk. This paper provides an overview of surgical practices at the time of Dr Studley and demonstrates Studley's unique contributions to the field of nutrition support. The search for more accurate methods of preoperative nutrition assessment is traced to show how subsequent research continues to validate the use of weight loss in the assessment of surgical risk. New developments center on techniques of body composition assessment to quantify weight lost as functional weight and clarify the impact of malnutrition on operative outcome.
Monitoring Feeding Tube Placement
Authors: Metheny Norma A. , Meert Kathleen L.
Published: May 2008

The purpose of this literature review is to describe currently available bedside methods to determine feeding tube placement. Described first are methods used at the time of blind insertion to distinguish between gastric and respiratory placement and gastric and small‐bowel placement. Discussed next are methods used after feedings are initiated to determine if the tube has remained in the desired position in the gastrointestinal tract. Some of the methods are research‐based, whereas others are opinion‐based. The level of accuracy of the methods discussed in the review varies widely. No sure nonradiographic method exists to differentiate between respiratory, esophageal, gastric, and small bowel placement of blindly inserted feeding tubes in the fed or unfed state. However, a combination of some of the simpler and more accurate methods may be used to guide feeding tube placement during insertion and help identify the point at which an abdominal radiograph is most likely to confirm the desired location. In addition, methods described in this review can help determine when a radiograph is needed to confirm that a feeding tube has remained in the correct position after the initiation of feedings. Minimizing the number of radiographs taken to assure correct tube placement is important, especially in young children and in the critical care setting where the need for radiographs for other reasons is common.
Factors Causing Interrupted Delivery of Enteral Nutrition in Trauma Intensive Care Unit Patients
Authors: Morgan Laurie M. , Dickerson Roland N. , Alexander Kathryn H. , Brown Rex O. , Minard Gayle
Published: May 2008

Background: The intent of this study was to ascertain the adequacy of delivery of enteral nutrition (EN) to critically ill adult multiple trauma patients and to identify potential detrimental factors that affect EN delivery. Methods: Retrospective observational study. Trauma intensive care unit (TICU) in a university‐affiliated hospital. Adult patients (≥18 years of age) admitted to the TICU who received enteral feeding. Results: Fifty‐six adult patients were enrolled for study. Patients received, on average, 67% ± 19% of what was prescribed for 5.7 ± 2.0 days. A total of 222 occurrences for temporary discontinuation of tube feeding were identified. Gastrointestinal intolerance, as defined by a gastric residual volume of >150 mL, abdominal pain, or >3 liquid stools per day, accounted for only 11% of the occurrences for discontinuation of feeding. Surgery (27%) and diagnostic procedures (15%) represented the majority of reasons for inadequate nutrient delivery. Minor factors for EN interruptions were mechanical feeding tube problems (8%), pharmacy delivery delay (4%), and miscellaneous factors (3%). Multiple and unknown reasons contributed to 14% and 18% of the occurrences, respectively. Conclusions: Surgery and diagnostic procedures accounted for the largest factor in enteral feeding discontinuations in our critically ill trauma patients. Gastrointestinal intolerance contributed a minor role in the temporary discontinuation of enteral feeding.
The Effect of Vasopressin on Gastric Perfusion in Catecholamine‐Dependent Patients in Septic Shock
Authors: van Haren FMP , Rozendaal FW , van der Hoeven JG
Published: May 2008

Objectives: To study the effect of continuous infusion of vasopressin on the splanchnic circulation in patients with severe septic shock. Methods: Prospective clinical study. ICU in a teaching hospital. Eleven consecutive patients with documented septic shock who remained hypotensive despite norepinephrine infusion at a rate ≥0.2μ g/kg/min. Insertion of a gastric tonometry catheter, and continuous infusion of vasopressin 0.04 units/min during 4 hours. Results: Difference between gastric and arterial CO2 partial pressure (P[g‐a]CO2 gap), mean arterial pressure, and cardiac index were recorded at baseline and after 15 minutes, 30 minutes, 60 minutes, 120 minutes, and 240 minutes. The median P[g‐a]CO2 gap increased from 5 mm Hg at baseline to 19 mm Hg after 4 hours (p = .022). Mean arterial pressure increased from 61 ± 13 mm Hg at baseline to 68 ± 9mm Hg after 4 hours (p = .055). No significant changes in cardiac index were noted. Conclusions: In norepinephrine‐dependent patients in septic shock, continuous infusion of low‐dose vasopressin results in a significant increase of the P[g‐a]CO2 gap compatible with gastrointestinal hypoperfusion.
Postoperative Jejunal Feeding and Outcome of Pancreaticoduodenectomy
Authors: Baradi H , Walsh RM , Henderson JM , Vogt D , Popovich M
Published: May 2008

Complications after pancreaticoduodenectomy are common, partly because of nutritional debilitation. The aim of this study was to evaluate the impact of early postoperative tube feeding on outcome of pancreaticoduodenectomy and determine the best method for delivering enteral feeding. A retrospective review of 180 consecutive patients undergoing Whipple operations from 1994 to 2000 was performed. Two nonrandomized patient groups were retrospectively studied: those with early postoperative tube feeding vs those with no planned feeding. Ninety‐eight patients (54%) received postoperative jejunal feeding, whereas 82 patients (46%) did not. Jejunal feeding was delivered via a bridled nasojejunal tube in 55 patients (56%) and a gastrojejunal tube in 43 (44%). Vomiting (10% vs 29%; p = .002) and use of total parenteral nutrition (TPN) (6% vs 27%; p < .0001) were less in the jejunal feeding group and rates of readmission (12% vs 27%; p = .022), early (52% vs 62%; p = .223) and late (12% vs 31%, p = .005) complications and infections (13% vs 20%, p = .014). Tube‐related complications occurred in 6 of 98 patients, all of which were associated with gastrojejunal tubes (p = .021). Early postoperative tube feeding after pancreaticoduodenectomy is associated with significantly less use of TPN and lower rates of readmission and complications. A bridled nasojejunal feeding tube appears to be a safe and reliable method of short‐term enteral feeding.
Current Nutrition Practices in Adult Lung Transplantation
Authors: Tynan Cameo , Hasse Jeanette M.
Published: May 2008

Nutrition therapy is vital to the overall management of lung transplant recipients. The objective of this review is to outline the current applications of pre‐ and posttransplant nutrition management of the adult lung transplant recipient. Pretransplant nutrition therapy decisions are based on cause of end‐stage lung disease, transplant indications, and pretransplant nutritional status. Maintaining adequate nutrient stores is the major goal of nutrition therapy for patients awaiting transplantation. In the posttransplant course, several gastrointestinal (GI) complications such as gastroesophageal reflux, gastroparesis, and distal intestinal obstruction syndrome complicate nutritional recovery. Long‐term nutrition therapy for lung transplant recipients is aimed at management of common comorbid conditions such as obesity, diabetes mellitus, hypertension, osteoporosis, and hyperlipidemia. Lung transplantation outcomes are steadily improving; however, much has yet to be explored to improve the nutrition management of these patients in both the pre‐ and posttransplantation course.
Experimental Studies Defining ω‐3 Fatty Acid Antiinflammatory Mechanisms and Abrogation of Tumor‐Related Syndromes
Authors: Babcock Tricia A. , Dekoj Thomas , Espat N. Joseph
Published: May 2008

Clinical and experimental evidence has supported a benefit for the inclusion of fish oils (a primary source of ω‐3 fatty acids) as a component of a normal healthy diet. Polyunsaturated ω‐3 fatty acids have been demonstrated to be of benefit in a number of inflammation‐associated disease states, including atherosclerosis, autoimmune disorders, malignancy, and sepsis. The beneficial effects of ω‐3 fatty acids are thought to occur through the postulated antiinflammatory actions of ω‐3 fats; however, the specific mechanism(s) of action has not been completely defined. In this review, we discuss the recent progress made in our laboratory on defining the mechanisms of ω‐3 fatty acids activity.
Emerging Concepts in Nutrigenomics: A Preview of What Is to Come
Authors: Kauwell Gail P. A.
Published: May 2008

This article provides an overview of the fundamental principles of genetics and emerging concepts related to the ways in which nutrients and bioactive food components may interact with the genome and subsequently affect human health. This exciting area of research is likely to have far‐reaching implications for the assessment and treatment of critically and chronically ill individuals that will affect nutrition standards of care and practice. A brief overview of some of the ethical, legal, and social implications of genomic research and genome‐based health care and a list of genetics resources also are provided.
Prebiotics and Synbiotics in Clinical Medicine
Authors: Bengmark Stig , Martindale Robert
Published: May 2008

Pharmaceutical medicine has thus far been unable to stop the increasing global morbidity and mortality both in acute and chronic diseases. Typically, medical practice has focused on reducing the aggressor with treatments such as antibiotics; little interest has been given to efforts to increase the individual's resistance to disease. The increased morbidity has occurred in parallel to a deviation from a large consumption of fresh fruits, vegetables, and tubers rich in live lactic acid bacteria (LAB), plant fibers, and natural antioxidants to an industry‐produced diet rich in fat and refined sugar but containing little fiber, antioxidants, and LAB. Plant fiber/prebiotics, plant‐derived antioxidants, and LAB/probiotics are known to have the potential to reinforce the immune system of the body and increase resistance to disease. However, this depends on the type of fiber, antioxidant, and strain or combination of strain used. At this stage, only about 10% of the LAB studied have proven strong immunosupportive effects. Similarly, only a few plants contain what has been called superantioxidants, antioxidants 10 or more times stronger than vitamin C and E. Increasing evidence suggests that combining several probiotic bacteria into multistrain probiotics will achieve stronger effects than single‐strain probiotics. And combining probiotics and prebiotics into “synbiotics” will further enhance the immunosupportive effects. There is little evidence that a single‐strain‐based“ superprobiotic”/magic LAB will ever be found. Instead, combining several specific and defined probiotics and several key plant fibers into multistrain/multifiber synbiotics appears to be the most promising alternative. Some edge‐cutting effects from using multistrain and multifiber compositions are reported both from animal and controlled clinical studies.
Predicted vs Measured Energy Expenditure in Critically Ill, Underweight Patients
Authors: Campbell Christina Gayer , Zander Elin , Thorland William
Published: May 2008

A retrospective analysis was conducted to compare 4 energy‐prediction equations against measured resting energy expenditure (MREE) determined via indirect calorimetry. Data from a heterogeneous group of 42 critically ill, severely underweight (59.50 ± 17.30 kg; 77.1 ± 9.7% ideal body weight [IBW]) male patients were assessed. The Hamwi formula was used to determine IBW. The Harris‐Benedict (HB) equation was calculated for patients <90% IBW using both current body weight (CBW) and IBW. Energy needs were also estimated with an Ireton‐Jones formula for all mechanically ventilated patients (n = 37). For patients <85% IBW (n = 31), an adjusted body weight was determined ([CBW + IBW]/2) and used in the HB formula. The HB formula using the IBW, CBW, and adjusted body weight was significantly different (p < .05) than MREE. The Ireton‐Jones equation was not significantly different (p > .05) from MREE but tended to overestimate energy needs (109.3% ± 16.8% MREE). Conversely, using the CBW or IBW in the HB underestimated the patient's energy needs; 77.0% ± 11.6% MREE and 90.9 ± 16.1% MREE, respectively. For patients <85% IBW, use of the adjusted body weight in the HB represented 84.2% ± 13.9% MREE. The average caloric need was 31.2 ± 6.0 kcal/kg CBW. Indirect calorimetry remains the best method of determining a patient's energy needs. Until a large prospective trial is conducted, a combination of prediction equations tempered with clinical judgment and monitoring the appropriateness of the nutrition prescription remains the best approach to quality patient care.
Ω‐3 Fatty Acid Supplements for Cancer‐Associated Weight Loss
Authors: Jatoi Aminah
Published: May 2008

Ω‐3 fatty acids have been tested for the treatment of cancer anorexia/weight loss, a syndrome that predicts a poor prognosis among cancer patients with incurable disease. This review focuses on both the preclinical and clinical data of ω‐3 fatty acids for treating this syndrome. Overall, the promise of the former does not seem to be borne out completely in the latter. This review includes a discussion of how these data might be interpreted and explained to cancer patients who are striving to cope with this syndrome.