bluuebunny/crossref_metadata_2025 huggingface dataset:
A Microbiologic Study of Enteral Feeding Hang Time in a Burn Hospital: Can Feeding Costs be Reduced Without Compromising Patient Safety?
Authors: Neely Alice N. , Mayes Theresa , Gardner Jason , Kagan Richard J. , Gottschlich Michele M.
Published: May 2008

Background: Procedural changes for hospitalized patients must always balance safety with fiscal constraints. Microbiologic contamination of enteral feeding solutions has been previously associated with nosocomial infections. Formula manipulation and hang time contribute to microbial load, and there is considerable variation in hang time recommendations in the medical literature. With cost containment in mind, the purpose of this performance improvement study was to determine if an increase in hang time of a modular tube feeding product would increase microbial load or affect the nosocomial infection rate in pediatric burn patients. Methods: This biphasic trial initially evaluated the microbial load of the feeding after delivery of two 4‐hour aliquots into a container using the same delivery set (total hang time of 8 hours; number of tests = 20). Second, once this feeding procedure was deemed microbiologically safe, tube feedings were administered to patients, and both microbial load and nosocomial infection rate were monitored for 1 year. Results: Contamination levels at the end of the 8‐hour period using the same feeding set with 2 consecutive 4‐hour feeding aliquots (number of tests = 38) were lower than standard recommendations. The hospital's nosocomial infection rate was not altered by this procedural change, and feeding‐set expenses were reduced. Conclusions: The hang time of our enteral feeding administration set can be increased safely from 4 hours to 8 hours, with the tube feeding preparation added as two 4‐hour aliquots without a significant change in microbial load or nosocomial infection rate, thus promoting simultaneous fiscal responsibility and patient safety.
Nonalcoholic Fatty Liver Disease and Obesity
Authors: Saadeh Sherif
Published: May 2008

Nonalcoholic fatty liver disease (NAFLD) is an increasingly recognized medical condition that may progress to hepatic cirrhosis with liver failure. The pathologic picture resembles that of alcohol‐induced liver injury, but it occurs in patients who do not abuse alcohol. NAFLD is more common among patients with evidence of insulin resistance. NAFLD refers to a wide spectrum of liver damage, ranging from simple steatosis to steatohepatitis, fibrosis, and cirrhosis. The clinical implications of NAFLD are derived mostly from its common occurrence in the general population, specifically in obese individuals, and its potential to progress to cirrhosis and liver failure. It is difficult to propose a treatment strategy for NAFLD because its pathogenesis is poorly understood; however, the most commonly associated clinical features of obesity, diabetes mellitus, lipid disorders, and hypertension deserve therapeutic interventions independent of NAFLD. It is also not known if and how treatment of these other conditions affects the natural history of NAFLD, particularly in the long term.
The Obesity‐Survival Paradox in Hemodialysis Patients: Why Do Overweight Hemodialysis Patients Live Longer?
Authors: Schmidt Darren , Salahudeen Abdulla
Published: May 2008

Obesity is increasingly common in the United States, and it frequently coexists with diabetes and hypertension. Given that diabetes and hypertension are the 2 most common causes of end‐stage renal disease, it is not surprising that obesity is also highly prevalent in the US hemodialysis population. However, unlike in the general population, obesity is associated with improved survival in hemodialysis patients. This phenomenon, the obesity‐survival paradox, is neither universally accepted nor completely understood. In this article, we review the available data and provide potential reasons for the obesity‐survival paradox in the dialysis population.
Gastric Bypass in Chronic Renal Failure and Renal Transplant
Authors: Alexander J. Wesley , Goodman Hope
Published: May 2008

Background: Morbid obesity has reached epidemic proportions in developed nations worldwide, causing considerable mortality and increased healthcare expenditures. The use of gastric bypass surgery to achieve weight loss in morbidly obese patients with chronic renal failure (CRF) and postrenal transplant patients has not been studied adequately. Methods: Forty‐one patients with different stages of CRF (25 already receiving dialysis) underwent a gastric bypass (GBP), and an additional 10 patients underwent a GBP after becoming morbidly obese after transplantation. Results: Of the 41 patients with CRF, 5 stabilized or resolved their kidney disease and 9 underwent successful transplantation. These patients had a loss of 68% excess body mass index (BMI) by 12 months after GBP. Of the 10 patients with GBP after transplant, the mean loss of excess BMI was 70.5%. There were no in‐hospital or 30‐day mortalities, but 8 of the 51 patients died from 112 to 2869 days postoperatively, 7 from cardiac or vascular events and 1 from an automobile accident. This compares with an approximate 10% mortality per year for patients receiving dialysis. Comorbid conditions associated with morbid obesity improved in all patients and permitted eligibility for transplantation. Conclusions: GBP for massive weight reduction in morbidly obese renal failure and transplant patients leads to a reduction in comorbid conditions that are associated with an increased risk for cardiovascular deaths. There was no operative mortality in this series, and all but 1 death were related to previously existing disease of the cardiovascular system.
Pharmacologic Treatment Options for Obesity: Current and Potential Medications
Authors: Fujioka Ken , Lee Michael W.
Published: May 2008

Pharmacotherapy has a role in obesity management when combined with diet, physical activity, and behavior modification. Currently available therapies are safe when used appropriately. New treatments with novel mechanisms of action are likely to be available in the future.
Development of the Infant Intestine: Implications for Nutrition Support
Authors: Commare Coryn E. , Tappenden Kelly A.
Published: May 2008

The incidence of preterm births has continued to increase over the past 25 years, and therefore the optimal feeding of these infants is an important clinical concern. This review focuses on intestinal development and physiology, with a particular emphasis on developmentally immature functions of the preterm intestine and the resulting implications for nutrition therapies used to feed the preterm infant.
The Use of Carnitine in Pediatric Nutrition
Authors: Crill Catherine M. , Helms Richard A.
Published: May 2008

Carnitine is synthesized endogenously from methionine and lysine in the liver and kidney and is available exogenously from a meat and dairy diet and from human milk and most enteral formulas. Parenteral nutrition (PN) does not contain carnitine unless it is extemporaneously added. The primary role of carnitine is to transport long‐chain fatty acids across the mitochondrial membrane, where they undergo β‐oxidation to produce energy. Although the majority of patients are capable of endogenous synthesis of carnitine, certain pediatric populations, specifically neonates and infants, have decreased biosynthetic capacity and are at risk of developing carnitine deficiency, particularly when receiving PN. Studies have evaluated for several decades the effects of carnitine supplementation in pediatric patients receiving nutrition support. Early studies focused primarily on the effects of supplementation on markers of fatty acid metabolism and nutrition markers, including weight gain and nitrogen balance, whereas more recent studies have evaluated neonatal morbidity. This review describes the role of carnitine in metabolic processes, its biosynthesis, and carnitine deficiency syndromes, as well as reviews the literature on carnitine supplementation in pediatric nutrition.
Nutrition Issues in Pediatric Crohn's Disease
Authors: Wiskin Anthony E. , Wootton Stephen A. , Beattie Robert M.
Published: May 2008

Twenty‐five percent of inflammatory bowel disease (IBD) diagnoses present in childhood, with Crohn's disease (CD) being the most common type. Many children have poor nutrition status at presentation of the disease, which may worsen during the clinical course, with a significant number of children having impaired linear growth. The cause of this poor nutrition status is complex, and contributing factors include inadequate intake, malabsorption, altered energy demands, and losses through stool, particularly in colitis. The principal aim of medical management is to induce disease remission, with minimal side effects, thereby enabling normal growth and development. This must include active consideration of the nutrition needs of such children and how they may be best met. However, our understanding of the manner in which the disease process affects the energy demands of children with CD or how poor nutrition, in turn, may affect the disease course is limited. This may constrain the efficacy and effectiveness of standard therapeutic approaches to care.

This review explores the many factors of relevance in the delivery of nutrition support to children with inflammatory bowel disease, and explores the role of exclusive enteral nutrition as a corticosteroid‐sparing strategy to induce remission in children with active Crohn's disease.
24‐Hour Indirect Calorimetry in Mechanically Ventilated Critically Ill Patients
Authors: Zijlstra Nicolien , Dam Suzanne M. ten , Hulshof Paul J. M. , Ram Colette , Hiemstra Gertien , de Roos Nicole M.
Published: May 2008

Background: Energy imbalance in critically ill, mechanically ventilated patients may lead to medical complications. The nutrition care team needs accurate, noninvasive, rapid methods to estimate energy requirements. We investigated whether brief measurements of indirect calorimetry at any time of the day would give valid estimates of 24‐hour energy expenditure (EE). Methods: EE of 12 mechanically ventilated critically ill patients (6 men, 6 women, mean ± SD age 67 ± 18 years, weight 70.2 ± 8.8 kg) was recorded every minute during 24 hours by indirect calorimetry. All patients were continuously fed enteral nutrition. Results: Mean± SD EE was 1658 ± 279 kcal/d (6941 ± 1167 kJ/d). Within patients, EE during the day fluctuated by 234 kcal in the most constant patient to 1190 kcal in the least constant patient, with a mean fluctuation of 521 kcal (12 patients). No statistically significant difference (p = .53) in mean EE between morning (6–12 hours, 1676 kcal), afternoon (12–18 hours, 1642 kcal), evening (18–24 hours, 1658 kcal), and night (0–6 hours, 1655 kcal) was found. A 2‐hour instead of a 24‐hour measurement resulted in a maximal error of 128 kcal (536 kJ), which was<10% of the average EE. The maximal error decreased with longer time intervals. Conclusions: In mechanically ventilated critically ill patients, 24‐hour indirect calorimetry measurements can be replaced by shorter (≥2 hours) measurements. Time of day did not affect EE.
Review of Postmenopausal Osteoporosis Pharmacotherapy
Authors: Mayes Stacey L.
Published: May 2008

The degradation of bone tissue leading to osteoporosis is often silent and unrecognized until a postmenopausal woman develops a bone fracture. The costs of medical treatment and subsequent changes in the quality of life of a patient are significant, and avoidance via proper nutrition, exercise, and pharmacologic therapy may be the key to decreasing healthcare costs associated with this disease state. A periodic review of current literature is necessary to update the reader of current therapeutic options for the treatment and prevention of osteoporosis. A number of medications exist, and new options are ongoing. Clinicians now have access to antiresorptive and anabolic therapy in addition to lifestyle modification as options for patients. This article consists of a review of established guidelines for screening, diagnosis, and pharmacologic modalities and will provide a comprehensive assessment of therapeutic options.
Calcium Supplementation in Clinical Practice: A Review of Forms, Doses, and Indications
Authors: Straub Deborah A.
Published: May 2008

Most Americans do not meet the adequate intake (AI) for calcium; calcium supplements can help meet requirements. Calcium supplementation has been found to be beneficial for bone health in children, young adults, and menopausal women. In addition to calcium, vitamin D is necessary for bone health and is generally deficient in the industrialized world. Calcium from carbonate and citrate are the most common forms of calcium supplements. Calcium carbonate, the most cost‐effective form, should be taken with a meal to ensure optimal absorption. Calcium citrate can be taken without food and is the supplement of choice for individuals with achlorhydria or who are taking histamine‐2 blockers or protein‐pump inhibitors. Calcium lactate and calcium gluconate are less concentrated forms of calcium and are not practical oral supplements. Research on hydroxyapatite as a source of calcium is limited, so this form of calcium is not recommended. The maximum dose of elemental calcium that should be taken at a time is 500 mg. U.S. Pharmacopeia–verified calcium supplements meet vigorous manufacturing and quality requirements. Absorption from calcium‐fortified beverages varies and in general is not equal to that of milk. Potential adverse effects of calcium supplementation include gastrointestinal complaints. Renal calculi in most studies have not been associated with calcium supplementation. The risk of advanced and fatal prostate cancer has been associated with calcium intakes from food or supplements in amounts >1500 mg/d.
Vitamin D and Its Role in Cancer and Immunity: A Prescription for Sunlight
Authors: Mullin Gerard E. , Dobs Adrian
Published: May 2008

Vitamin D has been recognized for more than a century as essential for the normal development and mineralization of a healthy skeleton. More extensive roles for vitamin D were suggested by the discovery of the vitamin D receptor (VDR) in tissues that are not involved in calcium and phosphate metabolism. VDR has been discovered in most tissues and cells in the body and is able to elicit a wide variety of biologic responses. These observations have been the impetus for a reevaluation of the physiologic and pharmacologic actions of vitamin D. Here, we review the role of vitamin D in regulation of the immune system and its possible role in the prevention and treatment of cancer and immune‐mediated diseases.
A Review of the Relationship Between Parenteral Nutrition and Metabolic Bone Disease
Authors: Ferrone Marcus , Geraci Matthew
Published: May 2008

Metabolic bone disease (MBD) refers to the conditions that produce a diffuse decrease in bone density and strength because of an imbalance between bone resorption and bone formation. MBD can be a potential complication in patients receiving chronic parenteral nutrition (PN) therapy and the management of this condition presents a challenge for many clinicians. The etiology of PN‐associated MBD is poorly understood, but traditional risk factors can include malnutrition, vitamin and mineral deficiencies, toxic contaminants in the PN solution, concomitant medications, and presence of certain disease states. Although additional studies are warranted to further elucidate the development and management of this condition, the following review discusses some of the important factors that may play a role in the genesis of PN‐associated MBD and evaluates some potential strategies for the diagnosis and treatment of this complication.
Principles and Strategies for Monitoring Home Parenteral Nutrition
Authors: Siepler John
Published: May 2008

Patients who cannot ingest adequate calories to maintain body weight via their gastrointestinal tract may require parenteral nutrition (PN) at home. As with any therapy, the patient must be evaluated to determine if the home PN (HPN) is effective and the patient is free of complications. This review discusses specific items to monitor for HPN patients. Parameters to monitor can be divided into those used to determine effectiveness and those used to prevent complications of HPN. In addition, potential HPN‐associated complications can be divided into those that occur with short‐ or long‐term PN administration. Specific items to monitor are discussed within this framework.
Indirect Calorimetry: A Practical Guide for Clinicians
Authors: Haugen Heather A. , Chan Lingtak‐Neander , Li Fanny
Published: May 2008

This review provides clinicians with a comprehensive overview of indirect calorimetry including the principles, methodology, technologic advancements, benefits, and challenges. Clinical applications for indirect calorimetry and the potential limitations are specifically addressed for both the inpatient and outpatient setting. Measurement of energy expenditure is the most accurate method to assess energy needs. Indirect calorimetry remains a gold standard in measuring energy expenditure in the clinical settings. The benefits of providing optimal nutrition for recovery from illness and chronic health management are well documented. Indirect calorimetry offers a scientifically‐based approach to customize a patient's energy needs and nutrient delivery to maximize the benefits of nutrition therapy. With recent advances in technology, indirect calorimeters are easier to operate, more portable, and affordable. Increased utilization of indirect calorimetry would facilitate individualized patient care and should lead to improved treatment outcomes.
Devices and Techniques for Bedside Enteral Feeding Tube Placement
Authors: Roberts Susan , Echeverria Pamela , Gabriel Sabrey A.
Published: May 2008

Enteral feedings are an integral part of care for many hospitalized patients. Accessing the gastrointestinal (GI) tract safely and in a timely manner can be challenging. Various techniques and devices to enhance the safety of bedside feeding tube placement are available for clinicians. Three specific devices are highlighted, including the colorimetric CO2 detector (CCD), a magnetically guided feeding tube (MGFT), and the electromagnetic tube placement device (ETPD). The CO2 detector is applied to detect the presence or absence of CO2, thus assisting in correct placement of the feeding tube tip into the GI tract vs the lung. The MGFT uses a magnetic device to manipulate the feeding tube through the GI tract into the small intestine. The ETPD provides real‐time visualization of the feeding tube as it progresses into the small intestine. Training and repetition are essential for safe and successful feeding tube placement, and the highlighted devices can contribute to both of these goals.
Medical Weight Loss Treatment Options in Obese Solid‐Organ Transplant Candidates
Authors: DiCecco Sara R.
Published: May 2008

With the increasing incidence of obesity in our country, the rate of obesity seen in organ transplant candidates is also rising. Accurate descriptions and measures of weight and degree of obesity vary between organ systems. Weight loss can be achieved in some patients while they wait for the transplant surgery. Weight reduction in transplant candidates involves a team approach, with a program of education and support, including medical nutrition therapy, physical therapy, and psychological support. The safety and applicability of weight loss medications to assist with pretransplant weight loss is also not well understood. It is not yet well known if weight loss before transplantation will improve posttransplant outcomes. Many questions regarding the treatment of obesity in transplant candidates remain unanswered.
Considerations of Study Design
Authors: Koretz Ronald L.
Published: May 2008

Research projects attempt to answer specific questions. The particular study design that is selected will depend in large measure on the nature of the question and the time and resources available. There are 5 common categories of clinical questions; they relate to etiology, prognosis, utility of diagnostic tests, efficacy of proposed interventions, and cost of treatment in specific disease states. A number of study designs can be used. Case reports serve to memorialize unusual or novel aspects of diseases. Retrospective case series are useful for defining natural history. Case‐control studies are used by epidemiologists to elucidate potential etiologies of diseases. Prospective cohort studies can be used to assess natural history or to assess potential disease etiologies. Controlled trials are designed to assess the efficacy of therapeutic interventions. Studies that define the sensitivity and specificity of diagnostic tests can be used to assess the utility of those tests. Economic analyses estimate the costs that particular diseases or therapies will require. Each of these study designs has limitations; with the exception of high‐quality randomized trials, none of these study designs can establish a causative relationship between putative etiologic (or therapeutic) factors and disease (outcomes).
Evidence‐Based Medicine for Nutrition Support: An Overview of the Process
Authors: Braunschweig Carol , Lown Deborah
Published: May 2008

On a daily basis, clinicians make decisions regarding therapies to result in the best outcome for their patients. These decisions should be based on the evidence in the literature, indicating a therapy will cause the best outcome. To facilitate this, many professional societies and scientific journals have published technical and scientific reviews, as well as evidence‐based standards of care focused on many issues of nutrition support practice. This paper provides an overview of how these reviews and standards of care are derived to promote both the understanding of what they can and cannot do to enhance clinical practice.
Funding Nutrition Research: Where's the Money?
Authors: Thomson Cynthia A.
Published: May 2008

While a great idea that can be developed into a viable hypothesis is central to the development of a meritorious research proposal, without funding, the evidence base supporting or reputing a hypothesis cannot be advanced. A wide variety of funding sources exist for nutrition research, including governmental, organizational, industrial, and intramural‐based funding; however, understanding the “language” of research funding can be challenging. This review provides an overview of funding sources, guidelines for securing funding, and recommendations to support a successful application for clinical nutrition research.
Understanding Institutional Review Boards: Practical Guidance to the IRB Review Process
Authors: Pech Carol , Cob Nichelle , Cejka John T.
Published: May 2008

The purpose of this paper is to provide practical guidance to assist investigators in the preparation of materials and obtaining approval for research projects that require oversight by an institutional review board (IRB). The central requirements for IRB approval and core considerations of IRBs are described. Specific suggestions for investigators regarding how to prepare their IRB applications to anticipate and address potential IRB concerns and questions are proposed. When researchers are familiar with these criteria and how they may be interpreted by an IRB, they can avoid deferrals or lengthy requests for protocol modifications or clarifications. General tips regarding the preparation of IRB submission materials that may allow for a smoother IRB review process are also discussed. A brief list of additional resources for investigators is appended.
Biostatistics Primer: Part I
Authors: Overholser Brian R. , Sowinski Kevin M.
Published: May 2008

Biostatistics is the application of statistics to biologic data. The field of statistics can be broken down into 2 fundamental parts: descriptive and inferential. Descriptive statistics are commonly used to categorize, display, and summarize data. Inferential statistics can be used to make predictions based on a sample obtained from a population or some large body of information. It is these inferences that are used to test specific research hypotheses. This 2‐part review will outline important features of descriptive and inferential statistics as they apply to commonly conducted research studies in the biomedical literature. Part 1 in this issue will discuss fundamental topics of statistics and data analysis. Additionally, some of the most commonly used statistical tests found in the biomedical literature will be reviewed in Part 2 in the February 2008 issue.
Writing a Scientific Paper
Authors: Van Way Charles W.
Published: May 2008

Scientific papers are written to a rigid format, composed of 4 sections, which correspond with the stages of the scientific method. This essay describes the relationship of the standard sections of a paper to the stages of the scientific method. Also for discussion will be the timing of the preparation of the paper and the relationship between the experimental protocol and the eventual paper.
A “How‐To” Guide in Preparing Abstracts and Poster Presentations
Authors: Boullata Joseph I. , Mancuso Carissa E.
Published: May 2008

The preparation of an abstract or poster to share information from a project or case report with colleagues is a professional goal for many nutrition support practitioners. This paper provides an approach to help practitioners prepare an abstract for submission and subsequently a poster for presentation at a meeting.

A nutrition support question that required collecting and evaluating information, or a unique patient case or case series, can serve as the focus of an abstract and subsequent poster. The professional meeting selected should be appropriate for the abstract topic, and the authors should closely adhere to the organization's abstract submission guidelines. The well‐prepared abstract will then serve as the outline for the poster content; the visual aspect of the poster is also important to effectively communicate the information to colleagues at the meeting. Adequate time is required to prepare both the abstract and the poster in order to fittingly reflect the value of the information. Efforts in preparing the abstract will be worthwhile once the abstract has been accepted by reviewers for a poster session at the meeting. Likewise, the effort in preparing the poster in advance allows the presenter to enjoy the poster session and discuss the project with colleagues.
The Role of an Intravenous Fat Emulsion Composed of Fish Oil in a Parenteral Nutrition‐Dependent Patient With Hypertriglyceridemia
Authors: Gura Kathleen , Strijbosch Robbert , Arnold Sarah , McPherson Christopher , Puder Mark
Published: May 2008

Hypertriglyceridemia is a common complication in patients receiving parenteral nutrition (PN). Management typically involves withholding the IV fat emulsion (IVFE) until serum triglyceride levels normalize. In some instances, this practice may predispose patients to the development of essential fatty acid deficiency (EFAD) unless alternative therapies such as oral or topical oils are used. This is especially true in patients unable to tolerate enteral intake. We describe the management of hypertriglyceridemia in a 12‐year‐old boy dependent on PN who developed EFAD due to prolonged use of fat‐free PN. His course was further complicated by PN‐associated liver disease. Treatment involved the use of an IVFE derived from fish oils. Within 3 weeks, there was clinical improvement in EFAD and hypertriglyceridemia. The patient's triene:tetraene ratio decreased from 0.207 to 0.044 (normal: 0.013–0.05). Similarly, his serum triglyceride levels decreased from 628 mg/dL to 183 mg/dL (normal: <200 mg/dL). After 2 months of treatment, he was successfully transitioned to enteral feedings; hepatic function normalized, as did the essential fatty acid profile and serum triglycerides levels. This suggests that using fish‐oil‐based IVFE may be an effective alternative to conventional IVFE in PN‐dependent patients whose clinical course is complicated by hypertriglyceridemia.
Complications After Bariatric Surgery: Survey Evaluating Impact on the Practice of Specialized Nutrition Support
Authors: Kumpf Vanessa J. , Slocum Kelsey , Binkley Jeff , Jensen Gordon
Published: May 2008

Background: The rapid growth of obesity rates has affected the practice of specialized nutrition support in various ways. One area that deserves special consideration is the impact that bariatric surgery, in particular complications resulting from bariatric surgery, has made on nutrition support practice. A descriptive survey was designed to evaluate this impact and to assess the various approaches to nutrition assessment and interventions in the postoperative bariatric surgery patient. Methods: A web‐based survey consisting of 17 questions was administered in April 2006 to American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) members with available e‐mail addresses. Participants were queried about professional background, primary practice setting, and various issues related to their involvement in the care of bariatric surgery patients. Results: There were 467 responses returned out of 3400 surveys delivered (14% response rate). Sixty percent of responders estimated they were consulted to see 1–10 patients requiring specialized nutrition support over the previous year as a result of complications of bariatric surgery. The most common indications for specialized nutrition support in these patients were anastomotic leak/fistula (49%) and chronic nausea/vomiting (27%). When estimating calorie goals, 62% used an adjusted body weight, 15% used ideal body weight, and 14% used actual weight. When estimating protein goals, 56% used an adjusted body weight, 29% used ideal body weight, and 8% used actual weight. Conclusion: These observations provide impetus for guideline development and highlight the priority for further research regarding the best practices to ensure that postoperative bariatric surgery patients receive safe and appropriate nutrition support.
Obesity, Inflammation, and the Potential Application of Pharmaconutrition
Authors: Cave Matt C. , Hurt Ryan T. , Frazier Thomas H. , Matheson Paul J. , Garrison Richard N. , McClain Craig J. , McClave Stephen A.
Published: May 2008

Obesity is an emerging problem worldwide. Hospitalized obese patients often have a worse outcome than patients of normal weight, particularly in the setting of trauma and critical care. Obesity creates a low‐grade systemic inflammatory response syndrome (SIRS) that is similar (but on a much smaller scale) to gram‐negative sepsis. This process involves up‐regulation of systemic immunity, is characterized clinically by insulin resistance and the metabolic syndrome, and puts the patient at increased risk for organ failure, infectious morbidity, and mortality. Through lipotoxicity and cytokine dysregulation, obesity may act to prime the immune system, predisposing to an exaggerated subsequent immune response when a second clinical insult occurs (such as trauma, burns, or myocardial infarction).

Specialized nutrition therapy for such patients currently consists of a hypocaloric, high‐protein diet. However, this approach does not address the putative pathophysiologic mechanisms of inflammation and altered metabolism associated with obesity. A number of dietary agents such as arginine, fish oil, and carnitine may correct these problems at the molecular level. Pharmaconutrition formulas may provide exciting innovations for the nutrition therapy of the obese patient.
Biostatistics Primer: Part 2
Authors: Overholser Brian R. , Sowinski Kevin M.
Published: May 2008

Biostatistics is the application of statistics to biologic data. This article is the second part of a 2‐part series on the application of statistics in nutrition science. The first article, published in the December 2007 issue, reviewed descriptive statistics. Inferential statistics, to be discussed in this article, can be used to make predictions based on a sample obtained from a population or some large body of information. It is these inferences that are used to test specific research hypotheses. This article focuses on inferential statistics and their application in the nutrition and biomedical literature. Additionally, this review will outline some of the most commonly used statistical tests found in the biomedical literature.
Advances and Controversies in Clinical Nutrition: The Education Outcome of a Live Continuing Medical Education Course
Authors: Scolapio James S. , DiBaise John K. , Schwenk W. Frederick , Macke Mary E. , Burdette Rosann
Published: May 2008

Background: The aim of this study was to assess participants' nutrition knowledge and practice behavior before and after completing a live continuing medical education (CME) nutrition course designed for practicing nutrition clinicians. Methods: Electronic surveys were sent to the first 100 registered participants before and after attending the course. The curriculum consisted of 16.75 hours of live education. The curriculum was revised when the precourse surveys identified a gap in medical knowledge or practice behavior. Knowledge change was assessed by a 15‐question survey given before and 1 week after the course. Change in practice behavior was accessed by a 10‐question survey administered 2 months after the course. Results: Dietitians were the predominant discipline group attending the course. Sixty‐three percent of those surveyed practiced hospital nutrition, 19% outpatient nutrition, and 18% an equal mix. Forty‐eight percent indicated that they write parenteral nutrition (PN) orders and 51% write enteral nutrition (EN) orders; of these, 62% indicated they are comfortable writing PN orders and 81% are comfortable writing EN orders. Twenty‐three percent indicated that they manage home PN and EN patients. Twenty‐six percent stated they were certified in nutrition support. Seventy‐eight percent of the participants responded to survey 2; the median correct response rates were 51% pre‐ and 76% postcourse. Seventy percent responded to survey 3; the median positive clinical practice behavior change was 69%. Conclusion: This live CME course improved knowledge, and a majority of attendants reported changing their nutrition practice after this course.
Nutritional Monitoring of a Pediatric Burn Patient
Authors: Hutsler Deborah A.
Published: May 2008

The pediatric burn patient presents a particular challenge nutritionally. Nutritional reserves are limited, and excesses are often poorly tolerated. Ongoing monitoring is essential for discovering at an early stage the dynamic shifts in energy, protein, and other nutrients that may be occurring. Adequate enteral intake may be difficult to achieve as a result of repeated holding of feedings on surgery days and gastrointestinal tolerance problems such as poor gastric emptying and abdominal distention. This case report illustrates techniques, such as the nutritional assessment record and parenteral nutrition evaluation form, which may assist the clinician in optimizing the nutritional management of the patient.
Technique for Intraduodenal Placement of Transnasal Enteral Feeding Catheters
Authors: Caulfield Kathy A. , Page Carey P. , Pestana Carlos
Published: May 2008

Timely initiation of enteral feeding requires efficient placement of nasoenteric feeding tubes. It is generally agreed that postpyloric placement of feeding tubes reduces the risk of regurgitation and aspiration of feeding formulas. The authors describe a simple, economic method of achieving postpyloric placement of feeding tubes in most patients.
Invited Review: Culture Methods to Evaluate Central Venous Catheter Sepsis
Authors: Curtas Susan , Tramposch Katherine
Published: May 2008

Sepsis is a frequent complication of central venous catheters, but the diagnosis of catheter sepsis is not always clear‐cut. A variety of culture methods is available to determine catheter‐related septicemia. Each method has advantages and disadvantages for the clinician to consider. This article reviews qualitative, quantitative, and other culture methods applicable to both blood and the device.
Invited Review: Infection Control of Parenteral Nutrition Solutions
Authors: Thompson Barbara , Robinson Lawrence A.
Published: May 2008

Microbial contamination of parenteral nutrition solutions is a preventable cause of infection in patients receiving nutrition support. The components of the parenteral nutrition solutions have variable microbial growth potential. Crystalline amino acid and dextrose solutions are poor growth media for bacteria but may support fungal growth. Lipid emulsions provide an excellent medium for growth of bacteria and fungal species. Total nutrient admixtures will support microbial growth better than standard parenteral nutrition solutions will but less well than will lipid emulsion alone. Control of infection related to contaminated infusate depends on compounding procedure, quality control, appropriate storage, and procedures to prevent in‐use contamination. Guidelines are presented for the preparation and administration of parenteral nutrition infusates that will minimize microbial contamination.
Invented Review: Getting Started in Clinical Nutrition Research
Authors: Twomey Patrick L.
Published: May 2008

Conducting nutrition research projects does not require a large, well‐funded laboratory and a team of assistants. The main requirement is an inquisitive, creative, and critical mind face to face with an unsolved problem. Nevertheless, the actual process of getting started in clinical nutrition research can present obstacles for the novice clinician that can impede successful implementation and completion of the project. This article reviews the initial steps involved in generating a hypothesis, study design, and preliminary data analysis.
Total Parenteral Nutrition in a Premature Rhinoceros Calf
Authors: Herrmann Virginia M. , Miller R. Eric
Published: May 2008

A female black rhinoceros calf developed significant hypoglycemia (blood glucose, 30 mg/dL) and hypothermia (97°F) within 48 hours of birth and refused to nurse. Normal gestation of the black rhinoceros is 15 months, but elongated hoof slippers and low birth weight (30 kg) suggested prematurity in this calf. Clinical symptoms of neonatal sepsis including lassitude and poor sucking continued in spite of the aggressive use of antibiotics, and the calf required mechanical ventilatory support on day 7. Nutritional support including enteral gavage feedings (Pedialyte/4 ounces of SMA [Wyeth Ayerst] with sucraflox) had been instituted and was supplemented with total parenteral nutrition on day 5. Central venous access was obtained via a jugular cutdown. The total parenteral nutrition included appropriate electrolytes and vitamins for the neonatal calf but did not include trace elements. The use of total parenteral nutrition by our zoos for therapeutic purposes is increasing. Experience with total parenteral nutrition in exotic animals such as the black rhinoceros is limited, yet this may be an important therapeutic modality in these animals, particularly those in danger of extinction.
Invited Review: From Diet to DNA: Dietary Patterning of Gene Expression
Authors: McGrane Mary M. , Hanson Richard W.
Published: May 2008

The role of molecular biology in understanding structure/function relationships as well as the influence of metabolic processes on host nutrition is becoming increasingly important. Not only is this field having a major effect in elucidating the detailed structure of nutritionally important enzymes but it is also allowing the nutrition scientist to study metabolic function and the significance of different pathways in whole animals. In this review, the use of gene transfer studies, in particular, the creation of transgenic animals to study mechanisms in which nutrients may regulate gene expression is discussed. Although these studies are presently quite specific, it is envisioned that these studies will ultimately lead to a better understanding of dietary host interactions, which may lead to the ability of the clinician to optimize dietary intake in order to more favorably modify metabolic disorders.
Glutamine Content of Whole Proteins: Implications for Enteral Formulas
Authors: Swails Wendy S. , Bell Stacey J. , Borlase Bradley C. , Forse R. Armour , Blackburn George L.
Published: May 2008

In two recent clinical trials in surgical patients, supplementation of total parenteral nutrition with daily doses of 12 or 20 g of glutamine resulted in a diminished loss of free glutamine in skeletal muscle tissue. Studies in animals exploring the use of both enteral and parenteral glutamine supplementation suggest that glutamine may be an essential nutrient in the maintenance of gut structure and function during critical illness. These findings have led to heightened interest in the glutamine content of enteral formulas. This article describes a method for estimating the glutamine content of whole‐protein enteral formulas. The average amount of glutamine in selected, whole‐protein formulas ranges from a minimum of 3.55 g/4200 kJ to a maximum of 5.15 g/4200 kJ. Although it is still too early to define the safest and most effective dose of glutamine, there are two points regarding glutamine supplementation that clearly merit further investigation: no clinical trials have been conducted to assess the potential benefits of glutamine supplementation of an enteral diet or to assess the effects of using diets containing protein‐bound glutamine rather than free glutamine.
Nutritional Management of Infants With Bronchopulmonary Dysplasia
Authors: Reimers Kristin J. , Carlson Susan J. , Lombard Kenneth A.
Published: May 2008

The nutritional needs of the child with bronchopulmonary dysplasia (BPD) vary significantly from those of a healthy child. To address the many special aspects of the nutritional care of the child with BPD, a nutrition management protocol was established at the University of Iowa Hospitals and Clinics. This protocol discusses caloric requirements; selection of enteral feedings; electrolyte, vitamin, and mineral supplements; growth, oral feeding advancement, and monitoring of nutritional status. Although many of the guidelines are supported by research, some are based on clinical practice. Many questions remain to be answered about the optimal nutrition therapy for these infants. One goal of this protocol is to stimulate discussion and research that will lead to a better understanding of the nutritional requirements of the BPD population.
The Essential Fatty Acids
Authors: Sardesai Vishwanath M.
Published: May 2008

In animal and human tissues, there are four families of fatty acids that are derived from the precursors palmitoleic, oleic, linoleic, and linolenic acids. Of these, linoleic and linolenic acids are essential dietary elements for humans and all higher animals. The four precursor fatty acids are metabolized (through desaturation and chain elongation) to form the long‐chain polyunsaturated fatty acids. The principal fatty acids derived from linoleic acid are arachidonic acid, which contains four double bonds (tetraene) and dihomogamma linolenic acid, whereas products formed from linolenic acid are eicosapentaenoic acid and docosahexaenoic acid. The major products from palmitoleic and oleic acids are the 20 carbon fatty acids with three double bonds (triene). In the presence of adequate dietary amounts of essential fatty acids, tetraene products predominate in plasma. When the intakes of both linoleic and linolenic acids are low, triene formation is high and hence the triene/tetraene ratio in plasma is used to assess the index of essential fatty acid deficiency. The polyunsaturated fatty acids derived from essential fatty acids serve as cellular membrane phospholipid components which can influence the physicochemical characteristics of the lipid bilayer. Changes in membrane lipids can modify the mobility and function of a variety of membrane proteins which may result in altered cell/organ functions. Linoleic acid is specifically required in the skin to maintain the integrity of epidermal water barrier. The dihomogamma linolenic acid, arachidonic acid, and eicosapentaenoic acid are the precursors of eicosanoids which influence many cell processes and organ functions. Docosahexaenoic acid is found in high concentrations in the structural lipids of the brain and retina and has a role in the development of the brain and visual function. Humans deprived of essential fatty acids develop deficiency symptoms characterized by dermatitis and thickening of the skin, fatty liver, and impaired water balance. The most common cause of essential fatty acid deficiency in humans is the long‐term intake of fat‐free “glucose‐containing” parenteral nutrition. The minimal requirements for linoleic and linolenic acids are estimated to be 2% and 0.2 to 0.3%, respectively, of total daily caloric intake. Vegetable oils such as corn and soybean oil are excellent sources of linoleic acid. Cold‐water fish is rich in linolenic acid‐derived polyunsaturated fatty acids.
Intravenous Fat Emulsions in Clinical Practice
Authors: Warshawsky Kathleen Young
Published: May 2008

The use of intravenous fat emulsions has become an integral part of the provision of parenteral nutrition. In the past, this was achieved by the administration of lipids separately from the dextrose‐amino acid base solution. More recently, lipids have been admixed along with the dextrose‐amino acid formula as a total nutrient admixture (TNA). This article discusses the advantages and disadvantages of TNAs, the factors that affect the stability of emulsions, the potential for microbial growth in TNAs, and guidelines for the compounding of TNAs.
Invited Review: Use of Indirect Calorimetry in Clinical Nutrition
Authors: McClave Stephen A. , Snider Harvy L.
Published: May 2008

The tremendous variability in resting energy expenditure makes efforts to predict caloric requirements difficult. Indirect calorimetry has provided a valuable tool in assessing energy expenditure, evaluating the way in which the body uses nutrient fuel, and designing nutritional regimens that best fit the clinical condition of the patient. The many indirect calorimetric instruments available vary in their application to clinical nutrition. The best metabolic studies are achieved by controlling the testing environment, accounting for the many clinical factors that may affect measurements, and eliminating potential sources for error. Although indirect calorimetry would seem to reduce the likelihood of complications from overfeeding, its greatest effect may be in cost savings by avoiding unnecessary nutritional support and in providing a means for clinical research.
Nutrition Support Team Recommendations Can Reduce Hospital Costs
Authors: Roberts Margot F. , Levine Gary M.
Published: May 2008

Providing nutrition support may be costly to hospitals under the prospective payment system. A nutrition support team, however, can be effective in controlling costs. To demonstrate the importance of the nutrition support team and to quantify the potential cost savings that can be achieved, a retrospective review of the effect of our team on hospital costs was conducted for the 12‐month period of October 1989 to September 1990. The team supervises but does not regulate the use of total parenteral nutrition (TPN). During this time period, 176 patients received TPN. In 14 patients, the use of TPN was inappropriate, representing $65,349 in excess costs. After the cost of providing enteral nutrition to these patients (estimated at $2,430) was deducted, a net loss of $62,919 occurred. Nutrition support team action saved an additional $45,186 in hospital charges when recommendations to discontinue TPN were eventually heeded. Nutrition support team approval before TPN is initiated would achieve cost savings.