Showing papers in "Journal of Parenteral and Enteral Nutrition in 2006"
TL;DR: In normal and overweight adults, phase angle increased with increasing BMI, but there was an inverse association at a BMI >40 kg/m2, and in cirrhosis, the prevalence of a low phase angles increased with the state of disease, whereas it was not different between patients with the metabolic syndrome and controls.
Abstract: Background: The use of bioelectrical impedance phase angle has been recommended as a prognostic tool in the clinical setting, but published reference data bases are discrepant and incomplete (eg, they do not consider body mass index [BMI], and data are lacking for children). Methods: Phase angle reference values stratified by age, sex, and BMI were generated in a large German data base of 15,605 children and adolescents and 214,732 adults, and the determinants of phase angle values were assessed. The reference values were applied to 3 groups of patients and compared with previously published reference values from the United States and Switzerland. Results: Gender and age were the main determinants of phase angle in adults, with men and younger subjects having higher phase angles. In children and adolescents, age and BMI were the main determinants of phase angle. In normal and overweight adults, phase angle increased with increasing BMI, but there was an inverse association at a BMI >40 kg/m2. In cirrhosis...
422 citations
TL;DR: Turmeric, an approved food additive, or its component curcumin, has shown surprisingly beneficial effects in experimental studies of acute and chronic diseases characterized by an exaggerated inflammatory reaction.
Abstract: Background: The world suffers a tsunami of chronic diseases, and a typhoon of acute illnesses, many of which are associated with the inappropriate or exaggerated activation of genes involved in inflammation. Finding therapeutic agents which can modulate the inflammatory reaction is the highest priority in medical research today. Drugs developed by the pharmaceutical industry have thus far been associated with toxicity and side effects, which is why natural substances are of increasing interest. Methods: A literature search (PubMed) showed almost 1500 papers dealing with curcumin, most from recent years. All available abstracts were read. Approximately 300 full papers were reviewed. Results: Curcumin, a component of turmeric, has been shown to be non-toxic, to have antioxidant activity, and to inhibit such mediators of inflammation as NFκB, cyclooxygenase-2 (COX-2), lipooxygenase (LOX), and inducible nitric oxide synthase (iNOS). Significant preventive and/or curative effects have been observed in experime...
311 citations
TL;DR: Patients with acute severe pancreatitis should begin EN early because such therapy modulates the stress response, promotes more rapid resolution of the disease process, and results in better outcome, and EN is the preferred route and has eclipsed PN as the new "gold standard" of nutrition therapy.
Abstract: Background: Failure to use the gastrointestinal (GI) tract in patients with acute pancreatitis may exacerbate the stress response and disease severity, leading to greater incidence of complications and prolonged hospitalization. The objectives of this study were to determine the optimum route for nutrition support, whether nutrition therapy is better than no artificial nutrition support, whether specific additives to enteral or parenteral therapy can further enhance their efficacy, and whether methodologic differences in delivery of enteral nutrition (EN) influence tolerance. Methods: A computerized search was performed of MEDLINE, Cochrane database, EMBASE, and reference lists of pertinent review articles for prospective randomized trials in adult patients with acute pancreatitis that evaluated interventions with nutrition therapy. Primary outcome data and surrogate endpoint parameters (for nutrition indices, stress markers, and measures of the inflammatory/immune response) were extracted in duplicate in...
269 citations
TL;DR: The omega-3 PUFA used alone or as component of a new and complex LE (soy, MCT, olive and fish oil) has demonstrated anti-inflammatory and immunomodulatory effects.
Abstract: Routine use of parenteral lipid emulsions (LE) in clinical practice began in 1961, with the development of soybean oil (SO) – based LE. Although clinically safe, experimental reports indicated that SO-based LE could exert a negative influence on immunological functions. Those findings were related to its absolute and relative excess of ω-6 polyunsaturated fatty acids (PUFA) and the low amount of ω-3 PUFA and also to its high PUFA content with an increased peroxidation risk. This motivated the development of new LE basically designed along the reduction of ω-6 PUFA and the ω-3 PUFA addition in order to obtain balanced levels of the ω-6/ω-3 ratio. The new LE for clinical use (available in Europe and South America) are differentiated by their content in polyunsaturated (ω-6 and ω-3), monounsaturated, and saturated fatty acids (FA), as well as FA source of their origin, including soy, coconut, olive, and fish oil. This article presents the new LE nutrition and energy functions but also its biochemical, metabo...
205 citations
TL;DR: The control chart showed that after the intervention, there was a significant increase in the "number between" tube insertions without complications, confirming the effectiveness of the performance improvement (PI) project.
Abstract: Background: An intervention to reduce complications from insertion of small-bore nasogastric feeding tubes was performed. Methods: This was a Performance Improvement project with the Plan, Do, Study, Act (PDSA) format; interventions occurred in July 2003. Electronic searches of risk management and radiology databases identified feeding-tube malpositions and complications from January 1, 2001, through December 31, 2004. Chart abstraction and a pre- and postintervention comparison were performed. Interventions were adoption of a more compliant feeding tube, direct supervision of residents, technology-guided insertion, and implementation of explicit policies and procedures. Results: Of all small-bore nasogastric feeding-tube placements, 1.3%–2.4% resulted in 50 documented cases of feeding-tube malpositions during 4 years. Over half of the 50 patients were mechanically ventilated, and only 2 had a normal mental status. There were 13 complications (26% of malpositions), including 2 deaths, which were directly ...
150 citations
TL;DR: Semi-elemental and polymeric nutrition are very well tolerated in patients with acute pancreatitis, and the hypothesis of a more favorable clinical course than nutrition with a polymeric formula needs to be established in larger adequately powered clinical trials.
Abstract: Background: Jejunal nutrition is recommended during acute pancreatitis. The use of semi-elemental formulas presents several theoretical advantages over polymeric formulas, but their clinical value has been poorly documented. Our aim was to evaluate in patients with acute pancreatitis the effect of enteral nutrition by a semi-elemental formula compared with a polymeric formula. Methods: A randomized prospective pilot study, stratified according to severity, was performed in 30 consecutive patients with acute pancreatitis requiring jejunal nutrition. The semi-elemental group received 35 kcal/kg/d of Peptamen (n = 15), and the polymeric group received the same quantity of Sondalis-Iso (n = 15). Tolerance was evaluated after 7 days of enteral nutrition (D7) on visual analog scale (VAS), stool frequency, and 24-hour steatorrhea/creatorrhea. Outcome was evaluated by weight loss, length of hospital stay, and infection rate. Results: Results were calculated as mean ± SEM, t-test, or χ2. Patients of the 2 groups w...
123 citations
TL;DR: A patient developed a neurologic constellation of ataxia, myelopathy, and peripheral neuropathy similar to vitamin B(12) deficiency many years after gastrectomy for severe peptic ulcer disease, and over 3 months of follow-up, serum copper levels increased.
Abstract: Background: In animal studies, copper absorption has been demonstrated to occur in the proximal gut via duodenal enterocytes. Acquired copper deficiency is known as “swayback” in ruminant animals and Menkes' disease in humans. Copper is an essential micronutrient necessary for the hematologic and neurologic systems. Acquired copper deficiency in humans has been described, causing a syndrome similar to the subacute combined degeneration of vitamin B12 deficiency. Methods: This is a single case report. Our patient developed a neurologic constellation of ataxia, myelopathy, and peripheral neuropathy similar to vitamin B12 deficiency many years after gastrectomy for severe peptic ulcer disease. The patient was maintained for decades with enteral feedings via jejunostomy that provided the recommended dietary allowance (RDA) for copper. Results: Copper deficiency was suspected, identified, and treated. Over 3 months of follow-up, serum copper levels increased from 4 μg/dL to 20 μg/dL (70–150 μg/dL), and cerulop...
113 citations
TL;DR: Multifaceted interventions that may include anti-inflammatory diets, glycemic control, physical activity, appetite stimulants, anabolic agents, anti- inflammatory agents, anticytokines, and probiotics, will be necessary to blunt undesirable aspects of inflammatory response to preserve body cell mass and vital organ functions.
Abstract: There has been tremendous interest in inflammation by researchers, the medical community, and the lay public Modulation of injury response is felt to represent a tenuous balance of pro- and anti-inflammatory cytokines Adverse outcomes may result from severe, sustained, or repeated bouts of inflammation A critical observation is that nutrition support alone is inadequate to prevent muscle loss during active inflammation It is necessary to take inflammation into consideration in conducting appropriate nutrition assessment, intervention, and monitoring A host of medical conditions are actually inflammatory states that have important implications for nutrition care Multifaceted interventions that may include anti-inflammatory diets, glycemic control, physical activity, appetite stimulants, anabolic agents, anti-inflammatory agents, anticytokines, and probiotics, will be necessary to blunt undesirable aspects of inflammatory response to preserve body cell mass and vital organ functions Nutrition practitioners can seize this opportunity to be a part of the future medical team that brings highly individualized patient care to the bedside
112 citations
TL;DR: In chronic critical illness, allostatic overload leads to a plurality of organ-system derangements and eventually death, so intervention not only involves insulinization according to neurofuzzy logic but also targeting more proximate events with cognitive/behavioral therapy and hypothalamic releasing factors.
Abstract: Stress hyperglycemia has gained the attention of virtually every physician who encounters critically ill patients, with the emergence of clinical data supporting tight glycemic control and intensive insulinization for optimal outcome. In order to effectively manage stress hyperglycemia, newer theories of critical illness and the interactions of the brain, neuroendocrine axis, and immune system need to be explored. Nonlinear physiologic processes, glucose allostasis, immune-neuroendocrine axis activation, and molecular mechanisms of insulin receptor signal transduction contribute to a novel model of stress hyperglycemia. In chronic critical illness, allostatic overload leads to a plurality of organ-system derangements and eventually death. Intervention not only involves insulinization according to neurofuzzy logic but also targeting more proximate events with cognitive/behavioral therapy and hypothalamic releasing factors.
96 citations
TL;DR: It is found that therapy with insulin in adult patients hospitalized for a critical illness, other than hyperglycemic crises, may decrease mortality in certain groups of patients.
Abstract: Background: Hyperglycemia is common in critically ill hospitalized patients and has been associated with adverse outcomes, including increased mortality. In this review, we examine the effect of insulin therapy on mortality in critically ill patients. Methods: We updated our previous systematic review and meta-analysis to include recently published trials that report data on the effect of insulin therapy initiated during hospitalization on mortality in adult patients with a critical illness. We also include a short primer on the methods of systematic reviews and meta-analyses, outlining the specific steps and challenges of this methodology. We performed an electronic search in the English language of MEDLINE and the Cochrane Controlled Clinical Trials Register and a hand search of key journals and relevant review articles for randomized controlled trials that reported mortality data on critically ill hospitalized adult patients treated with insulin (regardless of method of administration). Results: We ide...
89 citations
TL;DR: Critical interventions are presented correlating current evidence with new discoveries in pathogenesis, including the discovery of the biofilm form of microbial life and the associated recalcitrance of biofilm bacteria to antimicrobials.
Abstract: Catheter-related bloodstream infection and catheter occlusion are potential significant complications of parenteral nutrition therapy. The increased incidence and associated morbidity, mortality, increased costs, and quality-of-life issues experienced with these adverse events necessitate specialized management of vascular access devices. The host coagulation response to biomaterials and the associated development of biofilm on vascular devices are complex phenomena. Multiple interventions are required to prevent access of bacteria to both intraluminal and extraluminal catheter surfaces, and the occurrence of catheter occlusion. The discovery of the biofilm form of microbial life and the associated recalcitrance of biofilm bacteria to antimicrobials has provided insight into the failure of current prevention, diagnostic, and treatment protocols. Critical interventions are presented correlating current evidence with new discoveries in pathogenesis.
TL;DR: The Editor-in-Chief, the American Society for Parenteral and Enteral Nutrition, and the Publisher have determined to retract the article.
Abstract: The authors of the above article have requested its withdrawal, notifying the Journal that the clinical trials described in the article were not conducted as written in the article. The Editor-in-Chief, the American Society for Parenteral and Enteral Nutrition, and the Publisher have determined to retract the article.
TL;DR: When long-term PN is given with a modest amount of total energy and a minimal amount of lipid emulsion, abnormal liver enzymes are common, but severe liver dysfunction is unusual, and there was a trend toward a greater amount oftotal calories, dextrose calories, and duration of PN exposure leading to the development of severe Liver dysfunction.
Abstract: Background: Abnormal liver enzymes and endstage liver disease are reported to occur in 25%–100% and 15%–40% of adult patients receiving long-term parenteral nutrition (PN), respectively. The purpose of this historic cohort study was to investigate the incidence of and possible factors leading to the development of liver disease in our large home PN population. Methods: All patients on home PN for at least 6 months from July 1991 through June 2002 were eligible. Patients were excluded if they had active malignancy, underlying liver disease, or exposure to a hepatotoxin. The presence of PN-associated liver disease was only considered if test results were elevated on more than 1 occasion over at least 6 or more months. The severity of liver-associated enzymes was based on the degree of elevation and was stratified as mild ( 5 times normal). Severe liver dysfunction was defined as having all of the following criteria: total bilirubin >3 mg/dL; albumin...
TL;DR: Antioxidants supplementation with or without B-group vitamins enhances antioxidant capacity, mitigates oxidative damage, and may have an anti-inflammatory effect immediately postinfarct in stroke disease.
Abstract: Background: Evidence shows that there is a rapid increase in the production of markers of oxidative damage immediately after acute ischemic stroke and that endogenous antioxidant defenses are rapidly depleted, thus permitting further tissue damage. Several studies point to an antioxidant effect of B-group vitamins and a pro-oxidant effect of elevated total plasma homocysteine (tHcy). Methods: To test whether supplementary antioxidants with or without B-group vitamins during this critical period enhance antioxidant capacity or mitigate oxidative damage, ninety-six acute ischemic stroke patients within 12 hours of symptom onset were randomly assigned to receive either daily oral 800 IU (727 mg) vitamin E and 500 mg vitamin C (n = 24), or B-group vitamins (5 mg folic acid, 5 mg vitamin B2, 50 mg vitamin B6, and 0.4 mg of vitamin B12; n = 24), both vitamins together (n = 24), or no supplementation (n = 24) for 14 days. Treatment groups and controls were matched for stroke subtype and age. Blood was obtained b...
TL;DR: It is suggested that preoperative intake of a carbohydrate-rich beverage can prevent surgery-induced immunodepression and thus might reduce the risk of infectious complications.
Abstract: Background: Fasting before surgery is still common care in a lot of western hospitals. Overnight fasting can induce postoperative insulin resistance. Insulin resistance has been shown to be related to infectious morbidity. It was shown that postoperative insulin resistance can be attenuated by preoperative intake of a clear carbohydrate-rich beverage. The aim of this study was to investigate whether preoperative intake of carbohydrate-rich beverages could postoperatively influence the immune system. Methods: In this randomized, controlled study, we investigated the effect of surgery on the postoperative immune response in 10 preoperatively fasted patients (control) and 2 groups of 10 patients receiving 2 different carbohydrate-rich beverages preoperatively, by measuring human leukocyte antigen (HLA)-DR expression on monocytes on the day before and on the day after surgery. Furthermore, we studied perioperative fluid homeostasis and preoperative well-being of the patients. Results: HLA-DR expression decreased significantly after surgery in the control group. Patients receiving any of the 2 carbohydrate-rich beverages did not show this postoperative decrease. Fluid homeostasis was not affected in any of the groups, and well-being tended to be better in patients receiving carbohydrate-rich beverages compared with controls. Conclusion: This study suggests that preoperative intake of a carbohydrate-rich beverage can prevent surgery-induced immunodepression and thus might reduce the risk of infectious complications.
TL;DR: LCT-MUFA showed lower in vitro and in vivo impact on neutrophil function compared with LCT and LCT-MCT, and Lipopolysaccharide (LPS)-induced increase in leukocyte rolling flux, adhesion, and emigration was inhibited by LCT, but unaffected in LCT -MUFA-treated rats.
Abstract: Background: Infection remains a drawback of parenteral nutrition (PN), probably related, among other factors, to immunosuppressive effects of its lipid component. Newer preparations may have lesser immunosuppressive impact. This study examines the effects of an olive oil–based lipid emulsion (long-chain triacylglycerols-monounsaturated fatty acids [LCT-MUFA]; ClinOleic) on various functions of human neutrophils in vitro and on rat leukocyte–endothelial cell interactions in vivo compared with LCT (Intralipid) and 50% LCT–50% medium-chain triacylglycerols (MCT; Lipofundin) mixture. Methods: Neutrophils isolated from healthy donors were incubated with concentrations (0.03–3 mmol/L) of lipid emulsions encompassing clinically relevant levels. In vivo leukocyte recruitment was studied with intravital microscopy within rat mesenteric microcirculation. Results: LCT-MUFA (3 mmol/L) did not alter the N-formyl-Met-Leu-Phe (FMLP)-induced rise in [Ca2+]i, oxidative burst, chemotaxis, and elastase release, whereas LCT-...
TL;DR: Overwhelming evidence in both surgical and medical patients conclusively demonstrates that hyperglycemia is a marker of severity of illness and is also an independent determinant of bad outcome, largely from infectious complications.
Abstract: Background: We sought to review the literature describing the benefits of tight glycemic control in critically ill patients, comparing outcome differences in subgroup populations. Methods: We searched PubMed for relevant literature on the topic of hyperglycemia and its management in the intensive care unit. Results: Overwhelming evidence in both surgical and medical patients conclusively demonstrates that hyperglycemia is a marker of severity of illness and is also an independent determinant of bad outcome, largely from infectious complications. Randomized trial evidence, in conjunction with historically controlled trials, supports the use of intensive insulin therapy and euglycemic control in critically ill patients, with nondiabetics possibly benefiting even more than diabetic patients. Euglycemia is best achieved, and hypoglycemia attenuated, through use of a protocolized approach. Further elaboration as to what threshold range defines euglycemia in patient subpopulations is needed and what pitfalls mu...
TL;DR: In this article, the authors measured the variability in resting metabolic rate (RMR) of 10 healthy adults during 5 separate testing sessions within a 2-week period where usual diet and physical activity were maintained.
Abstract: Background: To know if the magnitude of change in resting metabolic rate (RMR) observed during an intervention is meaningful, it is imperative to first identify the variability that occurs within individuals from day to day under normal conditions. The 2 most common systems used to measure RMR involve a ventilated hood or a mouthpiece & nose clip to collect expired gases. The variation in measurement using these 2 approaches has not been systematically compared. Methods: RMR was measured in 10 healthy adults during 5 separate testing sessions within a 2-week period where usual diet and physical activity were maintained. Each testing session consisted of one measurement of RMR using a ventilated hood system, followed by another using a mouthpiece & nose-clip system. Results: No significant difference in RMR was evident between measurement sessions using either indirect calorimeter. Oxygen consumption and RMR were significantly higher using the mouthpiece & nose-clip system. Average within-individual coefficient of variation for RMR was significantly lower for the ventilated-hood system. RMR measures were consistently lower using the ventilated-hood system by an average of 94.5 ± 63.3 kcal. Day-to-day variance was between 2% and 4% for both systems. Conclusions: The use of either system is appropriate for assessing RMR in clinical and research settings, but alternating between systems should be undertaken with caution. A change in RMR must be greater than -6% (96 kcal/d; 1.2 kcal/kg/d) or -8% (135 kcal/d; 1.7 kcal/kg/d) when using a ventilated-hood system or a mouthpiece & nose-clip system, respectively, to observe any meaningful intervention-related differences within individuals.
TL;DR: The results show the transdermal administration of clonidine is associated with a modest but clinically significant decrease in fecal output in patients with short bowel syndrome and high-output proximal jejunostomy that require chronic parenteral fluid infusion.
Abstract: Background: Patients with short bowel syndrome have significant fluid losses. This represents a significant management problem, especially in patients with minimal residual intestine. We determined whether clonidine, anα 2-adrenergic agonist, is effective in decreasing fecal water and sodium (Na) losses in patients with proximal jejunostomy. Eight parenteral nutrition (PN)–dependent subjects (3 men, 5 women), aged 49.9 ± 10.2 years, with a residual small bowel length of 71.8 ± 152.0 cm that ended in a jejunostomy, were studied. Methods: Subjects were admitted to the North-western General Clinical Research Center (GCRC) for a 2-day equilibrium period while receiving a self-selected 100 g fat diet with protein 1.5 g/kg/d and 30 kcal/kg/d and 1 L/d of oral rehydration solution. A d-xylose test was performed after an overnight fast. On days 3–5, all stool and urine were collected for volume, weight, fat, nitrogen, energy, sodium, magnesium, potassium, and calcium. Meals were provided in duplicate and the equi...
TL;DR: The most encouraging information on decreasing occlusion rate comes from experience with positive-pressure devices that attach to the hub of most catheter lumens and prevent retrograde blood flow and, consequently, decrease the risk of thrombus formation in the catheter lumen.
Abstract: A proper initial assessment of catheter occlusion is the key to successful management. The assessment screens are for both thrombotic and nonthrombotic causes (including mechanical occlusion). If mechanical occlusion is excluded, thrombotic occlusion is treated with alteplase. Nonthrombotic occlusions are treated according to their primary etiologies: lipid occlusion is treated with 70% ethanol, mineral precipitates are treated with 0.1-N hydrochloric acid (HCl), drug precipitates are treated according to their pH-acidic drugs can be cleared with 0.1-N HCl, basic medications can be cleared with sodium bicarbonate or 0.1-N sodium hydroxide (NaOH). Prevention of occlusion of central venous access devices is also critical. To date, no data conclusively show heparin flushes to be superior to saline flushes. No prophylactic regimen, including low-dose warfarin, low-molecular-weight heparin, or 1 unit heparin/mL of parenteral nutrition has been endorsed by any major medical, nursing, or pharmacy group due to lack of scientific evidence. The most encouraging information on decreasing occlusion rate comes from experience with positive-pressure devices that attach to the hub of most catheter lumens and prevent retrograde blood flow and, consequently, decrease the risk of thrombus formation in the catheter lumen.
TL;DR: Evidence is presented herein that soybean oil emulsion is less toxic to neutrophils than to lymphocytes, and promotes lymphocyte and neutrophil death that may enhance the susceptibility of the patients to infections.
Abstract: Background: The incorporation of lipid emulsions in parenteral diets is a requirement for energy and essential fatty acid supply to critically ill patients. In this study, the toxicity of a lipid emulsion rich (60%) in triacylglycerol of ω-6 polyunsaturated fatty acids on leukocytes from healthy volunteers was investigated. Methods: Eleven volunteers were recruited, and blood samples were collected before infusion of a soybean oil emulsion, immediately afterwards, and 18 hours later. The cells were studied immediately after isolation and again after 24 hours or 48 hours in culture. The following determinations were made: composition and concentration of fatty acids in plasma, lymphocytes and neutrophils, lymphocyte proliferation, levels of cell viability, DNA fragmentation, phosphatidylserine externalization, mitochondrial depolarization, reactive oxygen species production, and neutral lipid accumulation. Results: Soybean oil emulsion decreased lymphocyte proliferation and provoked neutrophil and lymphocy...
TL;DR: This weight-based phosphorus-dosing algorithm is safe for use in critically ill patients receiving nutrition support and effectively increase serum phosphorus concentrations in the moderate and severe-dose regimens.
Abstract: Background: Hypophosphatemia is a common metabolic complication in patients receiving specialized nutrition support. We changed our previously reported dosing algorithm because the low dose no longer appeared to be effective at increasing serum phosphorus concentrations. The purpose of this study was to evaluate the safety and efficacy of a revised weight-based phosphorus-dosing algorithm in critically ill trauma patients receiving specialized nutrition support. Methods: Seventy-nine adult trauma patients with hypophosphatemia (serum phosphorus concentration ≤0.96 mmol/L) receiving nutrition support received an IV dose of phosphorus on day 1 according to the serum concentration of phosphorus: 0.73-0.96 mmol/L (0.32 mmol/kg, low dose), 0.51-0.72 mmol/L (0.64 mmol/kg, moderate dose), and ≤0.5 mmol/L (1 mmol/kg, high dose). The IV phosphorus bolus dose was administered at 7.5 mmol/hour. Generally, patients with a serum potassium concentration <4 mmol/L received potassium phosphate and patients with a serum potassium concentration ≥4 mmol/L received sodium phosphate. Patients who still had hypophosphatemia on day 2 were dosed using the new dosing algorithm by the nutrition support service according to that day's serum concentration of phosphorus, or empirically by the trauma service. Results: Of the 79 patients studied, 57 were male and 22 were female with a mean age of 44.8 ± 20.6 years. Mean Injury Severity Scores and APACHE-II scores were 27.1 ± 11.6 and 15.2 ± 6.8, respectively. There was no difference in baseline characteristics among the 3 dosing groups. Of the 79 patients, 34 received the low dose, 30 received the moderate dose, and 15 received the high dose of phosphorous. Mean serum phosphorous concentrations on day 2 were significantly increased in the moderate-dosed group (0.64 ± 0.06 to 0.77 ± 0.22 mmol/L, p <.05) and high-dosed group (0.38 ± 0.06 to 0.93 ± 0.32 mmol/L, p <.01), respectively, when compared with day 1. Mean serum phosphorus concentrations were normal in all 3 groups on day 3. Serum concentrations of magnesium, sodium, and potassium, as well as arterial pH, were stable across the study. Mean concentrations of ionized calcium were not significantly different in any of the 3 dosing groups across the study period. Conclusions: This weight-based phosphorus-dosing algorithm is safe for use in critically ill patients receiving nutrition support. The moderate- and severe-dose regimens effectively increase serum phosphorus concentrations.
TL;DR: There appears to be an association between chronic severe constipation and being overweight among children with chronic constipation, and children with constipation are more likely to be overweight when compared with controls.
Abstract: Background: Obesity and functional constipation seem to share a common biopsychosocial model of causation. Though chronic constipation can significantly affect the quality of life of an overweight child, this association has not been highlighted in the literature. The purpose of this study was to compare the proportion of overweight children among children with chronic constipation with a control group of children with normal bowel habits. Methods: Retrospective chart review with a control population. One hundred one consecutive children 5–18 years of age referred to the Subspecialty Clinic for functional constipation were the study group. The control group consisted of 100 consecutive children from the general pediatric practice seen for physicals and minor illnesses. Children with a body mass index (BMI) of >85 percentile from the National Institutes of Health (NIH) 2000 chart were classified as overweight. Results: The control and study groups were statistically comparable in mean age (10.97± 3.83 year...
TL;DR: Although the survey found consistency in PN practices for many areas queried, significant variation exists in the manner by which PN is ordered and labeled.
Abstract: Background: The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) recently published a revision of its “Safe Practices for Parenteral Nutrition” guidelines. Because there is a paucity of published scientific evidence to support good practices related to ordering, compounding, and administering parenteral nutrition (PN), a survey was performed in the process of the revision to gain insight into the discrepancies between reported practices and previous guidelines. Methods: A web-based survey consisting of 45 questions was conducted (n = 651) June 1–30, 2003. Respondents were queried about primary practice setting, professional background, processes for writing PN orders, computer order entry of PN orders, problems with PN orders, and adverse events related to PN. Results: There were 651 survey responses, 90% of which were from hospital-based practitioners. Almost 75% of responders processed between 0 and 20 PN orders per day. Overall, physicians (78%) were responsible for writing PN orders,...
TL;DR: Dietitians, wound-care ostomy nurses, and other nutrition support specialists are encouraged to be more proactive with their participation in the care and management of the PEG site.
Abstract: Placement of a percutaneous endoscopic gastrostomy (PEG) tube creates a controlled perforation of a hollow viscous organ and an acute surgical wound. Physicians who place PEG tubes endoscopically or fluoroscopically often do not have the opportunity to provide these patients with long-term follow-up care. Thus, nutrition support specialists who do treat these patients may be the one member of the health care team who is in the most advantageous position for ongoing inspection and maintenance of the access device. Carefully monitored surveillance and adherence to routine principles of wound care assure the health of the skin, the underlying tissue, and the tract into the abdominal cavity through which the PEG passes. Having knowledge of the types of tubes placed, performing a regular physical examination of the PEG site, and maintaining good communication with the endoscopist results in early identification of problems, promotes rapid simple strategies to correct deficiencies, and the opportunity to minimize long-term complications. Dietitians, wound-care ostomy nurses, and other nutrition support specialists are encouraged to be more proactive with their participation in the care and management of the PEG site.
TL;DR: It is supported that lack of enteral nutrition, rather than absolute caloric levels, is responsible for many of the adverse effects of PN, and such changes increased with greater reduction of energy intake.
Abstract: Background: Parenteral nutrition (PN) is known to induce villus atrophy, epithelial cell (EC) apoptosis, and increase mucosal permeability. The study hypothesized that increasing amounts of energy delivery to mice would result in the best outcome, with the least effects on the mucosa. Methods: Mice were randomized to enteral controls (saline infusion with ad libitum enteral food) or to 1 of 3 PN groups (with no enteral nutrition): full (100% of daily average energy intake for the mouse), reduced (75% of energy intake) or very low (50% of energy intake). Mice received PN for 7 days. Mucosal morphology, EC apoptosis, and bacterial translocation were assessed. Results: Villus height decreased significantly with decreasing levels of caloric intake and was significantly lower in all PN groups compared with controls. Body weight loss was significantly greater in PN groups vs controls and was greatest in mice with the lowest caloric delivery. A consistent trend toward a higher EC apoptotic index with decreasing ...
TL;DR: This novel methodology enables in vivo quantification of the integrated response of muscle, wound, and skin protein/amino acid metabolism and confirms the long-held theory of a net catabolism of muscle and a net anabolisms of wound protein in patients after injury.
Abstract: Background: In response to injury, muscle catabolism can be extensive, and in theory, the wound consumes amino acids to support healing. The purpose of this study is to assess a technique by which in vivo protein kinetics of muscle, wound, and normal skin can be quantified in burn-injured patients. Methods: Study protocol consisting of infusion of d5 phenylalanine; biopsies of skeletal muscle, skin, and donor-site wound on the leg; quantification of blood flow to total leg, wound, and skin; and sequential blood sampling from the femoral artery and vein. Five-compartment modeling was used to quantify the rates of protein synthesis, breakdown, and phenylalanine transport between muscle, wound, and skin. Results: The study results demonstrated a net release of phenylalanine from muscle yet a net consumption of phenylalanine by the wound. Compared with skin, the wound had a substantially increased rate of protein synthesis and a reduced rate of protein breakdown (p < .01). Transport rates into and out of musc...
TL;DR: Milestones in the history of the development of vascular access and the subsequent advances in practical clinical applications of the knowledge, techniques, technology, and experience to the beneficial management of a variety of patients are described.
Abstract: Milestones in the history of the development of vascular access and the subsequent advances in practical clinical applications of the knowledge, techniques, technology, and experience to the beneficial management of a variety of patients are described. The original achievements are presented and briefly discussed primarily, but not exclusively, in relationship to the successful development of parenteral nutrition (PN). Beginning with the discovery of the circulation of blood, landmark events, resulting from astute observations, experimentation, and ingenious technological advances, are summarized or outlined chronologically over the past 4 centuries, with emphasis on the many recent accomplishments of basic and clinical scientists during the past 6 decades. Brief descriptions of several seminal contributions to safe and effective IV access, management, and therapy acknowledge and recognize the historical highlights that have allowed a complex and potentially hazardous therapeutic modality to evolve into a commonly applied useful adjunct to our current inpatient and outpatient armamentarium. A comprehensive list of references documents the highlights of the development of vascular access for the student of history.
TL;DR: After 24 weeks of i.v. carnitine therapy, SF-36 scores were improved and erythropoietin doses were reduced in hemodialysis patients, relative to the control group.
Abstract: Background: Previously, we demonstrated that selected groups of hemodialysis patients might be more likely to have abnormalities of carnitine metabolism. The purpose of the present study was to examine the effects of carnitine therapy in these selected groups of hemodialysis patients on quality-of-life measures and erythropoietin dose. Methods: This was a double-blind, randomized, controlled trial, in which 50 hemodialysis patients were treated with either 2 g IV carnitine or placebo. The treatment period was for 24 weeks. Results: Thirty-four patients (15 in the treatment group) completed the study. The mean age was 69 ± 15 years, 35% were women, and 44% had diabetes. Mean initial plasma total, free, short-chain acyl and long-chain acyl carnitine concentrations (μmol/L; mean ± SEM) were 35.9 ± 1.8, 18.2 ± 1.1, 11.6 ± 0.6, and 6.0 ± 0.3, whereas the plasma acyl-to-free-carnitine ratio was 1.02 ± 0.05. With respect to the Medical Outcomes Short Form-36 (SF-36), improvements from baseline were noted in the ...
TL;DR: Patients with traumatic brain injury induced into barbiturate coma develop a significant ileus that is refractory to prokinetic agents, and early parenteral nutrition should be considered in this patient population.
Abstract: Background: There is a paucity of data evaluating the efficacy of nutrition support in traumatic brain–injured patients induced into barbiturate coma for refractory intracranial hypertension. Our objective was to evaluate the efficacy of enteral nutrition in a select group of trauma patients. Methods: Prospective data were collected on severe traumatic brain–injured patients over a 4-year period. Patients were stratified by whether or not they were induced into a barbiturate coma. Barbiturate coma was defined as per American Association of Neurological Surgeons (AANS) guidelines. All patients were initially fed via the enteral route via a nasogastric feeding tube. Patients who did not tolerate feedings within 48 hours started receiving prokinetic agents. Feeding tolerance was defined as ability to tolerate enteral feedings with 72 hours. Results: Fifty-seven patients were induced into a barbiturate coma. All were victims of blunt-force trauma. Forty-two of 5...