Showing papers in "Journal of Parenteral and Enteral Nutrition in 2012"
TL;DR: The Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition recommend that a standardized set of diagnostic characteristics be used to identify and document adult malnutrition in routine clinical practice.
Abstract: The Academy of Nutrition and Dietetics (Academy) and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) recommend that a standardized set of diagnostic characteristics be used to identify and document adult malnutrition in routine clinical practice. An etiologically based diagnostic nomenclature that incorporates a current understanding of the role of the inflammatory response on malnutrition's incidence, progression, and resolution is proposed. Universal use of a single set of diagnostic characteristics will facilitate malnutrition's recognition, contribute to more valid estimates of its prevalence and incidence, guide interventions, and influence expected outcomes. This standardized approach will also help to more accurately predict the human and financial burdens and costs associated with malnutrition's prevention and treatment and further ensure the provision of high-quality, cost-effective nutrition care.
977 citations
TL;DR: Optimal nutritional therapy in mechanically ventilated, critically ill patients, defined as protein and energy targets reached, is associated with a decrease in 28-day mortality by 50%, whereas only reaching energy targets is not associated withA reduction in mortality.
Abstract: Background: Optimal nutrition for patients in the intensive care unit has been proposed to be the provision of energy as determined by indirect calorimetry and the provision of protein of at least 1.2 g/kg. Methods: Prospective observational cohort study in a mixed medical-surgical intensive care unit in an academic hospital. In total, 886 consecutive mechanically ventilated patients were included. Nutrition was guided by indirect calorimetry and protein provision of at least 1.2 g/kg. Cumulative intakes were calculated for the period of mechanical ventilation. Cox regression was used to analyze the effect of protein + energy target achieved or energy target achieved versus neither target achieved on 28-day mortality, with adjustments for sex, age, body mass index, Acute Physiology and Chronic Health Evaluation II, diagnosis, and hyperglycemic index. Results: Patients’ mean age was 63 ± 16 years; body mass index, 26 ± 6; and Acute Physiology and Chronic Health Evaluation II, 23 ± 8. For neither target, en...
325 citations
TL;DR: In this paper, an evidence analysis project was developed to identify the most valid and reliable nutrition screening tools for use in acute care and hospital-based ambulatory care settings, and evaluated articles for quality using criteria specified by the American Dietetic Association's Evidence Analysis Library.
Abstract: In response to questions about tools for nutrition screening, an evidence analysis project was developed to identify the most valid and reliable nutrition screening tools for use in acute care and hospital-based ambulatory care settings. An oversight group defined nutrition screening and literature search criteria. A trained analyst conducted structured searches of the literature for studies of nutrition screening tools according to predetermined criteria. Eleven nutrition screening tools designed to detect undernutrition in patients in acute care and hospital-based ambulatory care were identified. Trained analysts evaluated articles for quality using criteria specified by the American Dietetic Association's Evidence Analysis Library. Members of the oversight group assigned quality grades to the tools based on the quality of the supporting evidence, including reliability and validity data. One tool, the NRS-2002, received a grade I, and 4 tools-the Simple Two-Part Tool, the Mini-Nutritional Assessment-Short Form (MNA-SF), the Malnutrition Screening Tool (MST), and Malnutrition Universal Screening Tool (MUST)-received a grade II. The MST was the only tool shown to be both valid and reliable for identifying undernutrition in the settings studied. Thus, validated nutrition screening tools that are simple and easy to use are available for application in acute care and hospital-based ambulatory care settings.
193 citations
TL;DR: The lipid emulsion, based on a mixture of MCTs and soybean, olive, and fish oils, was safe and well tolerated by preterm infants while beneficially modulating the fatty acid profile.
Abstract: Background: For premature neonates needing parenteral nutrition (PN), a balanced lipid supply is crucial. The authors hypothesized that a lipid emulsion containing medium-chain triglycerides (MCTs) and soybean, olive, and fish oils would be as safe and well tolerated as a soybean emulsion while beneficially influencing the fatty acid profile. Methods: Double-blind, controlled study in 53 neonates (<34 weeks’ gestation) randomized to receive at least 7 days of PN containing either an emulsion of MCTs and soybean, olive, and fish oils or a soybean oil emulsion. Target lipid dosage was 1.0 g fat/kg body weight [BW]/d on days 1–3, 2 g/kg BW/d on day 4, 3 g/kg BW/d on day 5, and 3.5 g/kg BW/d on days 6–14. Results: Test emulsion vs control, mean ± SD: baseline triglyceride concentrations were 0.52 ± 0.16 vs 0.54 ± 0.19 mmol/L and increased similarly in both groups to 0.69 ± 0.38 vs 0.67 ± 0.36 on day 8 of treatment (P = .781 for change). A significantly higher decrease in total and direct bilirubin vs baseline was seen in the test group compared with the control group P < .05 between groups). In plasma and red blood cell phospholipids, eicosapentaenoic acid and docosahexaenoic acid were higher, and the n-6/n-3 fatty acid ratio was lower in the test group (P < .05 vs control). Conclusions: The lipid emulsion, based on a mixture of MCTs and soybean, olive, and fish oils, was safe and well tolerated by preterm infants while beneficially modulating the fatty acid profile.
142 citations
TL;DR: This lecture reviews the current understanding of how insulin resistance, as a marker of the metabolic stress, is involved in recovery after major surgery and recommends several treatments, such as preoperative carbohydrate treatment instead of overnight fasting, continuous epidural anesthesia for postoperative pain care, early feeding, and mobilization.
Abstract: This lecture reviews the current understanding of how insulin resistance, as a marker of the metabolic stress, is involved in recovery after major surgery. Insulin resistance develops as a graded response related to the magnitude of the operation. It lasts for weeks after medium-size surgery and affects all parts of body metabolism. Although hyperglycemia develops, muscle and fat uptake is reduced and other non-insulin-sensitive cells have an increase in glucose uptake as a result of the elevated glucose levels. Reduced glucose uptake and storage in muscle along with loss of lean body mass help explain reduced muscle function that will impair mobilization. The increased uptake of glucose in non-insulin-sensitive cells is involved in the development of several of the most common postoperative complications, including infections and cardiovascular problems. Many of the perioperative treatments in use are outdated, and modern care involves a multimodal approach with several treatments, such as preoperative carbohydrate treatment instead of overnight fasting, continuous epidural anesthesia for postoperative pain care, early feeding, and mobilization, all of which affect insulin by reducing the stress and enhancing recovery. Most of the previous mandatory catabolic responses to surgery can be avoided, resulting in substantially faster recovery and fewer complications. Methods to implement these modern treatments have been developed and used in Europe, resulting in improved care and shorter length of stay.
128 citations
TL;DR: Significant decreases in vitamin D status over the duration of the patient's ICU stay are demonstrated and are associated with longer time to ICU discharge alive and a trend toward increased risk of ICU-acquired infection.
Abstract: Background: Despite the numerous disease conditions associated with vitamin D deficiency in the general population, the relationship of this deficiency to outcome in critically ill patients remains unclear. The objective of this study is to determine the burden of vitamin D deficiency in intensive care unit (ICU) patients and determine if it is associated with poor patient outcomes. Methods: The authors conducted an analysis of samples collected from a prospective study of 196 patients admitted to a medical/surgical ICU in a tertiary care hospital. They measured serum 25-hydroxyvitamin D at admission and up to 10 days following admission and followed patients prospectively for 28-day outcomes. Results: Of analyzable patients, 50 (26%) were deficient (≤30 nmol/L) and 109 (56%) were insufficient (>30 and ≤60 nmol/L). Baseline 25(OH)D levels decreased significantly in all patients after 3 days in the ICU and remained significantly lower through 10 days (P < .001). 25(OH)D status was not significantly associa...
121 citations
TL;DR: Results indicate that PAB may not be a sensitive marker for evaluating the adequacy of nutrition support in critically ill patients with inflammation, suggesting that an improvement in inflammation, rather than nutrient intake, was responsible for the increases in PAB levels.
Abstract: Background: Serum prealbumin (PAB) is commonly used to assess protein status and is often used to monitor the response to nutrition support. However, during inflammation, the liver synthesizes acute-phase proteins such as C-reactive protein (CRP) at the expense of PAB. Objective: The purpose of this retrospective study was to determine whether changes in PAB reflect the delivery of adequate nutrients or changes in inflammatory status in hospitalized adults (≥18 years) receiving enteral nutrition (n = 154). Methods: Protein and energy intake were compared to changes in PAB, assessed at baseline and twice weekly. C-reactive protein was assessed when PAB was <18 mg/dL to determine the presence and severity of inflammation. Results: In a sample of mostly critically ill patients, there was no significant difference in change in PAB for those receiving ≥60% of calorie needs (2.74 ± 9.50 mg/dL) compared to <60% of calorie needs (2.48 ± 9.36 mg/dL; P = .86). Changes in PAB correlated only with changes in CRP (r =...
114 citations
TL;DR: The International Consensus Guideline Committee (ICGC) established a pancreatitis task force to review published guidelines for pancreatitis in nutrition support as discussed by the authors, which identified eleven guidelines were identified for review.
Abstract: Guidelines for nutrition support in pancreatitis have been inconsistently adapted to clinical practice. The International Consensus Guideline Committee (ICGC) established a pancreatitis task force to review published guidelines for pancreatitis in nutrition support. A PubMed search using the terms pancreatitis, acute pancreatitis, chronic pancreatitis, nutrition support, parenteral nutrition, enteral nutrition, and guidelines was conducted for the period from January 1999 to May 2011. Eleven guidelines were identified for review. The ICGC used the following process to develop unified guideline statements: summarize the strength of evidence (grading) of the guidelines; establish level of evidence for ICGC statements as high, intermediate, and low; assign published guideline levels of evidence; and define an ICGC grading system. International Pancreatitis Guideline Grades were established as follows: platinum—high level of evidence and consistent agreement among the guidelines; gold—acceptable level of evidence and no conflicting statements in guidelines; and silver—single existing guideline statement with no conflict in other guidelines. Eighteen ICGC statements were derived from the 11 published pancreatitis guidelines. Uniform agreement from widely disparate groups (United States, Europe, Japan, and China) resulted in 4 platinum-level guideline statements for nutrition in pancreatitis: nutrition support therapy (NST) is generally not needed for mild to moderate disease, NST is needed for severe disease, enteral nutrition (EN) is preferred over parenteral nutrition (PN), and use PN when EN is contraindicated or not feasible. This methodology provides a template for future ICGC nutrition guideline development. (JPEN J Parenter Enteral Nutr. 2012;36:284-291)
113 citations
TL;DR: It is demonstrated that negative immune-related effects of not breastfeeding and cesarean delivery can be mitigated by including Bb12 in infant formula, thereby providing infants a safe, dietary, immune-modulating bacterial introduction.
Abstract: Background: Addition of probiotics to infant formula may positively affect immune function in nonexclusively breastfed infants. This study aimed to investigate the effect of infant starter formula containing the probiotic Bifidobacterium animalis subspecies lactis (Bb12) on intestinal immunity and inflammation. Methods: Six-week-old healthy, full-term infants (n = 172) were enrolled in a prospective, randomized, double-blind, controlled clinical trial with 2 groups studied in parallel to a breastfed comparison group. Formula-fed (FF) infants were randomized to partially hydrolyzed whey formula (CON) or the same formula containing 106 colony-forming units (CFU) Bb12/g (PRO) for 6 weeks. Fecal secretory IgA (sIgA), calprotectin, lactate, and stool pH were assessed at baseline, 2 weeks, and 6 weeks. Anti-poliovirus-specific IgA and anti-rotavirus-specific IgA were assessed at 2 and 6 weeks. Results: Among vaginally delivered FF infants, PRO consumption increased (P < .05) fecal sIgA compared to CON. Anti-pol...
104 citations
TL;DR: As an interdisciplinary organization dedicated to advancing the science and practice of nutrition support therapy, the American Society for Parenteral and Enteral Nutrition works vigorously to support quality patient care, education, and research in the fields of nutrition and metabolic support in all healthcare settings.
Abstract: As an interdisciplinary organization dedicated to advancing the science and practice of nutrition support therapy, the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) works vigorously to support quality patient care, education, and research in the fields of nutrition and metabolic support in all healthcare settings. To promote safe and effective patient care by nutrition support practitioners, the A.S.P.E.N. Board of Directors published “Guidelines for the Use of Parenteral and Enteral Nutrition in Adult and Pediatric Patients” in 1993 and 2002. The format and methodology of the Clinical Guidelines (CG)s have changed over time, as a result of A.S.P.E.N.’s on-going efforts to improve the clarity and usefulness of the guidelines. The Institute of Medicine (IOM) has recently redefined Clinical Practice Guidelines as “statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.” To be trustworthy, IOM states that CGs should be based on a systematic
104 citations
TL;DR: Defining the symptoms and biochemical markers for gluten-sensitive conditions is an important area for future investigations, and high-quality, large-scale randomized trials are needed to prove the true benefits of the GFD in this evolving field.
Abstract: As the gluten-free diet (GFD) gains in popularity with the general public, health practitioners are beginning to question its real health benefits. For those patients with celiac disease (CD), the GFD is considered medical nutrition therapy, as well as the only proven treatment that results in improvements in symptomatology and small bowel histology. Those with wheat allergy also benefit from the GFD, although these patients often do not need to restrict rye, barley, and oats from their diet. Gluten sensitivity is a controversial subject, where patients who have neither CD nor wheat allergy have varying degrees of symptomatic improvement on the GFD. Conditions in this category include dermatitis herpetiformis (DH), irritable bowel syndrome (IBS), and neurologic diseases such as gluten-sensitive ataxia and autism. It is important for patients and healthcare practitioners to understand the differences between these conditions, even though they may all respond to a GFD. Patients with CD can experience comorbid nutrition deficiencies and are at higher risk for the development of cancers and other autoimmune conditions. Those with wheat allergy and gluten sensitivity are thought not to be at higher risk for these complications. Defining the symptoms and biochemical markers for gluten-sensitive conditions is an important area for future investigations, and high-quality, large-scale randomized trials are needed to prove the true benefits of the GFD in this evolving field.
TL;DR: A systematic review of the best available evidence to answer a series of questions regarding nutrition support of neonates at risk of NEC suggested that minimal enteral nutrition be initiated within the first 2 days of life and advanced by 30 mL/kg/d in infants ≥ 1, 000 g.
Abstract: Background: Necrotizing enterocolitis (NEC) is one of the most devastating diseases in the neonatal population, with extremely low birth weight and extremely preterm infants at greatest risk. Method: A systematic review of the best available evidence to answer a series of questions regarding nutrition support of neonates at risk of NEC was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development and Evaluation working group. A consensus process was used to develop the clinical guideline recommendations prior to external and internal review and approval by the A.S.P.E.N. Board of Directors. Results/Conclusions: (1) When and how should feeds be started in infants at high risk for NEC? We suggest that minimal enteral nutrition be initiated within the first 2 days of life and advanced by 30 mL/kg/d in infants ≥1000g. (Weak) (2) Does the provision of mother's milk reduce the risk of developing NEC? We suggest the exclusive use of mother's milk rather than bovine-based products or formula in infants at risk for NEC. (Weak) (3) Do probiotics reduce the risk of developing NEC? There are insufficient data to recommend the use of probiotics in infants at risk for NEC. (Further research needed.) (4) Do nutrients either prevent or predispose to the development of NEC? We do not recommend glutamine supplementation for infants at risk for NEC (Strong). There is insufficient evidence to recommend arginine and/or long chain polyunsaturated fatty acid supplementation for infants at risk for NEC. (Further research needed.) (5) When should feeds be reintroduced to infants with NEC? There are insufficient data to make a recommendation regarding time to reintroduce feedings to infants after NEC. (Further research needed.) (JPEN J Parenter Enteral Nutr. 2012;36:506-523)
TL;DR: This tutorial presents a systematic approach to nutrition assessment based on a modern appreciation for the contributions of inflammation that serve as the foundation for newly proposed consensus definitions for malnutrition syndromes.
Abstract: This tutorial presents a systematic approach to nutrition assessment based on a modern appreciation for the contributions of inflammation that serve as the foundation for newly proposed consensus definitions for malnutrition syndromes. Practical indicators of malnutrition and inflammation have been selected to guide diagnosis that include medical/surgical history and clinical diagnosis, clinical signs and physical examination, anthropometric data, laboratories, dietary assessment, and functional outcomes. Knowledge of systematic nutrition assessment and appropriate diagnosis of malnutrition will help to guide proper interventions and expected outcomes.
TL;DR: Infant formula containing the studied oligosaccharides was well tolerated, increased abundance and proportion of bifidobacteria, and reduced fecal pH in healthy infants and prebiotic supplementation did not alter stool patterns, tolerance, or growth.
Abstract: Background: Prebiotic-containing infant formula may beneficially affect gastrointestinal tolerance and commensal microbiota composition. Objective: Assess gastrointestinal tolerance and fecal microbiota, pH, and short-chain fatty acid (SCFA) concentrations of infants consuming formula with or without prebiotics. Design: Full-term formula-fed infants were studied to a breastfed comparison group (BF). Formula-fed infants (FF) were randomized to consume a partially hydrolyzed whey formula with (PRE) or without (CON) 4 g/L of galacto-oligosaccharides and fructo-oligosaccharides (9:1). Fecal bacteria, pH, and SCFA were assessed at baseline, 3 weeks, and 6 weeks. Caregivers of patients recorded stool characteristics and behavior for 2 days before the 3- and 6-week visits. Results: Feces from infants fed PRE had a higher absolute number (P = .0083) and proportion (P = .0219) of bifidobacteria than CON-fed infants and did not differ from BF. BF had a higher proportion of bifidobacteria than CON (P = .0219) and lo...
TL;DR: EEF may exert beneficial effects on the hormonal profile of TBI patients, possibly contributing to a better clinical outcome in this patient group.
Abstract: Background: Traumatic brain injury (TBI) results in a hypermetabolic and hypercatabolic status in which adequate nutrition support is essential to improve clinical outcome. The endocrine system of a patient with TBI is also affected and may play a critical role in either the metabolic or the immunologic response to the trauma. In the present study, the effect of standard, delayed enteral feeding (DEF), compared with early (within 24–48 hours) enteral feeding (EEF), on the endocrine function of patients with TBI was investigated. Methods: This comparative, prospective, open-labeled, randomized study included TBI patients admitted to the intensive care unit (ICU). Injury severity was assessed by the Glasgow Coma Scale and predicted mortality by the Acute Physiology and Chronic Health Evaluation II. Twenty-five patients received DEF and 34 patients received EEF. The effect of the onset of nutrition on pituitary, thyroidal, gonadal, and adrenal function was investigated on days 6 and 12 after admission to the...
TL;DR: The Institute of Medicine and the Endocrine Society's Clinical Guidelines recommended that to prevent and treat vitamin D deficiency, children 0-1 year and 1-18 years need 400-1000 and 600-1000 IU/d, respectively.
Abstract: Vitamin D deficiency and insufficiency is common in children. Vitamin D deficiency is defined as a 25-hydroxyvitamin D <20 ng/mL and insufficiency as 21-29 ng/mL. The major sources of vitamin D are sun exposure, diet, and supplements. In young children, vitamin D deficiency causes a mineralization defect of the skeleton, resulting in rickets. Vitamin D deficiency has been linked to many chronic diseases, including multiple sclerosis, type 1 diabetes, infectious diseases, heart disease, and type 2 diabetes. In utero vitamin D deficiency increases risk for preeclampsia and the need for a cesarean section. Children living at higher latitudes and who are presumed to be at increased risk for vitamin D deficiency are at higher risk for developing type 1 diabetes and multiple sclerosis later in life. The Institute of Medicine recommends that children 0-1 year and 1-18 years need 400 and 600 IU/d, respectively, of vitamin D for maximal skeletal health. The Endocrine Society's Clinical Guidelines recommended that to prevent and treat vitamin D deficiency, children 0-1 year and 1-18 years need 400-1000 and 600-1000 IU/d, respectively.
TL;DR: Both the observed rate of BSI and adjusted probability of developing a BSI remained significantly lower for the MCB than the compounded PN group, and it is indicated that MCB is associated with fewer infections than pharmacy-prepared PN.
Abstract: Background: The incidence of bloodstream infection (BSI) among patients receiving parenteral nutrition (PN) is reported to vary widely from 1.3%−39%. BSI rates in a large inpatient population were compared in this study to determine if PN prepared by different methods was associated with BSI. Methods: Data from Premier Perspective, the largest inpatient cost-based clinical and financial claims database in the United States, were analyzed. Included were all hospitalized patients age ≥18 years who received any PN from January 1, 2005, to December 31, 2007. BSI rates, the primary dependent variable, were defined as the occurrence ICD-9 codes of 038.x (septicemia), 995.91 (sepsis), 995.92 (severe sepsis), and 790.7 (bacteremia). The exposure cohort received PN in a commercial multichamber bag (MCB) (n = 4669), whereas the comparator group received PN prepared by a pharmacy (either hospital compounded or outsourced; n = 64,315). Observed data were adjusted using multivariate logistic regression for baseline di...
TL;DR: This study supports the efficacy and safety of ELT in reducing CRBSi-related admissions in HPN patients and potentially helps reduce the burden of CRBSI-related healthcare costs.
Abstract: BackgroundEquivocal data demonstrate the efficacy of ethanol lock therapy (ELT) in preventing catheter-related bloodstream infections (CRBSIs) in home parenteral nutrition (HPN) patients, but it is not currently a standard of practice. The objective of this study is to investigate the efficacy of ELT in reducing the incidence of CRBSIs in HPN patients.MethodsMedical records from the Cleveland Clinic database of adult HPN patients with CRBSIs placed on prophylactic ELT were retrospectively studied from January 2006 to August 2009 (n = 31). Outcomes were compared pre- and post-ELT with the patients serving as their own controls. Medical-grade (70%) ethanol was instilled daily into each lumen of the central venous catheter (CVC) between PN infusion cycles. Comparative analysis was performed using McNemar’s test and Wilcoxon ranked tests.ResultsThirty-one patients had 273 CRBSI-related admissions prior to ELT in comparison to 47 CRBSI-related admissions post-ELT. Adjusted data for only tunneled CVC pre- and p...
TL;DR: Modification of feeding duration and flow rate can be a useful adjunct to ameliorate GER in dysphagic neonates.
Abstract: Background. Feeding difficulties and gastroesophageal reflux (GER) are common problems in neonates. The authors hypothesize that GER could be influenced by feeding mechanics by evaluating the effects of feeding volumes, feeding durations, feeding flow rates, and caloric density on the chemical composition and clearance of GER in dysphagic neonates. Methods: Symptomatic dysphagic neonates (n = 35) underwent evaluation for suspected GER using pH-impedance methods. Results: The proportions of acid and nonacid GER were different during the first, second, and third postprandial hours (P < .0001). Prolonged feeding duration was significantly associated with decreased total, nonacid GER and BCT (P < .03). Significant positive correlations (P < .05) were detected between feeding flow rate vs frequency of total, nonacid GER and BCT. Significant positive correlation (P = .002) was noted between feeding volume and BCT. BCT decreased with each hourly interval (analysis of variance [ANOVA] P < .05); however, ACT incre...
University of Alberta1, National Institutes of Health2, University of Minnesota3, University of Oklahoma Health Sciences Center4, Mount Sinai St. Luke's and Mount Sinai Roosevelt5, Pennington Biomedical Research Center6, University of Kiel7, University of Cambridge8, Geneva College9, University of California, San Francisco10, Montclair State University11
TL;DR: Preoperative intake of a GLN-enriched CHO beverage appears to improve IR and antioxidant defenses and decreases the inflammatory response after video-cholecystectomy.
Abstract: Background: Prolonged preoperative fasting increases insulin resistance (IR). The authors investigated whether an abbreviated preoperative fast with glutamine (GLN) plus a carbohydrate (CHO)–based beverage would improve the organic response after surgery. Methods: Forty-eight female patients (19-62 years) were randomized to either standard fasting (control group) or to fasting with 1 of 3 different beverages before video-cholecystectomy. Beverages were consumed 8 hours (400 mL; placebo group: water; GLN group: water with 50 g maltodextrine plus 40 g GLN; and CHO group: water with 50 g maltodextrine) and 2 hours (200 mL; placebo: water; GLN: water with 25 g maltodextrine plus 10 g GLN; and CHO: water with 25 g maltodextrine) before anesthesia. Blood samples were collected pre- and postoperatively. Results: The mean (SEM) postoperative homeostasis model assessment–insulin resistance was greater (P < .05) in control patients (4.3 [1.3]) than in the other groups (placebo, 1.6 [0.3]; CHO, 2.3 [0.4]; and GLN, 1...
TL;DR: The spectrum of C difficile infection (CDI) is highly variable, ranging from mild to severe illness, presenting with single to multiple disease recurrences, and patients with selective risk factors are often vulnerable to the toxigenic potential of this virulent healthcare pathogen as discussed by the authors.
Abstract: Clostridium difficile is the leading cause of healthcare-associated infectious diarrhea. Although C difficile is part of normal flora in some healthy individuals, patients with selective risk factors are often vulnerable to the toxigenic potential of this virulent healthcare pathogen. The spectrum of C difficile infection (CDI) is highly variable, ranging from mild to severe illness, presenting with single to multiple disease recurrences. Current approaches to treatment are based on severity of illness, number of recurrences, and clinical presentation. Oral vancomycin and metronidazole have formed the foundation for treatment of CDI, but therapeutic failures are commonly reported, especially involving hypervirulent clones. Alternative therapies, including newer antimicrobials, probiotics, immunotherapy, and fecal transplantation, have all met with varying degrees of efficacy. Although toxigenic culture (TC) testing from anaerobic culture remains the gold standard, newer technologies, including enzyme immunoassay, common antigen (glutamate dehydrogenase) testing, and real-time polymerase chain reaction (PCR) are less time-consuming and rapid. However, TC and PCR have reported high specificity and sensitivity when compared with other laboratory tests. Because of the significant morbidity and mortality associated with CDI, a high index of suspicion is warranted. Prevention and eradication of CDI require a multidisciplinary approach, including early disease recognition through appropriate surveillance, implementation of effective contact isolation strategies, adherence to environmental controls, judicious hand hygiene, evidence-based treatment, and management that includes antibiotic stewardship, continuous education of healthcare workers, and administrative support.
TL;DR: Compounded PN was associated with a higher incidence of BSIs and CLABs, suggesting that the use of MCB PN may play a role in reducing the incidence ofBSIs in patients who receive PN.
Abstract: Background:Parenteral nutrition (PN) is associated with an increased risk of developing bloodstream infections (BSIs) but the impact of the PN delivery system upon BSI rates remains unclear. This was an international, multicenter, prospective, randomized, open-label, controlled trial that investigated the differences of BSIs associated with 2 different PN systems.Methods:Patients were randomly allocated in a 2:1:1 ratio to receive either PN delivered by a multichamber bag (MCB group), or by compounded PN made with olive oil (COM1 group) or with MCT/LCT (COM2 group). Blood cultures were performed to evaluate the incidence of BSIs, and catheter use data was collected to calculate CLAB and central venous catheter device use ratio (CVC-DUR). Secondary outcomes included the development of severe sepsis/septic shock, number of intensive care unit (ICU) and hospital days, and all-cause mortality at Day 28.Results:406 patients were included: 202 in the MCB group, 103 in the COM1 group, and 101 in the COM2 group. ...
TL;DR: Parenteral fish oil in combination with ω-6/9 lipid emulsions was associated with improved outcome in premature neonates with SBS, suggesting that this mixed lipid emulsion may facilitate intestinal adaptation by increasing the IFALD-free period.
Abstract: Background:Newborn infants with short bowel syndrome (SBS) represent a high risk group of developing intestinal failure-associated liver disease (IFALD) which may be fatal. However, infants have a ...
TL;DR: With the possible exceptions of Vitamin D and omega-3 fatty acids there is no data to support the widespread use of dietary supplements in Westernized populations; indeed, many of these supplements may be harmful.
Abstract: Background: Dietary supplements are regularly used by at least half of the American population, yet the health benefits of these agents are unclear. Objective: A systematic review to determine the benefits and risks of dietary supplements in Westernized societies. Data Sources: MEDLINE, Embase, Cochrane Register of Controlled Trials and citation review of relevant articles. Study Selection: Randomized, placebo-controlled clinical trials in non-pregnant Westernized adults that evaluated clinical outcomes of nutritional supplements. Data Extraction: Data were abstracted on study design, study size, study setting, patient population, dietary intervention and clinical outcomes. The outcome of each study was classified as non-beneficial, beneficial or harmful according to whether theend-point(s) of interest reached statistical significance. Data Synthesis: Sixty-three studies met the criteria for our systematic review. No benefit was recorded in 45 studies, with 10 of these showing a trend towards harm and wit...
TL;DR: Linking insulin to carbohydrate in PN leads to improved glycemic control with a low rate of hypoglycemia, and protocol-directed management of PN-induced hyperglycemia is superior to ad hoc insulin dosing.
Abstract: Background: The authors investigated whether an insulin protocol for parenteral nutrition (PN)–induced hyperglycemia is superior to conventional management relying primarily on sliding-scale insulin at a large county hospital. Methods: A prospective cohort study with historical controls was completed. Adult patients receiving PN were managed with a protocol that determined insulin doses based on carbohydrate delivery and capillary blood glucose (CBG) if half or more of CBG measurements in the first 24 hours after initiation of PN exceeded 140 mg/dL. Control data were obtained from records of patients who met study eligibility criteria but had been managed before implementation of the insulin protocol. Results: Mean CBG after the start of insulin therapy was 138 ± 37 mg/dL for protocol patients and 159 ± 46 mg/dL for controls (P < .0001). Proportion of CBG values in the target range of 80–140 mg/dL was 60% in the protocol group and 35% in the control group (P < .0001). Hypoglycemia, defined as CBG <80 mg/d...
TL;DR: PN and enteral nutrition (EN) when given continuously as an elemental diet reduces insulin sensitivity and the secretion of key gut incretins and produced the optimal effect on metabolic function.
Abstract: Background:We previously showed that parenteral nutrition (PN) compared with formula feeding results in hepatic insulin resistance and steatosis in neonatal pigs. The current aim was to test whether the route of feeding (intravenous [IV] vs enteral) rather than other feeding modalities (diet, pattern) had contributed to the outcome.Methods:Neonatal pigs were fed enterally or parenterally for 14 days with 1 of 4 feeding modalities as follows: (1) enteral polymeric formula intermittently (FORM), (2) enteral elemental diet (ED) intermittently (IEN), (3) enteral ED continuously (CEN), and (4) parenteral ED continuously (PN). Subgroups of pigs underwent IV glucose tolerance tests (IVGTT) and hyperinsulinemic-euglycemic clamps (CLAMP). Following CLAMP, pigs were euthanized and tissues collected for further analysis.Results:Insulin secretion during IVGTT was significantly higher and glucose infusion rates during CLAMP were lower in CEN and PN than in FORM and IEN. Endogenous glucose production rate was suppresse...
TL;DR: Prebiotic and/or synbiotic supplementation resulted in enhanced structure and function throughout the residual intestine in neonatal piglets and identification of a synergistic prebiotics and probiotic combination may enhance the promising results obtained with prebiotic treatment alone.
Abstract: Background:Butyrate has been shown to stimulate intestinal adaptation when added to parenteral nutrition (PN) following small bowel resection but is not available in current PN formulations. The authors hypothesized that pre- and probiotic administration may be a clinically feasible method to administer butyrate and stimulate intestinal adaptation.Methods and Materials:Neonatal piglets (48 hours old, n = 87) underwent placement of a jugular catheter and an 80% jejunoileal resection and were randomized to one of the following treatment groups: control (20% standard enteral nutrition/80% standard PN), control plus prebiotic (10 g/L short-chain fructooligosaccharides [scFOS]), control plus probiotic (1 × 109 CFU Lactobacillus rhamnosus GG [LGG]), or control plus synbiotic (scFOS + LGG). Animals received infusions for 24 hours, 3 days, or 7 days, and markers of intestinal adaptation were assessed.Results:Prebiotic treatment increased ileal mucosa weight compared with all other treatments (P = .017) and ileal ...
TL;DR: Hyperglycemia and hypoglycemia are clinically-relevant complications that should be considered in caring for the neonate receiving parenteral nutrition and it is important to examine the parameters for defining these conditions.
Abstract: This Clinical Guideline has been developed to guide clinical practice based on the authors’ assessment of current published evidence on glycemic control in the neonate (within the first month of life) receiving parenteral nutrition (PN). The neonate receiving PN is worthy of special consideration with respect to glucose control, as this population carries an elevated risk of hyperand hypoglycemia and may be more susceptible to deleterious effects associated with these conditions. Untreated hyperor hypoglycemia may lead to undesirable clinical outcomes. Prolonged or symptomatic hypoglycemia may result in neurodevelopmental impairment. Severe hyperglycemia can lead to osmotic diuresis resulting in dehydration and electrolyte imbalance. Furthermore there is some evidence to suggest that hyperglycemia in premature infants (particularly those that are very low birth weight (VLBW <1500 g) or extremely low birth weight (ELBW <1000 g)) has been positively correlated with morbidity and mortality, spurring questions about more proactive measures of managing elevated blood glucose levels in this group of patients. Thus, hyperglycemia and hypoglycemia are clinically-relevant complications that should be considered in caring for the neonate receiving PN and it is important to examine the parameters for defining,
TL;DR: PICUs might have to prioritize performing IC in patients who are <2 years of age, malnourished (underweight/overweight) on admission, or PICU stay of >5 days, and future studies should determine the cost-benefit ratios.
Abstract: Background: Critically ill children differ in their energy needs from healthy children in terms of underlying metabolic derangement, comorbidities, energy reserve, and response to illness. This study determined how many pediatric intensive care unit (PICU) patients were candidates for indirect calorimetry (IC), per American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) recommendations. Methods: Admission diagnosis, demographics, type/amount of nutrition support, length of intensive care unit/hospital stay were collected. Patients were classified as candidates for IC per A.S.P.E.N. guidelines. Results: Mean (SD) age of patients (n = 150) was 6.7 (5.6) years, with PICU length of stay of 3.9 (5.3) days. IC was indicated in 72.0% (108/150) of patients during PICU days 1–7. Patients with miscellaneous (50%), neurological (73%), respiratory (81%), sepsis (83%), and oncology (100%) diagnoses were candidates for IC. Underweight/overweight/obese (32.4%), hypermetabolism (26.4%), and not meeting nutriti...