Early Fish Oil Supplementation and Organ Failure in Patients With Septic Shock From Abdominal Infections

Background: Fish oil (FO) has immunomodulating effects and may improve organ function and outcome in critically ill patients. This retrospective, propensity‐matched cohort study investigates the effects of early intravenous FO supplementation on organ failure in patients with septic shock from abdominal infection. Methods: A medical database was retrospectively searched for critically ill patients admitted because of septic shock from abdominal infection (n = 194). Demographic, clinical, and laboratory data; FO supplementation (10 g/d) (n = 42); rate, degree, and number of organ failures assessed by the Sequential Organ Failure Assessment (SOFA) score; and secondary outcome variables were recorded. A propensity score‐based model was used to establish 2 comparable groups (FO, n = 29; control, n = 29). Mann‐Whitney rank sum test, Fisher exact test, and logistic regression analyses were used to compare variables between groups. Results: There were no differences in the rate of single organ failures, the maximum SOFA score (median [interquartile range (IQR)], 12 [8‐15] vs 11 [9‐14]; P = .99), or the number of organ failures (median [IQR], 2 [1‐3] vs 2 [1‐3]; P = .54] between patients receiving FO supplementation and those not receiving supplementation. There were no group differences in the maximum C‐reactive protein levels (P = .1), duration of mechanical ventilation (P = .65) or hemofiltration (P = .21), intensive care unit–acquired infections, intensive care unit length of stay (P = .59), and intensive care unit (P = 1) or hospital mortality (P = 1). Conclusions: Early intravenous FO may not decrease the number and degree of organ failures in patients with septic shock from abdominal infection. Future trials are needed before FO supplementation in septic shock from abdominal infection can be recommended.     

Caloric Restriction and L‐Carnitine Administration Improves Insulin Sensitivity in Patients With Impaired Glucose Metabolism

Background: Reduced circulating and tissue carnitine levels, possibly leading to impaired mitochondrial function, have been postulated to be involved in the pathogenesis of insulin resistance. However, whether L‐carnitine administration may improve insulin sensitivity in patients with impaired fasting glucose (IFG) or type 2 diabetes mellitus (DM‐2) is still controversial. The aim of the study was to explore the role of L‐carnitine supplementation in influencing insulin sensitivity. Methods: A randomized controlled study involving adult outpatients was designed. Adult patients referred to the outpatient clinic and within 10 days of the diagnosis of IFG or DM‐2 were consecutively enrolled. Exclusion criteria were concomitant antidiabetic therapy and modifications of lifestyle during the previous 4 weeks. Patients were randomly assigned to receive a hypocaloric diet for 10 days (group C; n = 8) or the same dietetic regimen in addition to oral L‐carnitine (2 g twice daily) supplementation (group LC; n = 8). Oral glucose tolerance test (OGTT), fasting plasma insulin levels, and homeostasis model assessment of insulin resistance (HOMA‐IR) were assessed at the beginning and end of the study. Data were statistically analyzed using the Student t test for paired and unpaired data. Results: OGTT at 2 hours improved in both groups. Only in the L‐carnitine–supplemented group did plasma insulin levels and HOMA‐IR significantly decrease when compared to baseline values. Conclusions: Considering the role of caloric restriction in increasing the intestinal uptake of carnitine, the results suggest that oral L‐carnitine administration, when associated with a hypocaloric feeding regimen, improves insulin resistance and may represent an adjunctive treatment for IFG and DM‐2.     

A Randomized Controlled Trial Investigating the Effects of Parenteral Fish Oil on Survival Outcomes in Critically Ill Patients With Sepsis

Introduction: Death from sepsis in the intensive care unit (ITU) is frequently preceded by the development of multiple organ failure as a result of uncontrolled inflammation. Treatment with ω‐3 has been demonstrated to attenuate the effects of uncontrolled inflammation and may be clinically beneficial. Method: A randomized control trial investigating the effects of parenteral ω‐3 was carried out. Consecutive patients diagnosed with sepsis were entered into the study and randomized to receive either parenteral ω‐3 or standard medical care only. The primary outcome measure was a reduction in organ dysfunction using the Sequential Organ Failure Assessment (SOFA) score as a surrogate marker. The secondary outcome measures were mortality, length of stay, mean C‐reactive protein (CRP), and days free of organ dysfunction/failure. Results: Sixty patients were included in the study. The baseline demographics were matched for the two cohorts. Patients treated with parenteral ω‐3 were associated with a significant reduction in new organ dysfunction (Δ‐SOFA 2.2 ± 2.2 vs. 1.0 ± 1.5, P = .005 and maximum‐SOFA 10.1 ± 4.2 vs. 8.1 ± 3.2, P = .041) and maximum CRP (186.7 ± 78 vs. 141.5 ± 62.6, P = .019). There was no significant reduction in the length of stay between cohorts. Patients treated with ω‐3 in the strata of less severe sepsis had a significant reduction in mortality (P = .042). Conclusion: The treatment of critically ill septic patients with parenteral ω‐3 is safe. It is associated with a significant reduction in organ dysfunction. It may be associated with a reduction in mortality in patients with less severe sepsis.     

儿童重症监护病房脓毒性休克患者死亡危险因素

目的分析儿童重症监护病房(PICU)脓毒性休克患者死亡的危险因素,为降低脓毒性休克死亡,为早期防治措施的制定提供依据。方法回顾性分析2015年5月—2018年5月某院PICU收治的脓毒性休克患儿的临床资料,按休克转归分为存活组和死亡组,采用单因素、多因素logistic回归分析其死亡的危险因素。结果共收集脓毒性休克患儿62例,其中存活31例(存活组),死亡23例(死亡组),放弃治疗8例,脓毒性休克患者儿病死率为42.6%。多因素logistic回归分析显示,清蛋白降低、脏器功能障碍数目大于3个、血糖增高、C反应蛋白增高、有效复苏时间超过6 h、血压需药物维持、细菌培养阳性、6 h乳酸清除率低是脓毒性休克死亡的独立危险因素。存活组复苏后6 h乳酸水平低于死亡组[1.4(1.2～2.1)mmol/L VS 5.6(3.5～8.7)mmol/L],乳酸清除率水平高于死亡组[0.4(0.23～0.52)%VS-0.16(-0.39～0.13)%],差异均有统计学意义(均P0.05)。存活组治疗24 h降钙素原水平低于死亡组[1.1(0.5～1.6)ng/mL VS23.5(12.9～55.1)ng/mL],降钙素原清除率水平高于死亡组[0.47(0.27～0.69)%VS-0.9(-5.5～0.1)%],差异均有统计学意义(均P0.05)。结论儿童脓毒性休克临床病死亡高,早期监测脏器功能,动态测定乳酸水平和有效液体复苏并进行有效干预有助于改善预后。     

Tolerability and Safety of Enteral Nutrition in Critically Ill Patients Receiving Intravenous Vasopressor Therapy

Background: Enteral nutrition (EN) is recommended within the first 24–48 hours following admission to an intensive care unit (ICU) once resuscitation and hemodynamic stability have been achieved; however, hemodynamic stability is not well defined. Objective: To evaluate the tolerability and safety of EN in critically ill patients receiving intravenous (IV) vasopressor therapy. Methods: A retrospective medical record review was conducted in an urban academic medical center and included adult ICU patients from 2011 who received concomitant EN and IV vasopressor therapy for ≥1 hour. EN tolerance was defined as an absence of gastric residuals ≥300 mL, emesis, positive finding on abdominal imaging, and evidence of bowel ischemia/perforation. Results: Two hundred fifty‐nine patients received 346 episodes of concomitant EN and IV vasopressor therapy. Overall EN tolerability was 74.9%. Adverse events included rising serum lactate (30.6%), elevated gastric residuals (14.5%), emesis (9.0%), positive finding on kidney/ureter/bladder radiograph (4.3%), and bowel ischemia/perforation (0.9%). An inverse relationship was found between maximum norepinephrine equivalent dose and EN tolerability (12.5 mcg/min for patients who tolerated EN vs 19.4 mcg/min, P = .0009). This relationship remained statistically significant after controlling for other variables (P = .019). Patients who tolerated EN were less likely to have received dopamine (63.8% vs 77.6%, P = .018) or vasopressin (58.9% vs 77.9%, P = .0027). These patients received concomitant therapy for less time and received more nutrition. Conclusions: Most patients receiving IV vasopressor therapy tolerate EN. Tolerability was related to the maximum cumulative vasopressor dose and may be related to the specific vasopressor administered.     

Enteral L‐Arginine Supplementation for Prevention of Necrotizing Enterocolitis in Very Low Birth Weight Neonates

Background: Necrotizing enterocolitis (NEC) is the most common acquired gastrointestinal disease in premature infants and has high mortality and morbidity. Endothelial nitric oxide is an important regulator of vascular perfusion and is synthetized from the amino acid L‐arginine. Hypoargininemia is frequently observed in preterm neonates and may predispose them to NEC. Our objective was to determine the effect of enteral L‐arginine supplementation on the incidence and severity of NEC in very low birth weight (VLBW) neonates. Materials and Methods: We conducted a parallel blind randomized pilot study, comprising VLBW neonates with birth weight ≤1500 g and gestational age ≤34 weeks. VLBW neonates were randomly assigned to receive enteral L‐arginine supplementation (1.5 mmol/kg/d bid) between the 3rd and 28th day of life or placebo. Diagnosis and classification of NEC were done according to modified Bell's criteria. Results: Eighty‐three neonates were randomized to the arginine (n = 40) or placebo (n = 43) group. No adverse effects were observed in neonates receiving L‐arginine supplementation. The incidence of NEC stage III was significantly lower in the arginine‐supplemented group (2.5% vs 18.6%, P = .030). Conclusions: Enteral L‐arginine supplementation of 1.5 mmol/kg/d bid can be safely administered in VLBW neonates from the 3rd to the 28th day of life. Enteral L‐arginine supplementation appears to reduce the incidence of stage III NEC in VLBW infants. Larger studies are needed to further evaluate the effect of L‐arginine supplementation in preventing NEC in VLBW infants.     

Acute Effects of a Glucagon‐Like Peptide 2 Analogue,Teduglutide, on Gastrointestinal Motor Function and Permeability in Adult Patients With Short Bowel Syndrome on Home Parenteral Nutrition

Background: Glucagon‐like peptide 2 (GLP‐2) agonists decrease the need for parenteral nutrition (PN) in short bowel syndrome (SBS); mechanisms evaluated to date have focused on the intestinotrophic effect of GLP‐2 agonists such as increased absorptive capacity of the remnant intestine and increased citrulline levels. Other mechanisms may also play a role in effects of GLP‐2 agonists. Aim: To measure effects of a GLP‐2 agonist, teduglutide (TED), compared with placebo (PLA) on gastric emptying (GE), overall gut transit, fluid balance, intestinal monosaccharide absorption, and permeability in patients with SBS on home PN (HPN). Materials and Methods: In 8 adults with SBS on HPN, we compared daily subcutaneous TED (0.05 mg/kg) and PLA (crossover design, each treatment 7 days with a 14‐day washout) on gut transit, intestinal absorption, and permeability after oral mannitol (200 mg) and lactulose (1 g), as well as stool weight and urine volume over 8 hours. Analysis used the paired t test. Results: Of 8 patients, 4 were men, with a mean ± SD age of 54 ± 1 years, body mass index of 25 ± 4 kg/m², residual small intestine of 63 ± 12 cm, and 25% ± 15% of residual colon. The overall gut transit (% emptied at 6 hours) was 53.4% ± 15% for TED vs 62.4% ± 15.2% for PLA (P = .075), with no effect on GE (P = .74). TED increased urine mannitol excretion at 0–2 hours (16.2 ± 3.6 mg TED vs 11.3 ± 2.2 mg PLA, P = .20) and 0–8 hours (32.7 ± 5.9 mg PLA vs 48.8 ± 8.9 mg TED, P = .17). There were no differences in urine lactulose excretion or lactulose/mannitol ratio (0.024 ± 0.005 TED vs 0.021 ± 0.005 PLA). Over 8 hours, TED (vs PLA) numerically reduced stool weight (mean ± SEM, 77 ± 18 g TED vs 106 ± 43 g PLA, P = .42) and increased urine volume (408.9 ± 52.2 mL TED vs 365.7 ± 57.3 mL PLA, P = .34). Conclusion: Seven‐day TED treatment in 8 participants suggests beneficial effects on fluid balance and monosaccharide absorption, and it retarded overall gut transit with no effects on GE or mucosal permeability. Larger, longer, mechanistic studies of TED in SBS are warranted. This trial was registered at clinicaltrials.gov as NCT02099084.     

血管紧张素转换酶基因多态性与呼吸ICU脓毒性休克患者病情及预后分析

目的探讨血管紧张素转换酶(ACE)基因多态性与呼吸重症监护室(ICU)脓毒性休克患者病情及预后关联性。方法选择湖州市中心医院呼吸重症监护室2016年6月-2020年3月收治的脓毒性休克患者80例作为研究组,按照1∶1选择同期呼吸ICU收治的脓毒症患者80例作为对照组。所有患者均于入住ICU后抽取外周静脉血,采用聚合酶链式扩增反应(PCR)对模板中目标序列进行扩增,并对分型结果进行鉴定。对血清中ACE水平进行检测。统计研究组患者入住ICU 24 h后急性生理与慢性健康评分(APACHE II)、序贯器官衰竭评分(SOFA)、ICU住院时间及28 d死亡情况。结果研究组ACE基因rs4291位点AA、TT基因型及C、T等位基因频率分别为:23.75%、26.25%、48.75%、51.25%,与对照组相比差异有统计学意义(P<0.05);该位点TT基因型(OR=1.134)及T等位基因(OR=1.316)是脓毒症患者发生脓毒性休克的影响因素(P<0.05);AT型/TT型研究组患者血清ACE水平、APACHE II评分、SOFA评分、ICU住院时间及28 d病死率分别为(6.51±2.12)ng/ml、(31.26±12.41)、(10.39±2.59)、(16.84±4.38)d、40.98%(25/61)高于AA型研究组患者(P<0.05)。结论 ACE基因rs4291位点多态性与本地区人群脓毒性休克易感性有关,其中T等位基因为易感基因,携带该基因患者病情加重及不良预后的风险明显增加。     

Improved Glucose Profile in Patients With Type 2 Diabetes With a New,High‐Protein,Diabetes‐Specific Tube Feed During 4 Hours of Continuous Feeding

Background: Hyperglycemia frequently occurs in hospitalized patients receiving nutrition support. In this study, the effects of a new diabetes‐specific formula (DSF) on glucose profile during 4 hours of continuous feeding and 4 hours after stopping feeding were compared with a standard formula (SF). Materials and Methods: In this randomized, controlled, double‐blind, crossover study, ambulant, nonhospitalized patients with type 2 diabetes received the DSF or an isocaloric, fiber‐containing SF via a nasogastric tube. After overnight fasting, the formula was continuously administered to the patients during 4 hours. Plasma glucose and insulin concentrations were determined during the 4‐hour period and in the subsequent 4 hours during which no formula was provided. Results: During the 4‐hour feeding period, DSF compared with SF resulted in a lower mean delta glucose concentration in the 3‐ to 4‐hour period (0.3 ± 1.0 and 2.4 ± 1.5 mmol/L; P < .001). Also, the (delta) peak concentrations, (delta) mean concentrations, and incremental area under the curve (iAUC) for glucose and insulin were significantly lower during DSF compared with SF feeding (all comparisons: P < .001). Furthermore, fewer patients experienced hyperglycemia (>10 mmol/L) on DSF compared with SF (2 vs 11, P = .003, respectively). No differences in number of patients with hypoglycemia (<3.9 mmol/L) were observed. No significant differences in tolerance were observed. Conclusion: Administration of a new, high‐protein DSF during 4 hours of continuous feeding resulted in lower glucose and insulin levels compared with a fiber‐containing SF in ambulant, nonhospitalized patients with type 2 diabetes. These data suggest that a DSF may contribute to lower glucose levels in these patients.     

Glutamine Restores Tight Junction Protein Claudin‐1 Expression in Colonic Mucosa of Patients With Diarrhea‐Predominant Irritable Bowel Syndrome

Background:Recent studies showed that patients with diarrhea‐predominant irritable bowel syndrome (IBS‐D) had an increased intestinal permeability as well as a decreased expression of tight junctions. Glutamine, the major substrate of rapidly dividing cells, is able to modulate intestinal permeability and tight junction expression in other diseases. We aimed to evaluate, ex vivo, glutamine effects on tight junction proteins, claudin‐1 and occludin, in the colonic mucosa of patients with IBS‐D. Materials and Methods: Twelve patients with IBS‐D, diagnosed with the Rome III criteria, were included (8 women/4 men, aged 40.7 ± 6.9 years). Colonic biopsy specimens were collected and immediately incubated for 18 hours in culture media with increasing concentrations of glutamine from 0.6–10 mmol/L. Claudin‐1 and occludin expression was then measured by immunoblot, and concentrations of cytokines were assessed by multiplex technology. Claudin‐1 expression was affected by glutamine (P < .05, analysis of variance). In particularly, 10 mmol/L glutamine increased claudin‐1 expression compared with 0.6 mmol/L glutamine (0.47 ± 0.04 vs 0.33 ± 0.03, P < .05). In contrast, occludin expression was not significantly modified by glutamine. Interestingly, glutamine effect was negatively correlated to claudin‐1 (Pearson r = ‐0.83, P < .001) or occludin basal expression (Pearson r = ‐0.84, P < .001), suggesting that glutamine had more marked effects when tight junction protein expression was altered. Cytokine concentrations in culture media were not modified by glutamine treatment. Conclusion: Glutamine increased claudin‐1 expression in the colonic mucosa of patients with IBS‐D. In addition, glutamine effect seems to be dependent on basal expression of tight junction proteins.     

Efficacy of Glutamine in the Prevention of Acute Radiation Enteritis

Background: Acute radiation enteritis is a common adverse effect related to radiotherapy (RT). Glutamine is an immune modulator and antioxidant amino acid that can exert a protective role in patients receiving abdominal or pelvic radiation. The aim of this study was to test if glutamine prevents radiation enteritis during RT. Materials and Methods: Double‐blind, randomized, controlled trial including 69 patients who needed RT because of pelvic or abdominal malignancies and received glutamine (30 g/d) or placebo (casein, 30 g/d). Enteritis was evaluated according to the Radiation Therapy Oncology Group scale, intestinal inflammation using fecal calprotectin, and gut integrity with citrulline. The incidence of enteritis was analyzed by Kaplan‐Meier curves, and the hazard ratio (HR) was calculated using Cox regression. Results: Patients were predominantly male (65.2%), with an average (SD) age of 66.6 (9.9) years, with urologic (44.9%), rectal (24.6%), or gynecological cancer (23.1%). More patients developed enteritis with glutamine than with the placebo (55.9% vs 22.0%; P = .002), with an HR of 1.59 (95% confidence interval, 0.62–4.05). There were no differences in final calprotectin levels (glutamine, 57.9 [85.8] mg/kg vs placebo, 54.0 [57.7] mg/kg; P = .182) or the number of patients with values >50 mg/kg (glutamine, 58.1% vs placebo, 54.6%; P = .777). Final citrulline levels were similar between groups (glutamine, 26.31 [10.29] mmol/L vs placebo, 27.69 [12.31] mmol/L; P = .639), without differences in the number of patients with <20 mmol/L (glutamine, 24.1% vs placebo, 25.0%; P = .938). Citrulline concentration was reduced during RT with placebo but remained unchanged with glutamine. Conclusion: Glutamine does not prevent the development of enteritis during RT.     

Supplemental Parenteral Vitamin E Into Conventional Soybean Lipid Emulsion Does Not Prevent Parenteral Nutrition–Associated Liver Disease in Full‐Term Neonatal Piglets

Background: Parenteral nutrition–associated liver disease (PNALD) continues to cause morbidity and mortality for neonates with intestinal failure. Lipid peroxidation is one potential etiological factor. This study was designed to test if supplementing vitamin E into conventional soy‐based lipid would reduce the risk of PNALD. Methods: Sixteen piglets, aged 2–5 days and weighing 1.8–2.5 kg, were randomized to parenteral nutrition (PN) with soy lipid (SO, n = 8) or the same lipid plus α‐tocopherol, the most bioactive form of vitamin E (SO+E, n = 8). After 17 days, bile flow, liver chemistry, gene expression associated with bile acid metabolism, and bile acid composition were assessed. C‐reactive protein (CRP) and oxidative stress markers, including plasma 8‐isoprostane, were measured. All results were compared with a sow‐reared control group (CON). Results: Comparing PN‐treated groups, SO vs SO+E mean bile flow (5.91 vs 5.54 µL/g liver; P = .83), serum bile acid concentration (39.2 vs 26.6 µmol/L; P = .12), and total bilirubin (35.2 vs 26.9 µmol/L; P = .56) were not different. Gene expression related to bile acid metabolism and bile composition was not different between PN groups. There was no difference in CRP (41.8 vs 36.8 µg/mL; P = .22) or in plasma 8‐isoprostane (27.9 vs 26.1 pg/mL; P = .77). Conclusions: In term neonatal piglets, supplemental vitamin E did not prevent cholestasis. Additional vitamin E was not associated with reduced inflammation or oxidative stress. The benefit of supplementing vitamin E into conventional lipid, vs adding fish oil, to prevent early onset of PNALD requires further clarification.     

“Cool” Topic: Feeding During Moderate Hypothermia After Intracranial Hemorrhage

Background: Therapeutic moderate hypothermia (MH; T_core 33°C–34°C) is being studied for treatment of spontaneous intracerebral hemorrhage (ICH). Nutrition assessment begins with accurate basal metabolic rate (BMR) determination. Although early enteral nutrition (EN) is associated with improved outcomes, it is often deferred until rewarming. We sought to determine the accuracy of predictive BMR equations and the safety and tolerance of EN during MH after ICH. Materials and Methods: Patients were randomized to 72 hours of MH or normothermia (NT; T_core 36°C–37°C). Harris‐Benedict (BMR‐HB) and Penn‐State equation (BMR‐PS) calculations were compared with indirect calorimetry (IC) at day (D) 0 and D1–3. Patients with MH received trophic semi‐elemental gastric EN. Occurrences of feeding intolerance, gastrointestinal (GI)–related adverse events, and ventilator‐associated pneumonia (VAP) were analyzed with a double‐sided matched pairs t test. Results: Thirteen patients with ICH participated (6 MH, 7 NT). Mean time to initiate EN: 29.9 (MH) vs 18.4 (NT) hours (P = .046). Average daily EN calories received D0–3: 398 (MH) vs 1006 (NT) (P < .01). Three patients with MH experienced high gastric residuals prior to prokinetic agents, 1 had mild ileus, and 1 patient with NT vomited. No GI‐related adverse events were reported. One patient with MH and 1 patient with NT had VAP. Two patients with MH received IC, and from D0 to D1–3, BMR‐HB remained stable (1331 kcal), BMR‐PS decreased (1511 vs 1145 kcal, P = .5), and IC decreased (1413 vs 985 kcal, P = .2). Conclusions: In patients with ICH undergoing MH, resting energy expenditure is decreased and predictive equations overestimate BMR. EN is feasible, although delayed EN initiation, high gastric residuals, and less EN provision are common. Future studies should focus on EN initiation within 24 hours, advanced EN rates, and postpyloric feeds during hypothermia.     

Mixture of Arginine,Glutamine, and β‐hydroxy‐β‐methyl Butyrate Enhances the Healing of Ischemic Wounds in Rats

Background: This study investigated the effects of an amino acid mixture containing arginine, glutamine, and β‐hydroxy‐β‐methyl butyrate on secondary healing of ischemic wounds in a rat model (N = 18). Methods: After the formation of a bipediculated flap on each rat, 2 full‐thickness excisional skin wounds (2 × 2 cm) were created on every flap. The rats were then randomized into the control and treatment groups. Every rat received standardized rat food throughout the study. The rats in the treatment group were administered an extra 200 mg/kg of L‐arginine, 200 mg/kg of L‐glutamine, and 40 mg/kg of β‐hydroxy‐β‐methyl butyrate per day. Wound sizes were measured on days 0, 4, 10, and 14. The rats were sacrificed, and the wounds were excised for biochemical and histologic examination on the 14th day. Results: As compared with the control group, the treatment group's wound sizes were significantly smaller on days 10 and 14 (P < .001), as was its inflammatory cell accumulation score (P = .008). There was no significant difference between the 2 groups in collagen accumulation (P = .340), granulation tissue maturation (P = .161), angiogenesis (P = .387), or reepithelialization (P = .190) and no significant difference between hydroxyproline concentrations in wounds (P = .287). Discussion: This amino acid combination seems to have a positive impact on the secondary healing of experimental ischemic wounds when introduced as a supplement to the standard diet, and the reduction in the inflammatory process appears to play a role in this effect.     

Effects of Lactose‐Containing vs Lactose‐Free Infant Formula on Postprandial Superior Mesenteric Artery Flow in Term Infants

Background: Dietary dextrose and fructose may promote vascular inflammation and endothelial dysfunction. In certain infant populations, altered postprandial mesenteric hyperemia (PPH) may increase risk for feeding intolerance. Objective: To compare superior mesenteric artery (SMA) PPH following feeds of lactose‐containing (LC) formula vs lactose‐free (LF; dextrose + sucrose) formula. Methods: In a 2 × 2 crossover study with 6 term newborns, 3 received LC first followed by LF 3 hours later. The remaining 3 received the reverse order. Ultrasound measures of pre‐ and postprandial SMA flow, diameter, and resistance were taken 5 minutes preprandial and 10, 30, and 40 minutes postprandial. Results: Mean ± SD age and weight (n = 6) were 24.1 ± 2.3 hours and 3.1 ± 0.21 kg. Formula intake was similar for LC and LF (22.5 ± 2.8 mL and 25 ± 1.8 mL, respectively; P = .076). Both formulas increased SMA flow at 10 and 30 minutes. However, postprandial flow was greater for LC overall (P = .004) and especially at 30 minutes (LC 103 mL/min, 52% increase vs LF 92.7 mL/min, 31% increase; P = .014). For both formulas, vasodilation was seen at 10 and 30 minutes and was overall significantly greater following LC than following LF (9.1% vs 6.5%; P = .028). Both formulas elicited significant decreases in SMA vascular resistance over the 10‐ to 30‐minute period (overall P = .016). However, decreases did not differ across formulas (P = .672). Conclusions: The LC formula elicited a greater SMA PPH response than did LF. SMA flow for both formulas was within normal limits; thus, differences are likely inconsequential for a term newborn. However, in a vulnerable preterm infant, differences may become significant.     

Effects of a Carbohydrate‐, Glutamine‐, and Antioxidant‐Enriched Oral Nutrition Supplement on Major Surgery‐Induced Insulin Resistance: A Randomized Pilot Study

Background: Insulin resistance after surgery hampers recovery. Oxidative stress is shown to be involved in the occurrence of postoperative insulin resistance. Preoperative carbohydrate‐rich oral nutrition supplements reduce but do not prevent insulin resistance. The aim of the present study was to investigate the effect of a carbohydrate‐, glutamine‐, and antioxidant‐enriched preoperative oral nutrition supplement on postoperative insulin resistance. Methods: A double‐blind randomized controlled pilot study in 18 patients with rectal cancer, who received either the supplement (S) or the placebo (P) 15, 11, and 4 hours preoperatively, was conducted. Insulin sensitivity was studied prior to surgery and on the first postoperative day using a hyperinsulinemic euglycemic 2‐step clamp. Results: Hepatic insulin sensitivity (insulin‐mediated suppression of glucose production) decreased significantly after surgery in both groups, with no differences between the groups. Peripheral insulin sensitivity (glucose rate of disappearance, Rd) was significantly decreased after surgery in both groups (S: 37.2 [19.1–50.9] vs 20.6 [13.9–27.9]; P: 23.8 [15.7–35.5] vs 15.3 [12.6–19.1] µmol/kg·min) but less pronounced in the supplemented group (P = .04). The percentage decrease in glucose Rd did not differ between the groups. Adipose tissue insulin sensitivity (insulin‐mediated suppression of plasma free fatty acids) decreased to the same extent after surgery in both groups. Conclusion: Rectal cancer surgery induced profound insulin resistance, affecting glucose and fatty acid metabolism. The preoperative nutrition supplement somewhat attenuated but did not prevent postoperative peripheral insulin resistance.     

Hepatic Indicators of Oxidative Stress and Tissue Damage Accompanied by Systemic Inflammation in Rats Following a 24‐Hour Infusion of an Unstable Lipid Emulsion Admixture

Background: Use of lipid emulsions in parenteral nutrition therapy is an important source of daily energy in substitution of potentially harmful glucose calories when given in excess in the intensive care unit. When added to parenteral nutrition (PN) admixtures as a total nutrient admixture (TNA), the stability and safety of the emulsion may be compromised. Development of a rat model of a stable vs unstable lipid infusion would enable a study of the potential risk. Design: Prospective, randomized, controlled study. Methods: Surgical placement of a jugular venous catheter for the administration of TNAs was performed. Two groups were studied: a stable or s‐TNA (n = 16) and an unstable or u‐TNA (n = 17) as a 24‐hour continuous infusion. Stability of TNAs was determined immediately before and after infusion using a laser‐based method approved by the United States Pharmacopeia. Results: Blood levels of aspartate aminotransferase, glutathione‐S‐transferase, and C‐reactive protein were significantly elevated in u‐TNA vs s‐TNA (P < .05). Also, liver tissue concentrations of malondialdehyde were significantly higher in the u‐TNA group (P < .05), and triglyceride tissue levels were also higher in u‐TNA and approached statistical significance (P = .077). Conclusions: Unstable lipid infusions over 24 hours produce evidence of hepatic accumulation of fat associated with oxidative stress, liver injury, and a low‐level systemic inflammatory response.     

Fat‐Modified Enteral Formula Improves Feeding Tolerance in Critically Ill Patients: A Multicenter,Single‐Blind,Randomized Controlled Trial

Background: Improvement of fat digestion and absorption was supposed to relieve feeding intolerance. This trial aimed to evaluate the effect of a fat‐modified enteral formula on feeding tolerance in critically ill patients. Materials and Methods: This trial was conducted in 7 hospitals in China. In total, 144 intensive care unit (ICU) patients with estimated need of enteral nutrition (EN) for at least 5 days were randomly given fat‐modified enteral formula containing medium‐chain triglycerides (MCT), carnitine, and taurine (interventional feed group, n = 71) or standard enteral formula (control feed group, n = 73). EN intake, feeding intolerance (diarrhea, vomiting, gastric retention, and abdominal distension) and outcomes (mechanical ventilator‐free days of 28 days, length of ICU stay, length of hospital stay, and in‐hospital mortality) were collected. Results: Daily calories and protein intake were increased in the interventional feed group compared with the control feed group (P < .01). Total incidence of feeding intolerance was 42.3% in the interventional feed group and 65.7% in the control feed group (P < .001). Daily incidence of feeding intolerance was 11.3%, 18.3%, 14.1%, 25.4%, and 26.1% in the interventional feed group and 31.5%, 32.9%, 34.2%, 34.2%, and 30.4% in the control feed group from study days 1–5 (P = .0083). Incidence of feeding intolerance without abdominal distention was 32.9% in the interventional feed group and 49.3% in the control feed group (P = .047), while the incidence of abdominal distension was 26.8% in the interventional feed group and 43.8% in the control feed group (P = .03). No significant differences existed in outcomes between the 2 groups. Conclusions: The fat‐modified enteral formula containing MCT, carnitine, and taurine may improve feeding tolerance in critically ill patients.     

Hospital Readmissions for Catheter‐Related Bloodstream Infection and Use of Ethanol Lock Therapy

Background: Catheter‐related bloodstream infection (CRBSI) is the most serious long‐term infectious complication of long‐term home parenteral nutrition (PN). Ethanol is being used more commonly as a catheter locking solution in the home PN setting for prevention of CRBSI; however, no current literature reports the use of ethanol lock (ETL) in skilled nursing facility (SNF) patients. Methods: The authors evaluated the number of hospital readmissions for CRBSI and length of stay between SNF (not receiving ETL) and home patients (receiving or not receiving ETL) receiving PN or intravenous fluid therapy. Results: SNF patients had a significantly longer length of stay (LOS) for CRBSI hospital admissions compared with patients receiving PN at home with or without ETL (P < .001; 16 vs 8 vs 8 days). There was no LOS difference for CRBSI between home patients with or without ETL. Home PN patients not receiving ETL were more likely to have a CRBSI from Staphylococcus sp (48% vs 27%; P = .015), whereas SNF PN patients not receiving ETL were more likely to have a CRBSI from Enterococcus sp (16% vs 3%; P = .004). Conclusion: Despite different causative organisms and medical acuity likely affecting the differences observed in LOS, the SNF population is another setting ETL can be used to prevent CRBSI.     

The diet quality of adult women participating in a behavioural weight‐loss programme

Background: Diet quality plays an important role in health and has been shown to impact the risk of heart disease and certain cancers. The present study aimed to examine baseline and 16‐week follow‐up levels of energy intake, energy density and diet quality, as measured by the Healthy Eating Index 2005 (HEI‐2005), in overweight and obese women participating in a behavioural weight‐loss programme. Methods: Sixty‐six women [mean (SD) age 48.6 (10.8) years; body mass index 31.8 (3.7) kg m^?2; 92% Caucasian] completed dietary measures at baseline and follow‐up. All participants received a 16‐week Internet Behavioural weight‐loss programme based on the core of the Diabetes Prevention Program. Dietary intake was measured using the 2005 Block food frequency questionnaire. Diet quality was calculated using the HEI‐2005. Paired t‐tests were used to determine changes over time. Results: There was a reduction in reported energy intake [7.867 (3.232) MJ versus 5.748 (1.775) MJ, P < 0.001] over the 16 weeks. Participants had an increase in diet quality [HEI score = 53.9 (9.9) versus 57.4 (10.6), P = 0.002] as well as a reduction in energy density [0.0088 (0.0021) MJ g^?1 to 0.0080 (0.0021) MJ g^?1 (P = 0.002)]. All micronutrient intakes decreased over the 16 weeks. Conclusions: Participation in a 16‐week behavioural weight‐loss programme significantly improved diet quality and reduced dietary energy density and energy intake in adult women. However, despite the overall increase in diet quality score, there were deficiencies in key micronutrients in the diets of most women at the conclusion of the 16‐week study.