全肠外营养相关肠黏膜免疫屏障损伤小鼠模型的建立

目的:建立一种稳定有效的小鼠模型,为进一步研究全肠外营养(TPN)相关肠黏膜屏障损伤的机制和干预措施。方法:将22只小鼠随机分为对照组(n=10)和TPN组(n=12)。小鼠经颈内静脉置管后,对照组给予正常饮食,用微量泵持续输注等渗盐水;TPN组给予禁食后用微量泵持续输注PN液。5 d后比较两组小鼠生存率、肠道菌群易位情况、肠道杯状细胞数量以及潘氏细胞变化。结果:两组小鼠的生存率无显著性差异。TPN组肠道菌群淋巴结易位率增加(6/10 vs 1/10,P0.05),杯状细胞数量减少[(61.6±6.5)个vs(33.0±7.8)个,P0.01)],隐窝处潘氏细胞内抗菌多肽颗粒明显减少,溶菌酶和黏蛋白2(MUC2)含量显著降低。结论:TPN组小鼠能作为后期研究TPN诱导肠黏膜免疫屏障受损的模型,用于患病机制、药物治疗的观察和研究。     

含鱼油脂肪乳剂在儿童肠外营养相关性肝病的临床应用进展

肠外营养相关性肝病(PNALD)是长期肠外营养(PN)支持导致的肝损害性疾病.尽早肠道喂养替代PN是有效的防治方法,但对无法脱离PN的肠衰竭病儿,脂肪乳剂剂量及类型的选择是防治的关键之一.近年来,许多研究发现,含鱼油脂肪乳剂(FO LE)具有改善甚至逆转PNALD的作用.现对FOLE在儿童PNALD临床研究进展作一综述.     

谷胱甘肽防止幼兔全胃肠外营养所致肝损害

目的研究氧化损伤及凋亡在全胃肠外营养(TPN)相关肝损害机制中的作用,并探讨谷胱甘肽防止TPN相关肝损害的有效性。方法将35只出生后6～8天的新西兰兔分为3组:正常对照组(n=12,母乳喂养);PN组(n=12,全肠外营养组,持续静脉营养10天);PN+GSH组(n=11,全肠外营养+还原型谷胱甘肽20mg/kg·d)。10天后比较3组间肝功能、肝脏光镜和电镜病理变化、TUNEL法检测肝细胞凋亡以及肝组织丙二醛(MDA)含量。结果PN组血直接胆红素、胆汁酸均明显高于正常对照组和PN+GSH组(P<0.05)。PN+GSH组病理无胆管扩张和胆汁淤积表现,电镜超微结构变化与病理相符。PN组肝组织MDA含量及肝细胞凋亡阳性率明显高于对照组和PN+GSH组(P<0.05,P<0.01)。结论氧化损伤及凋亡在TPN相关肝损害机制中可能起着重要作用;谷胱甘肽可明显减轻TPN所致肝细胞损害,可能与其抗氧化、抗凋亡作用有关。     

小剂量红霉素对极低出生体重儿胃肠外营养相关性胆汁淤积症防治作用

目的:探讨小剂量红霉素对极低出生体重儿(VLBW)胃肠外静脉营养相关性胆汁淤积症(PNAC)防治作用。方法:收集自2007年10月～2010年10月入住新生儿科重症监护病房极低出生体重儿,随机分为观察组和对照组,观察组入院即常规治疗基础上给予红霉素5 mg.kg-1.d-1静滴治疗,连用7～10 d。比较两组间PNAC发生率、PNAC危险因素的差异。结果:①观察组PN持续时间(19.3±2.3)d、住院时间(31.2±3.3)d,少于对照组〔(22.7±3.4)d,(35.2±3.7)d〕,两组比较有显著差异(P<0.05)。观察组发生喂养不耐受5例(14.3%),而对照组15例(42.9%),两组差异有统计学意义(P<0.05);②观察组发生胆汁淤积1例(2.86%),对照组发生胆汁淤积6例(17.10%),两组差异有统计学意义(P<0.05);③观察组患儿第21天血清结合胆红素、谷丙转氨酶水平较对照组低,但差异无统计学意义(P>0.05)。结论:小剂量红霉素降低喂养不耐受的发生,尽早建立完全胃肠道喂养,减少PN持续时间,减少PN用量,可降低极低出生体重儿PNAC的危险因素,降低PNAC发生率,因此对PNAC的发生有预防作用。同时,研究未观察到药物不良反应。     

富含n-3多不饱和脂肪酸的肠外营养对脓毒症大鼠T淋巴细胞亚群和炎性因子的影响

目的:探讨富含n-3多不饱和脂肪酸(PUFA)的肠外营养(PN)对脓毒症大鼠外周血T淋巴细胞亚群和血清炎性因子的影响。方法:将36只大鼠随机分为四组,颈静脉置管术2 d后行盲肠结扎穿孔术或假手术,1对照组:给予自由饮食;2NS组:给予等渗盐水输注+自由饮食;3SO组:给予富含豆油的标准肠外营养(PN)液;4FO组:给予富含PUFA的PN液。脓毒症5 d后,检测IL-6、IL-10和T细胞亚群等。结果:脓毒症5 d后,FO组大鼠外周血CD3+、CD4+、CD4+/CD8+与NS组和SO组比有所升高,但较对照组大鼠下降;与NS组大鼠比,FO组血清IL-6、IL-10、外周血Tregs比例有所下降。结论:应用富含n-3 PUFA的PN可降低脓毒症大鼠血清炎性因子和调控外周血T淋巴细胞亚群。     

长期肠外营养与胆汁淤积症相关因素的临床分析

目的:分析危重症新生儿肠外营养(PN)相关性胆汁淤积症(PNAC)的临床特点及影响因素,探讨其预后.方法:在我院接受PN治疗时间超过2周的婴儿64例,其中发生PNAC 15例(PNAC组)和未发生PNAC(对照组)49例.所有病儿均明确原基础疾病治疗恢复情况以及PN实施情况,特别是在PN期间有无肠道喂养以及何时开始喂养等,计算每天PN补充热量及各种营养成分.对发生胆汁淤积症病儿均进行常规保肝、利胆治疗2～4周,期间每周监测血生化、肝功能,并监测经皮胆红素.治疗结束后根据情况每2～4周复查肝功能和血生化及肝B超.所有病儿均随访至6个月.结果:①本组PNAC总发生率为23.4%.PNAC组中,体质量＜2000g者占80.0%;而对照组中占42.9%,两组比较有显著性差异(P＜0.05).②PN第1周内完全禁食者,PNAC组为80.0%,对照组为22.4%,两组比较有显著性差异(P＜0.05).③PNAC组中预后良好者为73.3%,而对照组为95.9%,两组比较有显著性差异(P＜0.05).结论:新生儿长期PN相关性胆汁淤积症的发生与否,与病儿出生时体质量、PN过程中是否尽早进行胃肠内营养密切相关.     

肠内与肠外营养对住院患者营养状况影响的研究

目的:比较肠内营养(EN)与肠外营养(PN)对住院患者营养状况的影响。方法:回顾性调查并比较北京和上海6所综合性医院的胃肠外科、心胸外科、消化内科、呼吸内科、神经内科、神经外科和重症监护病房接受EN或PN的1142例住院患者在营养支持前后体重(BW)、血红蛋白(Hb)和血清白蛋白(sALB)的变化。结果:两组BW、Hb及sALB在营养支持后均显著降低,EN组BW和sALB的下降差值显著低于PN组(BW:-1.58±2.36kgvs-2.09±2.66kg,P<0.002;sALB:-2.10±4.13g/Lvs-3.03±4.04g/L,P<0.001),而Hb的变化没有显著性意义。EN组低体重指数(BMI)和低白蛋白血症的患病率在支持后较PN组显著地降低(低体重指数:11.63%vs17.90%,P<0.01;低白蛋白血症:20.51%vs26.24%,P<0.01)。贫血的患病率在EN或PN后均增高,两组间差异无显著性意义。结论:与PN比较,EN在减少体重丢失和减少血清白蛋白降低方面,以及在改善住院患者营养不良患病率方面疗效基本一致或稍好。     

脂肪乳剂在极低出生体重儿早期肠外营养中的作用

目的:探讨早期肠外营养(EPN)对极低出生体重儿(VLBW)体重增长的影响和不良反应发生情况。方法:将体重1 500 g的极低体重儿随机分为治疗组(40例)和对照组(38例)。治疗组病儿出生后24 h即应用含脂肪乳的PN,并辅以少量的胃肠道喂养和非营养性吸吮。对照组应用不含脂肪乳的PN,其他同治疗组。10 d后,检测体重变化、相关生化指标和并发症情况。结果:治疗组病儿每天体重增长幅度明显高于对照组,未增加病儿患氮质血症、高胆红素和胆汁淤积等的危险性。两组病儿并发症的发生率无显著性差异(P0.05)。结论:应用脂肪乳剂EPN,能缩短病儿平均住院时间,促进体重增长。     

肠内营养对胃癌患者术后肠黏膜屏障功能的影响

目的 探讨胃癌患者术后早期施行肠内营养(EN)支持对胃肠道黏膜屏障功能的影响.方法 58例患者被随机分为EN组和肠外营养(PN)组,两组营养支持均等热量、等氮量,EN组于术后第1天开始由鼻肠管内输注营养液,PN组经静脉输注营养液,于术前1 d及术后第7天测定两组患者尿乳果糖与甘露醇的比值(L/M)、血浆内毒素、肿瘤坏死因子(TNF)及IgA.结果 术后第7天,EN组L/M、血浆内毒素、TNF、IgA分别为0.08±0.03、(0.49±0.12)EU/ml、(39.40±4.62)μg/ml、(2.65±0.07)g/L,PN组分别为0.24±0.05、(0.55±0.12)EU/ml、(43.01±8.12)μg/ml、(2.17±0.10)g/L,两组比较差异有统计学意义(P＜0.01或P＜0.05).结论 胃癌患者术后早期EN对肠黏膜屏障功能具有一定的保护作用.     

肠外肠内营养支持用于溃疡性结肠炎的效果

目的 探讨肠外营养(PN)及肠内营养(EN)支持对溃疡性结肠炎的效果.方法 本前瞻性研究选取2012年1月至2013年9月本科收治的112例溃疡性结肠炎患者,采用随机数字表法分为PN+ EN组(n=56)及对照组(n=56).两组均接受4周溃肠性结肠炎药物治疗,4周后比较两组的治疗效果及治疗前后的Mayo评分、总蛋白、白蛋白、前白蛋白和体重指数.结果 PN+ EN组营养支持4周后总有效率显著高于对照组(83.93％比48.21％,P=0.00),Mayo评分显著低于对照组(3.11 ±0.46比7.46 ±0.88,P=0.00).与对照组比较,PN+ EN组营养支持后总蛋白[(65.32±6.78) g/L比(59.81 ±6.98) g/L,P=0.00]、白蛋白[(36.20 ±6.89) g/L比(29.20 ±5.79) g/L,P=0.01]、前白蛋白[(267.23±63.48) g/L比(245.38±57.39) g/L,P=0.000]、体质量指数[(23.45±3.02) kg/m2比(21.34±3.07) kg/m2,P=0.04]均显著升高.结论 对溃疡结肠炎患者进行PN+ EN支持可提高临床治疗效果,降低溃疡性结肠炎活动性,并显著改善患者的营养状况.     

营养环境与人群营养素摄入水平的相关性

完善了营养环境的概念及指标，提出可以用线性规划建立的数学模型计算营养环境的指标，即由该模型得出的营养素的理论达标率和营养素的边际成本。用天津１９８９年的营养素的理论达标率和１９８８年天津人群的营养素实际达标率进行线性回归分析，得出回归方程：实际达标率（％）Ｙ＝１５．１５（％）＋０．７８８Ｘ（Ｘ为理论达标率，％），其相关性显著（Ｒ＝０．９８６，Ｐ＜０．００１）；还发现天津营养环境中脂肪、动物性蛋白质的边际成本大于零。讨论了上述方程的意义，营养环境与营养干预的关系。认为，改善食物的营养素含量、降低价格、增加营养素含量丰富的食物品种的营养干预措施，效果较好。     

The enteral vs parenteral nutrition debate revisited

Many trials and several meta-analyses have been devoted to comparing enteral with parenteral nutrition support. In this review, these studies are subjected to critical analysis with particular emphasis on their methodology and clinical relevance. Evidence is produced to suggest that the heterogeneous patient populations of the studies and the rigid approach taken to comparing different nutrition therapies inter alia render their conclusions highly questionable and of very doubtful clinical significance. An alternative approach to nutrition research is suggested in which strategies of nutrition support rather than fixed menus are compared. It is suggested that objective measures of intestinal function be evaluated more fully in patients requiring nonvolitional nutrition support, and these are briefly reviewed. In addition, a more scientific approach to evaluating the physiological effects of nutrition support, including chemical tagging and evaluation of muscle function, is recommended.     

Ceramide in Lipid Emulsions Used in Parenteral Nutrition

Parenteral nutrition-associated liver disease is a prevalent and severe complication of long term parenteral nutrition. We present here for the first time data on the presence of ceramide, a bioactive compound involved in a variety of metabolic processes, in different lipid emulsions used in parenteral nutrition. Further research is needed to determine whether this potential harmful bioactive compound is involved in parenteral nutrition-associated liver disease.     

Nutrition knowledge and attitudes of New Zealand registered midwives

Aim: The importance of nutrition for a healthy pregnancy is well established. In New Zealand, the majority of women choose midwives as their maternity provider. Therefore, it is important that midwives have an understanding of nutrition issues related to pregnancy. The purpose of the present study was to determine the nutrition knowledge of New Zealand midwives, and to assess the importance they place on nutrition during pregnancy. Methods: An 18‐question postal survey was sent to all members of the New Zealand College of Midwives (n = 1340). Results: A total of 370 questionnaires were returned (response rate of 27.6%). Less than 40% of midwives reported that they had formal nutrition education; however, nearly 75% of respondents indicated that they had received nutrition information through their midwifery education. Most midwives indicated that nutrition was important or very important during pregnancy (98.4%), and that they had a significant or very significant role in educating pregnant women (94.9%) about nutrition. Midwives generally reported a high level of confidence in dealing with nutrition‐related issues. Midwives answered most of the nutrition knowledge questions correctly. However, 64.6% of midwives (n = 369) incorrectly identified spirulina as a good source of iron for vegetarians, 28.1% (n = 104) incorrectly answered that maternal intake of cabbage and beans are often responsible for colic in breastfed infants, and 40.0% (n = 128) incorrectly answered that to reduce food allergies all lactating women should avoid peanuts and shellfish. Conclusion: Overall, midwives were knowledgeable on nutrition issues related to pregnancy and reported a high level of confidence on educating women about nutrition.     

Practice Analysis of Nutrition Support Professionals

Background: The National Board of Nutrition Support Certification (NBNSC) is an independent credentialing board responsible for administering the multidisciplinary certification examination in nutrition support. For an exam to be legally and practically defensible, it must represent practice. Validation is by practice audit, the highest level of supporting evidence. Objectives: To define the role of the nutrition support professional (NSP) and the current elements (knowledge and functions) required for competent NSP practice. Methods: A survey instrument was constructed using a content validation strategy to establish the link between job tasks and the content of the examination. Internet‐based surveys were made available to 5100 NSPs. NSP duties performed and knowledge required for patient safety and welfare were analyzed for the group as a whole and for each profession separately. Results: A total of 765 surveys were completed (return rate of 15%). The results of the practice audit demonstrate a common core of practice across the nutrition support disciplines as well as a universal core of elements believed to be important for competent nutrition support practice. Conclusion: The results of this survey continue to support a common core of practice across nutrition support disciplines as well as a common core of elements believed to be important for competent nutrition support practice. Accordingly, the NBNSC will continue to offer one examination to all disciplines both nationally and internationally and confer the Certified Nutrition Support Clinician (CNSC) credential to all individuals who successfully pass this validated examination.     

Future Doctors' Perceptions about Incorporating Nutrition into Standard Care Practice

Objective: The increasing prevalence of chronic disease has been largely attributed to long-term poor nutrition and lifestyle choices. This study investigates the attitudes of our future physicians toward nutrition and the likelihood of incorporating nutrition principles into current treatment protocols.Methods: Setting: The setting of this study was an Australian university medical school. Subjects: Subjects including year 1–4 students (n = 928) in a 4-year medical bachelor, bachelor of surgery (MBBS) degree program. Students were invited to participate in a questionnaire based on an existing instrument, the Nutrition in Patient Care Attitude (NIPC) Questionnaire, to investigate their attitudes toward nutrition in health care practices.Results: Respondents indicated that “high risk patients should be routinely counseled on nutrition” (87%), “nutrition counseling should be routine practice” (70%), and “routine nutritional assessment and counseling should occur in general practice” (57%). However, despite overall student support of nutritional counseling (70%) and assessment (86%), students were reluctant to perform actual dietary assessments, with only 38% indicating that asking for a food diary or other measure of dietary intake was important.Conclusion: These findings demonstrate that future physicians are aware of the importance of considering nutrition counseling and assessment. However, students are unlikely to adequately integrate relevant nutritional information into their treatment protocols, evidenced by their limited use of a basic nutritional assessment. This is potentially the result of a lack of formal nutrition education within their basic training.     

Transition Phase Nutrition Recommendations: A Missing Link in the Nutrition Management of Preterm Infants

Background: Despite the availability of international nutrition recommendations, preterm infants remain vulnerable to suboptimal nutrition. The standard approach of assessing nutrient intakes chronologically may make it difficult to identify the origin of nutrient deficits and/or excesses. Objective: To develop a “nutrition phase” approach to evaluating nutrition support, enabling analysis of nutrient intakes during the period of weaning from parenteral nutrition (PN) to enteral nutrition (EN), called the transition (TN) phase, and compare the data with those analyzed using the standard “chronological age” approach to assess whether the identification of nutrient deficits and/or excesses can be improved. Methods: Analysis of a comprehensive nutrition database developed using actual nutrient intake data collected on an hourly basis in 59 preterm infants (birth weight ≤1500 g, gestation <34 weeks) over the period of PN delivery (range, 2–21 days). Results: The nutrition phase analysis approach revealed substantial macronutrient and energy deficits during the TN phase. In particular, deficits were identified as maximal during the EN‐dominant TN phase (enteral feeds ≥80 mL/kg/d) of the infant’s nutrition course. In contrast, the chronological age analysis approach did not reveal a corresponding pattern of deficit occurrence but rather intakes that approximated or exceeded recommendations. Conclusion: Actual intakes of nutrients, analyzed using a nutrition phase approach to evaluating nutrition support, enabled a more infant‐driven rather than age‐driven application of nutrition recommendations. This approach unmasked nutrient deficits occurring during the transition phase. Overcoming nutrient deficits in this nutrition phase should be prioritized to improve the nutrition management of preterm infants.