Forse Ra

Randomized phase I/II trial of a macrophage-specific immunomodulator (PGG-glucan) in high-risk surgical patients

ObjectiveThe safety and efficacy of PGG-glucan in surgical patients at high risk for postoperative infection who underwent major thoracic or abdominal surgery were determined. Summary Background DataRecent studies have reported a 25% to 27% infectious complication rate in patients undergoing major surgery with an average cost per infected patient of

L-[1-13C] phenylalanine oxidation as a measure of hepatocyte functional capacity in end-stage liver disease**

12,000. The efficacy of PGG-glucan pretreatment in prevention of sepsis has been demonstrated in rodent models for gram-negative and gram-positive bacterial and yeast infections. In vitro studies have demonstrated enhanced microbial killing by monocytes and neutrophils in healthy volunteers after PGG-glucan administration. Thus, PGG-glucan may play a role in decreasing the infectious complication rate in patients undergoing major surgery. MethodsA double-blind, placebo-controlled randomized study was performed in 34 high-risk patients undergoing major abdominal or thoracic surgery. ResultsThere were no adverse drug experiences associated with PGG-glucan infusion. Patients who received PGG-glucan had significantly fewer infectious complications (3.4 infections per infected patient vs. 1.4 infections per infected patient, p = 0.05), decreased intravenous antibiotic requirement (10.3 days vs. 0.4 days, p = 0.04) and shorter intensive care unit length of stay (3.3 days vs. 0.1 days, p = 0.03). ConclusionsPGG-glucan is safe and appears to be effective in the further reduction of the morbidity and cost of major surgery.

Sites of Conditional Essential Fatty Acid Deficiency in End Stage Liver Disease

Background Liver disease is associated with impaired metabolism of these amino acids phenylalanine and tyrosine. Decreased metabolism of these amino acids leads to abnormal plasma elevations and impaired clearance rates. We have developed a noninvasive breath test that measures hepatic cytosolic enzyme activity. Methods The rate of hepatic phenylalanine metabolism was quantitatively calculated from the appearance of 13 CO 2 in the breath using the non-radioactive tracer L-[1- 13 C]phenylalanine. Results Normal controls (n = 47) oxidized phenylalanine more than twice that of end-stage liver disease patients (n = 117). Significant differences in the percent of phenylalanine oxidized per hour (mean ± SEM) were found between controls (7.08% ± 0.33%, 95% Cl: 6.42%–7.74%) and Child Pugh classification patients, class A (4.96% ± 0.69%, 95% Cl: 3.50%–6.42%), class B (2.88% ± 0.13, 95% Cl: 2.39%–3.38%) and class C (1.75% ± 0.13, 95% Cl: 1.50%–2.01%). The phenylalanine breath test score significantly correlated with albumin levels, prothrombin time and total bilirubin. Conclusion We have demonstrated that phenylalanine oxidation is significantly decreased with end-stage liver disease and is correlated with the best clinical measures of liver disease.

Nutrition support and the human immunodeficiency virus (HIV).

BACKGROUND End stage liver disease (ESLD) is a devastating illness. Its protean manifestations involve many different aspects of disturbed hepatic function. One consequence of ESLD is a decrease in plasma levels of very long chain polyunsaturated fatty acids (VL-PUFAs), particularly arachidonic acid (AA) and docosahexaenoic acid (DHA), the former important for eicosanoid metabolism and the latter for retinal and brain membrane structure. The purpose of this study was to define the VL-PUFA changes in liver disease by comparing plasma and tissue levels of VL-PUFAs in controls to patients with ESLD. METHODS Fatty acid profiles from plasma, red blood cell (RBC) membranes, muscle, liver, and fat tissue from ESLD patients undergoing liver transplants were measured and compared with control patients undergoing elective liver resection. RESULTS Fatty acid profiles from plasma and RBC membranes showed significant decreases in AA and DHA levels in patients with ESLD compared with controls. However, there were no significant differences in tissue fatty acid composition between ESLD patients and controls. CONCLUSIONS ESLD affects the livers ability to maintain circulating levels of AA and DHA, and thereby presumably RBC membrane levels. However, solid tissues appear not to be affected by ESLD. Although the mechanism for these changes remains to be defined, it is consistent with hepatic impairment of elongation and desaturation to produce VL-PUFA for transport. The present results also suggest that dietary interventions to include preformed VL-PUFA rather than their precursors, linoleic and alpha linolenic acid, would be needed to normalize plasma VL-PUFA levels in patients with ESLD.

Nutrition support for patients after cardiopulmonary bypass: required modifications of the TPN solution.

Nutritional support of patients with HIV or acquired immune deficiency syndrome (AIDS) has many similarities to other disease states in that the same nutritional products and techniques are used. Some patients with HIV, and many with AIDS without secondary infection, experience a metabolic milieu similar to patients with cancer cachexia. In providing dietary counselling to the HIV patient, we encounter many of the obstacles that must be overcome to improve nutrition in cancer: anorexia, gastrointestinal discomfort, lethargy, and poor nutrient utilization, which limit the ability for nutritional repletion. When a secondary infection is superimposed on HIV, patients resemble more highly catabolic trauma patients or patients in the intensive care unit (ICU), where, despite aggressive efforts to feed, there is usually a net nitrogen wasting leading to the more rapid development of cachexia. However, even in this setting, feeding will limit substantially net catabolism when compared to total starvation. Because the nutritional needs of HIV patients vary greatly, individual strategies have to be designed as the patient moves through the stages of disease. Patients are generally able to consume adequate nutrition either as regular food or dietary supplements during the latency period of viral replication. Once secondary infections become prevalent, artificial diets administered by tube or by vein may be required during the period of active secondary infections, with dietary supplements often helpful during more quiescent periods. Patients with HIV are among the most challenging for clinicians providing nutritional support. Knowledge from treatment of patients with other diseases may be useful, but more data must be gathered on the unique aspects of aetiology and treatment of the anorexia, malabsorption, and ultimate wasting associated with AIDS.

Relationship between obesity and uterine leiomyomata

OBJECTIVE This study was designed to identify the unique metabolic characteristics of patients undergoing cardiopulmonary bypass (CPB) surgery who require postoperative parenteral nutrition. SUMMARY BACKGROUND DATA Patients undergoing CPB surgery occasionally develop postoperative complications that result in the need for nutrition support. Although enteral nutrition is generally the preferred feeding route, symptomatic hyperlipasemia has been described in critically ill CPB patients receiving enteral nutrition proximal to the ligament of Treitz. In such instances, enteral feeding must be temporarily discontinued or severely curtailed, thereby necessitating the initiation of parenteral nutrition for full or partial support. METHODS The period from 1988 through 1993 during which time 4091 CPB procedures were performed was reviewed. Data were retrospectively collected on 208 (5%) of the patients who underwent CPB who developed postoperative complications that necessitated the initiation of parenteral nutrition (PN) support. A random sample of 79 patients who underwent CPB who did not require PN were selected as controls. RESULTS Patients requiring PN after CPB were significantly older and had a higher prevalence of diabetes and metabolic complications, specifically volume overload, hyponatremia, metabolic alkalosis, uremia, and hyperglycemia, than those patients who did not require PN after CPB. In addition, patients requiring PN after CPB were significantly more hypotensive and required more vasopressive drugs during the first 24 to 48 hours after surgery than control patients. CONCLUSIONS In patients with postoperative complications after CPB, PN is often necessary to correct the metabolic characteristics of overhydration, hyponatremia, uremia, hyperglycemia, and alkalosis.