Satomi Ichimaru

Changes of energy metabolism, nutritional status and serum cytokine levels in patients with Crohn’s disease after anti-tumor necrosis factor-α therapy

We investigated the effects of treatment with antibodies against tumor necrosis factor (TNF)-α on energy metabolism, nutritional status, serum cytokine levels in patients with Crohn’s disease (CD). Twelve patients were enrolled. Resting energy expenditure (REE) levels were measured by indirect calorimetry. Crohn’s disease activity index (CDAI) significantly decreased after treatment with anti-TNF-α therapy. Anti-TNF-α therapy did not affect REE, but respiratory quotient (RQ) significantly increased after treatment. Serum interleukin-6 levels were significantly decreased and RQ were significantly increased in high REE (≥25 kcal/kg/day) group as compared to low REE (<25 kcal/kg/day) group. In conclusion, high REE value on admission is a predictive factor for good response to treatment with anti-TNF-α antibodies in active CD patients.

Determinant factors of the viscosity of enteral formulas: basic analysis of thickened enteral formulas.

BACKGROUND Thickened enteral formula (TEF), which is made by adding thickener to enteral formula, has been used mainly in Japan to reduce the incidence of clinical complications associated with enteral nutrition. However, the optimal viscosity of TEF needed to achieve a high efficiency is different for each medical complication and for individual patients. METHODS The viscosity of TEF, which consists of enteral formula and thickener, was determined by 5 factors: (1) formula energy density, (2) formula temperature, (3) stirring speed, (4) stirring time, and (5) time elapsed since preparation. Then, the changing index (CI) was calculated for each of the 5 factors to determine which exerts the most influence on TEF viscosities. RESULTS The most influential factor (CI ≥-50%) for the decrease in TEF viscosity was formula energy density. In contrast, the most influential factors (CI ≥50%) for the increase in TEF viscosity were stirring time and time elapsed since preparation. CONCLUSION The results of this study indicate that formula energy density, stirring time, and time elapsed since preparation are the most influential factors to consider during manipulation of TEF viscosity.

Intestinal Starvation is Associated with Diarrhea in Older Adult Patients after Percutaneous Endoscopic Gastrostomy(PEG) Creation

Intestinal Starvation is Associated with Diarrhea in Older Adult Patients after Percutaneous Endoscopic Gastrostomy (PEG) Creation Percutaneous endoscopic gastrostomy (PEG) creation is generally recognized to be an easier and safer procedure for creating an enteral route than the open surgery procedure for nutritional supports. However, all enteral nutrition support is associated with gastro-intestinal-related complications such as diarrhea and constipation. Here, we clarified the prevalence of diarrhea and constipation after PEG insertion as less invasive procedure in an older adult (>60 years old) population and determined factors which influence it.

The application of a feeding protocol in older patients fed through percutaneous endoscopic gastrostomy tubes by the intermittent or bolus methods: a single-center, retrospective chart review

BACKGROUND While previous studies have reported that feeding protocols improved clinical outcomes in critical care settings, the evidence supporting the application of feeding protocols in older patients has not yet been assessed. Here, we evaluated the effects of a feeding protocol in older patients fed through percutaneous endoscopic gastrostomy (PEG) tubes. METHODS We conducted a retrospective chart review of 109 patients aged >=65 who underwent PEG placement between April 2010 and March 2012 at a single acute care hospital. The protocol group was administered enteral nutrition (EN) according to a feeding protocol, while the non-protocol group was administered EN at the attending physicians discretion. RESULTS Length of hospital stay (LOS) overall and after EN initiation were significantly shorter in the protocol group than in the non-protocol group. (LOS: p=0.001; LOS after EN initiation: p=0.026). During the second week after EN initiation, significantly fewer patients had percutaneous oxygen saturation (SpO2) <93% and required oxygen therapy in the protocol group (p=0.032 for both comparisons). Nutrition intakes via PEG in the protocol group were significantly greater from Days 6 to 13 for energy and from Days 6 to 11 for protein compared with the non-protocol group. CONCLUSION The application of a feeding protocol after PEG placement in older patients was associated with shorter LOS, more efficient EN delivery, and lower incidence of low SpO2 than non-protocol group. Larger prospective studies are required to determine whether a feeding protocol is useful in improving health outcomes in this population.

Which Is More Effective to Prevent Enteral Nutrition–Related Complications, High- or Medium-Viscosity Thickened Enteral Formula in Patients With Percutaneous Endoscopic Gastrostomy? A Single-Center Retrospective Chart Review

BACKGROUND Administration of thickened enteral formula (TEF) through a percutaneous endoscopic gastrostomy (PEG) tube is becoming a common practice in Japan to prevent enteral nutrition (EN)-related complications. However, what constitutes an adequate viscosity of TEF remains unclear. The aim of this study was to examine the clinical effects of TEFs with different viscosities administered through PEG. METHODS The subjects were 50 patients admitted to a single institution who underwent PEG placement. Viscosities of TEFs frequently administered to the patients were measured, and EN-related complications, nutrition intakes, and clinical outcomes were compared between high- and medium-viscosity TEFs during the first 2 weeks after TEF feeding initiation. RESULTS The measured viscosities of high- and medium-viscosity TEFs were 10,382 ± 931 and 3492 ± 296 mPa·s, respectively. Protein and fluid intakes with TEF were significantly less in the high-viscosity group. There was no significant difference in EN-related complications, energy intakes, or clinical outcomes between high- and medium-viscosity TEFs. CONCLUSION In this study, high-viscosity TEFs showed no statistical difference in either EN-related complications or clinical outcomes, in comparison with medium-viscosity TEF.

Low Energy Intake During the First Week in an Emergency Intensive Care Unit Is Associated With Reduced Duration of Mechanical Ventilation in Critically Ill, Underweight Patients A Single-Center Retrospective Chart Review

BACKGROUND Although nutrition support is essential in intensive care units, optimal energy intake remains unclear. Here, we assessed the influence of energy intake on outcomes of critically ill, underweight patients. METHODS A retrospective chart review was conducted in patients with body mass index (BMI) of <20.0 kg/m(2) in an emergency intensive care unit (EICU). Patients were categorized into 4 groups by initial Sequential Organ Failure Assessment score (I-SOFA) and average daily energy intake during the first week: group M-1, I-SOFA ≤8 and <16 kcal/kg/d; group M-2, I-SOFA ≤8 and ≥16 kcal/kg/d; group S-1, I-SOFA >8 and <16 kcal/kg/d; and group S-2, I-SOFA >8 and ≥16 kcal/kg/d. RESULTS The study included 51 patients with a median age of 69 years. No significant differences were noted in all-cause mortality and length of stay in the EICU and hospital between groups M-1 and M-2 or groups S-1 and S-2. The mechanical ventilation duration (MVD) was significantly shorter in group M-1 than M-2 (2.7 [1.0-5.7] vs 9.2 [4.2-17.4] days; P = .040) and in group S-1 than S-2 (3.1 [0.7-6.0] vs 8.8 [6.1-23.1] days; P = .006). The number of patients who underwent tracheostomy in hospital was significantly lower in group S-1 than in S-2 (20% vs 32%; P = .002). Multivariable analyses to adjust for confounders revealed that average energy intake during the first week in EICU was a significant factor independently associated with MVD but not with the requirement of tracheostomy. CONCLUSION Reduced energy intake during the first week in EICU was associated with a reduced MVD in clinically ill patients with BMI <20.0 kg/m(2).

Methods of Enteral Nutrition Administration in Critically Ill Patients: Continuous, Cyclic, Intermittent, and Bolus Feeding

There are several methods of enteral nutrition (EN) administration, including continuous, cyclic, intermittent, and bolus techniques, which can be used either alone or in combination. Continuous feeding involves hourly administration of EN over 24 hours assisted by a feeding pump; cyclic feeding involves administration of EN over a time period of <24 hours generally assisted by a feeding pump; intermittent feeding involves administration of EN over 20-60 minutes every 4-6 hours via pump assist or gravity assist; and bolus feeding involves administration of EN over a 4- to 10-minute period using a syringe or gravity drip. In practice, pump-assisted continuous feeding is generally acceptable for critically ill patients to prevent EN-related complications. However, a limited number of studies have been conducted to support this practice. In addition, regarding muscle protein synthesis and gastrointestinal hormone secretion, intermittent or bolus feeding may be more beneficial than continuous EN feeding for critically ill patients. For medically stable patients with feeding tubes terminating in the stomach, bolus feeding is favored with respect to practical factors, such as cost, convenience, and patient mobility. However, few studies have shown whether intermittent or bolus feeding is beneficial in a critical care setting at present. Additional randomized controlled studies comparing intermittent with bolus feeding are required.