Parenteral Supplementation Research Articles

Glutamine supplementation to prevent morbidity and mortality in preterm infants.

Glutamine is a conditionally essential amino acid. Endogenous biosynthesis may be insufficient for tissue needs in states of metabolic stress. Evidence exists that glutamine supplementation improves clinical outcomes in critically ill adults. It has been suggested that glutamine supplementation may also benefit preterm infants. To determine the effects of glutamine supplementation on mortality and morbidity in preterm infants. We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL, 2015, Issue 12), MEDLINE, EMBASE and Maternity and Infant Care (to December 2015), conference proceedings and previous reviews. Randomised or quasi-randomised controlled trials that compared glutamine supplementation versus no glutamine supplementation in preterm infants at any time from birth to discharge from hospital. We extracted data using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by two review authors. We synthesised data using a fixed-effect model and reported typical relative risk, typical risk difference and weighted mean difference. We identified 12 randomised controlled trials in which a total of 2877 preterm infants participated. Six trials assessed enteral glutamine supplementation and six trials assessed parenteral glutamine supplementation. The trials were generally of good methodological quality. Meta-analysis did not find an effect of glutamine supplementation on mortality (typical relative risk 0.97, 95% confidence interval 0.80 to 1.17; risk difference 0.00, 95% confidence interval -0.03 to 0.02) or major neonatal morbidities including the incidence of invasive infection or necrotising enterocolitis. Three trials that assessed neurodevelopmental outcomes in children aged 18 to 24 months and beyond did not find any effects. The available trial data do not provide evidence that glutamine supplementation confers important benefits for preterm infants.

Leucine ameliorates endotoxin‐induced alterations in protein‐protein interactions within mTORC1 complex in neonatal piglets

Sepsis decreases protein synthesis in skeletalmuscle in part by limiting the phosphorylation of translation initiationregulatory factors, eukaryotic initiation factor (eIF) 4E‐binding protein (4EBP1)and S6 kinase (S6K1), that are downstream of the mammalian target of rapamycincomplex 1 (mTORC1). Previous work inmature rats suggests that decreased raptor binding activity to eIF3b mayunderline the sepsis‐induced reduction in protein synthesis in skeletal muscle. Raptor‐eIF3b interaction is crucial for thestimulation of protein translation and its alteration during endotoxemia inmature animals appears to block the anabolic response to the branched‐chainamino acid, leucine (Leu). We have shown in healthy neonatal pigs that Leu supplementation increases muscle protein synthesis by enhancing the activation of mTORC1 and its downstream targets, 4EBP1 and S6K1. To determine if supplemental Leu can stimulate raptor‐eIF3b binding and muscle protein synthesis in theneonate during endotoxemia, overnight fasted neonatal pigs (n=6–8/group) were infused for 8 h with LPS or saline while plasma amino acids, glucose, and insulin were maintained at fasting levels during pancreatic‐substrate clamps. Leu (400 μmol·kg−1·hr−1) or saline was infused during the last h. Phosphorylation of 4EBP1 and S6K1, eIF4E‐eIF4G complex formation, raptor‐eIF3b binding, protein synthesis rates, ribosomal translational capacity (Cs) and translational efficiency (KRNA) were determined in longissimus dorsi (LD), gastrocnemius (Gast) and soleus muscles. LPS decreased protein synthesis and KRNA in LD, Gast, and soleus muscles (P<0.05) while Cs did not change compared to controls. Leu infusion in the LPS group increased 4EBP1 and S6K1 phosphorylation, eIF4E‐eIF4G complex formation, KRNA, and the binding of raptor to eIF3b (by 2 to 3 fold) and protein synthesis (by over 80%) in LD, Gast, and soleus muscles compared to LPS infusion alone (P<0.05). Compared to saline, Leu infusion increased protein synthesis, KRNA, raptor‐eIF3b interaction, 4EBP1 and S6K1 phosphorylation and eIF4E·eIF4G complex formation in all muscles (P<0.05). Raptor‐eIF3b binding showed a linear correlation with 4EBP1 and S6K1 phosphorylation, eIF4E‐eIF4G formation, and protein synthesis in LD, Gast, and soleus muscles that was independent of treatment(P<0.01). These findings suggest that parenteral Leu supplementation attenuates the reduction in muscle protein synthesis induced by endotoxemia by stimulating the interaction of raptor with eIF3 within the mTORC1 complex in the neonate.Support or Funding InformationSupported by NIH AR444474, USDA/ARS 6250‐51000‐055, NIH HD072891, and USDA NIFA 2013‐67015‐20438

Effect of Parenteral Antioxidant Supplementation During the Dry Period on Postpartum Glucose Tolerance in Dairy Cows.

BackgroundExacerbated postparturient insulin resistance (IR) has been associated with several pathologic conditions in dairy cattle. Oxidative stress (OS) plays a causative role in IR in humans, and an association, but not direct relationship, between OS and IR recently has been reported in transition dairy cattle.HypothesisSupplementation with antioxidants shortly before calving improves glucose tolerance after parturition in dairy cattle.AnimalsTen late‐pregnant Holstein cows entering their 2nd to 5th lactation.MethodsRandomized placebo‐controlled trial: 15 ± 2 days before expected calving, the treatment group received an injection of DL‐alpha‐tocopheryl acetate at a dosage of 6 mg/kg body weight (BW) and 0.06 mg/kg BW of sodium selenite, and the control group was injected with isotonic saline. During the first week after calving, both groups underwent glucose tolerance testing (0.25 g glucose/kg BW). Commercial assays were used to quantify the concentrations of glucose, insulin, nonesterified fatty acids (NEFA), beta‐hydroxybutyrate, and markers of redox status in blood. Data were analyzed using the Mann–Whitney U‐test (α = 0.05).ResultsSupplemented cows showed a lower risk for OS, as reflected by a lower OS index (P = .036), different areas under the curve for the concentrations of glucose (P < .01), insulin (P = .043), and NEFA (P = .041), more rapid elimination rates (P = .080, <.01 and .047 respectively), and shorter half‐lives (P = .040, <.01 and .032) of these metabolites.Conclusions and Clinical ImportanceSupplementation with antioxidants before calving resulted in greater insulin sensitivity after calving, thereby suggesting the role of OS in the development of IR in cattle and the potential benefits of antioxidant supplementation in minimizing the consequences of negative energy balance.

Behavior of suckling pigs supplemented with an encapsulated iron oral formula

Parental iron supplementation in neonatal piglets is a routine management to solve anemia but may cause welfare problems. The aim of this study was to assess behavior responses generated after oral or parenteral iron supplementation. Parenteral supplementation consisted of 200 mg of iron dextran intramuscular. The novel oral iron supplement was a combination of encapsulated nonheme/heme iron (252 mg of total iron) delivered orally. Two litters formed by 11, 2-day-old piglets were assigned to each treatment. The litters were video recorded for 6 hours, 3 before and 3 after iron supplementation. Scan sampling every 3 minutes was used to register the occurrence of 7 behaviors. The highest overall percentage of time was allocated to resting, 46.5% (167.4 minutes) for the parenteral group and 42.4% (152.6 minutes) for the oral group; and suckling 24.6% (88.6 minutes) for the parenteral group and 27.8% (100.1 minutes) for the oral group. Resting time was higher after 1 hour of iron supplementation in the parenteral group 51.9% (31.1 minutes) vs. 33.8% (19.7 minutes). In conclusion, the oral iron supplementation resulted in a higher behavioral disruption in neonatal pigs, probably associated to increased handling time and aversive flavor of the supplement.

Glutamine metabolism in advanced age.

Glutamine, reviewed extensively in the last century, is a key substrate for the splanchnic bed in the whole body and is a nutrient of particular interest in gastrointestinal research. A marked decrease in the plasma glutamine concentration has recently been observed in neonates and adults during acute illness and stress. Although some studies in newborns have shown parenteral and enteral supplementation with glutamine to be of benefit (by decreasing proteolysis and activating the immune system), clinical trials have not demonstrated prolonged advantages such as reductions in mortality or risk of infections in adults. In addition, glutamine is not able to combat the muscle wasting associated with disease or age-related sarcopenia. Oral glutamine supplementation initiated before advanced age in rats increases gut mass and improves the villus height of mucosa, thereby preventing the gut atrophy encountered in advanced age. Enterocytes from very old rats continuously metabolize glutamine into citrulline, which allowed, for the first time, the use of citrulline as a noninvasive marker of intestinal atrophy induced by advanced age.

Response to parenteral iron therapy distinguish unexplained refractory iron deficiency anemia from iron‐refractory iron deficiency anemia

We evaluated that response to parenteral iron therapy could be helpful in distinguishing the types of iron deficiency anemia. This study analyzed responses to IV iron sucrose therapy of 15 children with unexplained refractory iron deficiency anemia (URIDA). We compared the results at diagnosis, 6 weeks and 6 months after the therapy. Results were compared with responses of 11 patients' results with iron-refractory iron deficiency anemia (IRIDA) from our previous study. Six weeks after the start of treatment, ferritin, MCV, MCH and Hb values were in normal range in 10 patients. The increase in Hb, MCH, MCV, and ferritin values ranged 2.6-3.5 g/dL, 1.7-4.2 pg, 2-9 fL, and 13-25 ng/mL, respectively. In five patients, Hb, MCH, and MCV mean (range) values [11.2 g/dL (11-12.2), 24.5 pg (24-25.6), and 67 fL (65-70)] were nearly normal but ferritin mean (range) values [9.8 ng/mL (8-11)] were below normal. Six weeks after the start of treatment, Hb, MCH, MCV and ferritin values of patients with IRIDA were increased. The increase in Hb, MCH, MCV, and ferritin values ranged 0.8-2.7 g/dL, 1.7-4.2 pg, 2-9 fL, and 13-25 ng/mL, respectively. IRIDA is only partially responsive to parenteral iron supplementation. In conclusion, this study demonstrated that the response to intravenous iron therapy for the URIDA cases improved blood parameters more effectively than hereditary IRIDA. Response to parenteral iron therapy would be helpful to distinguish unexplained refractory IDA from hereditary IRIDA for clinicians who do not have access to hepcidin or TMPRS6 mutation analysis.

Glutamine supplementation to prevent morbidity and mortality in preterm infants.

Glutamine is a conditionally essential amino acid. Endogenous biosynthesis may be insufficient for tissue needs in states of metabolic stress. Evidence exists that glutamine supplementation improves clinical outcomes in critically ill adults. It has been suggested that glutamine supplementation may also benefit preterm infants. To determine the effects of glutamine supplementation on mortality and morbidity in preterm infants. We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL, 2015, Issue 12), MEDLINE, EMBASE and Maternity and Infant Care (to December 2015), conference proceedings and previous reviews. Randomised or quasi-randomised controlled trials that compared glutamine supplementation versus no glutamine supplementation in preterm infants at any time from birth to discharge from hospital. We extracted data using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by two review authors. We synthesised data using a fixed-effect model and reported typical relative risk, typical risk difference and weighted mean difference. We identified 12 randomised controlled trials in which a total of 2877 preterm infants participated. Six trials assessed enteral glutamine supplementation and six trials assessed parenteral glutamine supplementation. The trials were generally of good methodological quality. Meta-analysis did not find an effect of glutamine supplementation on mortality (typical relative risk 0.97, 95% confidence interval 0.80 to 1.17; risk difference 0.00, 95% confidence interval -0.03 to 0.02) or major neonatal morbidities including the incidence of invasive infection or necrotising enterocolitis. Three trials that assessed neurodevelopmental outcomes in children aged 18 to 24 months and beyond did not find any effects. The available trial data do not provide evidence that glutamine supplementation confers important benefits for preterm infants.

Trace Element Supplementation Following Severe Burn Injury: A Systematic Review and Meta-Analysis.

Trace elements have an important physiological role after severe burn injury with patients routinely receiving supplementation. Although commonly prescribed after burn injury, variation exists among supplement composition, frequency, and the dosage administered. This review aims to assess the effectiveness of trace element supplementation on clinically meaningful outcomes in patients who have sustained a severe burn injury. Supplementation of selenium, copper and zinc, either alone or combined, compared with placebo or standard treatment were eligible for inclusion. Predetermined primary outcome measures were mortality, length of stay, rate of wound healing, and complications. A comprehensive search strategy was undertaken. Methodological quality of eligible studies was appraised and relevant data extracted for meta-analysis. Eight studies met eligibility criteria for the review; four randomized controlled trials and four nonrandomized experimental trials, including a total of 398 participants with an age range of 6 to 67 years. Parenteral supplementation of combined trace elements was associated with a significant decrease in infectious episodes (weighted mean difference: -1.25 episodes, 95% confidence intervals: -1.70, -0.80; P < .00001). The results of this review indicate that the use of parentally administered combined trace elements after burn injury confer positive effects in decreasing infectious complications. Combined parenteral trace element supplementation and combined oral and parenteral zinc supplementation have potentially clinically significant findings on reducing length of stay. Oral zinc supplementation shows possible beneficial effects on mortality. Definitive studies are required to accurately define optimal trace element supplementation regimens, dosages, and routes after burn injury.

Effect of Previous High Glutamine Infusion on Inflammatory Mediators and Mortality in an Acute Pancreatitis Model.

Parenteral glutamine supplementation in acute inflammatory conditions is controversial. We evaluated the inflammatory and survival responses after parenteral glutamine infusion in sodium taurocholate-induced acute pancreatitis (AP) model. Lewis rats received 1 g/kg parenteral glutamine (n = 42), saline (n = 44), or no treatment (n = 45) for 48 h before AP induction. Blood, lung, and liver samples were collected 2, 12, and 24 h after AP to measure serum cytokines levels and tissue heat shock protein (HSP) expression. From each group, 20 animals were not sacrificed after AP for a 7-day mortality study. Serum cytokine levels did not differ among groups at any time point, but the intragroup analysis over time showed higher interferon-γ only in the nontreatment and saline groups at 2 h (versus 12 and 24 h; both p ≤ 0.05). The glutamine group exhibited greater lung and liver HSP90 expression than did the nontreatment group at 2 and 12 h, respectively; greater liver HSP90 and HSP70 expression than did the saline group at 12 h; and smaller lung HSP70 and liver HSP90 expression than did the nontreatment group at 24 h (all p ≤ 0.019). The 7-day mortality rate did not differ among groups. In experimental AP, pretreatment with parenteral glutamine was safe and improved early inflammatory mediator profiles without affecting mortality.

Effect of parenteral supplementation with glutamine dipeptide on neutrophil recovery among patients with acute myeloid leukaemia in Alexandria Main University Hospital

Effect of parenteral supplementation with glutamine dipeptide on neutrophil recovery among patients with acute myeloid leukaemia in Alexandria Main University Hospital

Oral Cobalamin Supplementation in Dogs with Chronic Enteropathies and Hypocobalaminemia

BackgroundCobalamin deficiency is commonly associated with chronic enteropathies (CE) in dogs and current treatment protocols recommend parenteral supplementation. In humans, several studies have reported equal efficacy of oral and parenteral cobalamin administration of cobalamin.ObjectivesTo retrospectively evaluate whether oral cobalamin supplementation can restore normocobalaminemia in dogs with CE and hypocobalaminemia.AnimalsFifty‐one client‐owned dogs with various signs of CE and hypocobalaminemia.Material and MethodsRetrospective study based on a computerized database search for dogs treated at Evidensia Specialist Animal Hospital, Helsingborg, Sweden during January 2012–March 2014. Inclusion criteria were dogs with signs of CE, an initial serum cobalamin ≤270 ng/L (reference interval: 234–811 ng/L) and oral treatment with cobalamin tablets. Serum cobalamin for follow‐up was analyzed 20–202 days after continuous oral cobalamin supplementation started.ResultsAll dogs became normocobalaminemic with oral cobalamin supplementation. The mean increase in serum cobalamin concentration after treatment was 794 ± 462 ng/L. Serum cobalamin concentrations were significantly higher after supplementation (mean 1017 ± 460 ng/L; P < .0001) than at baseline (mean 223 ± 33 ng/L).Conclusion and Clinical ImportanceOur results suggest that oral cobalamin supplementation is effective in normalizing serum cobalamin concentrations in dogs with CE. Prospective studies comparing cellular cobalamin status in dogs being treated with parenteral versus oral cobalamin supplementation are warranted before oral supplementation can be recommended for routine supplementation.

Short-term amino acid infusion improves protein balance in critically ill patients.

IntroductionEvidence behind the recommendations for protein feeding during critical illness is weak. Mechanistic studies are needed to elucidate the effects of amino acid and/or protein supplementation on protein metabolism before larger clinical trials with higher levels of protein feeding are initiated.MethodsWe studied the effects of parenteral amino acid supplementation (equivalent to 1 g/kg/day) over the course of 3 hours on whole-body protein turnover in critically ill patients in the intensive care unit (ICU) during the first week after admission. Patients were studied at baseline during ongoing nutrition and during extra amino acid supplementation. If the patient was still in the ICU 2 to 4 days later, these measurements were repeated. Protein kinetics were measured using continuous stable isotope-labeled phenylalanine and tyrosine infusions.ResultsThirteen patients were studied on the first study occasion only, and seven were studied twice. Parenteral amino acid supplementation significantly improved protein balance on both occasions, from a median of −4 to +7 μmol phenylalanine/kg/hr (P =0.001) on the first study day and from a median of 0 to +12 μmol phenylalanine/kg/hr (P =0.018) on the second study day. The more positive protein balance was attributed to an increased protein synthesis rate, which reached statistical significance during the first measurement (from 58 to 65 μmol phenylalanine/kg/hr; n =13; P =0.007), but not during the second measurement (from 58 to 69 μmol phenylalanine/kg/hr; n =7; P =0.09). Amino acid oxidation rates, estimated by phenylalanine hydroxylation, did not increase during the 3-hour amino acid infusion. A positive correlation (r =0.80; P <0.0001) was observed between total amino acids and/or protein given to the patient and whole-body protein balance.ConclusionExtra parenteral amino acids infused over a 3-hour period improved whole-body protein balance and did not increase amino acid oxidation rates in critically ill patients during the early phase (first week) of critical illness.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-015-0844-6) contains supplementary material, which is available to authorized users.

TREATMENT OF ANEMIA AND IMPROVEMENT OF QUALITY OF LIFE AMONG PATIENTS WITH CROHN'S DISEASE: experience using ferric carboxymaltose.

Anemia is the most common hematological alteration in patients with Crohn's disease, and is frequently related to intestinal inflammatory activity. Its cause is multifactorial and mostly associated with absolute iron deficiency (iron deficiency anemia) and/or functional iron deficiency (inflammation anemia or anemia of chronic disease). It may also be identified through other causes, such as folic acid or vitamin B12 deficiency and secondary to adverse effects from medications (salicylic derivatives and immunosuppressive drugs). In the present study, patients with active Crohn's disease and anemia were evaluated and treated with intravenous ferric carboxymaltose. We discuss the therapeutic schemes (doses), safety, results and improvement of quality of life. In the present prospective study, 10 consecutive patients with Crohn's disease, with moderate to severe activity, with anemia (Hb: 6.7 to 10 g/dL), who were attended between March 2014 and March 2015, were evaluated. Six (60%) were men and four were women, all with moderate or severe anemia (hemoglobin <10 g/dL). They were treated with a maximum of three intravenous infusions of 1000 mg of ferric carboxymaltose, of at least 15 minutes in duration. It was also sought to correlate the inflammatory Crohn's disease activity degree (measured using the Crohn's Disease Activity Index, CDAI) and C-reactive protein level with the severity of anemia. The primary outcome was an increase in Hb of ≥2 g/dL and the secondary outcome was the normalization of anemia (Hb ≥12 g/dL for women and ≥13 g/dL for men) and the improvement in quality of life seen 12 weeks after the last application of carboxymaltose. Among the 10 patients studied, parenteral iron supplementation was administered in three cases during hospitalization and the others received this on an outpatient basis. The total iron dose ranged from 1,000 to 2,000 mg, with an average of 1,650 mg. Crohn's disease activity measured using CDAI and C-reactive protein correlated with the intensity of anemia. An increase of 2 g/dL occurred in eight (80%) patients after 12 weeks and normalization of anemia was found in seven (70%) patients. Improvements in quality-of-life scores were found for all (100%) patients after 12 weeks. Carboxymaltose was well tolerated. Three patients presented adverse reactions (two with nausea and one with headache) of mild intensity. Anemia is a frequent complication for Crohn's disease patients. Intravenous iron therapy has been recommended for Crohn's disease patients, because for these patients, oral iron absorption is very limited. This is because of the inflammatory state and "blocking" of iron entry into enterocytes through hepcidin action on ferroportin, along with the elevated rates of gastrointestinal adverse events that compromise adherence to treatment and possibly aggravate the intestinal inflammatory state. The degree of Crohn's disease activity, as measured using CDAI and C-reactive protein, correlates with the severity of anemia. Carboxymaltose is a safe drug, which can be administrated in high doses (up to 1,000 mg per application per week) and corrects anemia and iron stocks over a short period of time, with consequent improvement in quality of life.

Parenteral glutamine supplement has synergic effects in minimally invasive surgery of subtotal gastrectomy patients.

Exogenous glutamine supplement is known to improve morbidity and mortality of critically-ill patients. This study was conducted to elucidate the role of glutamine in minimally invasive surgery. We retrospectively reviewed subtotal gastrectomy patients in National Taiwan University Hospital from Dec 2005 to Dec 2008. The patients were divided into three groups. Group 1 underwent subtotal gastrectomy by laparotomy without glutamine supplement, group 2 underwent subtotal gastrectomy by laparotomy with glutamine supplement and group 3 underwent gasless laparoscopy-assisted subtotal gastrectomy with parenteral glutamine supplement. There were 155 patients in total; 85 patients in group 1, 17 in group 2 and 53 in group 3. The mean flatus days after operation are 3.6, 3.1 and 2.8 for groups 1, 2 and 3, respectively (p=0.001). Oral intake after operation was commenced after 6.7, 5.0 and 4.7 days (p=0.006). The body temperature had borderline differences between groups 3 and 1. There were significant differences in postoperative systemic responses including heart rates (p<0.001) and tenderness (p=0.011) 5 days after operation for group 3 vs. group 1. Minimally invasive surgery was a negative factor for postoperative body temperature change. Glutamine was a significant factor for postoperative heart rate change and reduction of tenderness. Glutamine supplement may have synergic effects of rapid recovery in minimal invasive surgery for subtotal gastrectomy patients by minimizing the postoperative systemic response and accelerating recovery.

Problematic PEG: A Case of Enteral Feeding Tube Seeding Malignancy to the Abdominal Wall

The patient is a 57yo African American male with a history of tonsillar squamous cell carcinoma who presented with abdominal pain, distention and leakage from his enteral feeding tube site. He underwent uncomplicated percutaneous gastrostomy and tracheostomy placement following cancer resection surgery 3 years prior. The tracheostomy was removed shortly afterward, but gastrostomy tube was retained for medications and nutrition. Over the next several months, the patient developed worsening pain and drainage at the gastrostomy tube site. He then developed an exophytic mass that grew rapidly to surround the gastrostomy tube and tract. A CT scan of the abdomen described a 5.5 x 4.0cm solid, left anterior abdominal wall mass along the percutaneous gastrostomy tube tract. The patient underwent biopsy of the mass, which showed metastatic invasive tonsillar squamous cell carcinoma. Upon identification of metastatic cancer, the patient was tried on several systemic chemotherapeutic treatments without improvement. The treatment regimen was supplemented with palliative local radiation to the abdominal wall metastasis. For over 6 months following the addition of palliative radiation, the metastatic mass remained quiescent and the patient was symptom free. He was able to use the enteral feeding tube for nutrition and medications without complication. Despite thorough treatment, the mass enlarged and gastrostomy leakage returned. A gastrostomy-jejunostomy tube was placed, which temporarily helped control the leakage and improved delivery of medications and nutrition. During the last two months of the patient's life, he was transitioned to parenteral nutrition supplementation. He was eventually started on a patientcontrolled anesthesia regimen for pain control and discharged to inpatient hospice. Following surgical intervention for many head and neck cancers, patients typically require tracheostomy and enteral feeding tube placement to allow for adequate healing. Seeding of an enteral feeding tube site with oral, head and neck cancers is a rare occurrence. Two theories for seeding currently exist: hematogenous spread versus direct tumor transplantation during endoscopic placement usually seen with traumatic PEG placement or multiple passes of the endoscope during placement of the enteral feeding device. In the setting of development of metastasis to the abdominal wall, local chemoradiation can be used to improve quality at the end of life. This case highlights the importance of utilizing local chemoradiation as a palliative measure for certain patients. Palliative care in this situation should be personalized to the patient, and should include discussion of enteral or parenteral feeding options if indicated in the end of life.Figure 1Figure 2Figure 3

Early Parenteral Supplementation with Glutamine Dipeptide for Acute Myeloid Leukaemia Patients Receiving High Dose Chemotherapy

Early Parenteral Supplementation with Glutamine Dipeptide for Acute Myeloid Leukaemia Patients Receiving High Dose Chemotherapy

Role of Parenteral Glutamine in Nutrition Support for Critically Ill Patients

Glutamine is the most abundant amino acid, composed of more than 50 percent of free amino acid in the human body. It had been regarded as a conditional essential amino acid and its concentration is markedly reduced in critically ill patients with trauma, burn, or sepsis. From the early 1990s, many parenteral glutamine studies on critical illness have reported the benefits in mortality, infection, and length of stay. However, its clinical efficacy was based on out-of-date, smaller, single-center studies. Clinical effects of parenteral glutamine have shown no benefits or even harms in recent clinical trials and meta-analysis. Furthermore, it has challenged the hypothesis that low plasma glutamine concentration was associated with poor outcomes in critically ill patients. Although many studies showing the efficacy of glutamine have been reported, parenteral glutamine supplementation may be harmful in patients with multiorgan failure or baseline kidney dysfunction. Further studies should be conducted to identify the use of glutamine supplementation in combination with parenteral and enteral nutrition or enteral/oral nutrition alone, specific adult or pediatric patients, the appropriate time and doses for administration of glutamine, cost-benefit analysis, and the exact mechanisms of action.

Nimesulide Induced Stevens Johnson Syndrome: A Case Report

Stevens-Johnson Syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare, life-threatening mucocutaneous reaction that predominantly involve the skin and mucous membranes and which is most often elicited by drugs and occasionally by infections. SJS and TEN are considered to be the same condition on two ends of a spectrum, differing only by the extent of epidermal detachment. Several drugs are at high risk of implicating TEN/SJS including: antimicrobials like sulfonamide followed by nonsteroidal anti-inflammatory drugs (NSAIDs), anticonvulsant drugs, and anti-gout drug etc. Here report a case of TEN in 23 year old male following the ingestion of Tab. Nimesulide. Nimesulide is a nonsteroidal antiinflammatory (NSAID) drug with antipyretic and analgesic properties. There have been very few previous reports of SJS/TEN induced by the ingestion of Nimesulide in the medical literature. The patient was managed aggressively with parenteral corticosteroids, antimicrobial drugs, emollients, nutritional supplement and palliative care. This case highlights the importance of Nimesulide and other NSAIDS as the possible cause of SJS/TEN. Nimesulide has never been approved for use in countries like USA, UK, Canada, Australia, New Zealand, Japan and other countries in view of concerns over its safety profile. However, in India, due to paucity of data, the drug is rampantly used and available as OTC product. Government of India and Regulatory Authorities should createawareness among practitioners to report all the ADRs to the Adverse Drug Reactions Reporting Centers.

Could a trace mineral deficiency be associated with congenital chondrodystrophy of unknown origin (CCUO) in beef cattle in Australia?

Congenital chondrodystrophy of unknown origin (CCUO) has been reported in beef cattle worldwide. A trace mineral deficiency in pregnant dams has been suggested as causing the deformities seen in CCUO calves. An extended outbreak of CCUO in Australia between 2002 and 2009 provided an opportunity to examine the pattern of trace mineral status in gestating cows and the effect of parenteral trace mineral supplementation on a herd at risk of CCUO calves. A property with a strong history of CCUO was identified from a previous case-control study. A randomly selected sample of multiparous (8 to 10 years old) Angus and Angus cross cows (n = 20) was assigned to control (no injection) or supplement group given three injections at the recommended dose rate of chelated mineral supplement (Mn, Zn, Cu and Se) at 6-week intervals in mid- to late gestation. Liver biopsies were performed to measure liver Mn, Zn, Cu and Fe at each injection time and 1 month post-calving. Pasture samples were also collected for analysis. Supplemented cows had higher liver Cu levels compared to control cows (p < 0.001), but there was no difference between supplement and control cows for liver Zn, Fe or Mn. Liver Cu (p < 0.001), Fe (p < 0.001) and Zn (p < 0.001) fell during gestation and liver Mn increased after calving (p < 0.001). Three cows from the control group and two from the supplement group had liver zinc levels below the normal values at the end of the trial. Two cows from the control group and one from the treatment group gave birth to cows with signs of CCUO including superior brachygnathia. All cows except one from the control group had rough dry coats with excessive dander. The role of trace mineral status in the birth of CCUO calves, especially the role of zinc deficiency, requires further investigation.

Congenital cobalamin malabsorption (Imerslund-Gräsbeck syndrome) in two Beagles in the UK

Two immature Beagles, one nine months old and one six months old, presented with a variety of clinical signs, including pyrexia, lethargy, weight loss and intermittent vomiting and diarrhoea in...