Total Parenteral Nutrition Group Research Articles

Early enteral feeding for burned patients—An effective method which should be encouraged in developing countries

A randomized control trial was conducted to investigate impact of early enteral feeding on immune, metabolic aspects and outcomes of 82 severe burned patients admitting to National Institute of Burns, Hanoi, Vietnam from November 2003 to November 2004. Fourty-one patients were in early enteral group and 41 patients were in total parenteral nutrition group. Blood samples were collected at admission and 7th day postburn to determine plasma level of IgG, IgM, insulin, corrtisol and blood absolute number of TCD4, TCD8. Intestinal chyme was drawn through a weighted feeding tube to determine intestinal secreted IgA. Results showed that, at the 7th day after burn, both humoral and cellular immunology recovered faster in enteral nutrition group as compared to total parenteral group ( p < 0.05). In the early enteral nutrition group, after 1 week, plasma concentration of cortisol decreased from 599.70 to 437 nmol/l and that of insulin increased from 12.07 to 30.34 μmol/ml. Vice versa, in the control group the change was in the reverse direction ( p < 0.01). Overall complication decreased in the enteral nutrition group in comparison with parenteral group. Finally, mortality was significantly lower in early enteral nutrition group as compared to the parenteral group (14.65% and 36.58%, respectively). In conclusion, early enteral nutrition after burn has positive effects on immune and metabolic function, and reduces complication as well as death rate.

Nutrición enteral total vs. nutrición parenteral total en pacientes con pancreatitis aguda grave

To compare the efficacy of early total enteral nutrition (TEN) vs. total parenteral nutrition (TPN) in patients with severe acute pancreatitis (SAP). A total of 22 consecutive patients with SAP were randomized to receive TPN (group I) or TEN (group II). SAP was defined applying APACHE II score, C-reactive protein (CRP) measurements and/or Balthazar CT scan score. Acute inflammatory response (CRP, TNF-a, IL-6), visceral proteins (pre-albumin, albumin), complications (systemic inflammatory response syndrome, multiorgan failure, infections), surgical interventions, length of hospital stay and mortality were evaluated. No significant differences were found between the two groups in the APACHE II score, in CRP, TNF-a and IL-6 concentrations or in pre-albumin and albumin levels over the first 10 days. Seven patients in group I and 4 in group II suffered severe complications. Three patients in group I required surgical intervention. Length of hospital stay was alike in the two groups. Two patients from group I died in the course of the hospitalization. SAP patients with TEN feeding showed a tendency towards a better outcome than patients receiving TPN.

A comparison study between early enteral nutrition and parenteral nutrition in severe burn patients

This clinical study compares effects between enteral nutrition and parenteral nutrition in the early stage of severe burns. Nineteen cases of severe burn patients were divided randomly into total enteral nutrition group (TEN) and total parenteral nutrition group (TPN). Plasma motilin, malondialdehyde (MDA), superoxide dismutase (SOD), endotoxin, tumor necrosis factor (TNF), serum gastrin, diamine oxidase (DAO), and urine lactulose/mannitol ratio (L/M) was determined on post burn day (PBD) 1, 4, 8, 14, respectively. The results showed that serum gastrin, plasma motilin, and SOD were significantly higher in TEN than in TPN on PBD4, 8 ( p < 0.05–0.01). Plasma MDA was obviously lower in TEN than in TPN on PBD4, 8 ( p < 0.01). Plasma endotoxin was significantly lower in TEN than in TPN on PBD4, 8 ( p < 0.01). Plasma TNF were significantly lower in TEN than in TPN on PBD4, 8, 14 ( p < 0.01). The level of serum DAO and urine L/M ratio in TEN was obviously lower than in TPN on PBD4 and 8, respectively ( p < 0.05–0.01). A positive correlation between L/M and DAO, MDA, TNF ( r = 0.5822–0.7598, p < 0.05–0.01), and a negative correlation between L/M and SOD ( r = −0.7771, p < 0.01), and a positive correlation between plasma endotoxin and TNF, MDA ( r = 0.9038 and 0.6705, p < 0.05–0.01) were found. These results indicate that enteral nutrition was a more effective route to preserve gastrin secretion and motility of gastrointestinal tract, lower intestinal ischemia and reperfusion injury, reduce intestinal permeability, decrease plasma endotoxin and inflammatory mediators, and maintain mucosa barrier function. Whenever gastrointestinal function permits, enteral nutrition was superior to parenteral nutrition early after burn.

Early Postoperative Oral Feeding Accelerates Upper Gastrointestinal Anastomotic Healing in the Rat Model

The benefits of early postoperative oral feeding following colonic anastomosis have previously been demonstrated. However, early postoperative oral feeding in patients with upper gastrointestinal surgery has been avoided because of concerns regarding anastomotic leakage. We investigated whether early postoperative oral feeding was advantageous for upper gastrointestinal anastomosis in comparison to parenteral feeding with a fasting period. Male Sprague-Dawley rats were subjected to the same surgical manipulation, i.e., venous catheterization, gastrostomy, and proximal jejunal anastomosis. Rats were divided into two groups: the enteral nutrition (EN) group, which received nutrients via gastrostomy as a substitute for oral feeding, and the total parental nutrition (TPN) group, which was fed via a venous catheter. Identical nutritional solutions were administered to the two groups immediately after surgery. The anastomotic bursting pressure (ABP) and the content of hydroxyproline in the anastomotic tissue were measured 5 days postoperatively. The ABP in the EN group was significantly higher than that in the TPN group (214.6 +/- 42 versus 149.5 +/- 49 mmHg; p < 0.01). The hydroxyproline content in the EN group was also significantly higher (63.5 +/- 10 versus 50.5 +/- 12 micromol/g dry tissue; p < 0.01). Early enteral feeding via gastrostomy accelerated jejunal anastomotic healing in comparison to parenteral feeding. This study clearly indicates that early oral feeding after upper gastrointestinal surgery leads to prompt anastomotic healing.

A Randomized Controlled Trial of Enteral versus Parenteral Feeding in Patients with Predicted Severe Acute Pancreatitis Shows a Significant Reduction in Mortality and in Infected Pancreatic Complications with Total Enteral Nutrition

Background: Infectious complications are the main cause of late death in patients with acute pancreatitis. Routine prophylactic antibiotic use following a severe attack has been proposed but remains controversial. On the other hand, nutritional support has recently yielded promising clinical results. The aim of study was to compare enteral vs. parenteral feeding for prevention of infectious complications in patients with predicted severe acute pancreatitis. Methods: We screened 466 consecutive patients with acute pancreatitis. A total of 70 patients with objectively graded severe acute pancreatitis were randomly allocated to receive either total enteral nutrition (TEN) or total parenteral nutrition (TPN), within 72 h of onset of symptoms. Baseline characteristics were well matched in the two groups. Results: The incidence of pancreatic infectious complications (infected pancreatic necrosis, pancreatic abscess) was significantly lower in the enterally fed group (7 vs. 16, p = 0.02). In the TEN group, 7 patients developed multiple organ failure whereas 17 parenterally fed patients developed multiple organ failure (p = 0.02). Overall mortality was 20% with two deaths in the TEN group and twelve in the TPN group (p < 0.01). Conclusion: Early TEN could be used as prophylactic therapy for infected pancreatic necrosis since it significantly decreased the incidence of pancreatic infectious complications as well as the frequency of multiple organ failure and mortality.

Liver dysfunction associated with artificial nutrition in critically ill patients

IntroductionLiver dysfunction associated with artificial nutrition in critically ill patients is a complication that seems to be frequent, but it has not been assessed previously in a large cohort of critically ill patients.MethodsWe conducted a prospective cohort study of incidence in 40 intensive care units. Different liver dysfunction patterns were defined: (a) cholestasis: alkaline phosphatase of more than 280 IU/l, gamma-glutamyl-transferase of more than 50 IU/l, or bilirubin of more than 1.2 mg/dl; (b) liver necrosis: aspartate aminotransferase of more than 40 IU/l or alanine aminotransferase of more than 42 IU/l, plus bilirubin of more than 1.2 mg/dl or international normalized ratio of more than 1.4; and (c) mixed pattern: alkaline phosphatase of more than 280 IU/l or gamma-glutamyl-transferase of more than 50 IU/l, plus aspartate aminotransferase of more than 40 IU/l or alanine aminotransferase of more than 42 IU/l.ResultsSeven hundred and twenty-five of 3,409 patients received artificial nutrition: 303 received total parenteral nutrition (TPN) and 422 received enteral nutrition (EN). Twenty-three percent of patients developed liver dysfunction: 30% in the TPN group and 18% in the EN group. The univariate analysis showed an association between liver dysfunction and TPN (p < 0.001), Multiple Organ Dysfunction Score on admission (p < 0.001), sepsis (p < 0.001), early use of artificial nutrition (p < 0.03), and malnutrition (p < 0.01). In the multivariate analysis, liver dysfunction was associated with TPN (p < 0.001), sepsis (p < 0.02), early use of artificial nutrition (p < 0.03), and calculated energy requirements of more than 25 kcal/kg per day (p < 0.05).ConclusionTPN, sepsis, and excessive calculated energy requirements appear as risk factors for developing liver dysfunction. Septic critically ill patients should not be fed with excessive caloric amounts, particularly when TPN is employed. Administering artificial nutrition in the first 24 hours after admission seems to have a protective effect.

Atypical findings in a rat model for parenteral nutrition–induced cholestasis

The pathophysiology of parenteral nutrition–associated cholestasis (PNAC) in young children is poorly understood. The composition of the total parenteral nutrition (TPN) is reported to be of importance for the occurrence of PNAC. In this study, the effects of parenteral nutrition with different caloric loads and different amounts of lipids were studied in a rat model for PNAC. Four different groups of male Wistar rats were used. In 3 groups, a central catheter was placed in the right jugular vein. The first group (group A) received NaCl 0.9% and had free access to food and water; the other two (groups C and D) received TPN, containing 1142 and 1611 J kg −1 d −1, respectively. In group B, the common bile duct was ligated. Animals were killed after 7 or 14 days; at these points, liver enzymes were measured, and liver histology was assessed. In the bile duct ligation group, all liver enzymes significantly increased compared with baseline. Liver enzymes did not significantly change in the other groups. Histology showed cholestatic changes in the bile duct ligation group. In the parenteral nutrition groups, significant steatotic changes were found, and in the high caloric TPN group, more so than in the TPN group. In this study, TPN was not associated with abnormal liver function tests or with histological evidence of cholestasis. Total parenteral nutrition was associated with steatosis in this rat model, which is a finding commonly reported in the literature. Therefore, it is questionable whether the rat is a good model for TPN-associated cholestasis.

Quality evaluation of total parenteral nutrition in an acute care setting

To analyse the degree of compliance with internationally accepted standards defined for total parenteral nutrition (TPN) quality control in our hospital. The problems of quality which exist must be detected and possible solutions put into practice. Retrospective study of critically ill patients treated with TPN during two years in a university teaching hospital (n=92). Assessment of quality was performed through measurements of compliance using 20 criteria. These were evaluated both individually and gathered in three categories: appropriate, safe and accurate TPN. Three summary/indicators were also established which assessed simultaneous compliance with all the criteria in each group. Criteria compliance was compared to standards values. Patient (age, sex, diabetes) and process (TPN indication, patient's outcome, type of diet used) variables were analysed (using logistic regression models) as factors potentially associated with compliance with the quality criteria. Corrective measures aimed at resolving the quality problem were applied to the deficient criteria, paying particular attention to those criteria which presented the highest percentage of errors in the study carried out using a Pareto analysis. Compliance of six criteria was significantly below standard values. Simultaneous compliance of all criteria by group was 17% in adjusted TPN, 38% in safe TPN and 94% in exact TPN. There was a negative association between an age over 65 years and both a correct indication of TPN (OR: 9.4) and the indicator compliance of all criteria in the adjusted TPN group (OR: 2.9). The absence of metabolic complications was influenced (P<0.05) by the use of standardized diets (OR: 0.3). Effects of the change: the simultaneous compliance with all the criteria of a group improved in all three groups, but this was statistically significant in the 'appropriate' TPN and 'safe' TPN groups. The criteria analysed individually improved after the corrective measures in five of the six criteria which had been below standard in the first evaluation. The correct understanding and application of the indications, physiology and potential complications of TPN constitute the hub of the improvement process.

The effect of total parenteral nutrition on the survival of terminally ill ovarian cancer patients

Objectives. Total parenteral nutrition (TPN) for terminal ovarian cancer patients remains controversial. In this study, we compared survival from time of terminal intestinal obstruction (TIO) diagnosis in patients who received TPN versus those who did not. Methods. A historical cohort of 55 patients with stage IIIC/IV epithelial ovarian cancer hospitalized for TIO between 1994 and 2002 was studied. All patients were previously treated with paclitaxel/platinum following cytoreductive surgery. Exposure was administration of TPN after TIO. The primary outcome was survival from TIO diagnosis to death. Number of chemotherapy cycles completed after TIO diagnosis, major complications of TPN, and demographics were measured. Survival analysis was performed using Kaplan–Meier methods. Results. The median survival from time of TIO diagnosis was 72 days (range 16–485) for patients receiving TPN and 41.0 days (range 4–133) for those not receiving TPN ( P = 0.05), but no difference in survival was observed when adjusting for chemotherapy. Overall survival [median 23 (range 6–67) vs. 35 months (range 8–67), P = 0.03] was shorter for the TPN group. Demographic data were similar in both groups. Patients receiving TPN after obstruction were more likely to undergo concurrent chemotherapy (64 vs. 26%, P = 0.004). One major TPN-related complication was found. Conclusions. Ovarian cancer patients with TIO receiving TPN had a median survival benefit of 4 weeks. This benefit decreased when patients were treated with concurrent chemotherapy. Issues of cost, quality of life, and human values need to be investigated to assess the full impact of TPN in this patient population.

Breast cancer in young women (35 years or younger): features of disease presentation in a developing country

Adequate nutritional support is essential for improving outcomes in hospitalized critically ill patients, who have high rates of malnutrition. Critical illness is typically associated with a catabolic stress state in which patients commonly demonstrate a systemic inflammatory response. This response is coupled with complications. So, malnutrition and inappropriate nutritional support lead to increased morbidity and mortality, decreased quality of life, prolonged duration of mechanical ventilation, and increased length of hospital stay. Critically ill patients require special attention to prevent muscle wasting and to avoid a lot of complications.To throw light on nutritional assessment in critically ill patients and the effect of providing appropriate nutritional support in respiratory ICU based on patients, clinical condition on their outcome.A non-randomized clinical trial was carried out at Respiratory Intensive Care Unit at Zagazig University Hospitals during the study period (2014–2015). This study was conducted on 96 patients who were admitted to RICU. They were categorized into 3 groups according to nutritional support. Group (1): 32 patients supported by enteral nutrition (EN). Group (2): 32Patients with inadequate enteral nutrition and supported by complementary parenteral nutrition (Compl. PN) Group (3): 32 patients supported by total parenteral nutrition (TPN) as EN was contraindicated for them. All patients were subjected to full history taking, clinical examination, and nutritional assessment through dietary and fluid intake history, clinical assessment, biochemistry and anthropometry. The nutrition regimen was designed after assessing the patient requirements for energy, protein, fluid and electrolytes. Monitoring of patients was done by follow up of the anthropometry and laboratory parameters, finally, the outcome variables were compared between the 3 groups.Of the 3 studied groups, there were no differences in their daily caloric and protein requirements but the percentage of goal delivered was higher in Compl. PN and TPN groups than in the EN group (100% vs 81.41% ± 13.45%). EN group patients have better nitrogen balance than in the Compl. PN and TPN groups (p 0.02, <0.001 respectively) at follow up days. Pneumonia, sepsis and infections other than pneumonia were higher in the TPN group but vomiting and diarrhea were higher in the EN group and metabolic complications were higher in the TPN group as regardsthe duration of MV and the length of hospital stay both were higher in TPN group than in the other two groups, difficult and prolonged weaning were higher in the TPN group. Mortality was higher in the TPN group (p < 0.01).Sufficient nutritional support whether enteral or parenteral is very important in critically ill patients. TPN should never be used as a substitute for EN in patients who can tolerate enteral feeding as it is associated with infectious and metabolic complications and its deleterious effect on patients, outcome.

Soybean Oil Fat Emulsion to Prevent TPN-Induced Liver Damage: Possible Molecular Mechanisms and Clinical Implications

Long-term total parenteral nutrition (TPN) is known to be associated with cholestasis and hepatic steatosis, which can be lethal in infants who cannot be fed orally. The present review focuses on the metabolic complications in the liver that may occur due to the excessive administration of fat-free TPN. We have recently developed an infant rat model of hepatic dysfunction and steatosis induced by overdose of fat-free TPN. In this model, plasma levels of liver enzymes in the fat-free TPN group were found to be significantly higher than in the other groups (i.e., the oral diet and fat-containing TPN groups). Pathological examination showed hepatomegaly and severe fatty changes without cholestasis in the liver of infant rats that received fat-free TPN. We clearly demonstrated that the addition of soybean oil emulsion to the TPN regimen prevented hepatic dysfunction and fatty changes. In the present review, we discuss the molecular mechanism of the hepatic dysfunction induced by fat-free TPN and the role of soybean oil fat emulsion in the TPN regimen. We also discuss the clinical implications of soybean oil-containing TPN solutions and point out the importance of including fat in the TPN regimen in order to prevent the hepatic abnormalities associated with the excessive administration of fat-free TPN.

TOTAL PARENTERAL NUTRITION USING CONTINUOUS INTRAVENOUS INFUSION VIA THE POSTERIOR VENA CAVA IN RATS

This study was conducted to evaluate the feasibility of total parenteral nutrition (TPN) in rats using continuous intravenous infusion (tail cuff method) via the posterior vena cava. A catheter was inserted into the posterior vena cava from the femoral vein of 10 females (Experiment 1) and 16 females (Experiment 2). The depth of the inserted catheter from the femoral vein was set at 4.5 cm for Experiment 1 and was set at 6 cm for Experiment 2. The test animals were divided into two groups in each experiment: a 5% D-Mannitol (MAN) group and a TPN group. In Experiment 1, TPN rats showed macroscopic lesions (edema in peritoneum, increased collateral vasculature, induration in perivenous tissue, and thrombus) at the tip of the catheter. The diameter of the posterior vena cava (2.86 +/- 0.16 mm, mean +/- S.D.) was significantly greater than that of the anterior vena cava (2.45 +/- 0.22 mm) in 10 rats of Experiment 1. In Experiment 2, TPN rats showed no abnormalities at necropsy. Our findings suggest that TPN administered via the posterior vena cava in Sprague-Dawley rats requires the catheter to be inserted to a depth of 6 cm from the femoral vein. We hypothesize that this is because it is inserted to the level of the renal vein branch where the diameter of the posterior vena cava may be greatest.

Model of TPN-associated hepatobiliary dysfunction in the young pig.

Gallbladder 'sludge' and cholestasis are two common complications associated with total parenteral nutrition (TPN), but the aetiology of each is uncertain. An animal model has been developed in the young pig which demonstrates these two complications. Five female piglets, of Landrace Large White Cross variety weighing 4.5-5.9 kg, received nutritional support for 2 weeks with a continuous infusion of TPN solution at a dose of 150 kcal kg-1 day-1. The solution was 35 per cent dextrose, 5 per cent L-amino acids with conventional electrolyte, mineral and vitamin additives. No lipid was used in the solution. Five weight-matched animals were used as controls. All animals in the TPN group developed 'sludge' in their gallbladders, decreased basal bile flow, decreased bile salt excretion and a diminished response to bile salt stimulated bile flow, as compared with controls. There was no abnormality in routine liver function tests or liver histology. It is concluded that TPN therapy in this animal model is associated with the appearance of gallbladder 'sludge', and cholestasis as demonstrated by direct bile flow studies. It is suggested that this bile flow abnormality is due to a decrease in bile salt dependent and bile salt independent fractions of canalicular bile flow. The model provides the opportunity to investigate TPN related hepatobiliary dysfunction in an animal that has similar liver function to man and comparable nutritional requirements.

Metabolic effects of recombinant human growth hormone: Isotopic studies in the postabsorptive state and during total parenteral nutrition

We have performed a series of isotopic studies in 25 adult patients with sepsis and/or trauma in order to determine the metabolic effects of recombinant human growth hormone (rHGH) administration. Twelve of the patients were receiving total parenteral nutrition, and 13 were eating a normal ward diet and were studied postabsorption. Energy and protein kinetics were quantified isotopically before rHGH administration and following a 3-day course of rHGH (20 units subcutaneously daily). In the total parenteral nutrition group the rate of net loss of protein decreased from 0.82(0.17) g kg-1 day-1 to 0.43(0.20) g kg-1 day-1 (P less than 0.02) following the administration of rHGH. The rate of appearance of leucine was not altered, suggesting that the improvement in nitrogen balance following rHGH was because of an increased rate of protein synthesis rather than reduced catabolism. In the postabsorptive group, rHGH treatment significantly increased the rate of appearance of free fatty acids (from 7.4(2.2) mumol kg-1 min-1 to 11.1(2.6) mumol kg-1 min-1, P less than 0.03) and free fatty oxidation (from 1.3(0.4) mumol kg-1 min-1 to 1.7(0.4) mumol kg-1 min-1, P less than 0.06), while the rate of leucine oxidation was reduced (from 0.44(0.05) mumol kg-1 min-1 to 0.26(0.03) mumol kg-1 min-1, P less than 0.005). Glucose appearance and oxidation remained unchanged. These results suggest that fat was being oxidized in preference to protein, which resulted in a reduction in the net rate of loss of protein of 0.3 g kg-1 day-1 (P less than 0.05). We conclude that rHGH administration is capable of significantly reducing net protein loss in septic or injured surgical patients. Recombinant HGH may be clinically useful in supporting critically ill surgical patients who require intensive nutritional support.

EXOGENOUS INTERLEUKIN 7 AFFECTS GUT-ASSOCIATED LYMPHOID TISSUE IN MICE RECEIVING TOTAL PARENTERAL NUTRITION

In the absence of enteral nutrient delivery, gut-associated lymphoid tissue (GALT) mass and function are reduced. The purpose of this study was to examine whether exogenous interleukin (IL)-7 treatment reverses intravenous (IV)-total parenteral nutrition (TPN)-induced changes in GALT, immunoglobulin (Ig) A levels, and gut barrier function. Eighty-nine mice were randomized to chow, TPN, or TPN + IL-7 (1 microg/kg, administered IV twice a day) and treated for 5 days. The entire small intestine was harvested and lymphocytes were isolated from Peyer's patches (PPs), intraepithelial (IE) spaces, and the lamina propria (LP). Small intestinal and bronchoalveolar IgA levels were measured. Proximal and distal small intestinal levels of IgA-stimulating (IL-10) and IgA-inhibiting (IFNgamma) cytokines were determined with enzyme-linked immunoabsorbant assay. Moreover, 1 x 10 live Pseudomonas aeruginosa were delivered by gavage and survival was observed. TPN decreased total cell yields from PPs, IE spaces, and the LP compared with the chow group. IL-7 treatment restored cell numbers. PP CD4+, PP CD8+, IE gammadeltaTCR+, and LP CD4+ cell numbers were higher in the TPN + IL-7 group than in the TPN group. Secretory IgA levels were lower in the TPN and TPN + IL-7 than in the chow group. In the distal small intestine, IFNgamma levels were similar in the three groups, whereas IL-10 levels were reduced in the TPN and TPN + IL-7 groups relative to the chow group. Survival times were reduced in the TPN compared with the chow group, but IL-7 treatment significantly improved survival. Thus, exogenous IL-7 does not improve secretory IgA levels, nor are there any remarkable effects on levels of gut IgA-mediating cytokines. However, IL-7 treatment during TPN reverses TPN-induced GALT atrophy and improves survival in a gut-derived sepsis model.

The Intestinal Trophic Response to Enteral Food Is Reduced in Parenterally Fed Preterm Pigs and Is Associated with More Nitrergic Neurons

In term neonates, total parenteral nutrition (TPN) induces mucosal atrophy, whereas the first intake of milk is followed by intestinal growth. This may be explained in part by an NO-mediated increased blood flow. We hypothesized that the immature gut has an altered response to TPN and enteral nutrition. In Expt. 1, preterm caesarean-delivered pigs were administered elemental nutrients for 3 d, infused parenterally (TPN, n = 7) or enterally (TENT, n = 7). In Expt. 2, preterm pigs were fed sow's colostrum, cow's colostrum, or infant formula for 2 d after a 3-d TPN period (TPN-SOW, TPN-COW, TPN-FORM, n = 8-11). Intestinal morphology and the number of enteric neurons containing nitric oxide synthase-1 (NOS-1) were quantified. Both the TPN and TENT groups had increases in intestinal mass, circumference, and mucosal mass, volume, and surface density, relative to values at birth (+30-50%, P < 0.05). In Expt. 2, the magnitudes of the intestinal trophic responses to feeding were similar to those in Expt. 1, but were also associated with an increased number of nitrergic myenteric neurons and some mucosal damage, most frequently observed for the formula group. We conclude that 1) a short period of TPN does not induce mucosal atrophy in preterm pigs, whereas elemental nutrients infused luminally do not mimic the trophic response seen with milk diets, 2) enteral feeding of preterm pigs after a short period of TPN is associated with a modest, diet-dependent trophic response that may be related in part to the actions of an increased population of enteric NOS-1 neurons.

Patients with severe bowel malabsorption do not have changes in iodine status

Objective We evaluated the influence of intestinal malabsorption on iodine status in patients who had short gut syndrome and received total parenteral nutrition (group I) compared with control subjects who had eutrophia (group II) and patients who had other illnesses but normal digestive tracts (group III). Methods Twenty-seven subjects were studied. Iodine intake was determined by the measurement of iodine in ingested food and in parenteral nutrition solutions. Urinary iodine excretion was measured by the Sandell-Kalthoff reaction. Urinary creatinine, anthropometric, and thyroid hormone functions were also determined. Results Daily iodine intakes were 658 ± 125 (mean ± standard deviation), 573 ± 204, and 629 ± 208 μg for groups I, II, and III, respectively. Daily urinary iodine excretion levels were 399 ± 308, 439 ± 192, and 370 ± 268 μg and ratios of urinary iodine (micrograms) to creatinine (grams) were 614 ± 349, 354 ± 142, and 483 ± 292, respectively. There were no statistically significant differences across groups. Conclusion In Brazil the iodine provided by food, including iodized salt, has been sufficient to maintain iodine status in patients with short gut syndrome.

Leptin, cell proliferation and crypt fission in the gastrointestinal tract of intravenously fed rats.

Many peptides, hormones and growth factors have been implicated in the control of cell renewal in the gastrointestinal epithelium. Leptin is present in the stomach and salivary glands and leptin receptors are seen throughout the gut. Leptin can stimulate mitogen-activated protein kinase activity in vitro and short-term infusion has been reported to have a proliferative action on the colon in vivo, suggesting a biological link between obesity, physical activity and colon cancer. Food intake is one of the most important determinants of intestinal mucosal cell renewal, thus any direct effects of leptin on the gut may be hidden. This problem has been avoided experimentally by maintaining animals on total parenteral nutrition (TPN). Male Wistar rats were anaesthetized and cannulae were inserted into the jugular vein to deliver the TPN diet to which had been added 0, 0.5, 2.5, or 10 mg/kg of recombinant murine leptin. Orally fed rats were also studied. After 6 days of treatment, all animals were injected with vincristine and killed 2 h later. Tissue weight was recorded and crypt cell proliferation (arrested metaphases) and crypt fission were scored in 'microdissected' crypts. Leptin infusion led to a small decrease in body weight and in the weight of the caecum. Intestinal cell proliferation was significantly reduced by TPN when compared to the orally fed rats, but the addition of leptin had no effect on the small intestine or colon. Crypt fission was also significantly lowered in the TPN group. Fission was slightly but significantly increased in the proximal and mid-colon of the leptin-treated rats, but was decreased in the distal colon. Although leptin did not significantly alter cell proliferation, it had significant effects on the process of crypt fission in the colon, which varied according to the exact locality.

Quick recovery of serum diamine oxidase activity in patients undergoing total gastrectomy by oral enteral nutrition

Background Total parental nutrition (TPN) meets the metabolic needs of postoperative patients, but introduces potential complications, including intestinal mucosal atrophy. Surgical advances have increased the certainty of esophagoenteric anastomosis making early oral enteral feeding after surgery feasible. The objective of the current report is to compare the benefits of enteral nutrition (EN) and TPN in patients undergoing total gastrectomy for gastric cancer. Methods Forty-two patients who underwent total gastrectomy for gastrtic cancer were randomized to receive oral EN beginning on postoperative day (POD) 3 with peripheral supplements or TPN beginning on POD 3. Serum concentrations of albumin and retinol-binding protein (RBP) as nutritional parameters and diamine oxidase (DAO) activity, an enzyme reflecting mucosal integrity, were measured preoperatively and 1, 4, 7, and 14 days postoperatively and compared between the 2 groups. Complications, abdominal symptoms, duration of hospital stay, and treatment cost per hospitalization were also compared. Results Albumin and RBP concentrations changed little in either group. DAO activity decreased in both groups and recovered within 1 week in the EN group but not in the TPN group. Complications were similar in the 2 groups. Treatment cost was less and length of hospital stay was shorter in the EN group. Conclusions EN is an efficient way to provide nutrition to patients and possibly prevent intestinal atrophy in the patient who must endure prolonged postoperative fasting. Compared to TPN, EN reduces treatment cost and hospital length-of-stay.

Major Role of Soybean Oil in Preventing Decrease in CYP4A1 mRNA Content Relative to PPAR.ALPHA. mRNA Down-Regulation in Infant Rats

Changes in the levels of CYP4A1, PPARalpha, and RXRalpha mRNA expression in the liver following overdose of fat-free or fat-containing total parenteral nutrition (TPN) were studied in 3-week-old male Sprague-Dawley rats. The rats were divided into three groups: group 1, oral diet; group 2, fat-free TPN; and group 3, TPN with 20% of calories from soybean oil emulsion. Levels of CYP4A1, PPARalpha, and RXRalpha mRNA in the fat-free TPN group were significantly lower than those in the other groups. Levels of CYP4A1 and PPARalpha mRNA were strongly correlated (r=0.849), and levels of CYP4A1 and RXRalpha mRNA were weakly correlated (r=0.618). This is the first report of a strong correlation between the levels of CYP4A1 and PPARalpha mRNA following overdose of fat-free or fat-containing TPN in infant rats. Our results also indicate that it is important to include fat in TPN regimens in order to prevent CYP4A1 mRNA down-regulation, which may be related to changes in PPARalpha mRNA levels in the liver.