Total Parenteral Nutrition Support Research Articles

Evaluation of prognostic factors associated with intensive care unit mortality in patients with hematopoietic stem cell transplantation

Background & objective: Although the outcome of patients admitted to ICUs have considerably improved in recent years, hematopoietic stem cell transplantation (HSCT) continues to be significantly associated with mortality.
 We studied the prognostic factors associated with ICU mortality after HSCT. The Acute Physiological and Chronic Health Evaluation II (APACHE II) was used as a prognostic scoring system.
 Methods: Within the scope of the research, the clinical and laboratory data of 52 patients who were admitted to the ICU after undergoing HSCT between 2013 and 2019 were analyzed retrospectively.
 Results: Mortality risk was found to be 4.22 times higher in patients who received mechanical ventilation (MV) within the first 24 h (P = 0.047), 18.37 times higher in patients who received total parenteral nutrition (TPN) support (P = 0.007), and 158.17 times higher in recipients of vasopressor drug support compared to those who did not (P < 0.001). It was found that a one unit increase in GCS score decreased mortality risk by 0.58 fold (P = 0.015). Additionally, a one unit increase in heart rate was found to increase mortality risk by 1.03 fold (P = 0.010). Whereas, one unit increases in systolic blood pressure or diastolic blood pressure decreased the mortality risk by 0.91 and 0.92 fold, respectively (P = 0.001 and P = 0.002). Mortality was not associated with APACHE II or graft-versus-host disease.
 Conclusion: Receiving MV, TPN or vasopressor treatment, and having lower GCS, higher heart rate, lower systolic and diastolic blood pressure were associated with an increase in the risk of ICU mortality in HSCT recipients admitted to the ICU.
 Abbreviations: HSCT - hematopoietic stem cell transplantation; TPN - total parenteral nutrition; APACHE II - Acute Physiological and Chronic Health Evaluation II: GVHT - graft-versus-host disease; ICU - intensive care unit; GCS – Glasgow Coma Scale; MODS - Multiple organ dysfunction syndrome 
 Key words: Hematopoietic stem cell transplantation; Intensive care; Mortality; Mechanical ventilation, parenteral nutrition; MV- mechanical ventilation;
 Citation: Tunay B, Sadri S. Evaluation of prognostic factors associated with intensive care unit mortality in patients with hematopoietic stem cell transplantation. Anaesth. pain intensive care 2022;26(4):480-487 ; DOI: 10.35975/apic.v26i4.1951
 Received: Nov 12, 2021; Reviewed: May 11, 2022; Accepted: July 08, 2022

Preoperative Nutritional Status and Risk Factors Associated with Delayed Discharge in Geriatric Patients Undergoing Gastrectomy: A Single-Center Retrospective Study.

Objective Preoperative malnutrition is an independent risk factor for postoperative complications and survival for gastric cancer patients. The study is aimed at investigating the prevalence of malnutrition, perioperative nutritional support, and the risk factors associated with delayed discharge of geriatric patients undergoing gastrectomy. Methods A retrospective study of gastric cancer patients (age ≥ 65) who underwent gastrectomy at Zhongshan Hospital from January 2018 to May 2020 was conducted. Clinical data, including demographic information, medical history, surgery-related factors, and perioperative nutritional management, were collected and analyzed. Postoperative complications were assessed according to the Clavien-Dindo grading system, and the prognostic nutritional index (PNI) was calculated. The risk factors affecting the prolongation of postoperative hospital stay were analyzed. Results A total of 783 patients were reviewed. The overall frequency of malnutrition was 31.3% (249/783). The albumin, prealbumin, and hemoglobin levels were lower in the malnutrition group than in the well-nourished group. The proportion of patients who received preoperative total parenteral nutritional support in the malnutrition group was significantly higher than in the well-nourished group (12.4% vs. 3.7%, P < 0.001). All patients received postoperative parenteral nutrition (PN); the proportion of patients who received total nutrient admixture (TNA) in the malnutrition group was lower than in the well-nourished group (22.1% vs. 33.5%, P = 0.001). No significant difference was found in the duration of postoperative nutrition between groups (P > 0.05). The malnutrition group was associated with a higher rate of postoperative complications (P < 0.001). Univariate and multivariate regressions revealed that age > 70 years (OR = 1.216, 95% CI 1.048-1.411, P = 0.010), operation time > 180 min (OR = 1.431, 95% CI 1.237-1.656, P < 0.001), PNI < 44.5 (OR = 1.792, 95% CI 1.058-3.032, P = 0.030), and postoperative complications (OR = 2.191, 95% CI 1.604-2.991, P < 0.001) were significant risk factors associated with delayed discharge. Conclusion Malnutrition is relatively common in elderly patients undergoing gastrectomy. Advanced age, duration of surgery, lower levels of PNI, and postoperative complications were risk factors associated with delay discharge. Elderly gastric cancer patients with risk factors urgently require specific attention for reducing hospital stay.

Ethical Considerations for Equitable Access to Genomic Sequencing for Critically Ill Neonates in the United States.

Rare diseases impact all socio-economic, geographic, and racial groups indiscriminately. Newborn screening (NBS) is an exemplary international public health initiative that identifies infants with rare conditions early in life to reduce morbidity and mortality. NBS theoretically promotes equity through universal access, regardless of financial ability. There is however heterogeneity in access to newborn screening and conditions that are screened throughout the world. In the United States and some other developed countries, NBS is provided to all babies, subsidized by the local or federal government. Although NBS is an equitable test, infants admitted to neonatal intensive care units (NICUs) may not receive similar benefits to healthier infants. Newborns in the NICU may receive delayed and/or multiple newborn screens due to known limitations in interpreting the results with prematurity, total parenteral nutrition, blood transfusions, infection, and life support. Thus, genomic technologies might be needed in addition to NBS for equitable care of this vulnerable population. Whole exome (WES) and genome sequencing (WGS) have been recently studied in critically ill newborns across the world and have shown promising results in shortening diagnostic odysseys and providing clinical utility. However, in certain circumstances several barriers might limit access to these tests. Here, we discuss some of the existing barriers to genomic sequencing in NICUs in the United States, explore the ethical implications related to low access, consider ways to increase access to genomic testing, and offer some suggestions for future research in these areas.

This Month in Adult Urology

This Month in Adult Urology

Comparative study of the safety and efficacy of SMOFlipid vs non SMOFlipid as TPN for liver transplantation

BackgroundLiver transplantation (LT) is one of the widely recognised and leading treatments for end-stage liver disease. Nutrition impacts its success. Total parenteral nutrition (TPN) is usually prescribed for patients recommended prolonged fasting after LT. The supplement of SMOFlipid (soybean oil, MCT oil, olive oil, and fish oil) is easily metabolised to produce energy, and it possesses anti-inflammatory effects; however, SMOFlipid emulsion use raises concerns regarding coagulopathy after LT. This study investigated the postoperative correlation between SMOFlipid and coagulation in LT. Materials and methodsThe medical records of 54 recipients of living donor LT between January 2012 and June 2015 were retrospectively reviewed. Patients with pretransplant platelet count <40,000/μL and >40,000/μL were assigned to the non-SMOFlipid (n = 23) group and the SMOFlipid (n = 31) group, respectively. ResultsThe coagulation and nutrition profile of patients improved significantly after TPN support. No significant difference was observed in the coagulation profile between SMOFlipid and non-SMOFlipid groups. Although the SMOFlipid group exhibited a higher platelet count than the non-SMOFlipid group on day 7 (P < 0.001), no significant differences were observed in the platelet count on 14 and 30 days after TPN support between the 2 groups. ConclusionTPN using SMOFlipid after LT is a good strategy for improving nutritional status without increasing the risks of bleeding and coagulation in patients intolerant of early enteral nutrition. Moreover, SMOFlipid use may not cause coagulopathy up to 14 days after LT. Overall, SMOFlipid provides nutritional benefits without increasing the risk of bleeding.

Clinical Characteristics and Outcomes of S. Aureus Bacteremia in Patients Receiving Total Parenteral Nutrition.

Background: Patients on total parenteral nutrition (TPN) are at risk of developing central line-associated infections. Specifically, Staphylococcus aureus bacteremia (SAB) is feared for its high complication rates. This prospective cohort study compares characteristics, clinical course and outcome of SAB in patients with and without TPN support. Methods: Clinical and microbiological data from all patients with positive blood cultures for S. aureus from two facilities, including our referral center for TPN support, were retrieved (period 2013–2020). Primary outcome was overall mortality, and included survival analysis using a multivariate Cox regression model. Secondary outcomes comprised a comparison of clinical characteristics and outcomes between both patient groups and analysis of factors associated with complicated outcome (e.g., endocarditis, deep-seated foci, relapse and death) in patients on TPN specifically. Results: A total of 620 SAB cases were analyzed, of which 53 cases received TPN at the moment the blood culture was taken. Patients in the TPN group were more frequently female, younger and had less comorbidity (p < 0.001). In-hospital death and overall mortality were significantly lower in TPN patients (4% vs. 18%, p = 0.004 and 10% vs. 34%, p < 0.001, respectively). Positive follow-up blood cultures, delayed onset of therapy and previous catheter problems were associated with a higher incidence of complicated SAB outcome in patients on TPN. Conclusion: Our data show that patients on TPN have a milder course of SAB with lower mortality rates compared to non-TPN SAB patients.

Prevalence and Risk Factors of Total Parenteral Nutrition Induced Hyperglycemia at a Single Institution: Retrospective Study.

Background: Total parenteral nutrition (TPN) provides full nutrition support to critically ill patients with an impaired digestive tract. Patients who receive TPN support are at higher risk for complications such as hyperglycemia. In our study, we aim to assess the prevalence of hyperglycemia induced by TPN and identify its risk factors in hospitalized adult patients.Methods: Patients who received TPN between January 2012 and December 2017 at University of Pittsburgh Medical Center—St. Margaret hospital were retrospectively screened. TPN-induced hyperglycemia was confirmed whether blood glucose was ≥180 mg/dL at any point, from the time of TPN initiation until 1-day post TPN termination. Characteristics of the hyperglycemia and the nonhyperglycemia groups were analyzed to predict potential risk factors.Results: A total of 197 patients were screened, 55 were excluded (1 died, 37 diabetic, and 17 had elevated blood glucose before TPN), and 142 patients were included, 42 of them (29.6%) developed hyperglycemia following TPN administration. Duration of TPN, surgical indications, and obesity were significantly higher in the hyperglycemia group. Additionally, age and steroids use were independent predictors of hyperglycemia in TPN patients after applying multivariable logistic regression model on our sample.Conclusions: Hyperglycemia is common after TPN. Risk factors assessment may help optimizing glycemic control in higher risk individuals to improve their outcomes. These include patients with obesity, surgical indication of TPN, and longer duration of TPN.

The retrospective research of enteral nutrition with medium-chain triglyceride and total parenteral nutrition support of postoperative chylothorax in adults.

Background:Chylothorax is caused by thoracic lymphatic system injuries that leads to the lymph extravasating into the thoracic cavity. There are few reports comparing the therapeutic effects of enteral nutrition with medium-chain triglyceride and total parenteral nutrition, and the results are inconsistent. Our study aimed to research the optimum nutrition support method for chylothorax.Study design:We retrospectively reviewed 35 chylothorax patients after heart and chest surgery from 2014 to 2018, at West China Hospital of Sichuan University, among them there were 27 post-heart surgery patients. We analyzed the therapeutic effects and costs of enteral nutrition with medium-chain triglyceride (E group) and total parenteral nutrition (T group) for chylothorax.Results:The results were similar in patients with all surgeries and patients with only post heart surgery. The total cost during hospitalization in E group was higher than T group (P < 0.01), whereas the nutrition support cost was lower (P < 0.001). The length of hospital stay was longer in E group than T group (P > 0.05). Time from admission to surgery was shorter and from surgery to chylothorax diagnosis was longer in E group compared with T group. Time to resolution and removal of drainage was shorter in E group than T group but the differences were not significant.Conclusion:The therapeutic effects in enteral nutrition with medium-chain triglyceride and total parenteral nutrition had no obvious differences. Moreover, enteral nutrition with medium-chain triglyceride is safer and more economical. Therefore, we suggest that enteral nutrition with medium-chain triglyceride could be the first choice to treat postoperative chylothorax when the gastrointestinal tract function is allowed, and this result could be considered for postoperative chylous ascites.

P1.55: Does BMI Correlate with Enteral Autonomy Post Intestinal transplant?

Introduction: Intestinal transplant recipients often require total parenteral nutrition (TPN) support in the post-operative period until they achieve enteral autonomy. The time to enteral autonomy is a meaningful clinical outcome and indicator of successful graft function. Further, minimizing TPN exposure in the heavily immunosuppressed patient may mitigate infectious risk. TPN dependence after intestinal transplantation is variable and nutritional status at the time of transplant may be a determinant of the duration of TPN dependence. Body Mass Index (BMI) is one surrogate of nutritional status in the adult population. The aim of this study was to assess how BMI at the time of transplant impacts the duration of TPN after transplant. Methods: Adult patients who received an intestinal transplant at Georgetown University Hospital from 2006 to 2018, and survived beyond one year after transplant were retrospectively identified. BMI at the time of transplant was categorized based on current definitions (<18.5 indicates malnutrition, 18.5–24.9 healthy weight, 25–29.9 overweight, and >29.9 obesity), and compared to duration of TPN dependence in days. Results: 105 adult patients transplanted between 2006 and 2018 were included in the analysis. 51 of the patients were male and 54 were female. Median age was 43 years (range 18–66). Across all BMI categories the average days of TPN was 19.9 ± 12.6 days. Patients with a higher BMI at the time of transplant had the shortest duration of TPN post-transplant. Patients with a BMI of >30 (n= 11) had a mean of 16.1 ± 7.2 days; patients between 25–29.9 (n = 21) had an average of 18.9 ± 9.2 days; patients between 18.6–24.9 (n = 63) had an average of 20.6 ± 14.8 days; lastly, patients <18.5 (n = 10) had an average of 23.9 ± 8.7 days. There was a significant difference in duration of TPN in days between the <18.5 BMI and >30 BMI category (p=0.05) Conclusion: Achievement of enteral autonomy post-intestinal transplant is multifactorial. It is well established that post-transplant surgical and immunological complications are important factors that play a role in determining when TPN can be successfully weaned. Pre-transplant factors, however, may also contribute to enteral autonomy, such as recipient BMI at the time of transplant. Transplant practitioners should assist patients in avoiding a <18.5 BMI pre-transplant in order to potentially decrease the duration of TPN dependence post-transplant.

200.4: Serial Transverse Enteroplasty (STEP) for the Short Gut Syndrome (SGS) Patients with Gut Failure (GF)

Introduction: With recent evolution of gut rehabilitation, bowel lengthening is increasingly utilized to restore nutritional autonomy in patients with GF. This is the first largest single center experience with STEP particularly among adults with different causes of SGS including Crohn’s and allograft rejection. Methods: Over 7 years, 65 SGS-GF-patients received a total of 79 STEP procedures. Sixty one(94%) patients were adults and 4(6%) were children with an age ranging from 2 to 79 years. All patients suffered loss of nutritional autonomy with the requirement for total parenteral nutrition (TPN), or IVF-micronutrient replacement. The leading causes were vascular occlusion (n=22), surgical adhesions (n=13), and Crohn’s disease (n=12). Interestingly, the procedure was performed in an isolated intestinal allograft after partial recovery from acute rejection. The mean pre-STEP length of the residual bowel was 71 ± 13 cm with partially or fully preserved colon in 54(83%) and intact ileo-cecal valve in 14(22%) Reestablishment of gut continuity was accomplished preoperatively in 24(37%) and simultaneously performed in 41(63%). The procedure was reproducible in a total of 13(20%) patients. GLP2 was used as an adjunct therapy before and/or after the STEP procedure in 11(17%) patients. Results: With a total of 79 STEP-procedures and overall total number of 2 to 36 cuts, there was an increment in the bowel length ranging from 2 cm to 50 cm. The increase in the bowel length was influenced by length of the residual bowel, intestine diameter and the cumulative number of the transverse cuts. With a mean follow up of 19 ± 7 months, a total of 28(43%) patients achieved full nutritional autonomy with discontinuation of TPN therapy. The remaining 37(57%) experienced partial reduction in the TPN and IVF support. Length of residual bowel, volume/caloric contents of initial TPN therapy, and presence of the ileo-cecal valve were significant predictors of successful outcome. Conclusions: STEP along with autologous gut reconstruction is an effective bowel lengthening procedure for the management of SGS –GF patients. The operation is also technically feasible in Crohn’s disease patients and recipients of intestinal allografts.

Clinical efficacy of Da Vinci robot-assisted radical resection for right colon cancer

Objective To investigate the clinical efficacy of Da Vinci robot-assisted radical resection for right colon cancer. Methods The retrospective cross-sectional study was conducted. The clinical data of 85 patients with right colon cancer who were admitted to the First Hospital Affiliated to Army Medical University from August 2013 to February 2019 were collected. There were 56 males and 29 females, aged from 29 to 84 years, with an average age of 60 years. All patients underwent Da Vinci robot-assisted radical resection of right colon cancer, named right hemicolon D3 + complete mesocolic excision, and received infection prevention and total parenteral nutrition treatment after surgery. According to clinical pathological staging of guideline issued by National Comprehensive Cancer Network, patients underwent postoperative chemotherapy within 1 year after surgery. Observation indicators: (1) treatment status; (2) postoperative pathological examination; (3) follow-up. Follow-up was conducted using outpatient examination, telephone interview and mail every 3 months within 1 year after surgery, every 6 months from 1 to 3 years after surgery, and once a year from 3 to 5 years after surgery up to March 2019. The postoperative tumor metastasis and survival of patients were obtained. Measurement data with normal distribution were represented as Mean±SD, and measurement data with skewed distribution were described as M (range). Count data were expressed as absolute number. Survival rates were calculated using life-table method. Results (1) Treatment status: 85 patients underwent Da Vinci robot-assisted right hemicolon D3 + complete mesocolic excision successfully. The operation time, volume of intraoperative blood loss, time for postoperative out-of-bed activities, time to recovery of gastrointestinal function, time to liquid diet intake were (178±28)minutes, (85±33)mL, (2.9±1.8)days, (3.1± 2.7)days, (3.9±1.9)days, respectively. There was no perioperative death. Eleven patients had postoperative complications including 5 of anastomotic leakage, 2 of anastomotic bleeding, 2 of pulmonary infection, 1 of gastric emptying disorder and 1 of incomplete intestinal obstruction; they were cured and discharged after conservative treatment. All the 85 patients received postoperative infection prevention and total parenteral nutrition support, including 64 receiving systemic intravenous chemotherapy with 6-8 cycles of FOLFOX or XELOX, 7 receiving 6-8 cycles of oral capecitabine, and 14 receiving no chemotherapy. (2) Postoperative pathological examination: the number of harvested lymph nodes was 20±11 and 25 had lymph node metastasis. The length of proximal and distal cutting edge of the specimens was (16±5)cm and (9±5)cm, respectively. There was no cancerous cell on the cutting edge. High-differentiated adenocarcinoma, moderate-differentiated adenocarcinoma, moderate-differentiated tubular adenocarcinoma, low-differentiated adenocarcinoma, mucinous adenocarcinoma, tubular combined with mucinous adenocarcinoma were detected in 2, 40, 14, 16, 9, 4 patients, respectively. There were 8, 28, 24, 5, 12, 8 patients inⅠstage, ⅡA stage, ⅡB stage, ⅡC stage, ⅢB stage, ⅢC stage of TNM staging, respectively. (3) Follow-up: 85 patients were followed up for 1-67 months, with a median follow-up time of 19 months. During the follow-up, 1 of 85 patients had liver metastasis at 14 months after surgery and had survived after radiofrequency ablation treatment up to the end of follow-up. Three cases died of abdominal tumor metastases, 1 of which inⅡC stage died at 32 months after surgery, 1 in ⅢB stage died at 4 months after surgery and 1 in ⅢB stage died at 16 months after surgery. The 1-, 3-year overall survival rates were 97.1% and 94.0%, respectively. Conclusion Da Vinci robot-assisted radical resection of right colon cancer is safe and feasible, with good short- and long-term outcomes. Key words: Colon neoplasms; Right colon cancer; Right hemicolectomy; Da Vinci robotic surgical system; Prognosis

Effects of low nitrogen and low calorie parenteral nutrition combined with enteral nutrition on inflammatory factors and immune function in patients with gastric cancer

Objective To investigate the effect of low nitrogen and low calorie parenteral nutrition combined with enteral nutrition support on inflammatory factors and immune function in patients with gastric cancer. Methods From May 2013 to May 2015, ninety patients with gastric cancer underwent surgical treatment in the Affiliated Hospital of Yanbian University were selected in the research, and they were divided into control group and observation group according to different methods of nutritional support, with 45 cases in each group.The control group received total parenteral nutrition support, the observation group was given low nitrogen and low calorie parenteral nutrition and enteral nutrition support, and supplemented by targeted nursing measures.The changes of levels of inflammatory factors and immune proteins in the two groups before operation and 7d after operation were compared.All patients were followed up for 6 months, and the quality of life and nursing satisfaction rate were compared between the two groups. Results At 7d after operation, the levels of immunoglobulin IgA, IgM and IgG in the observation group were (2.62±0.43)g/L, (1.93±0.52)g/L, (14.58±3.32)g/L, respectively, which were significantly higher than those before operation [(2.01±0.30)g/L, (1.22±0.40)g/L, (12.42±5.64)g/L, t=7.805, 7.260, 2.214, all P<0.05] and those of the control group [(2.12±0.52)g/L, (1.53±0.41)g/L, (12.86±4.34)g/L, t=4.971, 4.052, 2.112, all P<0.05]. At 7d after operation, the levels of C reactive protein(CRP), tumor necrosis factor-α(TNF-α) in the observation group were (108.52±17.53)mg/L, (135.63±28.51)ng/L, respectively, which were lower than those before operation [(142.35±15.82)mg/L, (156.65±25.54)ng/L, t=9.611, 3.684, all P<0.05] and those of the control group[(135.68±14.54)mg/L, (145.52±27.53)ng/L, t=8.000, 3.824, all P<0.05], the level of interleukin-2(IL-2) was higher than those before operation[(65.71±10.23)ng/L vs.(54.32±7.83)ng/L, t=5.931, P<0.05] and that of control group[(57.62±5.86)ng/L, t=4.603, P<0.05]. At 6 months after operation, the quality of life scores of the observation group were higher than those of the control group(t=7.444, 6.892, 4.884, 5.957, 7.784, 12.992, 3.851, 6.706, all P<0.05). The nursing satisfaction rate of the observation group was 97.78%, which was higher than 82.22% of the control group (χ2=6.049, P<0.05). Conclusion Low nitrogen and low calorie parenteral nutrition combined with enteral nutrition support can effectively improve the immune function of patients with gastric cancer, reduce the inflammatory response and ensure the quality of life of the prognosis, which is suitable for clinical application. Key words: Parenteral nutrition; Enteral nutrition; Stomach neoplasms; Inflammation mediators; Immunologic

Clinical Characteristics of Children and Adolescents Undergoing Hematopoietic Cell Transplantation Who Develop Oral Mucositis.

To describe the clinical characteristics of children and adolescents undergoing hematopoietic cell transplantation (HCT) who develop oral mucositis. 45 patients who underwent HCT from July 2015 to May 2016 at St. Jude Children's Research Hospital in Memphis, Tennessee. Clinical factors were described as transplantation type, mucositis severity or grade, mucositis duration, days to engraftment, total parenteral nutrition (TPN) support, IV opioid pain management use during mucositis, positive blood or oral cultures, and length of hospitalization, then compared across mucositis grade. 24 patients had grade 3 or greater mucositis onset from day -3 to day 9 of transplantation; of these, 23 required IV opioid medication to treat mucosal pain. Patients with mucositis grade 3 or greater were more likely to have undergone an allogeneic transplantation, receive TPN, have documented positive blood or oral cultures, and have longer hospitalizations than those with low-grade mucositis. Nurses are in a unique position to propose and administer interventions to prevent and alleviate symptoms of mucositis.

Effet de la nutrition parentérale précoce : la cicatrisation et l’évolution des patients après sacrectomie

IntroductionSurgical site infection is one of the most common complications for patients after sacrectomy which often accompanied by poor wound healing, sinus formation and serious metabolic disturbance.Hypothesis We tried to avoid the surgical site infection caused by feces during early period after surgery through early fasting and total parenteral nutrition (TPN) support, then compared the clinical results of these patients with other patients that received enteral nutrition (EN) early after sacrectomy. MethodsForty-eight patients after sacrectomy (the level of sacrectomy above S2) were randomly divided into two groups: TPN group and EN group. The patients of two groups received different nutrition support from the first day to the seventh day after surgery, then the factors such as nutritional and metabolic status after surgery, incidence of complications as well as the time of incision healing and hospitalization were observed. ResultsThe p-value of total serum protein, albumin, serum alanine aminotransferase, total bilirubin at seventh day after sacrectomy between TPN group and EN group is<0.0005. The p-value of hemoglobin at seventh day after sacrectomy between TPN group and EN group is 0.001. The p-value of total serum protein at fourteenth day after sacrectomy between TPN group and EN group is 0.003. The p-value of albumin and total bilirubin at fourteenth day after sacrectomy between TPN group and EN group is 0.001. The p-value of hemoglobin, serum alanine aminotransferase at fourteenth day after sacrectomy between TPN group and EN group is<0.0005. The incidence of gastrointestinal complication and delay of apparition of feces in EN group were lower than that in TPN group (p=0.041, <0.0005). The incidence of surgical site infection, the time of incision healing and hospitalization in TPN group were lower than that in EN group (p=0.048, 0.008, <0.0005). ConclusionsThe method of fasting and supported by TPN during the early period after sacrectomy contribute to the incision healing, meanwhile, it shortens the hospitalization time and abates the incidence of complications in patients after sacrectomy. Type of studyIt is a comparative randomized study. Level of proofHigh-powered prospective randomized trial.

Early enteral nutrition and total parenteral nutrition on the nutritional status and blood glucose in patients with gastric cancer complicated with diabetes mellitus after radical gastrectomy.

Effects of early enteral nutrition (EEN) or total parenteral nutrition (TPN) support on nutritional status and blood glucose in patients with gastric cancer complicated with diabetes mellitus after radical gastrectomy were investigated. One hundred and twenty-nine patients with gastric cancer complicated with diabetes mellitus type 2 admitted to the First People's Hospital of Jinan (Jinan, China), from June 2012 to June 2016 were selected into the study. According to different nutrition support pathways, these patients were randomly divided into the EEN group and the TPN group. The improvement of nutritional indexes, postoperative complications, gastrointestinal function recovery and perioperative blood glucose fluctuation were compared between the two groups. On the 4th day after operation, the improvement levels of total bilirubin (TBL), alanine aminotransferase (ALT), aspartate transaminase (AST), total protein (TP), prealbumin (PAB), hemoglobin (HGB) and weight (Wt) in the EEN group were significantly higher than those in the conventional group (P<0.05). There were no significant differences between the two groups on the 8th day after operation (P>0.05). No patients had complications in the EEN group, while a total of 29 patients in the TPN group suffered adverse reactions, indicating that the incidence rate of complications in the EEN group was significantly lower than that in the TPN group (P<0.05). The postoperative evacuation time was earlier, hospitalization time was shorter and cost of postoperative hospitalization was less in the EEN group than those in the TPN group, and the differences were statistically significant (P<0.05). The blood glucose fluctuation values at fasting and 2 h after a meal in the TPN group were higher than those in the EEN group within 8 days after operation, and the differences were statistically significant (χ2=13.219, P=0.002; χ2=20.527, P<0.001). EEN support provides nutrition for patients with gastric cancer complicated with diabetes mellitus after radical gastrectomy, which is worthy of clinical promotion as it maintains good nutritional status, produces few postoperative complications and keeps the blood glucose level stable, by which the postoperative evacuation time is early, the hospitalization time is short and the cost is low.

Presentation and outcome of treatment of jejunoileal atresia in Nigeria.

Background:Intestinal atresia is a common cause of neonatal intestinal obstruction. Previous reports from Nigeria have indicated a high mortality rate. This is a report of current outcome review from one tertiary center.Patients and Methods:A retrospective analysis of infants managed for jejunoileal atresia in 10 years (2005–2014). The information retrieved from patients’ records was analyzed using SPSS 17.Results:There were 38 patients (19 boys and 19 girls) aged 1–28 days (median 4 days). Twenty-four patients (63.2%) presented after 48 h of life. Twenty-five (65.8%) had jejunal atresia and 13 (34.2%) had ileal atresia. Six patients had associated anomalies. The most common atresia was type III (39.5%, 15 patients). Twenty-eight (73.7%) patients had a resection of the atresia and anastomosis and others had enterostomies. Total parenteral nutrition and neonatal intensive care support were not available during the period of the study. Bowel function was established within 1 week and 27 (71.1%) patients commenced oral feeding. Twenty-six (68.4%) patients had postoperative complications resulting in prolonged hospital stay of 2–44 days (median = 13). Mortality was 34.2% (13 patients). Factors that significantly affected mortality were intestinal necrosis at presentation, postoperative complications, and severe malnutrition.Conclusion:Intestinal atresia is still associated with unacceptably high morbidity and mortality, due to late presentation, and lack neonatal intensive care services and parenteral nutritional support. Efforts need to be intensified to address these factors to improve outcome.

Supplementary choline attenuates olive oil lipid emulsion-induced enterocyte apoptosis through suppression of CELF1/AIF pathway.

Enterocyte apoptosis induced by lipid emulsions is a key cause of intestinal atrophy under total parenteral nutrition (TPN) support, and our previous work demonstrated that olive oil lipid emulsion (OOLE) could induce enterocyte apoptosis via CUGBP, Elav‐like family member 1 (CELF1)/ apoptosis‐inducing factor (AIF) pathway. As TPN‐associated complications are partially related to choline deficiency, we aimed to address whether choline supplementation could attenuate OOLE‐induced enterocyte apoptosis. Herein we present evidence that supplementary choline exhibits protective effect against OOLE‐induced enterocyte apoptosis both in vivo and in vitro. In a rat model of TPN, substantial reduction in apoptotic rate along with decreased expression of CELF1 was observed when supplementary choline was added to OOLE. In cultured Caco‐2 cells, supplementary choline attenuated OOLE‐induced apoptosis and mitochondria dysfunction by suppressing CELF1/AIF pathway. Compared to OOLE alone, the expression of CELF1 and AIF was significantly decreased by supplementary choline, whereas the expression of Bcl‐2 was evidently increased. No obvious alterations were observed in Bax expression and caspase‐3 activation. Mechanistically, supplementary choline repressed the expression of CELF1 by increasing the recruitment of CELF1 mRNA to processing bodies, thus resulting in suppression of its protein translation. Taken together, our data suggest that supplementary choline exhibits effective protection against OOLE‐induced enterocyte apoptosis, and thus, it has the potential to be used for the prevention and treatment of TPN‐induced intestinal atrophy.

Case 4: A Preterm Infant with a Necrotic Ulcer Over the Perianal Area

A 1.07-kg male infant with severe growth restriction is born at 30 weeks’ gestational age to a 36-year-old gravida 3, para 2 mother by emergency cesarean delivery for nonreassuring heart tracing. The parents are of low socioeconomic status and are first-degree consanguineous relatives. The mother received steroids and her membranes ruptured at delivery. At birth, the infant’s cord clamping was delayed, and after an initial weak cry he underwent intubation for poor respiratory efforts. Apgar scores were 4 and 7 at 1 and 5 minutes, respectively. His initial stabilization included surfactant administration, mechanical ventilation with volume guarantee, catheter line placement (umbilical venous and arterial catheters), initiation of total parenteral nutrition, antibiotics, and inotropic support. On day 3, he underwent extubation and received noninvasive intermittent positive pressure ventilation (NIPPV), inotropic support was discontinued, and antibiotics were stopped, because his blood culture was sterile. He demonstrated steady clinical improvement in the next 3 days, was weaned from NIPPV to nasal continuous positive pressure, and nasogastric feeds progressed gradually. On day 6, the bedside nurse noticed a small macule and blister with surrounding erythema over the lateral aspect of his right thigh, which progressed rapidly in hours to blackish-gray discoloration of skin in an area 4 × 1 cm in size with a small hemorrhagic lesion in the center (Fig 1). The infant’s clinical condition worsened rapidly in the next 24 hours; he became lethargic, hypothermic, tachycardic, hypotensive with poor perfusion, and apneic with increased oxygen requirement. He underwent elective reintubation for recurrent apnea and mixed respiratory and metabolic acidosis. A limited sepsis screening (complete blood cell count and cultures from blood, skin wound, and urine) was performed. Empiric antibiotic treatment with piperacillin-tazobactam was commenced. The infant received a bolus of normal saline, and dopamine treatment was commenced for low mean blood pressure. …

Parenteral nutrition combined with enteral feeding improves the outcome of cancer patients.

This study investigated whether total parenteral nutrition combined with enteral nutrition is associated with improved biochemical and clinical outcomes in cancer patients with gastrointestinal dysfunction. From January to December 2014, the clinical data of 68 patients in a cancer ward were retrospectively collected, and these patients were classified into two groups according to nutrition delivery, through parenteral nutrition, combined with enteral nutrition more (group A) or less (group B) than 250 kcal/day. The following variables were analyzed: the route and percentage of nutritional support, total caloric intake, age, gender, body weight, body mass index, diagnosis at admission, complications of intestinal failure, modified Glasgow Prognostic Score, co-morbidities, duration of total parenteral nutrition support, performance status scale, and plasma nutritional markers. A significant difference was observed between the two groups in functional capacity, including the Karnofsky index, World Health Organization/Eastern Cooperative Oncology Group score, body-weight loss, and serum albumin levels. However, no significant difference was observed in the modified Glasgow Prognostic Score. Cancer patients receiving total parenteral nutrition who were fed enterally more than 250 kcal/d exhibited more favorable clinical outcomes than those who were fed enterally less than 250 kcal/d. Enteral nutrition should be considered for these severely ill patients.

Epidemiology and outcome of acute pancreatitis in end-stage renal disease dialysis patients: a 10-year national cohort study.

The objective of this study is to determine the incidence and severity of acute pancreatitis (AP) in patients with end-stage renal disease (ESRD) on dialysis and whether the dialysis modality [hemodialysis (HD) versus peritoneal dialysis (PD)] confers a higher risk for AP as well as complications or mortality related to AP. We analyzed national health insurance claims data of 67 078 ESRD patients initiating dialysis between 1999 and 2007 in Taiwan. All patients were followed up from the start of their dialysis to first AP diagnosis, death, end of dialysis or 31 December 2008. Cox proportional hazards models were used to identify risk factors. The cumulative incidence rates of AP were 0.6, 1.7, 2.6, 3.4 and 4% at 1, 3, 5, 7 and 9 years, respectively. ESRD patients on HD and PD had an AP incidence of 5.11 and 5.86 per 1000 person-years, respectively. Independent risk factors for AP in this population were being elderly, being female, having biliary stones or liver disease, and being on PD. Severe AP occurred in 44.9% of the HD patients and in 36% of the PD patients. Patients with AP on HD had a higher incidence of upper gastrointestinal (UGI) bleeding than those on PD (P = 0.002). In contrast, those with AP on PD had a higher incidence of need for total parenteral nutrition (TPN) support than those on HD (P = 0.072). Overall in-hospital mortality was 8.1%. The risk factors for mortality after an AP attack were male gender, increased age, AP severity, and the presence of diabetes mellitus or liver disease. ESRD patients on PD were at higher risk for AP than those on HD. HD patients with AP attacks had a greater incidence of UGI bleeding and PD patients with AP attacks a more frequent need for TPN support.