101
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Barlow R, Price P, Reid TD, Hunt S, Clark GWB, Havard TJ, Puntis MCA, Lewis WG. Prospective multicentre randomised controlled trial of early enteral nutrition for patients undergoing major upper gastrointestinal surgical resection. Clin Nutr 2011; 30:560-6. [PMID: 21601319 DOI: 10.1016/j.clnu.2011.02.006] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2010] [Revised: 01/25/2011] [Accepted: 02/23/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The evidence in support of Early Enteral Nutrition (EEN) after upper gastrointestinal surgery is inconclusive. The aim of this study was to determine if EEN improved clinical outcomes and shortened length of hospital stay. METHODS Open, prospective multicentre randomised controlled trial within a regional UK Cancer Network. One hundred and twenty-one patients with suspected operable upper gastrointestinal cancer (54 oesophageal, 38 gastric, 29 pancreatic) were studied. Patients were randomised to receive EEN (n = 64) or Control management postoperatively (nil by mouth and IV fluid, n = 57). Analysis was based on intention-to-treat and the primary outcome measure was length of hospital stay. RESULTS Operative morbidity was less common after EEN (32.8%) than Control management (50.9%, p = 0.044), due to fewer wound infections (p = 0.017), chest infections (p = 0.036) and anastomotic leaks (p = 0.055). Median length of hospital stay was 16 days (IQ = 9) after EEN compared with 19 (IQ = 11) days after Control management (p = 0.023). CONCLUSIONS EEN was associated with significantly shortened length of hospital stay and improved clinical outcomes. These findings reinforce the potential benefit of early oral nutrition in principle and as championed within enhanced recovery after surgery programmes, and such strategies deserve further research in the arena of upper GI surgery.
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102
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Omata J, Fukatsu K, Murakoshi S, Moriya T, Ueno C, Maeshima Y, Okamoto K, Saitoh D, Yamamoto J, Hase K. Influence of Adding Pyrroloquinoline Quinone to Parenteral Nutrition on Gut-Associated Lymphoid Tissue. JPEN J Parenter Enteral Nutr 2011; 35:616-24. [DOI: 10.1177/0148607110395512] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Jiro Omata
- Department of Surgery, National Defense Medical College, Tokorozawa, Japan
| | | | - Satoshi Murakoshi
- Division of Traumatology, National Defense Medical College Research Institute, Tokorozawa, Japan
| | - Tomoyuki Moriya
- Department of Surgery, National Defense Medical College, Tokorozawa, Japan
| | - Chikara Ueno
- Department of Surgery, National Defense Medical College, Tokorozawa, Japan
| | - Yoshinori Maeshima
- Department of Surgery, National Defense Medical College, Tokorozawa, Japan
| | - Koichi Okamoto
- Department of Surgery, National Defense Medical College, Tokorozawa, Japan
| | - Daizoh Saitoh
- Division of Traumatology, National Defense Medical College Research Institute, Tokorozawa, Japan
| | - Junji Yamamoto
- Department of Surgery, National Defense Medical College, Tokorozawa, Japan
| | - Kazuo Hase
- Department of Surgery, National Defense Medical College, Tokorozawa, Japan
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103
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Fukatsu K, Tanabe K, Maeshima Y, Omata J, Yasuhara H, Saitoh D. Neutrophil elastase inhibitor restores gut ischemia reperfusion-induced impairment of gut immunity with reduced plasma interleukin-6 concentrations in mice. Surg Infect (Larchmt) 2011; 11:517-22. [PMID: 20969469 DOI: 10.1089/sur.2010.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND PURPOSE Gut-associated lymphoid tissue (GALT) is regarded as central mucosa-associated lymphoid tissue that influences systemic mucosal immunity. Our previous study revealed that gut ischemia and reperfusion (I/R) reduces GALT lymphocyte numbers. Because gut hypoperfusion frequently occurs in trauma, shock, and surgery patients, establishment of a therapeutic method to preserve GALT mass after gut I/R may be important for the prevention of infections. We examined the effects of sivelestat sodium hydrate, a selective inhibitor of neutrophil elastase, on GALT mass and plasma cytokine concentrations in a murine gut I/R model. METHODS Seventy male ICR mice were randomized to the control (n = 34) or the sivelestat (n = 36) group. After intravenous cannulation of the animals, the superior mesenteric artery was occluded for 60 min. After reperfusion, physiologic saline or sivelestat 5 mg/kg hourly was infused for 24 h. Sixteen mice in the control and 22 in the sivelestat group were alive at 24 h. Twenty-six mice (n = 13 in each group) were chosen randomly for harvest of the small intestine. Lymphocytes from Peyer patches (PP), the intraepithelial space (IE), and the lamina propria (LP) were counted; and their phenotypes (αβT-cell receptor (TCR), γδTCR, CD4, CD8, B cell) were determined by flow cytometry. Cytokine concentrations (interleukin [IL]-6, IL-1β, IL-10) in the plasma and bronchoalveolar lavage fluid were measured by enzyme-linked immunosorbent assay. RESULTS Sivelestat treatment did not improve survival but increased PP and IE lymphocyte numbers significantly and reduced the LP CD8(+) cell percentage and plasma IL-6 concentration compared with controls. There were no significant differences between the two groups in other cell phenotypes or cytokine concentrations. CONCLUSION Sivelestat treatment after gut I/R may be useful for maintaining gut immunity and preventing systemic inflammatory responses.
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104
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Siggers RH, Siggers J, Thymann T, Boye M, Sangild PT. Nutritional modulation of the gut microbiota and immune system in preterm neonates susceptible to necrotizing enterocolitis. J Nutr Biochem 2010; 22:511-21. [PMID: 21193301 DOI: 10.1016/j.jnutbio.2010.08.002] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2010] [Accepted: 08/23/2010] [Indexed: 02/07/2023]
Abstract
The gastrointestinal inflammatory disorder, necrotizing enterocolitis (NEC), is among the most serious diseases for preterm neonates. Nutritional, microbiological and immunological dysfunctions all play a role in disease progression but the relationship among these determinants is not understood. The preterm gut is very sensitive to enteral feeding which may either promote gut adaptation and health, or induce gut dysfunction, bacterial overgrowth and inflammation. Uncontrolled inflammatory reactions may be initiated by maldigestion and impaired mucosal protection, leading to bacterial overgrowth and excessive nutrient fermentation. Tumor necrosis factor alpha, toll-like receptors and heat-shock proteins are identified among the immunological components of the early mucosal dysfunction. It remains difficult, however, to distinguish the early initiators of NEC from the later consequences of the disease pathology. To elucidate the mechanisms and identify clinical interventions, animal models showing spontaneous NEC development after preterm birth coupled with different forms of feeding may help. In this review, we summarize the literature and some recent results from studies on preterm pigs on the nutritional, microbial and immunological interactions during the early feeding-induced mucosal dysfunction and later NEC development. We show that introduction of suboptimal enteral formula diets, coupled with parenteral nutrition, predispose to disease, while advancing amounts of mother's milk from birth (particularly colostrum) protects against disease. Hence, the transition from parenteral to enteral nutrition shortly after birth plays a pivotal role to secure gut growth, digestive maturation and an appropriate response to bacterial colonization in the sensitive gut of preterm neonates.
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MESH Headings
- Animals
- Animals, Newborn
- Enterocolitis, Necrotizing/etiology
- Enterocolitis, Necrotizing/immunology
- Enterocolitis, Necrotizing/microbiology
- Gastrointestinal Tract/growth & development
- Gastrointestinal Tract/immunology
- Gastrointestinal Tract/microbiology
- Heat-Shock Proteins/metabolism
- Humans
- Immune System/immunology
- Infant Nutritional Physiological Phenomena
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/etiology
- Infant, Premature, Diseases/immunology
- Infant, Premature, Diseases/microbiology
- Intestinal Mucosa/immunology
- Intestinal Mucosa/microbiology
- Intestine, Small/metabolism
- Metagenome/physiology
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Affiliation(s)
- Richard H Siggers
- Department of Human Nutrition, Faculty of Life Sciences, University of Copenhagen, 30 Rolighedsvej, DK-1958 Frederiksberg C, Denmark
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105
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Jonker MA, Hermsen JL, Gomez FE, Sano Y, Kudsk KA. Injury induces localized airway increases in pro-inflammatory cytokines in humans and mice. Surg Infect (Larchmt) 2010; 12:49-56. [PMID: 21166596 DOI: 10.1089/sur.2010.040] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Secretory immunoglobulin A (sIgA) increases in the airways of humans and mice after injury to protect against infection. The pro-inflammatory cytokines tumor necrosis factor (TNF)-α, interleukin (IL)-1β, and IL-6 are linked molecularly to sIgA production and secretion and are required for sIgA increases in the airway after injury in a mouse model. We investigated the injury effect on airway and serum concentrations to determine the source of the cytokines involved in the airway IgA response. METHODS In the first experiment, TNF-α, IL-1β, and IL-6 concentrations in bronchoalveolar lavage (BAL) fluid and serum obtained from 11 ventilated trauma patients within 30 h of admission were compared with those in eight elective surgical patients. In the second experiment, male ICR mice received no injury (n = 7) or injury with sham celiotomy and neck incisions (n = 8) with sacrifice of all animals at 8 h for BAL fluid and serum cytokine measurements by enzyme-linked immunosorbent assay. RESULTS Injured patients had significantly higher BAL fluid and serum TNF-α, IL-1β, and IL-6 concentrations, with greater increases in the BAL fluid than in the serum. Injured mice had significantly increased BAL fluid concentrations of TNF-α, IL-1β, and IL-6 without significant changes in serum TNF-α or IL-1β. Serum IL-6 increased significantly. CONCLUSIONS Injury significantly increases human and mouse airway TNF-α, IL-1β, and IL-6. Increases are greater in the airway than in serum, implying a local rather than a systemic stress response to injury.
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Affiliation(s)
- Mark A Jonker
- Surgical Services, William S. Middleton Memorial Veterans Hospital, Madison, WI 53792, USA
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106
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Jonker MA, Hermsen JL, Sano Y, Heneghan AF, Lan J, Kudsk KA. Small intestine mucosal immune system response to injury and the impact of parenteral nutrition. Surgery 2010; 151:278-86. [PMID: 21145571 DOI: 10.1016/j.surg.2010.10.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2010] [Accepted: 10/19/2010] [Indexed: 01/15/2023]
Abstract
BACKGROUND Both humans and mice increase airway immunoglobulin A (IgA) after injury. This protective response is associated with TNF-α, IL-1β, and IL-6 airway increases and in mice is dependent upon these cytokines as well as enteral feeding. Parenteral nutrition (PN) with decreased enteral stimulation (DES) alters gut barrier function, decreases intestinal IgA, and decreases the principal IgA transport protein pIgR. We investigated the small intestine (SI) IgA response to injury and the role of TNF-α, IL-1β, IL-6, and PN/DES. METHODS Expt 1: Murine kinetics of SI washing fluid (SIWF) IgA; SI, SIWF and serum TNF-α, IL-1β, and IL-6, was determined by ELISA from 0 to 8 hours after a limited surgical stress injury (laparotomy and neck incisions). Expt 2: Mice received chow or PN/DES before injury and SIWF IgA and SI pIgR levels were determined at 0 and 8 hours. Expt 3: Mice received PBS, TNF-α antibody, or IL-1β antibody 30 minutes before injury to measure effects on the SIWF IgA response. Expt 4: Mice received injury or exogenous TNF-α, IL-1β, and IL-6 to measure effects on the SIWF IgA response. RESULTS Expt 1: SIWF IgA levels increased significantly by 2 hours after injury without associated increases in TNF-α or IL-1β whereas IL-6 was only increased at 1 hour after injury. Expt 2: PN/DES significantly reduced baseline SIWF IgA and SI pIgR and eliminated their increase after injury seen in Chow mice. Expt 3: TNF-α and IL-1β blockade did not affect the SIWF IgA increase after injury. Expt 4: Exogenous TNF-α, IL-1β, and IL-6 increased SIWF IgA similarly to injury. CONCLUSION The SI mucosal immune responds to injury or exogenous TNF-α, IL-1β, and IL-6 with an increase in lumen IgA, although it does not rely on local SI increases in TNF-α or IL-1β as it does in the lung. Similar to the lung, the IgA response is eliminated with PN/DES.
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Affiliation(s)
- Mark A Jonker
- Surgical Service and Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, WI, USA
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107
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Proinflammatory cytokine surge after injury stimulates an airway immunoglobulin a increase. ACTA ACUST UNITED AC 2010; 69:843-8. [PMID: 20173656 DOI: 10.1097/ta.0b013e3181c45284] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND : Injury stimulates an innate airway IgA response in severely injured patients, which also occurs in mice. Tumor necrosis factor (TNF)-α and interleukin (IL)-1β stimulate the production of polymeric immunoglobulin receptor, the protein required to transport immunoglobulin A (IgA) to mucosal surfaces. Blockade of TNF-α and IL-1β eliminates the airway IgA response to injury. IL-6 stimulates differentiation of B cells into IgA-secreting plasma cells at mucosal sites. We investigated the local and systemic kinetics of TNF-α, IL-1β, and IL-6 after injury in mice. We also hypothesized that injection of exogenous TNF-α, IL-1β, and IL-6 would replicate the airway IgA response to injury. METHODS : Experiment 1: male Institute of Cancer Research mice were randomized to uninjured controls (n = 8) or to surgical stress with laparotomy and neck incisions, with killing at 1, 2, 3, 5, or 8 hours after injury (n = 8/group). Bronchoalveolar lavage (BAL) and serum levels of TNF-α, IL-1β, and IL-6 were analyzed by enzyme-linked immunosorbent assay. Experiment 2: male Institute of Cancer Research mice were randomized to uninjured controls (n = 6), injury (surgical stress that was similar to experiment 1 except the peritoneum was left intact, n = 6), or cytokine injection with intraperitoneal injection of recombinant TNF-α, IL-1β, and IL-6. Animals were killed at 2 hours after injury, and nasal airway lavage and BAL IgA were analyzed by enzyme-linked immunosorbent assay. RESULTS : Experiment 1: BAL TNF-α, IL-1β, and IL-6 levels increased in bimodal pattern after injury at 3 hours and 8 hours versus controls (p < 0.05). Serum IL-6 did not increase at 3 hours, but did show a significant increase by 5 hours versus control (p < 0.05). Serum levels of TNF-α and IL-1β did not change. Experiment 2: both Injury and combination TNF-α, IL-1β, and IL-6 cytokine injection significantly increased IgA levels in airway lavage (BAL + nasal airway lavage) compared with control (p < 0.01 for both). CONCLUSIONS : Airway levels of TNF-α, IL-1β, and IL-6 increase in a bimodal pattern after injury with peaks at 3 hours and 8 hours, which do not correspond to serum changes. The peak at 8 hours is consistent with the known increase in airway IgA after injury. Intraperitoneal injection of a combination exogenous TNF-α, IL-1β, and IL-6 replicates the airway IgA increase after injury. This effect is not seen with individual cytokine injections.
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108
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Boukhettala N, Ibrahim A, Aziz M, Vuichoud J, Saudan KY, Blum S, Déchelotte P, Breuillé D, Coëffier M. A diet containing whey protein, free glutamine, and transforming growth factor-beta ameliorates nutritional outcome and intestinal mucositis during repeated chemotherapeutic challenges in rats. J Nutr 2010; 140:799-805. [PMID: 20181781 DOI: 10.3945/jn.109.119222] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Anticancer chemotherapy often induces side effects such as mucositis. Recent data suggest that a diet, Clinutren Protect (CP), containing whey proteins, glutamine, and transforming growth factor-beta (TGFbeta)-rich casein limits intestinal mucositis and improves recovery after a single methotrexate (MTX) challenge in rats. Chemotherapy consists of alternating periods of treatment and rest. Thus, our study evaluated the effects of CP on nutritional outcome and intestinal mucositis in rats receiving repeated chemotherapeutic challenges. Thirty-six Sprague-Dawley rats received 3 cycles of MTX at 8-d intervals. Rats had free access to CP or control diet (Co) from 7 d before the first MTX injection until the end of the experiment at d 27. In Co, whey proteins and TGFbeta-rich casein were replaced by TGFbeta-free casein. L-Glutamine was replaced by L-alanine. Body composition was assessed by dual energy X-ray absorptiometry. Before MTX challenges, food intake and body weight were similar in both groups but became higher during MTX challenges in CP (P < 0.05). Fat mass decreased similarly in both groups. In contrast, the decrease of fat free mass between d -1 and d 27 was less pronounced in the CP group (-9.5 g) than in the Co group (-57.2 g) (P < 0.05). The intestinal damage score was lower in the CP group (0.6 +/- 0.3 vs. 2.1 +/- 0.6; P < 0.05). Fecal IgA increased over time in the CP group (P < 0.05) but not in the Co group. A diet containing whey proteins, glutamine, and TGFbeta improves nutritional outcome by limiting the reduction of fat free mass and reduces intestinal mucositis during repeated chemotherapeutic challenges in rats.
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109
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Che L, Thymann T, Bering SB, LE Huërou-Luron I, D'inca R, Zhang K, Sangild PT. IUGR does not predispose to necrotizing enterocolitis or compromise postnatal intestinal adaptation in preterm pigs. Pediatr Res 2010; 67:54-9. [PMID: 19816236 DOI: 10.1203/pdr.0b013e3181c1b15e] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
IUGR and preterm birth are leading causes of neonatal morbidity. We tested the hypothesis that IUGR predisposes to gut maladaption and necrotizing enterocolitis (NEC) using preterm pigs as models for preterm infants. First, full-term normal birth weight (NW) and IUGR ( approximately 65% of NW) pigs were compared. IUGR reduced intestinal weight per length, proportion mucosa, villous area, and sucrase activity at 2 d after birth (p < 0.05) but did not change relative organ weights. Next, groups of preterm pigs were fed formula or colostrum, starting at birth or after 2-3 d of total parenteral nutrition (TPN). Neonatal mortality (not related to NEC) was increased in IUGR versus NW preterm pigs (28 vs 10%, p < 0.01). NEC incidence was similar between IUGR and NW but higher after formula than colostrum feeding (46 vs 12%, p < 0.01) and higher after TPN than without TPN (61 vs 34% for formula pigs, p < 0.01). After feeding, relative intestinal mass and length were higher in IUGR versus NW pigs (+25-80%, p < 0.05) while brush border enzyme activities were similar. An enhanced gut trophic response to enteral feeding may help to improve postnatal intestinal adaptation and NEC resistance in preterm IUGR newborns.
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Affiliation(s)
- Lianqiang Che
- Institute of Animal Nutrition, Sichuan Agricultural University, Sichuan, 625014, People's Republic of China
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110
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Su Y, Wu S, Fan Y, Jin J, Zhang Z. The preliminary experimental and clinical study of the relationship between the pigment gallstone and intestinal mucosal barrier. J Gastroenterol Hepatol 2009; 24:1451-6. [PMID: 19486450 DOI: 10.1111/j.1440-1746.2009.05842.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
AIMS To investigate the relations between the formation of pigment gallstone and the function of the intestinal mucosal barrier, as well as the underlying mechanism. METHODS Eighty guinea pigs were randomly divided into three groups in which they were respectively given normal diet, gallstone-causing diet, and gallstone-formation diet with a supplementary intestinal mucosal protection compound known as glutamine. The model of pigment gallstone was established after 8 weeks of dietary administration. Indices about the function of the intestinal mucosal barrier and bacterial translocation were measured. Clinical cases were divided into three groups: control, cholesterol gallstone, and pigment gallstone, where the levels of plasma diamine oxidase (DAO), plasma endotoxin and the excretion rates of technetium 99m-diethylene triamine pentaacetic acid (99mTC-DTPA) in the urine of each group were measured. RESULTS In the pigment gallstone group, the level of plasma DAO and endotoxin, the excretory ratio of lactulose and mannitol in urine, the bacterial translocation ratio in the celiac lymph nodes and the activities of beta-glucuronidase increased comparing to the control group. The gallstone-formation rate for the intestinal mucosal protection group (GLN) decreased, and other indices, except the activity of beta-glucuronidase, were all lower than that of gallstone-formation group. In the clinical experiment, the levels of plasma DAO and endotoxin, as well as the excretory rate of 99mTC-DTPA in urine were higher in the patients with gallstones than that in the control group. CONCLUSIONS The formation of pigment gallstone was related to the abnormal function of the intestinal mucosal barrier. The abnormality in the function of the intestinal mucosal barrier probably induced the formation of gallstone by a bacterial translocation mechanism.
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Affiliation(s)
- Yang Su
- Department of First Micro-injury and Biliary Surgery, Shenjing Hospital of China Medical University, Shenyang, China
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111
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McClave SA, Heyland DK. The physiologic response and associated clinical benefits from provision of early enteral nutrition. Nutr Clin Pract 2009; 24:305-15. [PMID: 19483060 DOI: 10.1177/0884533609335176] [Citation(s) in RCA: 170] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Provision of enteral nutrition (EN) to critically ill patients early upon admission to the intensive care unit exerts a beneficial physiologic effect that downregulates systemic immune responses, reduces oxidative stress, and improves patient outcome. Adding specific pharmaconutrient agents to EN in certain patient populations has a synergistic effect, magnifying the degree of this favorable physiologic response. In contrast, failure to provide enteral nutrients creates a physiologic profile that exacerbates oxidative stress and increases the systemic inflammatory response syndrome. Unfortunately, parenteral nutrition (PN) in the form and manner currently provided in North America does not appear to mimic the same physiologic response seen with EN. In the future, use of alternative fuel sources, steps to promote better tolerance of EN, and innovative strategies for delivery of both EN and PN may serve to further enhance the physiologic effect of nutrition therapy and to achieve even greater improvement in patient outcome.
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Affiliation(s)
- Stephen A McClave
- Division of Gastroenterology/Hepatology, University of Louisville, 550 S. Jackson St, Louisville, KY 40202, USA.
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112
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Hermsen JL, Gomez FE, Sano Y, Kang W, Maeshima Y, Kudsk KA. Parenteral feeding depletes pulmonary lymphocyte populations. JPEN J Parenter Enteral Nutr 2009; 33:535-40. [PMID: 19556609 DOI: 10.1177/0148607109332909] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The effect of parenteral nutrition (PN) on lymphocyte mass in the lung is unknown, but reduced mucosal lymphocytes are hypothesized to play a role in the reduced immunoglobulin A-mediated immunity in both gut and lung. The ability to transfer and track cells between mice may allow study of diet-induced mucosal immune function. The objectives of this study are to characterize lung T-cell populations following parenteral feeding and to study distribution patterns of transferred donor lung T cells in recipient mice. METHODS In experiment 1, cannulated male Balb/c mice are randomized to receive chow or PN for 5 days. Lung lymphocytes are obtained via collagenase digestion, and flow cytometric analysis is used to identify total T (CD3+) and B (CD45/B220+) cells. In experiment 2, isolated lung T cells from chow-fed male Balb/c mice are pooled and labeled in vitro with a fluorescent dye (carboxyfluorescein diacetate succinimidyl ester [CFSE]), and 1.1 x 10(8) CFSE+ cells (3.1 x 10(6) T cells) are transferred to chow-fed Balb/c recipients. Cells recovered from recipient lungs and intestinal lamina propria (LP) are analyzed by flow cytometry to determine CFSE/CD3+ T cells at 1, 2, and 7 days. In experiment 3, cells are transferred to PN-fed recipients. RESULTS In experiment 1, PN significantly decreases lung T- and B-cell populations compared with chow feeding. In experiment 2, CFSE+ T-cell retention is highest on day 1 in lung and LP, and decreases on day 2. Cells are gone by day 7; 98.1% of retained donor lung T cells migrate to recipient lungs and 1.9% to the intestine on day 1. Similar results are seen in experiment 3 after transfer of cells to PN-fed recipients. CONCLUSIONS PN reduces pulmonary lymphocyte populations consistent with impaired respiratory immunity. Transferred lung T cells preferentially localize to recipient lungs rather than intestine with maximal accumulation at 24 hours. Limited cross-talk of transferred lung T cells to the intestine indicates that mucosal lymphocyte traffic might be programmed to localize to specific effector sites.
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Affiliation(s)
- Joshua L Hermsen
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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113
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Formaggini L. Normograde, minimally invasive technique for oesophagostomy in cats. J Feline Med Surg 2009; 11:481-6. [PMID: 19119035 PMCID: PMC10832833 DOI: 10.1016/j.jfms.2008.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2008] [Indexed: 01/15/2023]
Abstract
A percutaneous technique to place oesophageal feeding tubes in cats is described. Nineteen traumatised cats underwent different surgical procedures for facial and/or oral trauma and subsequent oesophagostomy. The tube placement was easy to perform, requiring a 14G over-the-needle vascular catheter, a curved forceps and a 1.2mm feeding tube. During insertion, the tube was directed aborally (normograde direction) to its definitive position in a one-step procedure. The tube was removed when the patient started to eat voluntarily. A major limit of this technique was represented by the small diameter of the feeding tube, requiring the use of a liquid diet. However, considering the absence of complications, the rapidity of the procedure and its cost efficacy, it was considered as an effective alternative to more complicated and invasive techniques, in particular if a short period of starvation is predictable.
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Affiliation(s)
- Luca Formaggini
- 'Lago Maggiore' Veterinary Clinic, Corso Cavour 3, 28040 Dormelletto (NO), Italy
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114
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McClave SA, Martindale RG, Vanek VW, McCarthy M, Roberts P, Taylor B, Ochoa JB, Napolitano L, Cresci G. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient:. JPEN J Parenter Enteral Nutr 2009; 33:277-316. [DOI: 10.1177/0148607109335234] [Citation(s) in RCA: 1284] [Impact Index Per Article: 85.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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115
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Affiliation(s)
- Urban Flaring
- Department of Paediatric Anaesthesia and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska Hospital, Stockholm, Sweden.
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116
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Hermsen JL, Sano Y, Kudsk KA. Food fight! Parenteral nutrition, enteral stimulation and gut-derived mucosal immunity. Langenbecks Arch Surg 2009; 394:17-30. [PMID: 18521625 PMCID: PMC2739933 DOI: 10.1007/s00423-008-0339-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2008] [Accepted: 03/18/2008] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Nutrition support is an integral component of modern patient care. Type and route of nutritional support impacts clinical infectious outcomes in critically injured patients. DISCUSSION This article reviews the relationships between type and route of nutrition and gut-derived mucosal immunity in both the clinical and laboratory settings.
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Affiliation(s)
- Joshua L Hermsen
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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117
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Kudsk KA. Jonathan E Rhoads lecture: Of mice and men... and a few hundred rats. JPEN J Parenter Enteral Nutr 2008; 32:460-73. [PMID: 18596320 DOI: 10.1177/0148607108319795] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Kenneth A Kudsk
- Veterans Administration Surgical Services, William S Middleton Memorial Veterans Hospital Madison and the Department of Surgery, The University of Wisconsin-Madison. Madison, WI 53792-7375, USA.
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Braga-Neto MB, Warren CA, Oriá RB, Monteiro MS, Maciel AAS, Brito GAC, Lima AAM, Guerrant RL. Alanyl-glutamine and glutamine supplementation improves 5-fluorouracil-induced intestinal epithelium damage in vitro. Dig Dis Sci 2008; 53:2687-96. [PMID: 18320312 PMCID: PMC4003886 DOI: 10.1007/s10620-008-0215-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2007] [Accepted: 02/01/2008] [Indexed: 12/09/2022]
Abstract
In this study, we have examined the role of glutamine derivatives in reducing 5-fluorouracil (5-FU)-induced epithelial damage in an undifferentiated crypt intestinal cell line, IEC-6. In this model, we have investigated proliferation indirectly by detecting the enzyme-derived formazan dye from the tetrazolium salt WST-1 in viable cells at 24 and 48 h after 5-FU treatment. Migration was measured at 12 and 24 h after razor scraping of the cell monolayer. Cell death was measured by quantifying the percentage of apoptotic and necrotic figures by flow cytometry at 12 and 24 h following 5-FU challenge. Neither glutamine nor alanyl-glutamine prevented 5-FU-induced apoptosis and necrosis in IEC-6 cells at 12 and 24 h after 5-FU challenge. However, glutamine and alanyl-glutamine enhanced migration and proliferation when compared with 5-FU-treated controls (P < 0.05). These new findings support our earlier study on the benefit of oral glutamine in enhancing epithelial recovery after 5-FU challenge.
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Affiliation(s)
- Manuel B. Braga-Neto
- Institute of Biomedicine and Clinical Research Unit-University Hospital, Federal University of Ceará, Fortaleza, Brazil
| | - Cirle A. Warren
- Center for Global Health, School of Medicine, Division of Infectious Diseases and International Health, MR4, Lane Road, Room 3148, Charlottesville, VA 22908, USA
| | - Reinaldo B. Oriá
- Institute of Biomedicine and Clinical Research Unit-University Hospital, Federal University of Ceará, Fortaleza, Brazil. Department of Morphology, Federal University of Ceará, Fortaleza, Brazil
| | - Manuel S. Monteiro
- Institute of Biomedicine and Clinical Research Unit-University Hospital, Federal University of Ceará, Fortaleza, Brazil
| | - Andressa A. S. Maciel
- Institute of Biomedicine and Clinical Research Unit-University Hospital, Federal University of Ceará, Fortaleza, Brazil
| | - Gerly A. C. Brito
- Department of Morphology, Federal University of Ceará, Fortaleza, Brazil. Department of Pharmacology, Federal University of Ceará, Fortaleza, Brazil
| | - Aldo A. M. Lima
- Institute of Biomedicine and Clinical Research Unit-University Hospital, Federal University of Ceará, Fortaleza, Brazil. Department of Pharmacology, Federal University of Ceará, Fortaleza, Brazil
| | - Richard L. Guerrant
- Institute of Biomedicine and Clinical Research Unit-University Hospital, Federal University of Ceará, Fortaleza, Brazil. Center for Global Health, School of Medicine, Division of Infectious Diseases and International Health, MR4, Lane Road, Room 3148, Charlottesville, VA 22908, USA
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Reversal of parenteral nutrition-induced gut mucosal immunity impairment with small amounts of a complex enteral diet. ACTA ACUST UNITED AC 2008; 65:360-5; discussion 366. [PMID: 18695472 DOI: 10.1097/ta.0b013e31817c9711] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although parenteral nutrition (PN) prevents progressive malnutrition, lack of enteral nutrition (EN) during PN leads to gut associated lymphoid tissue (GALT) atrophy and dysfunction. Administering a small amount of EN with PN reportedly prevents increases in intestinal permeability. However, its effects on GALT remain unclear. We analyzed the minimum amount of EN required to preserve gut immunity during PN. METHODS Male Institute of Cancer Research mice underwent jugular vein catheter insertion and tube gastrostomy. They were randomized into four groups to receive isocaloric and isonitrogenous nutritional support with variable EN to PN ratios (EN 0, EN 33, EN 66, and EN 100). EN was provided with a complex enteral diet. After 5 days of feeding, the mice were killed and whole small intestines were harvested. GALT lymphocytes were isolated and counted. Their phenotypes were analyzed by flow cytometry. IgA levels of small intestinal washings were analyzed with enzyme-linked immunosorbent assay. RESULTS Body weight changes did not differ between any two of the groups. Peyer's patch lymphocyte numbers increased in proportion to EN amount, whereas lamina propria lymphocyte numbers were significantly higher in the EN 100 than in the EN 0 group, with no marked increases in the EN 33 and EN 66 groups. Small intestinal IgA levels increased EN amount-dependently and reached a plateau at EN 66. CONCLUSIONS A small amount of EN partially reverses PN-induced GALT changes, suggesting beneficial but limited effects on gut mucosal immunity.
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Xu Y, Hunt NH, Bao S. The effect of restraint stress on experimental colitis is IFN-gamma independent. J Neuroimmunol 2008; 200:53-61. [PMID: 18662832 DOI: 10.1016/j.jneuroim.2008.06.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2008] [Revised: 06/03/2008] [Accepted: 06/04/2008] [Indexed: 12/21/2022]
Abstract
Stress, a protective reaction to external threats, may be deleterious if linked to an inflammatory stimulus. Stress may influence intestinal immunity, thereby contributing to the development of colitis. Less severe histological abnormalities and clinical scores were detected in dextran sulphate sodium (DSS)-induced colitis in IFN-gamma(-/-), compared to Wt, mice. Disease severity was increased by restraint stress in DSS-treated IFN-gamma(-/-) and Wt mice, accompanied by suppressed colonic pro and anti inflammatory cytokine responses. Our data suggest that IFN-gamma is important in the development of acute colitis. Stress increases the severity of colitis, but is independent of the IFN-gamma pathway.
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Affiliation(s)
- Yinghua Xu
- Discipline of Pathology (D06), Bosch Institute and School of Medical Sciences, University of Sydney, NSW 2006, Australia
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Sezer MT, Demir M, Gungor G, Yavuz L. Relevance of Nutritional Route and Intercellular Adhesion Molecule-1 in Patients With Acute Renal Failure and Its Prognostic Implications. J Ren Nutr 2008; 18:288-93. [DOI: 10.1053/j.jrn.2007.11.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2007] [Indexed: 11/11/2022] Open
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de Aguilar-Nascimento JE, Kudsk KA. Early nutritional therapy: the role of enteral and parenteral routes. Curr Opin Clin Nutr Metab Care 2008; 11:255-60. [PMID: 18403921 DOI: 10.1097/mco.0b013e3282fba5c6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Early nutrition is defined as the initiation of nutritional therapy within 48 h of either hospital admission or surgery. However, optimal timing for initiation of nutritional therapy through either enteral or parenteral routes remains poorly defined with the existing data. We reviewed the recent literature investigating the role of early enteral and parenteral nutrition in critical illness and perioperative care. RECENT FINDINGS Recent studies in both trauma/surgical and nonsurgical patients support the superiority of early enteral over early parenteral nutrition. However, late commencement of enteral feeding should be avoided if the gastrointestinal tract is functional. Both prolonged hypocaloric enteral feeding and hypercaloric parenteral nutrition should be avoided, although the precise caloric target remains controversial. SUMMARY Early enteral nutrition remains the first option for the critically ill patient. However, there seems to be increased favor for combined enteral-parenteral therapy in cases of sustained hypocaloric enteral nutrition. The key issue is when the dual regimen should be initiated. Although more study is required to determine the optimal timing to initiate a combined enteral-parenteral approach, enteral nutrition should be initiated early and parenteral nutrition added if caloric-protein targets cannot be achieved after a few days.
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Mazaki T, Ebisawa K. Enteral versus parenteral nutrition after gastrointestinal surgery: a systematic review and meta-analysis of randomized controlled trials in the English literature. J Gastrointest Surg 2008; 12:739-55. [PMID: 17939012 DOI: 10.1007/s11605-007-0362-1] [Citation(s) in RCA: 124] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2007] [Accepted: 09/17/2007] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although previous studies recommend the use of enteral nutrition (EN), the benefit of EN after elective gastrointestinal surgery has not been comprehensively demonstrated as through a meta-analysis. Our aim is to determine whether enteral nutrition is more beneficial than parenteral nutrition. METHODS A search was conducted on Medline, Web of Science, the Cochrane Library electronic databases, and bibliographic reviews. The trials were based on randomization, gastrointestinal surgery, and the reporting of at least one of the following end points: any complication, any infectious complication, mortality, wound infection and dehiscence, anastomotic leak, intraabdominal abscess, pneumonia, respiratory failure, urinary tract infection, renal failure, any adverse effect, and duration of hospital stay. RESULTS Twenty-nine trials, which included 2,552 patients, met the criteria. EN was beneficial in the reduction of any complication (relative risk (RR), 0.85; 95% confidence interval (CI), 0.74-0.99; P = 0.04), any infectious complication (RR, 0.69; 95% CI, 0.56-0.86; P = 0.001), anastomotic leak (RR, 0.67; 95% CI, 0.47-0.95; P = 0.03), intraabdominal abscess (RR, 0.63; 95% CI, 0.41-0.95; P = 0.03), and duration of hospital stay (weighted mean difference, -0.81; 95% CI, -1.25-0.38; P = 0.02). There were no clear benefits in any of the other complications. CONCLUSION The present findings would lead us to recommend the use of EN rather than PN when possible and indicated.
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Affiliation(s)
- Takero Mazaki
- Department of Surgery, Nihon University School of Medicine, Nihon University Nerima-Hikarigaoka Hospital, 2-11-1 Hikarigaoka, Nerima-ku, Tokyo 179-0072, Japan.
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Hermsen JL, Gomez FE, Maeshima Y, Sano Y, Kang W, Kudsk KA. Decreased enteral stimulation alters mucosal immune chemokines. JPEN J Parenter Enteral Nutr 2008; 32:36-44. [PMID: 18165445 DOI: 10.1177/014860710803200136] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Migration of lymphocytes into and through the mucosal immune system depends upon adhesion molecules to attract circulating cells and chemokines to stimulate diapedesis into tissues. Decreased enteral stimulation significantly reduces mucosal addressin cellular adhesion molecule-1 (MAdCAM-1) levels, an adhesion molecule critical for homing of T and B cells to Peyer's patches (PP), which reduces PP and intestinal T and B cells. We studied the effect of type and route of nutrition on tissue specific chemokines in PP (CXCL-12, -13 and CCL-19, -20 and -21), small intestine (SI; CCL-20, -25 and -28) and lung (CXCL-12, CCL-28). METHODS Intravenously cannulated male Institute of Cancer Research (ICR) mice were randomized to chow or parenteral nutrition (PN) for 5 days. PP, SI, and lung chemokine mRNA levels were measured using real-time qRT-polymerase chain reaction, and analyzed semiquantitatively by the DeltaDeltaCt method. Protein levels were quantified using enzyme-linked immunosorbent assay (ELISA) techniques, and groups compared using Student's t-test. RESULTS PP CXCL13 protein significantly decreased, whereas CCL21 protein increased significantly in the parenterally fed group. Parenteral feeding significantly decreased SI CCL20 and CCL 25 protein levels. CCL28 decreased significantly in the SI and lung of intravenously fed animals. mRNA levels changed in the opposite direction (compared with protein) for all chemokines except CCL28. CONCLUSIONS Decreased enteral stimulation significantly alters key mucosal immune chemokine protein levels at multiple sites. In general, PN (and concomitant lack of enteral stimulation) results in decreased levels of chemokines that control lymphocyte migration within the mucosal immune system.
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Affiliation(s)
- Joshua L Hermsen
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin 53792-7375, USA
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Injury stimulates an innate respiratory immunoglobulin a immune response in humans. ACTA ACUST UNITED AC 2008; 64:316-23; discussion 323-5. [PMID: 18301193 DOI: 10.1097/ta.0b013e3181627586] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Secretory immunoglobulin A (SIgA) is the specific immune antibacterial defense. Since pneumonia frequently complicates the course of trauma patients, we studied early airway immune responses after injury. METHODS Twelve severely injured, intubated (expected for >/=5 d) patients had tracheal and bilateral lung lavage (BAL) within 30 hours of injury (n = 12). Epithelial lining fluid (ELF) volume and SIgA were measured by urea dilution and enzyme-linked immunosorbent assay (ELISA), respectively. Control BAL specimens were obtained from eight healthy elective surgical patients. Anatomically based comparisons were made between groups with Welch's unpaired t test. To verify human data, 30 male mice received no injury (time 0, n = 7) or injury with abdominal and neck incisions and were killed for airway IgA at 4 (n = 7), 8 (n = 8), and 24 (n = 8) hours. Analysis of variance (ANOVA) and Fisher's protected least significant difference testing was used to analyze animal data. RESULTS Initial trauma patient SIgA concentration (SIgA/mL ELF) increased compared with control in the lungs bilaterally (p < 0.05 both right and left). ELF volume was significantly higher in the right lung (p = 0.02) and just missed statistical significance (p = 0.07) on the left. Mouse IgA increased 8 hours after stress (p < 0.05 versus 0, 4, and 24 hours) and returned to normal by 24 hours. CONCLUSION A previously unrecognized innate human airway mucosal immune response with increased airway SIgA and ELF occurs after severe injury and is reproducible experimentally. This accessible, quantifiable human response allows study of clinical strategies to reduce infections via mucosal immune therapies.
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Lam NN, Tien NG, Khoa CM. Early enteral feeding for burned patients—An effective method which should be encouraged in developing countries. Burns 2008; 34:192-6. [PMID: 17804169 DOI: 10.1016/j.burns.2007.03.010] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2006] [Accepted: 03/19/2007] [Indexed: 11/15/2022]
Abstract
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 437nmol/l and that of insulin increased from 12.07 to 30.34micromol/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.
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127
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Sano Y, Gomez FE, Hermsen JL, Kang W, Lan J, Maeshima Y, Kudsk KA. Parenteral nutrition induces organ specific alterations in polymeric immunoglobulin receptor levels. J Surg Res 2008; 149:236-42. [PMID: 18599079 DOI: 10.1016/j.jss.2007.12.790] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2007] [Revised: 11/12/2007] [Accepted: 12/26/2007] [Indexed: 11/26/2022]
Abstract
BACKGROUND Secretory immunoglobulin A (IgA) prevents pathogen adherence at mucosal surfaces to prevent infection. Polymeric immunoglobulin receptor (pIgR), located on the basolateral surface of mucosal cells, binds dimeric IgA produced by B cells with the cooperation of T cells in the lamina propria. This IgA-pIgR complex is transported apically, where it is exocytosed as secretory IgA to the mucosal surface. Our prior work shows that parenteral nutrition (PN) impairs both airway and small intestine mucosal immunity by reducing T and B cells and IgA levels. This work examines intestinal and respiratory tissue-specific pIgR responses to PN. METHODS Cannulated male Institute of Cancer Research mice were randomized to Chow (n = 10) or PN (n = 10). After 5 days, animals were sacrificed and lavages obtained from the small intestine, lung (BAL = bronchoalveolar lavage), and nasal airways (NAL). Small intestine, lung, and nasal passage tissues were also collected. Lavage and tissue homogenate IgA levels were quantified by enzyme-linked immunosorbent assay and pIgR by Western blot. RESULTS PN group SIL and NAL IgA levels dropped significantly compared with Chow. PN significantly reduced pIgR levels in the SI while no pIgR change was noted in nasal passages and lung pIgR actually increased with PN. Tissue homogenate IgA levels did not change with PN in the SI while levels in the nasal passage and lung decreased. CONCLUSIONS PN impairs airway mucosal immunity by reduction in IgA available for transport rather than via a reduction in pIgR levels. In the small intestine, diminished pIgR is implicated in the deterioration of antibody-mediated mucosal immunity.
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Affiliation(s)
- Yoshifumi Sano
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
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Kang W, Kudsk KA, Sano Y, Lan J, Yang-Xin F, Gomez FE, Maeshima Y. Effects of lymphotoxin beta receptor blockade on intestinal mucosal immunity. JPEN J Parenter Enteral Nutr 2007; 31:358-64; discussion 364-5. [PMID: 17712143 DOI: 10.1177/0148607107031005358] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Mucosal addressin cellular adhesion molecule-1 (MAdCAM-1) directs lymphocyte migration into gut-associated lymphoid tissue (GALT) through Peyer's patches (PPs). Parenteral nutrition (PN) impairs mucosal immunity by reducing PPs MAdCAM-1 expression, T and B cells in GALT, and intestinal and respiratory immunoglobulin (Ig) A levels. We previously showed that PN reduces lymphotoxin beta receptor blockade (LTbetaR) in PPs and intestine, and that stimulation with LTbetaR agonist antibodies reverses these defects. To confirm that LTbetaR regulates transcription of MAdCAM-1 message and more fully understand the effects of LTbetaR on MAdCAM-1 function within the mucosal immune system, we studied the effect of LTbetaR blockade with a chimeric LTbetaR Ig-fusion protein on MAdCAM-1 mRNA levels, PP lymphocyte mass and IgA levels in the intestinal and respiratory tracts. METHODS Mice were cannulated and killed 3 days after receiving chow + control Ig, chow + LTbetaR-Ig fusion protein (100 microg IV), or PN + control Ig. The PPs of half of the animals were processed for lymphocyte count, and the other half were processed for complementary DNA and subsequent polymerase chain reaction (PCR). mRNA levels of MAdCAM-1 were determined by real-time PCR; intestinal and respiratory IgA levels were measured by ELISA. RESULTS PN significantly reduced PP lymphocyte mass, MAdCAM-1 mRNA, and intestinal IgA. As anticipated, LTbetaR blockade significantly decreased PP cells and MAdCAM-1 mRNA, but not intestinal IgA because chow feeding was maintained. Both LTbetaR blockade and PN decreased nasal IgA, but not significantly. CONCLUSIONS LTbetaR blockade in chow animals significantly reduces transcription of MAdCAM-1 gene and PPs lymphocyte mass. These data implicate inadequate LTbetaR signaling as a major mechanism for decreased GALT cells with lack of enteral stimulation, and further establish the role of LTbetaR in the mucosal immune system.
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Affiliation(s)
- Woodae Kang
- Department of Surgery, University of Wisconsin-Madison College of Medicine and Public Health, Madison, Wisconsin, USA
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Maeshima Y, Fukatsu K, Moriya T, Ikezawa F, Ueno C, Saitoh D, Mochizuki H. Influence of adding fish oil to parenteral nutrition on gut-associated lymphoid tissue. JPEN J Parenter Enteral Nutr 2007; 31:416-22. [PMID: 17712151 DOI: 10.1177/0148607107031005416] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Lack of enteral nutrition reduces gut-associated lymphoid tissue (GALT) mass and function, a mechanism underlying the increased morbidity of infectious complications in severely injured or critically ill patients. Strategies to restore parenteral nutrition (PN)-induced changes of GALT mass and function have been pursued. However, the influences of adding fish oil to PN on gut immunity remain to be clarified. METHODS Male Institute of Cancer Research (ICR) mice (n = 50) were randomized to 4 groups: ad libitum chow (chow), fat free PN (fat (-)-PN), PN + fish oil (FO-PN), and PN + safflower oil (SO-PN). The PN groups were given isocaloric and isonitrogenous PN solutions. The FO- and SO-PN groups received 20% of total calories from fat emulsions. After 5 days of feeding, lymphocytes from Peyer's patches (PPs), the intraepithelial space (IE), and the lamina propria (LP) of the entire small intestine were isolated. GALT lymphocyte numbers and phenotypes (CD4+, CD8+, alphabetaTCR+, gammadeltaTCR+, B220+ cells) were determined. Immunoglobulin A (IgA) levels of small intestinal washings were also measured by enzyme-linked immunosorbent assay. Another set of mice (n = 24) was used to determine plasma fatty acid compositions after feeding. RESULTS Lymphocyte numbers from PPs and the LP and intestinal IgA levels were significantly lower in the PN groups than in the chow group, with no significant differences between any 2 PN groups. The FO- and SO-PN groups showed moderate recovery of IE cell numbers compared with the fat (-)-PN group. Omega-3 and omega-6 fatty acid levels were increased with fish and safflower oil additions, respectively, compared with the fat (-)-PN group. CONCLUSIONS Adding fish oil to PN does not exacerbate PN-induced GALT changes but rather partially reverses these changes, with increased plasma omega-3 fatty acid levels.
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Abstract
The level of gastrointestinal (GI) maturity of an individual infant is a major determinant of whether the infant will be able to meet nutritional needs by sole use of the GI tract or if parenteral means will be necessary. The GI tract is not only an organ for digestion and absorption of nutrients; it also performs major endocrine, neural and immunologic functions. In this review, anatomic, functional and biochemical development will be described and related to means by which enteral nutrition can be used in the prematurely born infant to optimize health and prevent disease.
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Affiliation(s)
- Josef Neu
- Department of Pediatrics, Division of Neonatology, University of Florida, FL, USA.
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Abstract
The last 4 decades have seen an explosion in nutritional research investigating both clinical and laboratory issues occurring in diverse groups of patients who cannot maintain a normal oral diet. Over the past 25 years, researchers have investigated how the administration of macro- and micronutrients via the gastrointestinal tract provides additional benefit over parenteral administration of similar nutrients. The administration of enteral feeding provides effects that are far beyond those of merely administering macro- and micronutrients. Rather, the processing of nutrients via the gastrointestinal tract stimulates a complex response that has implications for body composition and for immunologic integrity. Route and type of nutrition are important aspects of successful patient recovery.
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Affiliation(s)
- Kenneth A. Kudsk
- Veterans Administration Surgical Services, William S. Middleton Memorial Veterans Hospital Madison and the Department of Surgery, The University of Wisconsin-Madison
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132
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Maeshima Y, Fukatsu K, Kang W, Ueno C, Moriya T, Saitoh D, Mochizuki H. LACK OF ENTERAL NUTRITION BLUNTS EXTRACELLULAR-REGULATED KINASE PHOSPHORYLATION IN GUT-ASSOCIATED LYMPHOID TISSUE. Shock 2007; 27:320-5. [PMID: 17304114 DOI: 10.1097/01.shk.0000239760.13206.18] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The mitogen-activated protein kinase (MAPK) family (extracellular-regulated kinase [ERK], p38, etc.) of signal transduction proteins includes important intracellular mediators of inflammation, playing critical roles in host defense. Phosphorylations of ERK and p38 are responsible for cell proliferation, cell differentiation, and cell death. We hypothesized that impaired gut-associated lymphoid tissue (GALT) function in the absence of enteral nutrition is associated with reduced MAPK phosphorylation in GALT cells. Fifty-three male Institute of Cancer Research mice were randomized into 3 groups; ad libitum chow, intragastric (i.g.)-TPN, and intravenous (i.v.)-TPN. TPN groups were administered a standard TPN solution. After 5 days of feeding, lymphocytes from Peyer patches (PPs), the lamina propria (LP) cells, and intraepithelial (IE) spaces in the small intestine were isolated. GALT lymphocyte numbers were determined. The lymphocytes were incubated with or without 50 ng/mL of phorbol myristate acetate (PMA) for 15 min, and phosphorylated ERK (p-ERK) and p38 (p-p38) levels were determined using laser scanning cytometry. In PP (GALT inductive site) lymphocytes, p-ERK was increased after PMA in all three groups. However, ERK phosphorylation in GALT effector sites (IE and LP) was enhanced only in the enteral groups. p38 phosphorylation was not increased in any GALT sites, in any of the three groups, in response to PMA. In another set of mice (n = 33), in vitro LP lymphocyte proliferation was assessed with BrdU with or without PMA. Cell proliferation was increased or maintained at high level with PMA in the i.g.-TPN and chow group, but remained low in the i.v.-TPN group. In conclusion, lack of enteral feeding blunts ERK activation and cell proliferation in response to PMA stimulation in GALT effector sites, which may be an important mechanism underlying reduced GALT function. The influence of nutrition on GALT p38 phosphorylation must be assessed with other types and dosages of stimulants.
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Affiliation(s)
- Yoshinori Maeshima
- Department of Surgery, National Defense Medical College Research Institute, Saitama, Japan
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A review on the interactions between gut microflora and digestive mucosal immunity. Possible ways to improve the health of rabbits. Livest Sci 2007. [DOI: 10.1016/j.livsci.2006.09.005] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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134
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Neu J. Gastrointestinal development and meeting the nutritional needs of premature infants. Am J Clin Nutr 2007; 85:629S-634S. [PMID: 17284768 DOI: 10.1093/ajcn/85.2.629s] [Citation(s) in RCA: 145] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The fear of necrotizing enterocolitis and feeding intolerance are major factors inhibiting the use of the enteral route as the primary means of nourishing premature infants. Parenteral nutrition may help to meet many of the nutritional needs of these infants, but has significant detrimental side effects that include intestinal atrophy, sepsis, and increased susceptibility to inflammatory stimuli and systemic inflammatory responses. Being able to minimize the use of the parenteral route and still maintain appropriate nutrition safely would be a major advance in neonatology. At the basis of our inability to use the enteral route is a poorly understood immature gastrointestinal tract. Approaches such as minimal enteral nutrition or trophic feedings may partially alleviate these problems. However, if we are to progress in greater utilization of the gastrointestinal tract, other factors need to be considered. These include the macronutrient composition of minimal enteral or trophic feedings and the microecology of the intestinal lumen. Some of the developmental aspects of the intestine, which include intestinal growth, motor activity, barrier and other innate immune functions, and the microecology of the developing intestine, are briefly reviewed here. The purpose of this review is to suggest important areas of future research in neonatal and developmental gastroenterology that could affect several conditions that are related to immaturity of the gastrointestinal tract.
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Affiliation(s)
- Josef Neu
- University of Florida, Department of Pediatrics, Gainesville, FL, USA.
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Kurtz CC, Carey HV. Seasonal changes in the intestinal immune system of hibernating ground squirrels. DEVELOPMENTAL AND COMPARATIVE IMMUNOLOGY 2007; 31:415-28. [PMID: 16930701 DOI: 10.1016/j.dci.2006.07.003] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2006] [Revised: 06/23/2006] [Accepted: 07/03/2006] [Indexed: 05/06/2023]
Abstract
Hibernation is associated with a prolonged fast (5-8 mo) which has the potential to affect intestinal immunity. We examined several aspects of the intestinal immune system in summer (non-hibernating) and hibernating ground squirrels. Peyer's patches were largely unaffected by hibernation, but numbers of intraepithelial lymphocytes (IEL) and lamina propria leukocytes (LPL) were greater in hibernators compared with summer. Hibernator IEL were less mature as demonstrated by low numbers of cells expressing activation-associated markers and co-receptors. Compared with summer, the percentage of B cells was higher and percentage of T cells was lower in the hibernator LPL. Hibernation was associated with greater mucosal levels of IFN-gamma, TNF-alpha, IL-10 and IL-4, but IL-6 and TGF-beta were unchanged. Mucosal IgA levels were greater in entrance and torpid hibernators compared with summer. The results suggest that modifications of the intestinal immune system during hibernation may help preserve gut integrity throughout the winter fast.
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Affiliation(s)
- Courtney C Kurtz
- Department of Comparative Biosciences, University of Wisconsin, School of Veterinary Medicine, 2015 Linden Drive, Madison, WI 53706, USA
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136
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Zborek A, Malusecka E, Rusin A, Krzyzowska-Gruca S, Krawczyk Z. Influx of macrophages into livers of rats treated with hepatotoxicants (thioacetamide, allyl alcohol, D-galactosamine) induces expression of HSP25. J Mol Histol 2006; 37:381-9. [PMID: 17103249 DOI: 10.1007/s10735-006-9068-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2006] [Accepted: 10/11/2006] [Indexed: 10/23/2022]
Abstract
Treatment of rats with a single dose of thioacetamide (TAA) provokes centrilobular inflammation and a significant expression of heat shock protein HSP25 in hepatocytes surrounding the area of inflammation. The HSP25 accumulation in hepatocytes adjacent to inflammatory regions was confirmed by identification of positive hepatocytes concentrated at periportal areas after treatment of rats with allyl alcohol (AA) or distributed diffusely throughout liver lobule after treatment with D-galactosamine (D-gal). In our model of TAA-treated rats the use of the anti-inflammatory drug-indomethacin, and the redox-regulating drug-N-acetylcysteine (NAC), significantly attenuated TAA-induced HSP25 expression and evoked morphological changes of recruited ED1+ macrophages. Treatment of rats with gadolinium chloride (GdCl(3)) decreased considerably the number of Kupffer cells (ED2+ macrophages) without affecting significantly the number and morphology of ED1+ macrophages as well as the expression pattern of TAA-induced HSP25. Our data shows for the first time that ED1+ macrophages recruited into the liver by treatment with TAA play a significant role in HSP25 induction in hepatocytes.
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Affiliation(s)
- A Zborek
- Department of Tumor Biology, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Wybrzeze Armii Krajowej 15, 44-101 Gliwice, Poland.
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137
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Abstract
The route, timing, and volume of enteral feeding delivered to a patient in the intensive care unit have a profound effect on clinical outcome. At the height of critical illness, problems with ileus, aspiration, and the systemic inflammatory response syndrome make the provision of enteral nutrients a difficult and somewhat risky endeavor. The gastrointestinal endoscopist has the technical skills to place feeding tubes deep within the jejunum and an underlying expertise in gut physiology to monitor patients effectively once feeds are initiated. Attention to detail in the techniques for attaining enteral access, early identification of potential problems, and quick institution of simple endoscopic strategies help improve delivery of nutrition support, minimize the likelihood for in-hospital complications, and optimize patient outcome.
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Affiliation(s)
- Stephen A McClave
- Department of Medicine, University of Louisville School of Medicine, Louisville, KY, USA.
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138
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Suri MP, Dhingra VJS, Raibagkar SC, Mehta DR. Nutrition in burns: Need for an aggressive dynamic approach. Burns 2006; 32:880-4. [PMID: 16949211 DOI: 10.1016/j.burns.2006.02.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2005] [Accepted: 02/13/2006] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Extensive burns elicit a pronounced metabolic response causing physiological derangements leading to the hyper-metabolic state. The hyper-metabolic response is accompanied by severe catabolism and a loss of lean body mass and also by a progressive decline of host defenses that impairs the immunological response. AIMS A study was conducted in our hospital to assess various aspects of nutritional management of burns considering the ground realities of general hospital. The main aim of the study was to assess the use of early naso-gastric tube insertion, charting out daily calorie intake and to appropriately decrease the deficit with use of low cost feeds taking in to consideration the local dietary habits. MATERIALS AND METHODS A total 138 cases were studied prospectively during April 2003 to March 2005, which were compared with 206 controls taken retrospectively from April 2000 to March 2003. The cases and controls were compared regarding the mortality rate, average days of stay and number of procedure done after dividing them in to various categories (%Burns) using the Z-test and student t-test. DISCUSSION AND CONCLUSION The use of early naso-gastric tube insertion, charting out daily calorie intake and using low cost feeds consistent with local dietary habits lead to a significant decrease in average number of days and the number of procedures in 20-39% TBSA burns; and caused the significant decrease in mortality, average number of days and the number of procedure in 40-59%TBSA burns.
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Affiliation(s)
- Manav P Suri
- SMT Shardaben Hospital, Burns and Plastic, Saraspur, Ahmedabad, Gujrat, India.
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139
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Donabedian H. Nutritional therapy and infectious diseases: a two-edged sword. Nutr J 2006; 5:21. [PMID: 16952310 PMCID: PMC1570358 DOI: 10.1186/1475-2891-5-21] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2006] [Accepted: 09/04/2006] [Indexed: 01/03/2023] Open
Abstract
The benefits and risks of nutritional therapies in the prevention and management of infectious diseases in the developed world are reviewed. There is strong evidence that early enteral feeding of patients prevents infections in a variety of traumatic and surgical illnesses. There is, however, little support for similar early feeding in medical illnesses. Parenteral nutrition increases the risk of infection when compared to enteral feeding or delayed nutrition. The use of gastric feedings appears to be as safe and effective as small bowel feedings. Dietary supplementation with glutamine appears to lower the risk of post-surgical infections and the ingestion of cranberry products has value in preventing urinary tract infections in women.
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Affiliation(s)
- Haig Donabedian
- Professor of Medicine, College of Medicine, University of Toledo, 3120 Glendale Avenue, Toledo, OH 43614, USA.
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140
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Ikezawa F, Fukatsu K, Moriya T, Maeshima Y, Okamoto K, Hara E, Hiraide H, Compher CW. Albumin infusion after reperfusion prevents gut ischemia-reperfusion-induced gut-associated lymphoid tissue atrophy. JPEN J Parenter Enteral Nutr 2006; 30:380-6; discussion 386-7. [PMID: 16931605 DOI: 10.1177/0148607106030005380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Our recent study clarified that gut ischemia-reperfusion (I/R) causes gut-associated lymphoid tissue (GALT) mass atrophy, a possible mechanism for increased morbidity of infectious complications after severe surgical insults. Because albumin administration reportedly reduces hemorrhagic shock-induced lung injury, we hypothesized that albumin treatment prevents GALT atrophy due to gut I/R. METHODS Male mice (n = 37) were randomized to albumin, normal saline, and sham groups. All groups underwent jugular vein catheter insertion. The albumin and normal saline groups underwent 75-minute occlusion of the superior mesenteric artery. During gut ischemia, all mice received normal saline infusions at 1.0 mL/h. The albumin group was given 5% bovine serum albumin in normal saline at 1.0 mL/h for 60 minutes after reperfusion, whereas the normal saline group received 0.9% sodium chloride at 1.0 mL/h. The sham group underwent laparotomy only. Mice were killed on day 1 or 7, and the entire small intestine was harvested. GALT lymphocytes were isolated and counted. Their phenotypes (alphabetaTCR, gammadeltaTCR, CD4, CD8, B220) were determined by flow cytometry. RESULTS On day 1, the gut I/R groups showed significantly lower total lymphocyte and B cell numbers in Peyer's patches and the lamina propria than the sham group. However, the albumin infusion partially but significantly restored these cell numbers. On day 7, there were no significant differences in any of the parameters measured among the 3 groups. CONCLUSIONS Albumin infusion after a gut ischemic insult may maintain gut immunity by preventing GALT atrophy.
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Affiliation(s)
- Fumie Ikezawa
- Division of Basic Traumatology, National Defense Medical College Research Institute, Tokorozawa, Japan
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141
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Saha S, Bose A. Percutaneous endoscopic gastrostomy (PEG) - An useful 'surgical' measure. Indian J Otolaryngol Head Neck Surg 2006; 58:235-8. [PMID: 23120301 DOI: 10.1007/bf03050827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Eight patients were studied to evaluate the efficacy of a surgeonled percutaneous endoscopic gastrostomy (PEG). Three patients underwent PEG at the time of elective surgery (carcinoma larynx-2, carcinoma tonsil-1), two underwent placements during emergency surgery for neck trauma (blunt injury-1, penetrating injury-1) and three for palliation (recurrent tongue carcinoma-1, recurrent epilaryngeal carcinoma-1, metastatic neck nodes-1). For patients undergoing intraoperative PEG, the operative time was prolonged by an average of 12 minutes. There were no major procedural or feedingrelated complications in any of the patients. Individual subjective tolerability was good in all patients. A surgeonled PEG is a simple and safe means of combining all the advantages of enteral nutrition with none of the disadvantages of nasogastric tube feeding in emergency, elective head and neck operations and in palliation. The procedure merits wider use in head and neck surgery units in India.
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142
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Neu J. NICHD: AAP workshop on neonatology research and training areas of research in neonatal gastroenterology. J Perinatol 2006; 26 Suppl 2:S19-22. [PMID: 16801963 DOI: 10.1038/sj.jp.7211424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Future research in neonatal and developmental gastroenterology should include inquiry well beyond finding a cure or better preventative measures against necrotizing enterocolitis. The gastrointestinal (GI) tract acts not only as a digestive-absorptive organ; it also serves major endocrine and neural functions. It encompasses a vast surface area exposed to the external environment and plays a major role in both innate and adaptive immunity. Numerous short- and long-term health benefits could be derived from a better understanding of the developing GI tract.
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Affiliation(s)
- J Neu
- Department of Pediatrics, University of Florida, College of Medicine, 32610, USA.
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143
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Abstract
PURPOSE OF REVIEW The gastrointestinal tract plays a major role in critical illness. We will review four common problem areas pertaining to the gut and abdominal compartment that intensivists managing critically ill patients must deal with on an everyday basis. RECENT FINDINGS In the area of enteral nutrition, there have been concerns that early feeding in hemodynamically unstable patients might cause bowel infarction by increasing the gut oxygen consumption beyond splanchnic oxygen delivery. The most recent data suggest that early enteral feeding, even when patients are receiving vasopressors, is safe and may actually protect the gut by increasing gut perfusion. Although there are no new treatments for ileus, in most critically ill patients ileus primarily affects the stomach and large intestine, and most patients who are diagnosed with ileus may still be fed enterally as long as they are fed distal to the stomach. Diarrhea is a common occurrence in the intensive care unit, particularly in patients who are being fed enterally. Of most import is the realization that Clostridium difficile infection is ubiquitous and must be considered in virtually every case of diarrhea. Abdominal compartment syndrome is usually a result of shock, and its resuscitation with increased intra-abdominal pressure results in many untoward hemodynamic and respiratory events. Early recognition and treatment seem to be associated with improved outcome. SUMMARY Continued progress in the areas of optimal nutritional support, understanding the implications of alterations in immune function of the gut, and the avoidance of such morbid complications as abdominal compartment syndrome are expected.
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Affiliation(s)
- Ziad N Kutayli
- Department of Surgery, Ohio State University, Columbus, Ohio, USA
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144
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Jabbar A, McClave SA. Pre-pyloric versus post-pyloric feeding. Clin Nutr 2006; 24:719-26. [PMID: 16143431 DOI: 10.1016/j.clnu.2005.03.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2005] [Accepted: 03/16/2005] [Indexed: 01/15/2023]
Abstract
Optimal management of the critically ill patient involves the initiation and rapid advancement of early enteral nutrition (EN). Compared to parenteral nutrition or no nutritional support, early enteral feeding favorably impacts patient outcome by reducing infectious morbidity and shortening hospital length of stay. Controversy exists over the true risks and benefits of pre-pyloric versus post-pyloric feeding. Placement of nasogastric tubes is easier than nasojejunal tubes, initiation of EN is more expedient, and intragastric feeds may provide greater physiologic benefits. Post-pyloric feeding, on the other hand, is associated with fewer interruptions once EN has been started, may reach goal calorie provision sooner, and may reduce risk for gastroesophageal reflux and aspiration. Overall differences in outcome between the two methods of feeding, however, are minimal. Thus, the final choice for the practicing clinician on the level of infusion of enteral feeding is based on institutional factors (related to protocols and available expertise) and the degree of risk and potential tolerance of the individual patient.
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Affiliation(s)
- Abdul Jabbar
- Department of Medicine, Division of Gastroenterology/Hepatology, University of Louisville School of Medicine, 550 S. Jackson St., Louisville, KY 40202, USA
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de Oliveira MA, Lemos DS, Diniz SOF, Coelho JV, Cardoso VN. Prevention of bacterial translocation using glutamine: a new strategy of investigation. Nutrition 2006; 22:419-24. [PMID: 16472985 DOI: 10.1016/j.nut.2005.11.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2005] [Revised: 10/25/2005] [Accepted: 11/26/2005] [Indexed: 12/01/2022]
Abstract
OBJECTIVE This study investigated the role of glutamine (Gln) on bacterial translocation in an intestinal obstruction model by using Escherichia coli labeled with technetium 99m (99mTc-E. coli). METHODS Intestinal obstruction was performed by a single ligature of the terminal ileum in rats. Animals in the control group (group 1) were sham operated (not obstructed). Experimental group 2 had intestinal obstruction. Groups 1 and 2 were not treated with Gln. Groups 3 and 4 were treated with Gln for 7 d before surgery with 250 and 500 mg x kg(-1) x d(-1), respectively. A suspension containing 100 million colony-forming units/mL of (99m)Tc-E. coli was injected into the lumen of the ileum. Twenty-four hours after surgery, blood, mesenteric lymph nodes, livers, spleens, and lungs were collected for determination of radioactivity. The Mann-Whitney U test was performed for statistical analysis. P <or= 0.05 was considered statistically significant. RESULTS Rats that had an intestinal obstruction showed a significant increase in 99mTc-E. coli translocation from the lumen to all organs investigated compared with the sham-operated group (P <or= 0.01). There was a significant difference between the intestinally obstructed group and Group 4 treated with Gln at 500 mg x kg(-1) x d(-1) (P <or= 0.05), which did not occur in Group 3 treated with Gln at 250 mg x kg(-1) x d(-1). CONCLUSIONS The new method using 99mTc-E. coli was found to be suitable for studies of bacterial translocation. Gln did not prevent bacterial translocation but did significantly decrease the spread of 99mTc-E. coli among organs such as the liver, lung, and spleen. The effect of Gln in cases of intestinal obstruction was found to be dose dependent.
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Affiliation(s)
- Mariana Andrade de Oliveira
- Radioisotope Laboratory, Faculty of Pharmacy, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
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Fukatsu K, Sakamoto S, Hara E, Ueno C, Maeshima Y, Matsumoto I, Mochizuki H, Hiraide H. Gut ischemia-reperfusion affects gut mucosal immunity: A possible mechanism for infectious complications after severe surgical insults*. Crit Care Med 2006; 34:182-7. [PMID: 16374173 DOI: 10.1097/01.ccm.0000196207.86570.16] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To examine influences of gut ischemia/reperfusion (I/R) on gut-associated lymphoid tissue (GALT) mass and function. DESIGN Prospective, randomized controlled study. SETTING Research laboratory. SUBJECTS Male Institute of Cancer Research mice. INTERVENTIONS Ninety mice were randomized to three groups: I/R (60-min gut ischemia), sham (laparotomy only), and control (no operation). On days 1, 2, 4, 7, and 10, mice were killed to harvest lymphocytes from Peyer patches, the intraepithelial space, and the lamina propria (LP) of the small intestine. Respiratory tract and small intestinal washings were also obtained. MEASUREMENTS AND MAIN RESULTS Gut I/R significantly reduced lymphocyte numbers in Peyer patches, the intraepithelial space, and the LP. The reduction was prominent in GALT effector sites, that is, the intraepithelial space and LP, but numbers recovered quickly in LP. Changes in cell numbers in Peyer patches, GALT inductive sites, were subtle but persistent. Gut I/R reduced B cell numbers in Peyer patches; alphabeta T cell receptor (TCR)+, gammadeltaTCR+, CD8+, and B cell numbers in the intraepithelial space; and gammadeltaTCR+, CD8+, and B cell numbers in the LP, in comparison with the sham or control group. There were no significant differences in respiratory tract immunoglobulin A levels between the I/R and sham groups. Intestinal immunoglobulin A was elevated on day 1 in the I/R group, with no significant difference after day 2 in comparison with the sham group. CONCLUSIONS Despite the maintained mucosal immunoglobulin A level, gut I/R markedly reduces GALT cell numbers, with changes in lymphocyte phenotypes. These alterations may be associated with increased morbidity due to infectious complications after severe surgical insults.
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Affiliation(s)
- Kazuhiko Fukatsu
- Division of Basic Traumatology, National Defense Medical College Research Institute, Tokyo, Japan
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147
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Su Y, Wu SD, Jin JZ, Zhang ZH, Fan Y. Influence of intestinal barrier function on pigment gallstone formation in guinea pig model. Shijie Huaren Xiaohua Zazhi 2005; 13:2853-2857. [DOI: 10.11569/wcjd.v13.i24.2853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the possible action and mechanism of the intestinal barrier function in the pathogenesis of pigment gallstone.
METHODS: Eighty guinea pigs were randomly divided into three groups: normal group (CON), pigment gallstone group (PS) and intestinal mucosa protection group (GLN). Normal forage, pigment gallstone-forming forage and pigment gallstone-forming forage with supplemental intestinal mucosa protector (glutamine) were given to the animals of corresponding groups, respectively. The gallstone-forming rate, morphological changes of intestinal mucosa, intestinal permeability, serum endotoxin and biliary β-glucuronidase were detected after 8 wk.
RESULTS: The gallstone-forming rate was 73.9% in PS. In comparison with those in CON, the intestinal mucosa damage, serum endotoxin level [(1367±525)×10-6 EU/L vs (77±43) ×10-6 EU/L, P < 0.01] and activity of biliary β-glucuronidase (endogenous: from 209.8±47.5 vs 122.1±39.5 Fishman Unit, P < 0.01; exogenous: from 2206.6±983.9 vs 573.5±476.9 Fishman Unit, P < 0.01) were significantly increased in PS. In GLN, the gallstone-forming rate was decreased to 44.4%, which was markedly higher than that in PS (P < 0.05). The morphological changes of intestinal mucosa, intestinal permeability and serum endotoxin [(156±97)×10-6 EU/L vs (1367±525)×10-6 EU/L, P < 0.05] were notably decreased in GLN as compared with those in PS, and there was no significant difference in β-glucuronidase activity.
CONCLUSION: Intestinal barrier function is correlated with pigment gallstone formation. Intestinal barrier function disorder may promote pigment gallstone formation through bacteria translocation, endotoxemia and change of biliary β-glucuronidase activity.
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148
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Abstract
Necrotizing enterocolitis (NEC) is a leading cause of mortality and morbidity in neonatal intensive care units. Here we review selected manifestations of NEC, risk factors involved in its pathophysiology as well as putative mechanisms associated with how an immature gut might be more susceptible to NEC. Treatment and potential preventive strategies are discussed.
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Affiliation(s)
- Josef Neu
- University of Florida, Department of Pediatrics, Gainesville, Florida 32610, USA
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149
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Abstract
The increased survival of very-low-birth-weight infants has resulted in the need to better understand the immaturities that challenge optimal nutrition for these infants and how to surmount them. This is critical if we are to prevent short and long term morbidity associated with poor nutrition. Here we describe several of these immaturities including those related to digestion and absorption, suck-swallow incoordination, delayed gastric emptying, and intestinal motility and how they lead to the common problem of feeding intolerance. Scientifically based strategies for introducing, stopping and continuing enteral feedings in association with parenteral nutrition are presented.
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Affiliation(s)
- Josef Neu
- University of Florida, Department of Pediatrics, Gainesville, Florida 32610, USA
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150
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Abstract
Interactions of resident intestinal microbes with the luminal contents and the mucosal surface play important roles in normal intestinal development, nutrition, and innate and adaptive immunity. The neonate, especially the premature, who possesses a highly immunoreactive intestinal submucosa underlying a single layer of epithelial cells that are continuously exposed to the luminal environment, is highly susceptible to perturbations of the luminal environment. Understanding the interactions of the intestinal ecosystem with the host and luminal nutritional environment, especially in regard to human milk and pre- and probiotics, has major implications for the pathogenesis of diseases that affect not only the intestine but distal organs such as the lung and brain.
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Affiliation(s)
- Ricardo A Caicedo
- Department of Pediatrics, University of Florida, College of Medicine, Gainesville, 32610, USA
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