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Vanzant E, Thompson A, Mendoza A, Yeh D. Current fistula management. Curr Opin Crit Care 2024; 30:172-177. [PMID: 38441138 DOI: 10.1097/mcc.0000000000001147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
PURPOSE OF REVIEW Enterocutaneous fistulas (ECFs) pose a significant impact in the healthcare system, both financially and in resource utilization. Delivery of optimal care is complex and involves intensive wound care, complex nutritional delivery and multidisciplinary care teams for optimization. Recently, there have been pushes to modernize the traditional approach to ECF care to a new paradigm of protocol-based individualized delivery of care. RECENT FINDINGS There is an increased trend towards pushing enteral nutrition for the management of ECF patients. Adjuncts, including improved fistuloclysis devices, supplements and absorptive aides have challenged the conventional dogma of ECF treatment. There has also been increased focus on surgical prehabilitation and the ability to improve patient outcomes. SUMMARY ECF care is complex and requires a multidisciplinary approach focused on source control, nutritional optimization with focus on enteral nutrition, wound care and prehabilitation.
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Affiliation(s)
- Erin Vanzant
- University of Florida, Gainesville, Florida, USA
| | | | - April Mendoza
- University of California San Francisco-East Bay, Oakland, California
| | - Dante Yeh
- Denver Health Medical Center, Denver, Colorado
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2
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Correia AM, Genova JL, Saraiva A, Rocha GC. Effects of crude protein and non-essential amino acids on growth performance, blood profile, and intestinal health of weaned piglets. Front Vet Sci 2023; 10:1243357. [PMID: 38098993 PMCID: PMC10720428 DOI: 10.3389/fvets.2023.1243357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 11/09/2023] [Indexed: 12/17/2023] Open
Abstract
This study investigated the effect of crude protein (CP) and non-essential amino acid (NEAA) supplementation on the growth performance, blood profile, intestinal morphology, mRNA relative abundance of inflammatory and antioxidant markers, and tight junction proteins in piglets over the first 2 weeks after weaning. Ninety 21-day-old piglets (7.55 ± 0.72 kg) were assigned in a randomized block design to one of three dietary treatments: (1) high CP, a diet with 24% CP; (2) low CP, a diet with 18% CP; and (3) low CP + NEAA, a diet with 18% CP supplemented with 5 g/kg Arg (L-arginine; purity >99%) and 10 g/kg Glu + Gln (minimum 10% L-glutamine and minimum 10% L-glutamate). Piglets were fed with corn-soybean meal basal diets in a 14-day trial. There was an improvement (p < 0.05) in the feed conversion ratio of piglets fed the high-CP diet compared to treatments with low CP or low CP + NEAA. Serum urea nitrogen was higher (p < 0.05) in piglets fed high CP compared to other dietary treatments. In the duodenum, the villus height of animals fed the low-CP + NEAA diets was greater (p < 0.05) than those fed with the high- and low-CP diets. The goblet cell proportion of piglets fed low CP + NEAA or high CP was higher (p < 0.05) compared to low CP. In the jejunum, the crypt depth of the piglets with the high-CP dietary treatment was greater (p < 0.05) in comparison with low CP + NEAA. In the jejunum, IFN-γ mRNA expression was higher (p < 0.05) in animals fed the high-CP diets compared to other dietary treatments. However, superoxide dismutase and occludin mRNA expression were higher (p < 0.05) in animals fed low CP + NEAA than in piglets on the high-CP diets. In the ileum, the number of Peyer's patches in piglets fed high CP was higher (p < 0.05) compared to other dietary treatments. In conclusion, the high-CP diet (24% CP) improves the feed conversion of piglets in the first 2 weeks after weaning compared to the low-CP diet (18% CP) supplemented or not with NEAA. However, the low-CP diet supplemented with NEAA (Arg, Gln, and Glu) improves intestinal health in piglets by promoting greater villus height and proportion of goblet cells in the duodenum, reducing jejunal crypt depth, and reducing Peyer's number patches in the ileum. In addition, piglets that received the low-CP + NEAA diet showed an increase in superoxide dismutase and occludin and a lower expression of IFN-γ mRNA.
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Affiliation(s)
| | | | | | - Gabriel Cipriano Rocha
- Muscle Biology and Nutrigenomics Laboratory, Department of Animal Sciences, Universidade Federal de Viçosa, Viçosa, Brazil
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3
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Andres SF, Zhang Y, Kuhn M, Scottoline B. Building better barriers: how nutrition and undernutrition impact pediatric intestinal health. Front Immunol 2023; 14:1192936. [PMID: 37545496 PMCID: PMC10401430 DOI: 10.3389/fimmu.2023.1192936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 06/26/2023] [Indexed: 08/08/2023] Open
Abstract
Chronic undernutrition is a major cause of death for children under five, leaving survivors at risk for adverse long-term consequences. This review focuses on the role of nutrients in normal intestinal development and function, from the intestinal epithelium, to the closely-associated mucosal immune system and intestinal microbiota. We examine what is known about the impacts of undernutrition on intestinal physiology, with focus again on the same systems. We provide a discussion of existing animal models of undernutrition, and review the evidence demonstrating that correcting undernutrition alone does not fully ameliorate effects on intestinal function, the microbiome, or growth. We review efforts to treat undernutrition that incorporate data indicating that improved recovery is possible with interventions focused not only on delivery of sufficient energy, macronutrients, and micronutrients, but also on efforts to correct the abnormal intestinal microbiome that is a consequence of undernutrition. Understanding of the role of the intestinal microbiome in the undernourished state and correction of the phenotype is both complex and a subject that holds great potential to improve recovery. We conclude with critical unanswered questions in the field, including the need for greater mechanistic research, improved models for the impacts of undernourishment, and new interventions that incorporate recent research gains. This review highlights the importance of understanding the mechanistic effects of undernutrition on the intestinal ecosystem to better treat and improve long-term outcomes for survivors.
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Affiliation(s)
- Sarah F. Andres
- Division of Pediatric Gastroenterology, Department of Pediatrics, Oregon Health and Science University, Portland, OR, United States
| | - Yang Zhang
- Division of Pediatric Gastroenterology, Department of Pediatrics, Oregon Health and Science University, Portland, OR, United States
| | - Madeline Kuhn
- Division of Pediatric Gastroenterology, Department of Pediatrics, Oregon Health and Science University, Portland, OR, United States
| | - Brian Scottoline
- Division of Neonatology, Department of Pediatrics, Oregon Health and Science University, Portland, OR, United States
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4
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Jeong H, Kim JH, Choo YH, Kim M, Lee S, Ha EJ, Oh J. Nutrition Therapy for Patients With Traumatic Brain Injury: A Narrative Review. Korean J Neurotrauma 2023; 19:177-184. [PMID: 37431366 PMCID: PMC10329886 DOI: 10.13004/kjnt.2023.19.e31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 06/15/2023] [Accepted: 06/18/2023] [Indexed: 07/12/2023] Open
Abstract
Traumatic brain injury (TBI) is a global health and socio-economic problem, resulting in significant disability and mortality. Malnutrition is common in TBI patients and is associated with increased vulnerability to infection, higher morbidity and mortality rates, as well as longer stays in the intensive care unit and hospital. Following TBI, various pathophysiological mechanisms, such as hypermetabolism and hypercatabolism, affect patient outcomes. It is crucial to provide adequate nutrition therapy to prevent secondary brain damage and promote optimal recovery. This review includes a literature review and discusses the challenges encountered in clinical practice regarding nutrition in TBI patients. The focus is on determining energy requirements, timing and methods of nutrition delivery, promoting enteral tolerance, providing enteral nutrition to patients receiving vasopressors, and implementing trophic enteral nutrition. Enhancing our understanding of the current evidence regarding appropriate nutrition practices will contribute to improving overall outcomes for TBI patients.
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Affiliation(s)
- Heewon Jeong
- Department of Neurosurgery, Chungnam National University Hospital, Daejeon, Korea
| | - Jae Hyun Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yoon-Hee Choo
- Department of Neurosurgery, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Moinay Kim
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seungioo Lee
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Jin Ha
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jiwoong Oh
- Division of Neurotrauma & Neurocritical Care Medicine, Department of Neurosurgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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5
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Zhao L, Ren P, Wang M, Wang J, He X, Gu J, Lu Y, Wu Y, Liu J, Wang L, Li H. Changes in intestinal barrier protein expression and intestinal flora in a rat model of visceral hypersensitivity. Neurogastroenterol Motil 2022; 34:e14299. [PMID: 34821442 DOI: 10.1111/nmo.14299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 08/30/2021] [Accepted: 11/10/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Destruction of the intestinal mucosal barrier and visceral hypersensitivity are main pathogenesis of irritable bowel syndrome (IBS). The study aimed to establish a rat model of visceral hypersensitivity and explore mechanisms involved the changes of the intestinal barrier protein expression and intestinal flora. METHODS A rat model of visceral hypersensitivity was established and evaluated using abdominal withdrawal reflex (AWR) scores, colonic paracellular permeability, and gastrointestinal motility. The expression of tight junction proteins, aquaporin proteins (AQPs), phosphorylated ERK, and proteinase-activated receptor-2 (PAR-2) was determined. The intestinal microflora was evaluated by high-throughput sequencing of the 16S rRNA gene. KEY RESULTS In model rats, AWR score and fecal water content were significantly increased, gastrointestinal motilities were disorder and characterized by an inhibition of gastric motility and an enhancement of small intestinal and colonic movement. The expressions of colonic occludin, ZO-1, AQP3, and AQP8 were decreased but claudin-2 and claudin-4 were markedly increased. Imbalance of intestinal flora appeared and showed an obvious decrease of Lactobacillus and an increase of Clostridiales_bacterium. Additionally, the total serine protease activity in feces, the expressions of PAR2 and phosphorylated ERK in the colon tissues were increased significantly. CONCLUSION AND INFERENCES The model rats of visceral hypersensitivity possess the decreased expression of occludin, ZO-1, AQP3, AQP8, and the increased expression of claudin-2 and claudin-4, meanwhile develop an imbalance of intestinal flora which probably increase serine protease activity, thereby activating the PAR2/ERK signaling and causing the intestinal barrier disorder.
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Affiliation(s)
- Li Zhao
- Department of Physiology, College of Basic Medicine, Lanzhou University, Lanzhou, China
| | - Peipei Ren
- Affiliated Hospital, Gansu University of Chinese Medicine, Lanzhou, China
| | - Miaolei Wang
- Affiliated Hospital, Gansu University of Chinese Medicine, Lanzhou, China
| | - Jingjing Wang
- Department of Physiology, College of Basic Medicine, Lanzhou University, Lanzhou, China
| | - Xueyun He
- Department of Physiology, College of Basic Medicine, Lanzhou University, Lanzhou, China
| | - Jingyan Gu
- Department of Physiology, College of Basic Medicine, Lanzhou University, Lanzhou, China
| | - Yanyu Lu
- Function Laboratory in College of Basic Medicine, Lanzhou University, Lanzhou, Gansu Province, China
| | - Yana Wu
- Affiliated Hospital, Gansu University of Chinese Medicine, Lanzhou, China
| | - Junhong Liu
- Affiliated Hospital, Gansu University of Chinese Medicine, Lanzhou, China
| | - Longde Wang
- Affiliated Hospital, Gansu University of Chinese Medicine, Lanzhou, China
| | - Hongfang Li
- Department of Physiology, College of Basic Medicine, Lanzhou University, Lanzhou, China.,Key Laboratory of Preclinical Study for New Drugs of Gansu Province, Lanzhou, China
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6
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Yu B, Wang J. The efficacy of parenteral nutrition (PN) and enteral nutrition (EN) supports in cirrhosis: A systematic review and network meta-analysis. Medicine (Baltimore) 2022; 101:e28618. [PMID: 35060537 PMCID: PMC8772655 DOI: 10.1097/md.0000000000028618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 12/30/2021] [Indexed: 01/05/2023] Open
Abstract
IMPORTANCE Multiple nutritional therapies are currently available for patients with liver cirrhosis, yet many interventions have not been compared head-to-head within randomized clinical trials. OBJECTIVE To evaluate the improvement of nutritional indicators and liver function indexes of liver cirrhosis treated with different nutrition intervention. DATA SOURCE We searched PubMed, Embase. com and Cochrane Library database from construction to April 3, 2020. After eliminating the duplicated or overlapping reports, 6 studies were included. We performed a Bayesian network meta-analysis by Stata 12.0 and GeMTC 0.14.3 in order to compare different nutritional interventions with consistency model. STUDY SELECTION Randomized clinical trials comparing 2 or more therapies in patients with cirrhosis were evaluated. Six randomized clinical trials met the selection criteria. DATA EXTRACTION AND SYNTHESIS Two investigators independently reviewed the full manuscripts of eligible studies and extracted information into an electronic database: patients' characteristics study design, interventions, the number of events of interest in each group. MAIN OUTCOMES AND MEASURES Body mass index, Child-Pugh score, model for end-stage liver disease score, total bilirubin, alanine transaminase, aspartate transaminase, total protein, Triceps skinfold, Midarm Muscle Circumference, Fischer ratio, overall survival. RESULTS There are 6 studies enrolling a total of 1148 patients who received different nutrition supports including parenteral nutrition (PN), enteral nutrition (EN), EN (without branched-chain amino acids), EN + intestinal probiotics, PN + EN, late evening snacks (LES), EN + LES, noLES. The direct comparisons showed that the effect of EN was better than EN (without branched-chain amino acids); EN + intestinal probiotics was better than EN and PN; PN + EN was better than them alone; EN + LES was better than LES and EN; LES was better than noLES. Although the difference of indirect comparisons between the included regimens was not statistically significant, the results showed that EN + intestinal probiotics appeared to be superior to PN + EN. While LES and EN + LES seemed to rank behind them and the difference between them was extremely small. CONCLUSION AND RELEVANCE Available evidence suggests that EN + intestinal probiotics appear to be the most effective strategy for patients with cirrhosis compared with other interventions.
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Affiliation(s)
- Bin Yu
- Department of Pharmacy, Mianyang Central Hospital, Mianyang, Sichuan, China
| | - Jiting Wang
- School of Pharmacy, Southwest Medical University, Luzhou, Sichuan, China
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7
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Thong D, Halim Z, Chia J, Chua F, Wong A. A Systematic Review and Meta-Analysis of the effectiveness of continuous versus intermittent enteral nutrition in critically ill adults. JPEN J Parenter Enteral Nutr 2021; 46:1243-1257. [PMID: 34965317 DOI: 10.1002/jpen.2324] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/09/2021] [Accepted: 12/21/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Continuous Enteral Nutrition (CEN) remains standard practice in Intensive Care Units (ICUs) worldwide. Intermittent Enteral Nutrition (IEN) may be a suitable alternative method. This meta-analysis aims to investigate the safety, tolerance, and effectiveness of IEN compared to CEN in critically ill adults in the ICU. METHODS Medline, CINAHL, Scopus, Embase and Google Scholar were searched for studies published up until 30th April 2020, along with manual searches in bibliographies. Eligible studies were trials that compared CEN versus IEN feeding in the ICU, and reported on at least one of the relevant outcomes - nutritional intake, gastric residual volume (GRV), aspiration pneumonia, vomiting, diarrhea, abdominal distension, glycemic variability. Secondary outcomes were ICU length of stay (LOS) and mortality. The Cochrane risk-of-bias tool for randomized trials was used to assess methodological quality. RESULTS Ten studies with 664 participants were included in the meta-analysis. The majority of studies had an overall 'High' risk of bias. Incidence of vomiting was significantly higher in CEN as compared to IEN groups (Risk Ratio 2.76; 95% CI, 1.23 - 6.23). There were no significant differences between CEN and IEN groups for nutritional intake, GRV, the incidence of aspiration pneumonia, diarrhea, abdominal distension, ICU LOS, and mortality. Definition and reporting of outcome measures were not standardized across studies, hence this heterogeneity limits generalisability of results. CONCLUSION Overall, the safety, tolerance, and effectiveness of CEN and IEN were found to be comparable. Future studies should explore monitoring larger sample sizes to determine best feeding practices in ICU. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Debbie Thong
- Dietetic and Food Services, Changi General Hospital, Singapore, Singapore
| | - Zakiah Halim
- Dietetic and Food Services, Changi General Hospital, Singapore, Singapore
| | - Joel Chia
- Dietetic and Food Services, Changi General Hospital, Singapore, Singapore
| | - Fionn Chua
- Dietetic and Food Services, Changi General Hospital, Singapore, Singapore
| | - Alvin Wong
- Dietetic and Food Services, Changi General Hospital, Singapore, Singapore
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8
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Angoorani P, Ejtahed HS, Hasani-Ranjbar S, Siadat SD, Soroush AR, Larijani B. Gut microbiota modulation as a possible mediating mechanism for fasting-induced alleviation of metabolic complications: a systematic review. Nutr Metab (Lond) 2021; 18:105. [PMID: 34906176 PMCID: PMC8670288 DOI: 10.1186/s12986-021-00635-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 11/30/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Intermittent fasting has been reported to have positive effects on obesity, diabetes, cardiovascular diseases, hypertension, and several neurodegenerative diseases through different mechanisms such as alteration in the gut microbiota. This systematic review was conducted with the aim of providing an overview of the existing animal and human literature regarding the gut microbiota alterations in various fasting regimens. METHOD A systematic literature search was conducted on PubMed, Scopus and Web of Science databases up to May 2021 to find all relevant studies examining the gut microbiota alteration during the fasting. Original researches on animal models or human patients were included in this study. RESULTS The search fulfilled 3072 documents from which 31 studies (20 animal and 11 human studies) were included. Upon fasting, abundance of several beneficial bacteria including Lactobacillus and Bifidobacterium shifted significantly. Moreover, some taxa, including Odoribacter which negatively associated with blood pressure bloomed during fasting. Ramadan fasting, as a kind of intermittent fasting, improves health parameters through positive changes in gut microbiota including upregulation of A. muciniphila, B. fragilis, Bacteroides and butyric acid-producing Lachnospiraceae. CONCLUSION The findings suggest that different fasting regimens including alternate-day fasting, calorie- and time-restricted fasting programs and Ramadan fasting could promote health maybe through the modulation of gut microbiome. However, further studies are needed to explore properly the connection between gut microbiota and meal frequency and timing.
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Affiliation(s)
- Pooneh Angoorani
- Obesity and Eating Habits Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Hanieh-Sadat Ejtahed
- Obesity and Eating Habits Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, North Kargar Ave, 1411413137, Tehran, Iran.
| | - Shirin Hasani-Ranjbar
- Obesity and Eating Habits Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Davar Siadat
- Department of Mycobacteriology and Pulmonary Research, Microbiology Research Center, Pasteur Institute of Iran, Tehran, Iran
| | - Ahmad Reza Soroush
- Obesity and Eating Habits Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Bagher Larijani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, North Kargar Ave, 1411413137, Tehran, Iran
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9
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The effect of enteral stimulation on the immune response of the intestinal mucosa and its application in nutritional support. Eur J Clin Nutr 2021; 75:1533-1539. [PMID: 33608653 DOI: 10.1038/s41430-021-00877-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 01/22/2021] [Accepted: 02/01/2021] [Indexed: 02/07/2023]
Abstract
The intestine plays a fundamental role as a regulator of the mucosal immune response, mostly through the production and secretion of secretory Immunoglobulin A (sIgA) by the gut-associated lymphoid tissue (GALT). Enteral stimulation, a balance between the commensal microbiota and pathogenic microorganisms, in addition to an adequate nutritional status is required for the optimal immune function of the intestine. Fasting subjects or those supported only with parenteral nutrition, show a progressive anatomical and physiological deterioration of the GALT, triggering a series of alterations resulting in a decrease in the intestinal immune response, modification in the type of microbiota, and changes that lead to or aggravate malnutrition. Patients with malnutrition present an increase in the rate of nosocomial infections, hospital length of stay, and mortality. An adequate nutritional assessment at hospital admission and avoiding long periods of fasting are paramount to prevent these unfavorable outcomes. Herein, we present a mini-state of the art review on the role and importance of enteral stimulation by GALT-mediated immune response.
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10
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Nishikawa H, Goto M, Fukunishi S, Asai A, Nishiguchi S, Higuchi K. Cancer Cachexia: Its Mechanism and Clinical Significance. Int J Mol Sci 2021; 22:8491. [PMID: 34445197 PMCID: PMC8395185 DOI: 10.3390/ijms22168491] [Citation(s) in RCA: 99] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 08/02/2021] [Accepted: 08/04/2021] [Indexed: 12/19/2022] Open
Abstract
The term "cachexia" is derived from the Greek words kakos (bad) and hexis (habit). Cachexia is a malnutrition associated with chronic diseases such as cancer, chronic heart failure, chronic renal failure, and autoimmune diseases, and is characterized by decreased skeletal muscle mass. Cancer cachexia is quite common in patients with advanced cancer. Weight loss is also a characteristic symptom of cancer cachexia, along with decreased skeletal muscle mass. As nutritional supplementation alone cannot improve cachexia, cytokines and tumor-derived substances have been attracting attention as its relevant factors. Cancer cachexia can be also associated with reduced chemotherapeutic effects, increased side effects and treatment interruptions, and even poorer survival. In 2011, a consensus definition of cachexia has been proposed, and the number of relevant research reports has increased significantly. However, the pathogenesis of cachexia is not fully understood, and there are currently few regulatory-approved standard treatments for cachexia. The main reason for this is that multiple etiologies are involved in the development of cachexia. In this review, we will outline the current status of cachexia, the mechanisms of which have been elucidated in recent years, especially from the perspective of advanced cancer.
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Affiliation(s)
- Hiroki Nishikawa
- The Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Takatsuki 569-8686, Japan; (M.G.); (S.F.); (A.A.); (K.H.)
- The Premier Departmental Research of Medicine, Osaka Medical and Pharmaceutical University, Takatsuki 569-8686, Japan
| | - Masahiro Goto
- The Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Takatsuki 569-8686, Japan; (M.G.); (S.F.); (A.A.); (K.H.)
| | - Shinya Fukunishi
- The Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Takatsuki 569-8686, Japan; (M.G.); (S.F.); (A.A.); (K.H.)
- The Premier Departmental Research of Medicine, Osaka Medical and Pharmaceutical University, Takatsuki 569-8686, Japan
| | - Akira Asai
- The Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Takatsuki 569-8686, Japan; (M.G.); (S.F.); (A.A.); (K.H.)
| | | | - Kazuhide Higuchi
- The Second Department of Internal Medicine, Osaka Medical and Pharmaceutical University, Takatsuki 569-8686, Japan; (M.G.); (S.F.); (A.A.); (K.H.)
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11
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Zhang J, Yu WQ, Wei T, Zhang C, Wen L, Chen Q, Chen W, Qiu JY, Zhang Y, Liang TB. Effects of Short-Peptide-Based Enteral Nutrition on the Intestinal Microcirculation and Mucosal Barrier in Mice with Severe Acute Pancreatitis. Mol Nutr Food Res 2020; 64:e1901191. [PMID: 31965752 DOI: 10.1002/mnfr.201901191] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 12/28/2019] [Indexed: 01/08/2023]
Abstract
SCOPE Short-peptide-based enteral nutrition (SPEN) is absorbed more efficiently in patients with severe acute pancreatitis (SAP). More importantly, SPEN decreases SAP-induced enterogenous infection risk. This study aims to investigate whether SPEN alleviates intestinal bacterial translocation in mice with SAP, and the underlying mechanisms. METHODS AND RESULTS The SAP model is established after pre-treatment with SPEN or intact-protein-based enteral nutrition. Although there is no improvement in pancreas injury, as evaluated through Hematoxylin-Eosin staining or serum amylase, SPEN obviously attenuates intestinal bacterial translocation after SAP. To unveil the mechanisms, it is found that the intestinal mechanical barrier destroyed by SAP is significantly relieved by SPEN, which presents with recovered ZO-1 expression, mucus layer, and goblet cell function. Additionally, SPEN alleviates local CCR6/CCL20 induced CD11c+ dendritic cell infiltration, systemic immunosuppression, and inhibits the secretion of luminal secretory immunoglobulin A. Possibly responsible for SAP-induced mucosal dysfunctions, destroyed intestinal mucosal microcirculation and local hypoxia are largely improved in SAP+SPEN group. CONCLUSION SPEN can improve downregulated intestinal mucosal microcirculation secondary to SAP, which may be responsible for mucosal inflammation relief, maintenance of the mechanical barrier and mucosal immunity, the correction of systemic immunosuppression, and play a protective role in defending commensal bacterial translocation after SAP.
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Affiliation(s)
- Jian Zhang
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University, Hangzhou, 310009, Zhejiang, China.,Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, 310009, Zhejiang, China.,Innovation Center for the Study of Pancreatic Diseases, Hangzhou, 310009, Zhejiang, China
| | - Wen-Qiao Yu
- Department of Surgical Intensive Care Unit, First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, 310009, Zhejiang, China
| | - Tao Wei
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University, Hangzhou, 310009, Zhejiang, China.,Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, 310009, Zhejiang, China.,Innovation Center for the Study of Pancreatic Diseases, Hangzhou, 310009, Zhejiang, China
| | - Cheng Zhang
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University, Hangzhou, 310009, Zhejiang, China.,Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, 310009, Zhejiang, China.,Innovation Center for the Study of Pancreatic Diseases, Hangzhou, 310009, Zhejiang, China
| | - Liang Wen
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University, Hangzhou, 310009, Zhejiang, China.,Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, 310009, Zhejiang, China.,Innovation Center for the Study of Pancreatic Diseases, Hangzhou, 310009, Zhejiang, China
| | - Qi Chen
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University, Hangzhou, 310009, Zhejiang, China.,Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, 310009, Zhejiang, China.,Innovation Center for the Study of Pancreatic Diseases, Hangzhou, 310009, Zhejiang, China
| | - Wei Chen
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University, Hangzhou, 310009, Zhejiang, China.,Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, 310009, Zhejiang, China.,Innovation Center for the Study of Pancreatic Diseases, Hangzhou, 310009, Zhejiang, China
| | - Jun-Yu Qiu
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University, Hangzhou, 310009, Zhejiang, China.,Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, 310009, Zhejiang, China.,Innovation Center for the Study of Pancreatic Diseases, Hangzhou, 310009, Zhejiang, China
| | - Yun Zhang
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University, Hangzhou, 310009, Zhejiang, China.,Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, 310009, Zhejiang, China.,Innovation Center for the Study of Pancreatic Diseases, Hangzhou, 310009, Zhejiang, China
| | - Ting-Bo Liang
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University, Hangzhou, 310009, Zhejiang, China.,Zhejiang Provincial Key Laboratory of Pancreatic Disease, Hangzhou, 310009, Zhejiang, China.,Innovation Center for the Study of Pancreatic Diseases, Hangzhou, 310009, Zhejiang, China
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Kothekar AT, Kulkarni AP. Gastrointestinal Tract: A Neglected Guardian Angel? Indian J Crit Care Med 2020; 24:S146-S151. [PMID: 33354032 PMCID: PMC7724944 DOI: 10.5005/jp-journals-10071-23616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Role of the gastrointestinal (GI) system is not limited to the digestion of food and absorption of water and nutrients. Gastrointestinal mucosa forms a barrier preventing translocation of microbes into the blood. Upper GI tract performs important function of swallowing and prevention of aspiration, failure of which mandates enteral tube feeding. Rate of gastric emptying depends on gastric volume and contents and delayed emptying is observed both in solid and in fatty food. Cricoid pressure during intubation is an important intervention for prevention of aspiration in critically ill patients who are considered as full stomach. To utilize mucosal barrier function optimally, hemodynamically stable patients should preferably receive enteral nutrition even if they are on small doses of vasopressors. Post-pyloric feeds may reduce risk of aspiration and hence are recommended for patients who are deemed to have high risk for aspiration. Bowel sounds have poor reproducibility, sensitivity, specificity, accuracy, and interobserver agreement, and absent bowel sounds should not be considered as a contraindication to enteral feeding. How to cite this article: Kothekar AT, Kulkarni AP. Gastrointestinal Tract: A Neglected Guardian Angel? Indian J Crit Care Med 2020;24(Suppl 4):S146–S151.
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Affiliation(s)
- Amol T Kothekar
- Division of Critical Care Medicine, Department of Anesthesia, Critical Care and Pain, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Atul P Kulkarni
- Division of Critical Care Medicine, Department of Anesthesia, Critical Care and Pain, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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Fuentes Padilla P, Martínez G, Vernooij RWM, Urrútia G, Roqué i Figuls M, Bonfill Cosp X. Early enteral nutrition (within 48 hours) versus delayed enteral nutrition (after 48 hours) with or without supplemental parenteral nutrition in critically ill adults. Cochrane Database Syst Rev 2019; 2019:CD012340. [PMID: 31684690 PMCID: PMC6820694 DOI: 10.1002/14651858.cd012340.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Early enteral nutrition support (within 48 hours of admission or injury) is frequently recommended for the management of patients in intensive care units (ICU). Early enteral nutrition is recommended in many clinical practice guidelines, although there appears to be a lack of evidence for its use and benefit. OBJECTIVES To evaluate the efficacy and safety of early enteral nutrition (initiated within 48 hours of initial injury or ICU admission) versus delayed enteral nutrition (initiated later than 48 hours after initial injury or ICU admission), with or without supplemental parenteral nutrition, in critically ill adults. SEARCH METHODS We searched CENTRAL (2019, Issue 4), MEDLINE Ovid (1946 to April 2019), Embase Ovid SP (1974 to April 2019), CINAHL EBSCO (1982 to April 2019), and ISI Web of Science (1945 to April 2019). We also searched Turning Research Into Practice (TRIP), trial registers (ClinicalTrials.gov, ISRCTN registry), and scientific conference reports, including the American Society for Parenteral and Enteral Nutrition and the European Society for Clinical Nutrition and Metabolism. We applied no restrictions by language or publication status. SELECTION CRITERIA We included all randomized controlled trials (RCTs) that compared early versus delayed enteral nutrition, with or without supplemental parenteral nutrition, in adults who were in the ICU for longer than 72 hours. This included individuals admitted for medical, surgical, and trauma diagnoses, and who required any type of enteral nutrition. DATA COLLECTION AND ANALYSIS Two review authors extracted study data and assessed the risk of bias in the included studies. We expressed results as risk ratios (RR) for dichotomous data, and as mean differences (MD) for continuous data, both with 95% confidence intervals (CI). We assessed the certainty of the evidence using GRADE. MAIN RESULTS We included seven RCTs with a total of 345 participants. Outcome data were limited, and we judged many trials to have an unclear risk of bias in several domains. Early versus delayed enteral nutrition Six trials (318 participants) assessed early versus delayed enteral nutrition in general, medical, and trauma ICUs in the USA, Australia, Greece, India, and Russia. Primary outcomes Five studies (259 participants) measured mortality. It is uncertain whether early enteral nutrition affects the risk of mortality within 30 days (RR 1.00, 95% CI 0.16 to 6.38; 1 study, 38 participants; very low-quality evidence). Four studies (221 participants) reported mortality without describing the timeframe; we did not pool these results. None of the studies reported a clear difference in mortality between groups. Three studies (156 participants) reported infectious complications. We were unable to pool the results due to unreported data and substantial clinical heterogeneity. The results were inconsistent across studies. One trial measured feed intolerance or gastrointestinal complications; it is uncertain whether early enteral nutrition affects this outcome (RR 0.84, 95% CI 0.35 to 2.01; 59 participants; very low-quality evidence). Secondary outcomes One trial assessed hospital length of stay and reported a longer stay in the early enteral group (median 15 days (interquartile range (IQR) 9.5 to 20) versus 12 days (IQR 7.5 to15); P = 0.05; 59 participants; very low-quality evidence). Three studies (125 participants) reported the duration of mechanical ventilation. We did not pool the results due to clinical and statistical heterogeneity. The results were inconsistent across studies. It is uncertain whether early enteral nutrition affects the risk of pneumonia (RR 0.77, 95% CI 0.55 to 1.06; 4 studies, 192 participants; very low-quality evidence). Early enteral nutrition with supplemental parenteral nutrition versus delayed enteral nutrition with supplemental parenteral nutrition We identified one trial in a burn ICU in the USA (27 participants). Primary outcomes It is uncertain whether early enteral nutrition with supplemental parenteral nutrition affects the risk of mortality (RR 0.74, 95% CI 0.25 to 2.18; very low-quality evidence), or infectious complications (MD 0.00, 95% CI -1.94 to 1.94; very low-quality evidence). There were no data available for feed intolerance or gastrointestinal complications. Secondary outcomes It is uncertain whether early enteral nutrition with supplemental parenteral nutrition reduces the duration of mechanical ventilation (MD 9.00, 95% CI -10.99 to 28.99; very low-quality evidence). There were no data available for hospital length of stay or pneumonia. AUTHORS' CONCLUSIONS Due to very low-quality evidence, we are uncertain whether early enteral nutrition, compared with delayed enteral nutrition, affects the risk of mortality within 30 days, feed intolerance or gastrointestinal complications, or pneumonia. Due to very low-quality evidence, we are uncertain if early enteral nutrition with supplemental parenteral nutrition compared with delayed enteral nutrition with supplemental parenteral nutrition reduces mortality, infectious complications, or duration of mechanical ventilation. There is currently insufficient evidence; there is a need for large, multicentred studies with rigorous methodology, which measure important clinical outcomes.
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Affiliation(s)
- Paulina Fuentes Padilla
- Iberoamerican Cochrane CentreC/ Sant Antoni Maria Claret 167Pavelló 18 Planta 0BarcelonaBarcelonaSpain08025
- Universidad de AntofagastaFaculty of Medicine and DentistryAntofagastaChile
- Servicio de Salud AntofagastaAntofagastaChile
| | - Gabriel Martínez
- Iberoamerican Cochrane CentreC/ Sant Antoni Maria Claret 167Pavelló 18 Planta 0BarcelonaBarcelonaSpain08025
- Universidad de AntofagastaFaculty of Medicine and DentistryAntofagastaChile
- Servicio de Salud AntofagastaAntofagastaChile
| | - Robin WM Vernooij
- University Medical Center UtrechtDepartment of Nephrology and Hypertension and Julius Center for Health Sciences and Primary CareHeidelberglaan 100UtrechtNetherlands3584 CX
| | - Gerard Urrútia
- CIBER Epidemiología y Salud Pública (CIBERESP)Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret, 167Pavilion 18 (D‐53)BarcelonaCataloniaSpain08025
| | - Marta Roqué i Figuls
- CIBER Epidemiología y Salud Pública (CIBERESP)Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret, 167Pavilion 18 (D‐53)BarcelonaCataloniaSpain08025
| | - Xavier Bonfill Cosp
- CIBER Epidemiología y Salud Pública (CIBERESP)Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau)Sant Antoni Maria Claret, 167Pavilion 18 (D‐53)BarcelonaCataloniaSpain08025
- Universitat Autònoma de BarcelonaSant Antoni Maria Claret, 167Pavilion 18 (D‐13)BarcelonaCatalunyaSpain08025
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de Souza Silva PM, de Sousa RV, Simão AA, Cesar PHS, Trento MVC, Marcussi S. Protective effect of β-D-glucan and glutamine on the genomic instability induced by Cytarabine/Ara-C in BALB/c mice. Int J Biol Macromol 2018; 117:559-564. [PMID: 29852229 DOI: 10.1016/j.ijbiomac.2018.05.206] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 03/22/2018] [Accepted: 05/24/2018] [Indexed: 10/14/2022]
Abstract
Prophylactic antibiotics and growth promoters have been substituted, mainly for livestock, by immunomodulators and intestinal health promoters - such as β-D-glucans and glutamine. The aim of this study was to verify the beneficial effects of β-D-glucans and glutamine against Cytarabine/Ara-C, evaluating the DNA damage in leukocytes, the leukogram, and the mitotic index of intestinal crypts cells. Balb/C mice received treatment with β-D-glucan (80 mg/Kg), glutamine (150 mg/Kg), or both, for 21 days. On the last two days of this period, Ara-C was administered (1.8 mg/animal) by intraperitoneal injection every 12 h. The animals submitted to the treatment with Ara-C presented the highest genotoxic index, a significant leukopenia, and a decrease in the mitotic index of the intestinal crypts cells. Treatment with β-D-glucan protected the leukocytes against DNA fragmentation induced by Ara-C. Glutamine alone promoted maintenance of the mitotic index and, in association with β-Dglucan, reduced leukopenia. Thus, the use of β-D-glucan and glutamine proved to be beneficial to intestinal tropism. This can happen once the damage to the genetic material, prevented by the treatments with β-D-glucan and glutamine, can result in genotoxicity. Not only this, but it might be capable of turning into a mutagenesis, with consequential physiopathological alterations.
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Affiliation(s)
- Priscilla Mirian de Souza Silva
- Veterinarian Medicine Department, Universidade Federal de Lavras-UFLA, University Campus, CP: 3037, Lavras 37200-000, Brazil
| | - Raimundo Vicente de Sousa
- Veterinarian Medicine Department, Universidade Federal de Lavras-UFLA, University Campus, CP: 3037, Lavras 37200-000, Brazil
| | - Anderson Assaid Simão
- Chemistry Department, Biochemistry Laboratory, Universidade Federal de Lavras-UFLA, University Campus, CP: 3037, Lavras 37200-000, Brazil
| | - Pedro Henrique Souza Cesar
- Chemistry Department, Biochemistry Laboratory, Universidade Federal de Lavras-UFLA, University Campus, CP: 3037, Lavras 37200-000, Brazil
| | - Marcus Vinicius Cardoso Trento
- Chemistry Department, Biochemistry Laboratory, Universidade Federal de Lavras-UFLA, University Campus, CP: 3037, Lavras 37200-000, Brazil
| | - Silvana Marcussi
- Chemistry Department, Biochemistry Laboratory, Universidade Federal de Lavras-UFLA, University Campus, CP: 3037, Lavras 37200-000, Brazil.
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Higashizono K, Fukatsu K, Watkins A, Watanabe T, Noguchi M, Ri M, Murakoshi S, Yasuhara H, Seto Y. Influences of Short-Term Fasting and Carbohydrate Supplementation on Gut Immunity and Mucosal Morphology in Mice. JPEN J Parenter Enteral Nutr 2018; 43:516-524. [PMID: 30260489 DOI: 10.1002/jpen.1446] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 08/16/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Preoperative carbohydrate (CHO) supplementation has been recommended in enhanced recovery after surgery protocols. However, the effects of CHO supplementation on gut and systemic immunity are not well understood. METHODS Mice (n = 60) were randomized to 1 of the following 5 groups: control (ad lib feeding), 12-hour fasting without CHO administration (fasting), and 12 hours of fasting with CHO administration at 2, 4, and 8 hours before sacrifice. Then, lymphocytes were isolated from gut-associated lymphoid tissue, that is, Peyer's patches, the intraepithelial space, and the lamina propria of the small intestine. These lymphocyte numbers and phenotypes were evaluated. IgA levels in respiratory and small-intestinal washings were determined by ELISA. Morphology, proliferation, and apoptosis of the intestinal epithelium were also evaluated histologically. RESULTS Although there were no significant differences in IgA levels among the 5 groups, fasting decreased intraepithelial and lamina propria, but not Peyer's patches lymphocyte numbers. CHO at 2 hours prevented lymphocyte loss in intraepithelial, whereas CHO at 4 hours reversed lamina propria lymphocytes numbers. Percentages of lymphocyte phenotypes were similar in each site among the 5 groups. Fasting caused villous atrophy; however, CHO at 2 hours restored villous structure along with maintenance of epithelial cell proliferation rate. CONCLUSIONS Only 12 hours of fasting causes marked gut-associated lymphoid tissue cell loss along with gut atrophy. However, CHO at 2 hours preserves gut immunity and morphology not completely but moderately.
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Affiliation(s)
- Kazuya Higashizono
- Department of Gastrointestinal Surgery, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan.,Surgical Center, the University of Tokyo Hospital, Tokyo, Japan
| | | | - Ayako Watkins
- Surgical Center, the University of Tokyo Hospital, Tokyo, Japan
| | - Tomoki Watanabe
- Surgical Center, the University of Tokyo Hospital, Tokyo, Japan
| | - Midori Noguchi
- Surgical Center, the University of Tokyo Hospital, Tokyo, Japan
| | - Motonari Ri
- Department of Gastrointestinal Surgery, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
| | | | | | - Yasuyuki Seto
- Department of Gastrointestinal Surgery, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan
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Chronic Critical Illness and Persistent Inflammation: What can we Learn from the Elderly, Injured, Septic, and Malnourished? Shock 2018; 49:4-14. [PMID: 28682945 DOI: 10.1097/shk.0000000000000939] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Patients in the intensive care unit (ICU) who develop chronic critical illness significantly stress the clinical capacity and financial resources of healthcare systems. Although vast improvements have been made in critical care management, outcomes for this ICU subset remain poor. A hallmark for patients who progress to chronic critical illness is the development of persistent inflammation and immunosuppression. The risk factors associated with the development of chronic critical illness include increased age, medical comorbidities, severe injury, septic shock, and malnutrition. Interestingly, each of these clinical states bears strikingly similar immune defects, often resulting in the activation of a persistent inflammatory state. Strategies aimed at the prevention or early recognition of this state of immune compromise may help improve outcomes for these individuals and minimize the number who progress to chronic critical illness. This review explores the current knowledge regarding the immune defects associated with the development of persistent inflammation, the ways in which it can manifest clinically, attempted therapeutic interventions to date, and future insights into improving outcomes for this patient population.
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18
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Lei Q, Bi J, Chen H, Tian F, Gao X, Li N, Wang X. Glucagon-like peptide-2 improves intestinal immune function and diminishes bacterial translocation in a mouse model of parenteral nutrition. Nutr Res 2018; 49:56-66. [DOI: 10.1016/j.nutres.2017.10.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 09/29/2017] [Accepted: 10/05/2017] [Indexed: 02/07/2023]
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The Importance of Enteral Nutrition. Dysphagia 2018. [DOI: 10.1007/174_2017_128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Sun H, Bi J, Lei Q, Wan X, Jiang T, Wu C, Wang X. Partial enteral nutrition increases intestinal sIgA levels in mice undergoing parenteral nutrition in a dose-dependent manner. Int J Surg 2017; 49:74-79. [PMID: 29248622 DOI: 10.1016/j.ijsu.2017.12.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Accepted: 12/12/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Partial enteral nutrition (PEN) protects parenteral nutrition (PN) induced gut mucosal immunity impairment. However, the gastrointestinal function of most patients with PN is too poor to tolerate full dosage of PEN and no guidelines recommend PEN dose. We aimed to identify an optimal PEN dose and to understand the protective mechanism. METHODS Mice were assigned to groups with total parenteral nutrition (TPN), total enteral nutrition (TEN), or various degrees of PEN with PN. Additionally, AS1517499 was used to inhibit STAT6. Five days after treatment, secretory immunoglobulin A (sIgA) levels of luminal washing fluid and JAK1-STAT6 signalling in ileum tissue of different groups were assessed. RESULTS We found that TPN lowered luminal sIgA and down-regulated pIgR, phosphorylated JAK1 and STAT6, IL-4 and IL-13 as well relative to TEN. Moreover, 40% EN were lowest dose that reversed these detrimental consequences of PN to an equivalent level as TEN. The rescue of pIgR and luminal sIgA expression was decreased when the JAK1-STAT6 pathway was inhibited. CONCLUSION We conclude that 40% EN is the optimal PEN dose that reverses PN-induced impairment of gut mucosal immunity. Additionally, we hypothesise that this benefit involves activation of the JAK1-STAT6 pathway.
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Affiliation(s)
- Haifeng Sun
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing 210002, Jiangsu Province, China
| | - Jingcheng Bi
- Department of Thyroid and Breast Surgery, Taizhou People's Hospital, Taizhou 225300, Jiangsu Province, China
| | - Qiucheng Lei
- Department of Liver Surgery, The First People's Hospital of Foshan, Foshan 528000, Guangdong Province, China
| | - Xiao Wan
- Anhui Provincial Hospital, Hefei 230001, Anhui Province, China
| | - Tingting Jiang
- Obstetrics and Gynecology Hospital of Fudan University, Shanghai 200011, China
| | - Chao Wu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Xinying Wang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing 210002, Jiangsu Province, China.
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McCue MD, Passement CA, Meyerholz DK. Maintenance of Distal Intestinal Structure in the Face of Prolonged Fasting: A Comparative Examination of Species From Five Vertebrate Classes. Anat Rec (Hoboken) 2017; 300:2208-2219. [PMID: 28941363 PMCID: PMC5767472 DOI: 10.1002/ar.23691] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 06/16/2017] [Accepted: 07/10/2017] [Indexed: 12/24/2022]
Abstract
It was recently shown that fasting alters the composition of microbial communities residing in the distal intestinal tract of animals representing five classes of vertebrates [i.e., fishes (tilapia), amphibians (toads), reptiles (leopard geckos), birds (quail), and mammals (mice)]. In this study, we tested the hypothesis that the extent of tissue reorganization in the fasted distal intestine was correlated with the observed changes in enteric microbial diversity. Segments of intestine adjacent to those used for the microbiota study were examined histologically to quantify cross-sectional and mucosal surface areas and thicknesses of mucosa, submucosa, and tunica muscularis. We found no fasting-induced differences in the morphology of distal intestines of the mice (3 days), quail (7 days), or geckos (28 days). The toads, which exhibited a general increase in phylogenetic diversity of their enteric microbiota with fasting, also exhibited reduced mucosal circumference at 14 and 21 days of fasting. Tilapia showed increased phylogenetic diversity of their enteric microbiota, and showed a thickened tunica muscularis at 21 days of fasting; but this morphological change was not related to microbial diversity or absorptive surface area, and thus, is unlikely to functionally match the changes in their microbiome. Given that fasting caused significant increases and reductions in the enteric microbial diversity of mice and quail, respectively, but no detectable changes in distal intestine morphology, we conclude that reorganization is not the primary factor shaping changes in microbial diversity within the fasted colon, and the observed modest structural changes are more related to the fasted state. Anat Rec, 300:2208-2219, 2017. © 2017 Wiley Periodicals, Inc.
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Doctor A, Zimmerman J, Agus M, Rajasekaran S, Wardenburg JB, Fortenberry J, Zajicek A, Typpo K. Pediatric Multiple Organ Dysfunction Syndrome: Promising Therapies. Pediatr Crit Care Med 2017; 18:S67-S82. [PMID: 28248836 PMCID: PMC5333132 DOI: 10.1097/pcc.0000000000001053] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To describe the state of the science, identify knowledge gaps, and offer potential future research questions regarding promising therapies for children with multiple organ dysfunction syndrome presented during the Eunice Kennedy Shriver National Institute of Child Health and Human Development Workshop on Pediatric Multiple Organ Dysfunction Syndrome (March 26-27, 2015). DATA SOURCES Literature review, research data, and expert opinion. STUDY SELECTION Not applicable. DATA EXTRACTION Moderated by an expert from the field, issues relevant to the association of multiple organ dysfunction syndrome with a variety of conditions were presented, discussed, and debated with a focus on identifying knowledge gaps and research priorities. DATA SYNTHESIS Summary of presentations and discussion supported and supplemented by relevant literature. CONCLUSIONS Among critically ill children, multiple organ dysfunction syndrome is relatively common and associated with significant morbidity and mortality. For outcomes to improve, effective therapies aimed at preventing and treating this condition must be discovered and rigorously evaluated. In this article, a number of potential opportunities to enhance current care are highlighted including the need for a better understanding of the pharmacokinetics and pharmacodynamics of medications, the effect of early and optimized nutrition, and the impact of effective glucose control in the setting of multiple organ dysfunction syndrome. Additionally, a handful of the promising therapies either currently being implemented or developed are described. These include extracorporeal therapies, anticytokine therapies, antitoxin treatments, antioxidant approaches, and multiple forms of exogenous steroids. For the field to advance, promising therapies and other therapies must be assessed in rigorous manner and implemented accordingly.
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Affiliation(s)
- Allan Doctor
- Departments of Pediatrics (Critical Care Medicine) and Biochemistry, Washington University in Saint Louis
| | - Jerry Zimmerman
- Department of Pediatrics (Critical Care Medicine), University of Washington, Seattle, WA
| | - Michael Agus
- Department of Pediatrics (Critical Care Medicine), Harvard University, Boston, MA
| | - Surender Rajasekaran
- Department of Pediatrics (Critical Care Medicine), Michigan State University, Grand Rapids, MI
| | | | - James Fortenberry
- Department of Pediatrics (Critical Care Medicine), Emory University, Atlanta, GA
| | - Anne Zajicek
- Obstetric and Pediatric Pharmacology and Therapeutics Branch, NICHD
| | - Katri Typpo
- Department of Pediatrics (Critical Care Medicine), University of Arizona, Phoenix, AZ
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Fuentes Padilla P, Martínez G, Vernooij RWM, Urrútia G, Roqué i Figuls M, Bonfill Cosp X. Early versus delayed enteral nutrition support for critically ill adults. Hippokratia 2016. [DOI: 10.1002/14651858.cd012340] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Paulina Fuentes Padilla
- Iberoamerican Cochrane Centre; C/ Sant Antoni Maria Claret 167 Pavelló 18 Planta 0 Barcelona Barcelona Chile 08025
- Universidad de Antofagasta; Faculty of Medicine and Dentistry; Antofagasta Chile
- Servicio de Salud Antofagasta; Antofagasta Chile
| | - Gabriel Martínez
- Universidad de Antofagasta; Faculty of Medicine and Dentistry; Antofagasta Chile
- Iberoamerican Cochrane Centre; Sant Antoni Maria Claret 167 Barcelona Spain 08025
- Institut Català de Neurociències Aplicades; Alzheimer Research Center and Memory Clinic of Fundació ACE; Barcelona Spain
| | - Robin WM Vernooij
- Iberoamerican Cochrane Centre; Sant Antoni Maria Claret 167 Barcelona Spain 08025
| | - Gerard Urrútia
- CIBER Epidemiología y Salud Pública (CIBERESP); Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau); Sant Antoni Maria Claret, 167 Pavilion 18 (D-53) Barcelona Catalonia Spain 08025
| | - Marta Roqué i Figuls
- CIBER Epidemiología y Salud Pública (CIBERESP); Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau); Sant Antoni Maria Claret, 167 Pavilion 18 (D-53) Barcelona Catalonia Spain 08025
| | - Xavier Bonfill Cosp
- CIBER Epidemiología y Salud Pública (CIBERESP); Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau); Sant Antoni Maria Claret, 167 Pavilion 18 (D-53) Barcelona Catalonia Spain 08025
- Universitat Autònoma de Barcelona; Sant Antoni Maria Claret, 167 Pavilion 18 (D-13) Barcelona Catalunya Spain 08025
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Feng Y, Barrett M, Hou Y, Yoon HK, Ochi T, Teitelbaum DH. Homeostasis alteration within small intestinal mucosa after acute enteral refeeding in total parenteral nutrition mouse model. Am J Physiol Gastrointest Liver Physiol 2016; 310:G273-84. [PMID: 26635320 PMCID: PMC4754738 DOI: 10.1152/ajpgi.00335.2015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 11/24/2015] [Indexed: 01/31/2023]
Abstract
Feeding strategies to care for patients who transition from enteral nutrient deprivation while on total parenteral nutrition (TPN) to enteral feedings generally proceed to full enteral nutrition once the gastrointestinal tract recovers; however, an increasing body of literature suggests that a subgroup of patients may actually develop an increased incidence of adverse events, including death. To examine this further, we studied the effects of acute refeeding in a mouse model of TPN. Interestingly, refeeding led to some beneficial effects, including prevention in the decline in intestinal epithelial cell (IEC) proliferation. However, refeeding led to a significant increase in mucosal expression of proinflammatory cytokines, including tumor necrosis factor-α (TNF-α), as well as an upregulation in Toll-like receptor 4 (TLR-4). Refeeding also failed to prevent TPN-associated increases in IEC apoptosis, loss of epithelial barrier function, and failure of the leucine-rich repeat-containing G protein-coupled receptor 5-positive stem cell expression. Transitioning from TPN to enteral feedings led to a partial restoration of the small bowel microbial population. In conclusion, while acute refeeding led to some restoration of normal gastrointestinal physiology, enteral refeeding led to a significant increase in mucosal inflammatory markers and may suggest alternative strategies to enteral refeeding should be considered.
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Affiliation(s)
- Yongjia Feng
- 1Section of Pediatric Surgery, Department of Surgery, the University of Michigan Medical School and the C. S. Mott Children's Hospital, Ann Arbor, Michigan;
| | - Meredith Barrett
- 1Section of Pediatric Surgery, Department of Surgery, the University of Michigan Medical School and the C. S. Mott Children's Hospital, Ann Arbor, Michigan; ,2General Surgery, Department of Surgery, the University of Michigan Medical School, Ann Arbor, Michigan;
| | - Yue Hou
- 1Section of Pediatric Surgery, Department of Surgery, the University of Michigan Medical School and the C. S. Mott Children's Hospital, Ann Arbor, Michigan; ,3University of Michigan, Ann Arbor, Michigan; and
| | - Hong Keun Yoon
- 1Section of Pediatric Surgery, Department of Surgery, the University of Michigan Medical School and the C. S. Mott Children's Hospital, Ann Arbor, Michigan; ,3University of Michigan, Ann Arbor, Michigan; and
| | - Takanori Ochi
- 1Section of Pediatric Surgery, Department of Surgery, the University of Michigan Medical School and the C. S. Mott Children's Hospital, Ann Arbor, Michigan; ,4Department of Pediatric Surgery, Juntendo Hospital, Juntendo University, Tokyo, Japan
| | - Daniel H. Teitelbaum
- 1Section of Pediatric Surgery, Department of Surgery, the University of Michigan Medical School and the C. S. Mott Children's Hospital, Ann Arbor, Michigan;
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Wilson B, Typpo K. Nutrition: A Primary Therapy in Pediatric Acute Respiratory Distress Syndrome. Front Pediatr 2016; 4:108. [PMID: 27790606 PMCID: PMC5061746 DOI: 10.3389/fped.2016.00108] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 09/20/2016] [Indexed: 12/18/2022] Open
Abstract
Appropriate nutrition is an essential component of intensive care management of children with acute respiratory distress syndrome (ARDS) and is linked to patient outcomes. One out of every two children in the pediatric intensive care unit (PICU) will develop malnutrition or have worsening of baseline malnutrition and present with specific micronutrient deficiencies. Early and adequate enteral nutrition (EN) is associated with improved 60-day survival after pediatric critical illness, and, yet, despite early EN guidelines, critically ill children receive on average only 55% of goal calories by PICU day 10. Inadequate delivery of EN is due to perceived feeding intolerance, reluctance to enterally feed children with hemodynamic instability, and fluid restriction. Underlying each of these factors is large practice variation between providers and across institutions for initiation, advancement, and maintenance of EN. Strategies to improve early initiation and advancement and to maintain delivery of EN are needed to improve morbidity and mortality from pediatric ARDS. Both, over and underfeeding, prolong duration of mechanical ventilation in children and worsen other organ function such that precise calorie goals are needed. The gut is thought to act as a "motor" of organ dysfunction, and emerging data regarding the role of intestinal barrier functions and the intestinal microbiome on organ dysfunction and outcomes of critical illness present exciting opportunities to improve patient outcomes. Nutrition should be considered a primary rather than supportive therapy for pediatric ARDS. Precise nutritional therapies, which are titrated and targeted to preservation of intestinal barrier function, prevention of intestinal dysbiosis, preservation of lean body mass, and blunting of the systemic inflammatory response, offer great potential for improving outcomes of pediatric ARDS. In this review, we examine the current evidence regarding dose, route, and timing of nutrition, current recommendations for provision of nutrition to children with ARDS, and the current literature for immune-modulating diets for pediatric ARDS. We will examine emerging data regarding the role of the intestinal microbiome in modulating the response to critical illness.
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Affiliation(s)
- Bryan Wilson
- Department of Emergency Medicine, University of Arizona College of Medicine , Tucson, AZ , USA
| | - Katri Typpo
- Department of Pediatrics, Steele Children's Research Center, University of Arizona College of Medicine , Tucson, AZ , USA
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Abstract
Abstract
Surgery represents a major stressor that disrupts homeostasis and can lead to loss of body cell mass. Integrated, multidisciplinary medical strategies, including enhanced recovery programs and perioperative nutrition support, can mitigate the surgically induced metabolic response, promoting optimal patient recovery following major surgery. Clinical therapies should identify those who are poorly nourished before surgery and aim to attenuate catabolism while preserving the processes that promote recovery and immunoprotection after surgery. This review will address the impact of surgery on intermediary metabolism and describe the clinical consequences that ensue. It will also focus on the role of perioperative nutrition, including preoperative nutrition risk, carbohydrate loading, and early initiation of oral feeding (centered on macronutrients) in modulating surgical stress, as well as highlight the contribution of the anesthesiologist to nutritional care. Emerging therapeutic concepts such as preoperative glycemic control and prehabilitation will be discussed.
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Huang X, Nie S, Xie M. Interaction between gut immunity and polysaccharides. Crit Rev Food Sci Nutr 2015; 57:2943-2955. [DOI: 10.1080/10408398.2015.1079165] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Partial Enteral Nutrition Preserves Elements of Gut Barrier Function, Including Innate Immunity, Intestinal Alkaline Phosphatase (IAP) Level, and Intestinal Microbiota in Mice. Nutrients 2015; 7:6294-312. [PMID: 26247961 PMCID: PMC4555127 DOI: 10.3390/nu7085288] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 05/20/2015] [Accepted: 07/22/2015] [Indexed: 01/28/2023] Open
Abstract
Lack of enteral nutrition (EN) during parenteral nutrition (PN) leads to higher incidence of infection because of gut barrier dysfunction. However, the effects of partial EN on intestina linnate immunity, intestinal alkaline phosphatase (IAP) and microbiota remain unclear. The mice were randomized into six groups to receive either standard chow or isocaloric and isonitrogenous nutritional support with variable partial EN to PN ratios. Five days later, the mice were sacrificed and tissue samples were collected. Bacterial translocation, the levels of lysozyme, mucin 2 (MUC2), and IAP were analyzed. The composition of intestinal microbiota was analyzed by 16S rRNA pyrosequencing. Compared with chow, total parenteral nutrition (TPN) resulted in a dysfunctional mucosal barrier, as evidenced by increased bacterial translocation (p < 0.05), loss of lysozyme, MUC2, and IAP, and changes in the gut microbiota (p < 0.001). Administration of 20% EN supplemented with PN significantly increased the concentrations of lysozyme, MUC2, IAP, and the mRNA levels of lysozyme and MUC2 (p < 0.001). The percentages of Bacteroidetes and Tenericutes were significantly lower in the 20% EN group than in the TPN group (p < 0.001). These changes were accompanied by maintained barrier function in bacterial culture (p < 0.05). Supplementation of PN with 20% EN preserves gut barrier function, by way of maintaining innate immunity, IAP and intestinal microbiota.
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Kohl KD, Amaya J, Passement CA, Dearing MD, McCue MD. Unique and shared responses of the gut microbiota to prolonged fasting: a comparative study across five classes of vertebrate hosts. FEMS Microbiol Ecol 2014; 90:883-94. [DOI: 10.1111/1574-6941.12442] [Citation(s) in RCA: 149] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 10/04/2014] [Accepted: 10/14/2014] [Indexed: 12/25/2022] Open
Affiliation(s)
- Kevin D. Kohl
- Department of Biology; University of Utah; Salt Lake City UT USA
| | - James Amaya
- Department of Biological Sciences; St. Mary's University; San Antonio TX USA
| | | | | | - Marshall D. McCue
- Department of Biological Sciences; St. Mary's University; San Antonio TX USA
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Feng F, Li XH, Shi H, Wu GS, Zhang HW, Liu XN, Zhao QC. Fast-track surgery combined with laparoscopy could improve postoperative recovery of low-risk rectal cancer patients: a randomized controlled clinical trial. J Dig Dis 2014; 15:306-13. [PMID: 24597608 DOI: 10.1111/1751-2980.12142] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE In this study we aimed to assess the feasibility and safety of fast-track surgery (FTS) combined with laparoscopy for treating patients with rectal cancer and compare the results with those of the conventional perioperative intervention group. METHODS A total of 120 patients with rectal cancer were prospectively randomly assigned to the FTS combined with laparoscopy group and the conventional perioperative intervention plus laparoscopy group from November 2011 to November 2012. All patients received radical anterior resection with total mesorectal excision. Their baseline characteristics and the perioperative outcomes were recorded for analyses. RESULTS Compared with the conventional perioperative intervention group, the fast-track protocol combined with laparoscopy could shorten the time to the first flatus (53.44 ± 23.64 h vs 67.85 ± 20.12 h, P = 0.001) and first defecation (65.23 ± 22.24 h vs 86.98 ± 24.85 h, P = 0.000) after operation, accelerate the decrease of white blood cell count (P < 0.05), inhibit body temperature augmentation (P < 0.05) and reduce postoperative complication rate (16.9% vs 3.5%, P = 0.030). In addition, the length of postoperative stay was also shortened (5.05 ± 1.38 days vs 6.98 ± 2.26 days, P = 0.000). The medical cost of hospitalization was also reduced in the FTS group. CONCLUSION FTS in combination with laparoscopy may accelerate the clinical recovery of patients with rectal cancer after surgery.
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Affiliation(s)
- Fan Feng
- Department of Digestive Surgery, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
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Martindale RG, McClave SA, Taylor B, Lawson CM. Perioperative nutrition: what is the current landscape? JPEN J Parenter Enteral Nutr 2014; 37:5S-20S. [PMID: 24009250 DOI: 10.1177/0148607113496821] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Poor nutrition status has long been linked to increases in postoperative complications and adverse outcomes for the patient undergoing elective surgery. While optimal planning for nutrition therapy should be comprehensive spanning throughout the perioperative period, recent advances have focused on the concept of "prehabilitation" to best prepare the patient prior to the insult of surgery. Adding immune/metabolic modulating formulas the week of surgery with carbohydrate drinks to optimize glycogen deposition immediately prior to surgery, enhances patient recovery and return to baseline function. Such nutrition strategies should now be combined with a host of other practices (such as smoking cessation, weight loss, glucose control, and specialized exercise program) as part of a structured protocol to maximize patients' chances for a full and rapid recovery from their elective surgical procedure.
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Affiliation(s)
- Robert G Martindale
- Department of Surgery, University of Oregon Health Sciences University, Portland, Oregon, USA
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Abstract
BACKGROUND Parenteral nutrition (PN) increases risks of infections in critically injured patients. Recently, PN was shown to reduce intestine luminal levels of the Paneth cell antimicrobial molecule secretory phospholipase A2 (sPLA2) and the goblet cell glycoprotein mucin2 (MUC2). These molecules are critical factors for innate mucosal immunity and provide barrier protection. Interleukin-4 (IL-4) and IL-13 regulate sPLA2 and MUC2 production through the IL-13 receptor. Because IL-25 stimulates IL-4 and IL-13 release and PN reduces luminal sPLA2 and MUC2, we hypothesized that adding IL-25 to PN would restore these innate immune factors and maintain barrier function. METHODS Two days after venous cannulation, male ICR (Institute of Cancer Research) mice were randomized to receive chow (n = 12), PN (n = 9), or PN + 0.7 μg of exogenous IL-25 (n = 11) daily for 5 days. Small-intestine wash fluid (SIWF) was collected for analysis of sPLA2 activity, MUC2 density, and luminal levels of IL-4 and IL-13. Small-intestinal tissue was harvested for analysis of tissue sPLA2 activity or immediate use in an ex-vivo intestinal segment culture (EVISC) to assess susceptibility of the tissue segments to enteroinvasive Escherichia coli. RESULTS PN reduced luminal sPLA2 (P < 0.0001) and MUC2 (P <0.002) compared with chow, whereas the addition of IL-25 to PN increased luminal sPLA2 (P < 0.0001) and MUC2 (P < 0.02) compared with PN. Tissue IL-4 and IL-13 decreased with PN compared with chow (IL-4: P < 0.0001, IL-13: P < 0.002), whereas IL-25 increased both cytokines compared with PN (IL-4: P < 0.03, IL-13: P < 0.02). Tissue levels of sPLA2 were significantly decreased with PN compared with chow, whereas IL-25 significantly increased tissue sPLA2 levels compared with PN alone. Functionally, more bacteria invaded the PN-treated tissue compared with chow (P < 0.01), and the addition of IL-25 to PN decreased enteroinvasion to chow levels (P < 0.01). CONCLUSIONS PN impairs innate mucosal immunity by suppressing luminal sPLA2 activity and MUC2 density compared with chow. PN also increases bacterial invasion in ex-vivo tissue. Administration of exogenous IL-25 reverses this dysfunction and increases luminal sPLA2 and MUC2. PN tissue treated with IL-25 was significantly more resistant to bacterial invasion than with PN alone, suggesting that IL-25-induced effects augment the barrier defense mechanisms.
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Abstract
PURPOSE OF REVIEW Enteral nutrition is recommended as a standard nutritional therapy in clinical settings. The rationale behind enteral nutrition may be decreased infectious morbidities compared with parenteral nutrition. However, the mechanism may not be well understood. RECENT FINDINGS Animal studies have revealed that enteral nutrition, compared with parenteral nutrition, preserves the gut-associated lymphoid tissue mass and function with well controlled gut cytokine milieu and intracellular signaling pathway, leading to the maintenance of intestinal and extraintestinal acquired mucosal immunity. Moreover, enteral nutrition can enhance the gut innate immunity by increasing the antimicrobial peptides, such as secretory phospholipase A2. More importantly, a recent clinical study demonstrated preoperative parenteral nutrition without enteral nutrition to decrease the number of T cells, IgA-producing cells, and mature dendritic cells in human terminal ileum, which are consistent with the data obtained from animal studies. Investigation of the mechanism has given us some surrogates of enteral nutrition during parenteral nutrition, such as glutamine, butyric acid, cytokines, and other mediators. However, to date, no surrogates can restore parenteral-nutrition-induced impairment of host defense completely. SUMMARY Because enteral nutrition is a practical way to preserve gut immunity, clinicians should make any efforts to shorten the period of enteral nutrition absence and increase the dose according to the degree of tolerance.
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Towards the determination of the nutritional needs of the body and its microbiome in sickness and in health. Curr Opin Gastroenterol 2014; 30:175-7. [PMID: 24445331 DOI: 10.1097/mog.0000000000000045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Lack of preoperative enteral nutrition reduces gut-associated lymphoid cell numbers in colon cancer patients: a possible mechanism underlying increased postoperative infectious complications during parenteral nutrition. Ann Surg 2014. [PMID: 23187750 DOI: 10.1097/sla.0b013e31827a0e05] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To examine preoperative dietary influences on gut-associated lymphoid tissue (GALT) cell number in the context of postoperative infectious complications. BACKGROUND There is little clinical evidence regarding whether nutritional routes affect GALT size and/or phenotype. The influence of GALT atrophy on clinical outcomes is also unclear. METHOD Patients with complete obstruction of the colon due to a tumor were excluded from this study. Study 1. Resected terminal ileum specimens, from 62 patients [preoperative parenteral nutrition (PN): n = 15, preoperative oral feeding (OF): n = 47] who underwent right colectomy during the period from 1997 to 2004 at our department, were immunohistochemically stained for counting numbers of T, IgA-producing, and mature and immature dendritic cells (DCs) in the lamina propria (LP) and intraepithelial space.Study 2. We reviewed 341 patients (PN: n = 99, OF: n = 242) with colon cancer who underwent colectomy during this period for postoperative complications. RESULTS Study 1. T cell numbers in the LP and intraepithelial space and IgA-producing cell number in the LP were significantly lower in the PN than in the OF group. Mature DC number in the LP was significantly lower in the PN than in the OF group, whereas total DC numbers (both mature and immature DC) were similar in the 2 groups.Study 2. The PN group had significantly higher rates of total infectious complications, surgical site infection, pneumonia, infectious colitis, and central venous catheter infection. CONCLUSIONS Lack of enteral delivery of nutrients reduces numbers of T and IgA-producing cells, as well as mature DCs, in GALT of colon cancer patients, as it does in animal models. A close association between GALT changes and infectious complication morbidity was confirmed.
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Demehri FR, Barrett M, Ralls MW, Miyasaka EA, Feng Y, Teitelbaum DH. Intestinal epithelial cell apoptosis and loss of barrier function in the setting of altered microbiota with enteral nutrient deprivation. Front Cell Infect Microbiol 2013; 3:105. [PMID: 24392360 PMCID: PMC3870295 DOI: 10.3389/fcimb.2013.00105] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2013] [Accepted: 12/09/2013] [Indexed: 12/12/2022] Open
Abstract
Total parenteral nutrition (TPN), a commonly used treatment for patients who cannot receive enteral nutrition, is associated with significant septic complications due in part to a loss of epithelial barrier function (EBF). While the underlying mechanisms of TPN-related epithelial changes are poorly understood, a mouse model of TPN-dependence has helped identify several contributing factors. Enteral deprivation leads to a shift in intestinal microbiota to predominantly Gram-negative Proteobacteria. This is associated with an increase in expression of proinflammatory cytokines within the mucosa, including interferon-γ and tumor necrosis factor-α. A concomitant loss of epithelial growth factors leads to a decrease in epithelial cell proliferation and increased apoptosis. The resulting loss of epithelial tight junction proteins contributes to EBF dysfunction. These mechanisms identify potential strategies of protecting against TPN-related complications, such as modification of luminal bacteria, blockade of proinflammatory cytokines, or growth factor replacement.
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Affiliation(s)
- Farokh R Demehri
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System Ann Arbor, MI, USA
| | - Meredith Barrett
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System Ann Arbor, MI, USA
| | - Matthew W Ralls
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System Ann Arbor, MI, USA
| | - Eiichi A Miyasaka
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System Ann Arbor, MI, USA
| | - Yongjia Feng
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System Ann Arbor, MI, USA
| | - Daniel H Teitelbaum
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System Ann Arbor, MI, USA
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Yanagawa M, Fukatsu K, Mitsui T, Murakoshi S, Yasuhara H, Nishimura R. Effects of a new immune-modulating diet enriched with whey-hydrolyzed peptide, fermented milk, and isomaltulose on gut associated lymphoid tissue in mice. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.clnme.2013.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
One of the most important factors affecting outcome and recovery from surgical trauma is preoperative nutritional status. Research in perioperative nutritional support has suffered from a lack of consensus as to the definition of malnutrition, no recognition of which nutrients are important to surgical healing, and a paucity of well-designed studies. In the past decade, there has been some activity to address this situation, recognizing the importance of nutrition as a therapy before surgery, after surgery, and possibly even during surgery.
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Affiliation(s)
- T Miko Enomoto
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, UHS-2, Portland, OR 97239, USA
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Heneghan AF, Pierre JF, Tandee K, Shanmuganayagam D, Wang X, Reed JD, Steele JL, Kudsk KA. Parenteral nutrition decreases paneth cell function and intestinal bactericidal activity while increasing susceptibility to bacterial enteroinvasion. JPEN J Parenter Enteral Nutr 2013; 38:817-824. [PMID: 23894173 DOI: 10.1177/0148607113497514] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Parenteral nutrition (PN) increases the risk of infection in patients with contraindication to enteral feeding. Paneth cells produce and secrete antimicrobial products that protect the mucosa from pathogens. Their loss is associated with increased host-pathogen interactions, mucosal inflammation, and altered microbiome composition. HYPOTHESIS We hypothesized that PN reduces Paneth cell product expression, and these changes would reduce bactericidal properties of tissue secretions following cholinergic stimulation, increase mucosal enteroinvasion, and shift the intestinal microbiome. METHOD Experiment 1: Male ICR mice were randomized to Chow (n = 8) or PN (n = 8). Ileum tissue was collected for Paneth cell antimicrobial expression using RT-PCR, stimulated with a cholinergic agonist degranulate Paneth cells bactericidal activity, or used to assess bacterial enteroinvasion in EVISC. Experiment 2: Mice were randomized to Chow (n = 11) or PN (n = 8) and ileum washing was collected for 16s pyrosequencing analysis. RESULTS Compared to Chow, PN decreased tissue expression of REGIII-g (p < 0.002), lysozyme (p < 0.002), and cryptdin-4 (p < 0.03). At the phylum level, PN decreased total Firmicutes but increased total Bacteroidetes, and Proteobacteria. Functionally, secretions from PN tissue was less bactericidal (p < 0.03) and demonstrated increased susceptibility to enteroinvasion by E coli (p < 0.02). CONCLUSION PN without enteral nutrition impairs innate mucosal immune function. Tissue expression of Paneth cell antimicrobial proteins decreases associated with compositional shifts to the microbiome, decreased bactericidal activity of mucosal secretions and greater susceptibility of to enteroinvasion by E coli. These changes may explain in-part the increased risk of infection in parenterally fed patients.
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Affiliation(s)
- Aaron F Heneghan
- Surgical Service of the William S. Middleton Veteran Memorial Hospital, Madison WI, USA.,Department of Surgery, University of Wisconsin-Madison, Madison, WI, USA
| | - Joseph F Pierre
- Surgical Service of the William S. Middleton Veteran Memorial Hospital, Madison WI, USA.,Department of Surgery, University of Wisconsin-Madison, Madison, WI, USA
| | - Kanokwan Tandee
- Department of Food Science, University of Wisconsin-Madison, Madison, WI, USA
| | | | - Xinying Wang
- Department of Surgery, University of Wisconsin-Madison, Madison, WI, USA.,Department of Surgery, Nanjing University, Jinling hospital, Nanjing, China
| | - Jess D Reed
- Reed Research Group, Department of Animal Sciences, University of Wisconsin -Madison, Madison, WI 53706
| | - James L Steele
- Department of Food Science, University of Wisconsin-Madison, Madison, WI, USA
| | - Kenneth A Kudsk
- Surgical Service of the William S. Middleton Veteran Memorial Hospital, Madison WI, USA.,Department of Surgery, University of Wisconsin-Madison, Madison, WI, USA
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Ralls MW, Miyasaka E, Teitelbaum DH. Intestinal microbial diversity and perioperative complications. JPEN J Parenter Enteral Nutr 2013; 38:392-9. [PMID: 23636012 DOI: 10.1177/0148607113486482] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIMS Enteral nutrient deprivation via parenteral nutrition (PN) in a mouse model leads to a local mucosal inflammatory response. This proinflammatory response leads to a loss of epithelial barrier function and atrophy of the intestine. Although the underlying mechanisms are unknown, a potential contributing factor is the impact PN has on the intestinal microbiome. We recently identified a shift in the intestinal microbial community in mice given PN; however, it is unknown whether such changes occur in humans. We hypothesized that similar microbial changes occur in humans during periods of enteral nutrient deprivation. METHODS A series of small bowel specimens were obtained from pediatric and adult patients undergoing small intestinal resection. Mucosally associated bacteria were harvested and analyzed using 454 pyrosequencing techniques. Statistical analysis of microbial diversity and differences in microbial characteristics were assessed between enterally fed and enterally deprived portions of the intestine. Occurrence of postoperative infectious and anastomotic complications was also examined. RESULTS Pyrosequencing demonstrated a wide variability in microbial diversity within all groups. Principal coordinate analysis demonstrated only a partial stratification of microbial communities between fed and enterally deprived groups. Interestingly, a tight correlation was identified in patients who had a low level of enteric microbial diversity and those who developed postoperative enteric-derived infections or intestinal anastomotic disruption. CONCLUSIONS Loss of enteral nutrients and systemic antibiotic therapy in humans is associated with a significant loss of microbial biodiversity within the small bowel mucosa. These changes were associated with a number of enteric-derived intestinal infections and intestinal anastomotic disruptions.
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Affiliation(s)
- Matthew W Ralls
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
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Pierre JF, Heneghan AF, Feliciano RP, Shanmuganayagam D, Roenneburg DA, Krueger CG, Reed JD, Kudsk KA. Cranberry proanthocyanidins improve the gut mucous layer morphology and function in mice receiving elemental enteral nutrition. JPEN J Parenter Enteral Nutr 2013; 37:401-9. [PMID: 23064255 PMCID: PMC4564871 DOI: 10.1177/0148607112463076] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Lamina propria Th2 cytokines, interleukin (IL)-4 and IL-13, stimulate goblet cell (GC) proliferation and MUC2 production, which protect the intestinal mucosa. Elemental enteral nutrition (EEN) reduces tissue IL-4 and impairs barrier function. Proanthocyanidins (PACs) stimulate oral mucin levels. We hypothesized that adding PAC to EEN would maintain Th2-without stimulating Th1-cytokines and preserve luminal MUC2 vs EEN alone. MATERIALS AND METHODS Seventy mice were randomized to 5 diet groups-standard chow, intragastric EEN, or EEN with lowPAC, midPAC (50 mg), or highPAC (100 mg PAC/kg BW)-for 5 days, starting 2 days after gastric cannulation. Ileal tissue was analyzed for histomorphology and the cytokines IL-4, IL-13, IL-1β, IL-6, and TNF-α by enzyme-linked immunosorbent assay. MUC2 was measured in intestinal washes. RESULTS EEN lowered IL-13 (P < .05) compared with standard chow, whereas IL-4 was not significant (P < .07). LowPAC and midPAC increased IL-13 (P < .05), whereas highPAC increased both IL-4 and IL-13 (P < .05) compared with EEN. All EEN diets reduced (P < .05) crypt depth compared with the chow group. Compared with standard chow, GC numbers and luminal MUC2 were reduced with EEN (P < .05). These effects were attenuated (P < .05) with midPAC and highPAC. No changes were observed in tissue Th1 cytokines. CONCLUSIONS Adding PACs to EEN reverses impaired intestinal barrier function following EEN by improving the gut mucous layer and function through increased GC size and number as well as levels of MUC2 and ileal IL-4 and IL-13.
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Affiliation(s)
- Joseph F Pierre
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Pierre JF, Heneghan AF, Feliciano RP, Shanmuganayagam D, Krueger CG, Reed JD, Kudsk KA. Cranberry proanthocyanidins improve intestinal sIgA during elemental enteral nutrition. JPEN J Parenter Enteral Nutr 2013; 38:107-14. [PMID: 23359014 DOI: 10.1177/0148607112473654] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Elemental enteral nutrition (EEN) decreases gut-associated lymphoid tissue (GALT) function, including fewer Peyer's patch lymphocytes and lower levels of the tissue T helper 2 (Th2) cytokines and mucosal transport protein polymeric immunoglobulin receptor (pIgR), leading to lower luminal secretory immunoglobulin A (sIgA) levels. Since we recently demonstrated that cranberry proanthocyanidins (PACs) maintain the Th2 cytokine interleukin (IL)-4 when added to EEN, we hypothesized the addition of PACs to EEN would normalize other GALT parameters and maintain luminal levels of sIgA. METHODS Institute of Cancer Research mice were randomized (12/group) to receive chow, EEN, or EEN + PACs (100 mg/kg body weight) for 5 days, starting 2 days after intragastric cannulation. Ileum tissue was collected to measure IL-4 by enzyme-linked immunosorbent assay, pIgR by Western blot, and phosphorylated STAT-6 by microarray. Intestinal wash fluid was collected to measure sIgA by Western blot. RESULTS Compared with chow, EEN significantly decreased tissue IL-4, phosphorylated STAT-6, and pIgR. The addition of PACs to EEN prevented these alterations. Compared with chow, EEN resulted in significantly lower levels of luminal sIgA. The addition of PACs to EEN increased luminal sIgA levels compared with EEN alone. CONCLUSIONS This study suggests the addition of PACs to EEN may support GALT function and maintain intestinal sIgA levels compared with EEN administration alone.
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Affiliation(s)
- Joseph F Pierre
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
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Abstract
To understand the role of human microbiota in health and disease, we need to study effects of environmental and other epidemiological variables on the composition of microbial communities. The composition of a microbial community may depend on multiple factors simultaneously. Therefore we need multivariate methods for detecting, analyzing and visualizing the interactions between environmental variables and microbial communities. We provide two different approaches for multivariate analysis of these complex combined datasets: (i) We select variables that correlate with overall microbiota composition and microbiota members that correlate with the metadata using canonical correlation analysis, determine independency of the observed correlations in a multivariate regression analysis, and visualize the effect size and direction of the observed correlations using heatmaps; (ii) We select variables and microbiota members using univariate or bivariate regression analysis, followed by multivariate regression analysis, and visualize the effect size and direction of the observed correlations using heatmaps. We illustrate the results of both approaches using a dataset containing respiratory microbiota composition and accompanying metadata. The two different approaches provide slightly different results; with approach (i) using canonical correlation analysis to select determinants and microbiota members detecting fewer and stronger correlations only and approach (ii) using univariate or bivariate analyses to select determinants and microbiota members detecting a similar but broader pattern of correlations. The proposed approaches both detect and visualize independent correlations between multiple environmental variables and members of the microbial community. Depending on the size of the datasets and the hypothesis tested one can select the method of preference.
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Ban K, Kozar RA. Protective role of p70S6K in intestinal ischemia/reperfusion injury in mice. PLoS One 2012; 7:e41584. [PMID: 22848534 PMCID: PMC3407246 DOI: 10.1371/journal.pone.0041584] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Accepted: 06/25/2012] [Indexed: 12/20/2022] Open
Abstract
The mTOR signaling pathway plays a crucial role in the regulation of cell growth, proliferation, survival and in directing immune responses. As the intestinal epithelium displays rapid cell growth and differentiation and is an important immune regulatory organ, we hypothesized that mTOR may play an important role in the protection against intestinal ischemia reperfusion (I/R)-induced injury. To better understand the molecular mechanisms by which the mTOR pathway is altered by intestinal I/R, p70S6K, the major effector of the mTOR pathway, was investigated along with the effects of rapamycin, a specific inhibitor of mTOR and an immunosuppressant agent used clinically in transplant patients. In vitro experiments using an intestinal epithelial cell line and hypoxia/reoxygenation demonstrated that overexpression of p70S6K promoted cell growth and migration, and decreased cell apoptosis. Inhibition of p70S6K by rapamycin reversed these protective effects. In a mouse model of gut I/R, an increase of p70S6K activity was found by 5 min and remained elevated after 6 h of reperfusion. Inhibition of p70S6K by rapamycin worsened gut injury, promoted inflammation, and enhanced intestinal permeability. Importantly, rapamycin treated animals had a significantly increased mortality. These novel results demonstrate a key role of p70S6K in protection against I/R injury in the intestine and suggest a potential danger in using mTOR inhibitors in patients at risk for gut hypoperfusion.
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Affiliation(s)
- Kechen Ban
- Department of Surgery, University of Texas Health Science Center at Houston, Houston, Texas, United States of America.
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The scope of the crustacean immune system for disease control. J Invertebr Pathol 2012; 110:251-60. [DOI: 10.1016/j.jip.2012.03.005] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2011] [Accepted: 12/01/2011] [Indexed: 11/20/2022]
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Fukatsu K. The Long Road to Optimizing the Parenteral Provision of Nutrients. JPEN J Parenter Enteral Nutr 2012; 36:157-8. [DOI: 10.1177/0148607111428324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Bastarache JA, Ware LB, Girard TD, Wheeler AP, Rice TW. Markers of inflammation and coagulation may be modulated by enteral feeding strategy. JPEN J Parenter Enteral Nutr 2012; 36:732-40. [PMID: 22318965 DOI: 10.1177/0148607111433054] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Although enteral nutrition (EN) is provided to most mechanically ventilated patients, the effect of specific feeding strategies on circulating markers of coagulation and inflammation is unknown. METHODS Markers of inflammation (tumor necrosis factor [TNF]-α, interleukin [IL]-1β, interferon [IFN]-γ, IL-6, IL-8, IL-10, IL-12) and coagulation (tissue factor [TF], plasminogen activator inhibitor-1) were measured at baseline (n = 185) and 6 days (n = 103) in mechanically ventilated intensive care unit patients enrolled in a randomized controlled study of trophic vs full-energy feeds to test the hypothesis that trophic enteral feeds would be associated with decreases in markers of inflammation and coagulation compared to full-energy feeds. RESULTS There were no differences in any of the biomarkers measured at day 6 between patients who were randomized to receive trophic feeds compared to full-energy feeds. However, TF levels decreased modestly in patients from baseline to day 6 in the trophic feeding group (343.3 vs 247.8 pg/mL, P = .061) but increased slightly in the full-calorie group (314.3 vs 331.8 pg/mL). Lower levels of TF at day 6 were associated with a lower mortality, and patients who died had increasing TF levels between days 0 and 6 (median increase of 39.7) compared to decreasing TF levels in patients who lived (median decrease of 95.0, P = .033). CONCLUSIONS EN strategy in critically ill patients with acute respiratory failure does not significantly modify inflammation and coagulation by day 6, but trophic feeds may have some modest effects in attenuating inflammation and coagulation.
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Affiliation(s)
- Julie A Bastarache
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee 37232-2650, USA.
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The Importance of Enteral Nutrition. Dysphagia 2012. [DOI: 10.1007/174_2012_578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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