Challenges in Septic Shock: From New Hemodynamics to Blood Purification Therapies

Sepsis and septic shock are associated with high mortality, with diagnosis and treatment remaining a challenge for clinicians. Their management classically encompasses hemodynamic resuscitation, antibiotic treatment, life support, and focus control; however, there are aspects that have changed. This narrative review highlights current and avant-garde methods of handling patients experiencing septic shock based on the experience of its authors and the best available evidence in a context of uncertainty. Following the first recommendation of the Surviving Sepsis Campaign guidelines, it is recommended that specific sepsis care performance improvement programs are implemented in hospitals, i.e., "Sepsis Code" programs, designed ad hoc, to achieve this goal. Regarding hemodynamics, the importance of perfusion and hemodynamic coherence stand out, which allow for the recognition of different phenotypes, determination of the ideal time for commencing vasopressor treatment, and the appropriate fluid therapy dosage. At present, this is not only important for the initial timing, but also for de-resuscitation, which involves the early weaning of support therapies, directed elimination of fluids, and fluid tolerance concept. Finally, regarding blood purification therapies, those aimed at eliminating endotoxins and cytokines are attractive in the early management of patients in septic shock.

Altered hepatic and intestinal homeostasis in a neonatal murine model of short-term total parenteral nutrition and antibiotics

Parenteral nutrition (PN) prevents starvation and supports metabolic requirements intravenously when patients are unable to be fed enterally. Clinically, infants are frequently provided PN in intensive care settings along with exposure to antibiotics (ABX) to minimize infection during care. Unfortunately, neonates experience extremely high rates of hepatic complications. Adult rodent and piglet models of PN are well-established but neonatal models capable of leveraging the considerable transgenic potential of the mouse remain underdeveloped. Utilizing our newly established neonatal murine PN mouse model, we administered ABX or controlled drinking water to timed pregnant dams to disrupt the maternal microbiome. We randomized mouse pups to PN or sham surgery controls +/- ABX exposure. ABX or short-term PN decreased liver and brain organ weights, intestinal length, and mucosal architecture (vs. controls). PN significantly elevated evidence of hepatic proinflammatory markers, neutrophils and macrophage counts, bacterial colony-forming units, and evidence of cholestasis risk, which was blocked by ABX. However, ABX uniquely elevated metabolic regulatory genes resulting in accumulation of hepatocyte lipids, triglycerides, and elevated tauro-chenoxycholic acid (TCDCA) in serum. Within the gut, PN elevated the relative abundance of Akkermansia, Enterococcus, and Suterella with decreased Anaerostipes and Lactobacillus compared with controls, whereas ABX enriched Proteobacteria. We conclude that short-term PN elevates hepatic inflammatory stress and risk of cholestasis in early life. Although concurrent ABX exposure protects against hepatic immune activation during PN, the dual exposure modulates metabolism and may contribute toward early steatosis phenotype, sometimes observed in infants unable to wean from PN.NEW & NOTEWORTHY This study successfully established a translationally relevant, murine neonatal parenteral nutrition (PN) model. Short-term PN is sufficient to induce hepatitis-associated cholestasis in a neonatal murine model that can be used to understand disease in early life. The administration of antibiotics during PN protects animals from bacterial translocation and proinflammatory responses but induces unique metabolic shifts that may predispose the liver toward early steatosis.

Pharmaconutrition strategy to resolve SARS-CoV-2-induced inflammatory cytokine storm in non-alcoholic fatty liver disease: Omega-3 long-chain polyunsaturated fatty acids

Inflammation is one of the primary factors associated with the causation and/or progression of several lifestyle disorders, including obesity, type 2 diabetes and non-alcoholic fatty liver disease (NAFLD). NAFLD is a spectrum of disorders, and starts with simple steatosis, progresses to non-alcoholic steatohepatitis, and then advances to fibrosis, cirrhosis and finally, hepatocellular carcinoma, due to perpetual cycles of insults caused by inflammation and other cellular stress. Emerging evidence has documented that patients with NAFLD have severe coronavirus disease 2019 (COVID-19), and patients with COVID-19 have a higher liver injury and mortality. Although the exact cause or mechanism is not known, inflammatory cytokine storm is a characteristic feature of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and is known to be associated with higher mortality among COVID-19 patients. Therefore, the COVID-19 pandemic seems to be a major concern in NAFLD patients, who have contracted SARS-CoV-2 infection and develop COVID-19. This is evident in patients at any stage of the NAFLD spectrum, as the inflammatory cytokine storm may cause and/or aggravate the progression or severity of NAFLD. Thus, there is a need for resolution of the inflammatory cytokine storm in these patients. A large body of evidence has demonstrated the efficacy of omega-3 long-chain polyunsaturated fatty acids (ω-3 LCPUFA) in NAFLD conditions, due to their anti-inflammatory, immunomodulatory and anti-viral properties. Therefore, intervention with ω-3 LCPUFA, an effective pharmaconutrient along with the standard treatment for COVID-19 may be useful in the management of the NAFLD spectrum in COVID-19 patients with pre-existing NAFLD conditions by resolving the inflammatory cytokine storm and thereby attenuating its progression. Although there are challenges in implementation, optimistically they can be circumvented and the pharmaconutrition strategy may be potentially helpful in tackling both the pandemics; NAFLD and COVID-19 at least in this subset of patients.

Immunonutrition in head and neck cancer: Systematic review and metanalysis of its clinical and nutritional effects

BACKGROUND AND AIMS

A systematic review was conducted to assess the effects of glutamine, arginine and omega-3 supplementation on the tolerance to treatment, nutritional status and immune function of head and neck cancer (HNC) patients undergoing chemoradiotherapy.

METHODS

Randomized clinical trials were searched in MEDLINE, EMBASE, CENTRAL, LILACS, ClinicalTrials.gov, OpenGrey and Proquest. Tolerance to treatment, nutritional status, immune function and mortality rate were the primary outcomes investigated. Secondary outcomes comprised functional status, weight loss and body composition. Risk of bias of individual studies and the overall quality of the evidence were assessed using the Cochrane and the GRADE tools, respectively.

RESULTS

Nineteen articles met the inclusion criteria and nine were included in the meta-analyses, which assessed mucositis severity, weight loss and handgrip strength. Ten studies were evaluated as high risk of bias. Glutamine supplementation has significantly reduced the risk of grade 2-4 mucositis (RR: 0.76, IC95% [0.63; 0.92], P = 0.006, I² = 0%; P = 0.792; 4 studies). Omega-3 supplementation did not show statistically significant results on weight loss (SMD: -0.042, 95% CI [-0.322; 0.238], P = 0.769, I² = 33.4%; P = 0.212; 4 studies). The overall quality of the evidence ranged from low to very low.

CONCLUSIONS

These results must be interpreted with caution due to differences between supplementations regimen, lack of methodological rigor in most studies and due to the possible role of glutamine in tumor metabolism. Studies focused on elucidating the contribution of each immunonutrient to HNC patients undergoing chemoradiotherapy deserve further investigation.

Pharmaconutrition in the Clinical Management of COVID-19: A Lack of Evidence-Based Research But Clues to Personalized Prescription

A scientific interest has emerged to identify pharmaceutical and nutritional strategies in the clinical management of coronavirus disease 2019 (COVID-19). The purpose of this narrative review is to critically assess and discuss pharmaconutrition strategies that, secondary to accepted treatment methods, could be candidates in the current context of COVID-19. Oral medicinal doses of vitamin C (1-3 g/d) and zinc (80 mg/d elemental zinc) could be promising at the first signs and symptoms of COVID-19 as well as for general colds. In critical care situations requiring parenteral nutrition, vitamin C (3-10 g/d) and glutamine (0.3-0.5 g/kg/d) administration could be considered, whereas vitamin D3 administration (100,000 IU administered intramuscularly as a one-time dose) could possess benefits for patients with severe deficiency. Considering the presence of n-3 polyunsaturated fatty acids and arginine in immune-enhancing diets, their co-administration may also occur in clinical conditions where these formulations are recommended. However, despite the use of the aforementioned strategies in prior contexts, there is currently no evidence of the utility of any nutritional strategies in the management of SARS-CoV-2 infection and COVID-19. Nevertheless, ongoing and future clinical research is imperative to determine if any pharmaconutrition strategies can halt the progression of COVID-19.

Nutrition in Sepsis: A Bench-to-Bedside Review

Nutrition therapy in sepsis is challenging and differs from the standard feeding approach in critically ill patients. The dysregulated host response caused by infection induces progressive physiologic alterations, which may limit metabolic capacity by impairing mitochondrial function. Hence, early artificial nutrition should be ramped-up and emphasis laid on the post-acute phase of critical illness. Caloric dosing is ideally guided by indirect calorimetry, and endogenous energy production should be considered. Proteins should initially be delivered at low volume and progressively increased to 1.3 g/kg/day following shock symptoms wane. Both the enteral and parenteral route can be (simultaneously) used to cover caloric and protein targets. Regarding pharmaconutrition, a low dose glutamine seems appropriate in patients receiving parenteral nutrition. Supplementing arginine or selenium is not recommended. High-dose vitamin C administration may offer substantial benefit, but actual evidence is too limited for advocating its routine use in sepsis. Omega-3 polyunsaturated fatty acids to modulate metabolic processes can be safely used, but non-inferiority to other intravenous lipid emulsions remains unproven in septic patients. Nutrition stewardship, defined as the whole of interventions to optimize nutritional approach and treatment, should be pursued in all septic patients but may be difficult to accomplish within a context of profoundly altered cellular metabolic processes and organ dysfunction caused by time-bound excessive inflammation and/or immune suppression. This review aims to provide an overview and practical recommendations of all aspects of nutritional therapy in the setting of sepsis.

Postoperative enteral immunonutrition in head and neck cancer patients: Impact on clinical outcomes

BACKGROUND

Head and neck cancer patients have a high rate of complications during the postoperative period that could increase their morbidity rate. Arginine has been shown to improve healing and to modulate inflammation and immune response. The aim of our study was to assess whether use of arginine-enriched enteral formulas could decrease fistulas and length of stay (LoS).

METHODS

A retrospective study was conducted in patients who had undergone head and neck cancer surgery and were receiving enteral nutrition through a nasogastric tube in the postoperative period between January 2012 and May 2018. The differences associated to use of immunoformula vs. standard formulas were analysed. Sociodemographic, anthropometric, and nutritional intervention variables, as well as nutritional parameters, were recorded during the early postoperative period. Occurrence of complications (fistulas), length of hospital stay, readmissions, and 90-day mortality were recorded.

RESULTS

In a univariate analysis, patients who received nutritional support with immunonutrition had a lower fistula occurrence rate (17.91% vs. 32.84%; p=0.047) and a shorter mean LoS [28.25 (SD 16.11) vs. 35.50 (SD 25.73) days; p=0.030]. After adjusting for age, energy intake, aggressiveness of surgery and tumour stage, fistula occurrence rate and LoS were similar in both groups irrespective of the type of formula.

CONCLUSIONS

Use of arginine-enriched enteral nutrition appears to decrease the occurrence of fistulas in the postoperative period in patients with head and neck cancer, with a resultant reduction in length of hospital stay. However, the differences disappeared after adjusting for age, tumour stage, or aggressiveness of the surgery.

Clinical Nutrition in Critical Care Medicine - Guideline of the German Society for Nutritional Medicine (DGEM)

PURPOSE

Enteral and parenteral nutrition of adult critically ill patients varies in terms of the route of nutrient delivery, the amount and composition of macro- and micronutrients, and the choice of specific, immune-modulating substrates. Variations of clinical nutrition may affect clinical outcomes. The present guideline provides clinicians with updated consensus-based recommendations for clinical nutrition in adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function.

METHODS

The former guidelines of the German Society for Nutritional Medicine (DGEM) were updated according to the current instructions of the Association of the Scientific Medical Societies in Germany (AWMF) valid for a S2k-guideline. According to the S2k-guideline classification, no systematic review of the available evidence was required to make recommendations, which, therefore, do not state evidence- or recommendation grades. Nevertheless, we considered and commented the evidence from randomized-controlled trials, meta-analyses and observational studies with adequate sample size and high methodological quality (until May 2018) as well as from currently valid guidelines of other societies. The liability of each recommendation was described linguistically. Each recommendation was finally validated and consented through a Delphi process.

RESULTS

In the introduction the guideline describes a) the pathophysiological consequences of critical illness possibly affecting metabolism and nutrition of critically ill patients, b) potential definitions for different disease phases during the course of illness, and c) methodological shortcomings of clinical trials on nutrition. Then, we make 69 consented recommendations for essential, practice-relevant elements of clinical nutrition in critically ill patients. Among others, recommendations include the assessment of nutrition status, the indication for clinical nutrition, the timing and route of nutrient delivery, and the amount and composition of substrates (macro- and micronutrients); furthermore, we discuss distinctive aspects of nutrition therapy in obese critically ill patients and those treated with extracorporeal support devices.

CONCLUSION

The current guideline provides clinicians with up-to-date recommendations for enteral and parenteral nutrition of adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function. The period of validity of the guideline is approximately fixed at five years (2018-2023).

Nutrition management for head and neck cancer patients improves clinical outcome and survival

Up to 80% of patients with head and neck cancers are malnourished because of their lifestyle and the risk factors associated with this disease. Unfortunately, nutrition management systems are not implemented in most head and neck cancer clinics. Even worse, many head and neck surgeons as well as hospital management authorities disregard the importance of nutrition management in head and neck cancer patients. In addition, the often extensive resection and reconstruction required for tumors in the upper aerodigestive tract pose special challenges for swallowing and sufficient food intake, placing special demands on nutrition management. This article presents the basics of perioperative metabolism and nutrition management of head and neck cancer patients and makes recommendations for clinical practice. Implementing a nutrition management system in head and neck cancer clinics will improve the clinical outcome and the survival of the patients.

Evidence-Based Support for Nutrition Therapy in Head and Neck Cancer

PURPOSE OF REVIEW

Patients diagnosed with head and neck (H&N) cancer often present in a malnourished state for varied reasons; nutritional optimization is therefore critical to the success of treatment for these complex patients. This article aims to review the current nutrition literature pertaining to H&N cancer patients and to present evidence-based strategies for nutritional support specific to this population.

RECENT FINDINGS

Aggressive nutritional intervention is frequently required in the H&N cancer patient population. Rehabilitating nutrition during operative and nonoperative treatment improves compliance with treatment, quality of life, and clinical outcomes. When and whether to establishing alternative enteral access are points of controversy, although recent evidence suggests prophylactic enteral feeding tube placement should not be universally applied. Perioperative nutritional optimization including preoperative carbohydrate loading and provision of arginine-supplemented immunonutrition has been shown to benefit at-risk H&N cancer patients.

SUMMARY

With multidisciplinary collaboration, H&N cancer patients can receive individualized nutritional support to withstand difficult cancer treatment regimens and return to acceptable states of nutritional health.

Gastrointestinal immune and microbiome changes during parenteral nutrition

Parenteral nutrition (PN) is a lifesaving therapy that provides intravenous nutrition support to patients who cannot, or should not, feed via the gastrointestinal (GI) tract. Unfortunately, PN also carries certain risks related to infection and metabolic complications compared with enteral nutrition. In this review, an overview of PN and GI immune and microbiome changes is provided. PN impacts the gut-associated lymphoid tissue functions, especially adaptive immune cells, changes the intestinal epithelium and chemical secretions, and significantly alters the intestinal microbiome. Collectively, these changes functionally result in increased susceptibility to infectious and injurious challenge. Since PN remains necessary in large numbers of patients, the search to improve outcomes by stimulating GI immune function during PN remains of interest. This review closes by describing recent advances in using enteric nervous system neuropeptides or microbially derived products during PN, which may improve GI parameters by maintaining immunity and physiology.

Oral administration of an aqueous extract from the oyster mushroom Pleurotus ostreatus enhances the immunonutritional recovery of malnourished mice

Mushroom nutriceutical components have lately attracted interest for developing immunonutritional support. However, there is relatively little information pertaining to the use of mushroom preparations for modulating the metabolic and immunological disorders associated to malnutrition. This study was aimed to evaluate the effects of oral administration of an aqueous extract (CW-P) from Pleurotus ostreatus on the recovery of biochemical and immunological functions of malnourished mice. 8-week old female BALB/c mice were starved for 3days and then refed with commercial diet supplemented with or without CW-P (100mg/kg) for 8days. Regardless of the diet used during refeeding, animal body weights and serum protein concentrations did not differ between groups. Oral treatment with CW-P normalized haemoglobin levels, liver arginase and gut mucosal weight. CW-P increased total liver proteins and also DNA and protein contents in gut mucosa. Pleurotus extract provided benefits in terms of macrophages activation as well as in haemopoiesis, as judged by the recovery of bone marrow cells and leukocyte counts. Moreover, CW-P stimulated humoral immunity (T-dependent and T non-dependent antibodies responses) compared to non-supplemented mice. CW-P extract from the oyster mushroom can be used to develop specific food or nutritional supplement formulations with potential clinical applications in the immunotherapy.

Argininemia and plasma arginine bioavailability - predictive factors of mortality in the severe trauma patients?

BACKGROUND

Arginine is an amino acid determinant in the metabolic, immune and reparative responses to severe trauma. The present study aims to determine argininemia and plasma arginine bioavailability (PAB) in critical trauma patients and to analyze its correlation with prognosis.

METHODS

A prospective study of 23 critical trauma patients was undertaken. Aminoacidemias were determined, by ion exchange chromatography, at admission and in the first and third days and compared with those of 11 healthy individuals. PAB was calculated. Severity indexes and outcome parameters were recorded.

RESULTS

Values of argininemia, citrullinemia and ornithinemia at the admission were significantly lower than those of the controls (arginine: 41.2 ± 20.6 versus 56.1 ± 11.9 μmol/L, P = 0.034). Hipoargininemia (<60 μmol/L) prevalence was 82.6 %. Mean PAB was 62.4 ± 25.6 %. Argininemia < 26 μmol/L constituted a significant predictive factor of in-hospital mortality [n = 4 (17.4 %); 75 versus 15.8 %, P = 0.04; odds ratio = 4.7; accuracy = 87 %] and lower actuarial survival (63.5 ± 43.9 versus 256.1 ± 33.3 days, P = 0.031). PAB <42 % [n = 6 (26.1 %)] was associated with higher lactacidemia levels (P = 0.033), higher in-hospital mortality (66.7 versus 11.8 %, P = 0.021; odds ratio = 5.7, accuracy = 82.6 %) and lower actuarial survival (87.2 ± 37.5 versus 261.4 ± 34.7 days, n.s.). Probability of in-hospital mortality was inversely and significantly related with PAB [61.8 ± 8.8 % (95 % CI 50.8-72.7) when PAB <41 % and 2.8 ± 1.9 % (95 % CI 1.9-8.3) when PAB > 81 %, P = 0.0001]. Charlson's index ≥1, APACHE II ≥19.5, SOFA ≥7.5, and glutaminemia < 320 μmol/L were also predictive factors of actuarial survival.

CONCLUSIONS

Those results confirm the high prevalence of arginine depletion in severe trauma patients and the relevance of argininemia and PAB as predictive factors of mortality in this context.

When Is It Appropriate to Use Arginine in Critical Illness?

In health, arginine is considered a nonessential amino acid but can become an essential amino acid (ie, conditionally essential amino acid) during periods of metabolic or traumatic stress as endogenous arginine supply is inadequate to meet physiologic demands. Arginine depletion in critical illness is associated with impairments in microcirculatory blood flow, impaired wound healing, and T-cell dysfunction. The purpose of this review is to (1) describe arginine metabolism and role in health and critical illness, (2) describe the relationship between arginine and asymmetric dimethylarginine, and (3) review studies of supplemental arginine in critically ill patients.

Indications and contraindications for infusing specific amino acids (leucine, glutamine, arginine, citrulline, and taurine) in critical illness

PURPOSE OF REVIEW

The review assesses the utility of supplementing parenteral or enteral nutrition of ICU patients with each of five specific amino acids that display pharmacological properties. Specifying indications implies also stating contraindications.Combined supplementation of amino acids with ω3-fatty acids and/or trace elements (immune-enhancing diets) will not be considered in this review because these mixtures do not allow the role of amino acids in the effect (positive or negative) of the mixture to be isolated, and so cannot show whether or not supplementation of a given amino acid is indicated.

RECENT FINDINGS

After decades of unbridled use of glutamine (GLN) supplementation in critically ill patients, recent large trials have brought a note of caution, indicating for example that GLN should not be used in patients with multiple organ failure. Yet these large trials do not change the conclusions of recent meta-analyses. Arginine (ARG), as a single dietary supplement, is probably not harmful in critical illness, in particular in a situation of ARG deficiency syndrome with low nitric oxide production. Citrulline supplementation strongly improves microcirculation in animal models with gut injury, but clinical studies are lacking. Taurine has a potent protective effect against ischemic reperfusion injury.

SUMMARY

Amino acid-based pharmaconutrition has displayed familiar 'big project' stages: enthusiasm (citrulline and taurine), doubt (GLN), hunt for the guilty (ARG), and backpedalling (leucine). Progress in this field is very slow, and sometimes gives way to retreat, as demonstrated by recent large trials on GLN supplementation.

Utility of a perioperative nutritional intervention on postoperative outcomes in high-risk head & neck cancer patients

OBJECTIVES

Investigate both the utility and feasibility of perioperative nutritional supplementation with an arginine-enriched immunonutrition formula to high-risk head and neck cancer surgical patients and examine its effects on acute post-operative clinical outcomes.

MATERIALS & METHODS

This prospective, non-randomized, interventional cohort study compared high-risk head and neck cancer surgical patients who consumed a pre- and post-operative arginine-based nutritional supplement to those that did not. Outcome measures included post-operative complications, length of hospitalization, readmission rates and measurement of nutritional biomarkers.

RESULTS

195 high-risk head and neck cancer surgical patients were enrolled. 59% of the patients used the nutritional supplement, 41% did not. Of the 80 patients who did not receive the immunonutrition formula, 38 (47.5%) experienced post-operative complications of all types as compared to 29 of the 115 (25.2%) patients who did consume the product (p=0.0021). Pharyngeal leaks or fistulas were the most common post-operative complications in both groups and more common in patients who did not receive supplementation (p=0.007). Length of stay was on average 2.8 days longer in patients who did not have enhanced nutrition (p=0.02), while readmission rates between the two groups were similar (p=0.91). Measurements of nutritional biomarkers were not reported secondary to low collection rates.

CONCLUSION

Enhanced perioperative nutrition may result in significant reductions of post-operative fistula formations and decreased length of stay in a high-risk head and neck cancer population, even in the setting of poor compliance. The potential quality improvement in both patient care and healthcare cost is both real and significant.

Human Protein and Amino Acid Requirements

Human protein and amino acid nutrition encompasses a wide, complex, frequently misunderstood, and often contentious area of clinical research and practice. This tutorial explains the basic biochemical and physiologic principles that underlie our current understanding of protein and amino acid nutrition. The following topics are discussed: (1) the identity, measurement, and essentiality of nutritional proteins; (2) the definition and determination of minimum requirements; (3) nutrition adaptation; (4) obligatory nitrogen excretion and the minimum protein requirement; (5) minimum versus optimum protein intakes; (6) metabolic responses to surfeit and deficient protein intakes; (7) body composition and protein requirements; (8) labile protein; (9) N balance; (10) the principles of protein and amino acid turnover, including an analysis of the controversial indicator amino acid oxidation technique; (11) general guidelines for evaluating protein turnover articles; (12) amino acid turnover versus clearance; (13) the protein content of hydrated amino acid solutions; (14) protein requirements in special situations, including protein-catabolic critical illness; (15) amino acid supplements and additives, including monosodium glutamate and glutamine; and (16) a perspective on the future of protein and amino acid nutrition research. In addition to providing practical information, this tutorial aims to demonstrate the importance of rigorous physiologic reasoning, stimulate intellectual curiosity, and encourage fresh ideas in this dynamic area of human nutrition. In general, references are provided only for topics that are not well covered in modern textbooks.

Peri-Surgical Nutrition: Perspectives and Perceptions

Peri-surgical nutrition of veterinary patients is in its infancy, with considerable research to be performed to help improve quality of life in our small animal patients. Clues from human immunonutrition may be starting places for investigation. Considerations for future investigations should include essential nutrients, the underlying disease process, therapeutic goals, and species (dog or cat). There are guidelines for caloric requirements. Planning for nutritional support before surgery takes place is likely to be beneficial to patient outcomes. Taking into account case history, method of feeding, metabolic abnormalities, and possible immunonutrition should be part of a complete surgical nutritional plan.

A systematic review and meta-analysis of the n-3 polyunsaturated fatty acids effects on inflammatory markers in colorectal cancer

BACKGROUND

Cancer and inflammation are closely related and an exacerbated inflammatory process can lead to tumor progression and a worse prognosis for the patient with cancer. Scientific literature has shown evidence that n-3 polyunsaturated fatty acids (PUFA) have anti-inflammatory action, and for this reason could be useful as an adjuvant in the treatment of some cancers.

OBJECTIVE

A systematic review and meta-analysis of the literature was conducted until September, 2014, to evaluate the effects of n-3 PUFA on inflammatory mediators in colorectal cancer (CRC) patients.

PATIENTS AND METHODS

Clinical trials were systematically searched in three electronic databases and screening reference lists. Random meta-analysis model was used to calculate the overall and stratified effect sizes.

RESULTS

Nine trials, representing 475 patients with CRC, evaluated effects of n-3 PUFA on cytokines (n = 6) and/or acute phase proteins (n = 5) levels. n-3 PUFA reduce the levels of IL-6 (SMD -2.34; 95% CI -4.37, -0.31; p = 0.024) and increase albumin (SMD 0.31; 95% CI 0.06, 0.56; p = 0.014) in overall analyses. In stratified analyses, reduction in IL-6 levels occurs in surgical patients that received 0.2 g/kg of fish oil parenterally at postoperative period (SMD -0.65; 95% CI -1.06, -0.24; p = 0.002), while, increase in albumin concentration occurs in surgical patients that received ≥ 2.5 g/d of EPA + DHA orally at preoperative period (SMD 0.34; 95% CI 0.02, 0.66; p = 0.038). In patients undergoing chemotherapy, the supplementation of 0.6 g/d of EPA + DHA during 9 week reduces CRP levels (SMD -0.95; 95% CI -1.73, -0.17; p = 0.017), and CRP/albumin ratio (SMD -0.95; 95% CI -1.73, -0.18; p = 0.016).

CONCLUSIONS

The results suggest benefits on some inflammatory mediators with the use of n-3 PUFA on CRC patients, but these benefits are specific to certain supplementation protocols involving duration, dose and route of administration, and also, the concomitant anti-cancer treatment adopted.

Biomarkers in critically ill patients with systemic inflammatory response syndrome or sepsis supplemented with high-dose selenium

OBJECTIVE

Low levels of selenium (Se) and glutathione peroxidase (GSHPx), a key selenoenzyme, were documented in systemic inflammatory response syndrome (SIRS) and sepsis, both associated with high mortality. Se supplementation had mixed effects on outcome. We hypothesized that Se supplementation could have a different impact on biomarkers and 28-day mortality in patients with SIRS vs. sepsis.

METHODS

Adult patients with SIRS or sepsis were randomized to either high-dose (Se+, n = 75) or standard-dose (Se-, n = 75) Se supplementation. Plasma Se, whole blood GSHPx activity, C-reactive protein (CRP), procalcitonin (PCT), prealbumin, albumin and cholesterol levels were measured serially up to day 14.

RESULTS

There was no difference in mortality between Se- (24/75) vs. Se+ group (19/75; p = 0.367) or between SIRS and septic patients (8/26 vs. 35/124; p = 0.794). There was a trend to reduced mortality in SIRS patients in the Se+ vs. Se- group (p = 0.084). Plasma Se levels increased in the Se+ group only in patients with sepsis but not in patients with SIRS. Plasma Se levels correlated with GSHPx. In SIRS/Se+ group, Se correlated only with GSHPx. In SIRS/Se- group, Se correlated with cholesterol but not with other biomarkers. In sepsis patients, Se levels correlated with cholesterol, GSHPx and prealbumin. Cholesterol levels were higher in survivors in the Se- group.

CONCLUSIONS

Se levels correlated with GSHPx activity and other nutritional biomarkers with significant differences between SIRS and sepsis groups. High-dose Se supplementation did not affect mortality but a strong trend to decreased mortality in SIRS patients warrants further studies in this population.

[Pharmaconutrition: pharmacological approach to nutrition therapy]

Reviewing the literature of nutrition therapy one can conclude that during the last decade the pharmacological action of several nutrients has been demonstrated. However, research activity is still at the beginning and it could be verified in a restricted number of nutrients only that in which conditions (illnesses), dose and duration we can expect therapeutic effect in addition to nutrition. The examples of glutamine, arginine, taurine, leucine, ω-3 fatty acids, however, support the possibility that complex reactions and treatment results observed in certain patients are not purely due to nutritional support but the consequence of additional pharmacological action as well. Evaluation of results of therapeutic intervention is especially difficult because in the everyday practice physicians try to use several therapeutic modalities that can be beneficial for the patient. Therefore, retrospective separation of beneficial components of the therapeutic agents is almost impossible. Only well designed, randomized and multicentric studies can verify specific therapeutic action of certain ingredients ie. nutrients.

Short bowel syndrome in infants: the critical role of luminal nutrients in a management program

Short bowel syndrome develops when the remnant mass of functioning enterocytes following massive resections cannot support growth or maintain fluid–electrolyte balance and requires parenteral nutrition. Resection itself stimulates the intestine’s inherent ability to adapt morphologically and functionally. The capacity to change is very much related to the high turnover rate of enterocytes and is mediated by several signals; these signals are mediated in large part by enteral nutrition. Early initiation of enteral feeding, close clinical monitoring, and ongoing assessment of intestinal adaptation are key to the prevention of irreversible intestinal failure. The length of the functional small bowel remnant is the most important variable affecting outcome. The major objective of intestinal rehabilitation programs is to achieve early oral nutritional autonomy while maintaining normal growth and nutrition status and minimizing total parenteral nutrition related comorbidities such as chronic progressive liver disease. Remarkable progress has been made in terms of survivability and quality of life, especially in the context of coordinated multidisciplinary programs, but much work remains to be done.

Efficacy of arginine-enriched enteral formulas in the reduction of surgical complications in head and neck cancer: a systematic review and meta-analysis

INTRODUCTION

Arginine improves healing and modulates inflammation and the immune response. A systematic review and meta-analysis were conducted to assess whether arginine-enriched enteral formulas reduce complications (fistulas, wound infections, other infections) and hospital length of stay (LoS) in patients undergoing surgery for head and neck cancer.

METHODS

Medline, CENTRAL, and Trip Database were searched using the search strategy "Head and Neck Neoplasms" AND "Enteral Nutrition" AND "Arginine" OR "Immunonutrition". Inclusion criteria comprised: type of study (RCT), language (English, Spanish), outcomes (complications of surgery, LoS), and methodological quality (Jadad scale). The odds ratio (OR) and confidence intervals (95% CI) were calculated using the Mantel-Haenszel method, and the mean difference (MD) with the random effects method. Heterogeneity was assessed using Cochran's Q.

RESULTS

Six studies were included, with 397 patients receiving peri/postoperative enteral nutrition with different doses of arginine (6.25-18.7 g/L). Enteral formulas containing arginine were associated with a reduction in fistulas [OR = 0.36 (95% CI 0.14-0.95), p = 0.039; Q = 3.93, p = 0.269], and LoS [MD = -6.8 (95% CI -12.6 to -0.9) days, p = 0.023; Q = 2.44, p = 0.486]. There were no reductions in wound infections [OR = 1.04 (95% CI 0.49-2.17), p = 0.925; Q = 1.60, p = 0.809] or other infections [OR = 0.79 (95% CI 0.48-1.31); p = 0.369; Q = 7.94, p = 0.094]. Arginine administration did not increase the occurrence of diarrhoea [OR = 1.80 (95% CI 0.50-6.52), p = 0.375; Q = 0.16, p = 0.691].

CONCLUSIONS

The administration of arginine-enriched enteral nutrition led to a significant reduction in fistulas and hospital stay in patients undergoing surgery for head and neck cancer.