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Serena TE, Yaakov RA, DeLegge M, Mayhugh TA, Moore S. Nutrition in patients with chronic non-healing ulcers: a paradigm shift in wound care. CWCMR 2018. [DOI: 10.2147/cwcmr.s155114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Abstract
BACKGROUND Abdominal and gastric wall inflammation, infection, and necrosis after percutaneous endoscopic gastrostomy (PEG) placement is a topic of importance but of limited study. Healing of the abdominal wound after PEG placement is thought to be dependent on a number of factors, including the patient's nutrition status, comorbid disease status, and postprocedural PEG wound care. Another important factor that may influence wound healing is tissue tension and compression. This requires special attention to the correct placement of the external bolster of the PEG tube against the abdominal wall. METHODS We performed a study in mongrel dogs to determine the relevance of tissue compression on PEG-tube wound healing; 8 mongrel dogs each received 3 separate 24 Fr PEG tubes at 1 endoscopic setting. After PEG placement, the external bolster was placed at 0 cm, 1 cm, or 4 cm from the abdominal wall. Post-PEG care and enteral feedings were standardized. The dogs were killed at 3 weeks. RESULTS Partial migration of the PEG internal bolster into the gastric wall occurred in 1 of 8 of the PEG tubes with the external bolster at 0 cm. PEG-tube-tract tissue inflammation was worse in the dogs with the external bolster placed at 0 cm. CONCLUSIONS The position of the external bolster in relation to the abdominal wall may be an important factor in the healing of a post-PEG-tube-placement tissue tract.
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Affiliation(s)
- Mark DeLegge
- Division of Gastroenterology, Medical University of South Carolina, Charleston, South Carolina, USA.
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Affiliation(s)
- Mark DeLegge
- Baxter Healthcare Corporation, Deerfield, Illinois
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Weijs PJM, Cynober L, DeLegge M, Kreymann G, Wernerman J, Wolfe RR. Proteins and amino acids are fundamental to optimal nutrition support in critically ill patients. Crit Care 2014; 18:591. [PMID: 25565377 PMCID: PMC4520087 DOI: 10.1186/s13054-014-0591-0] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Proteins and amino acids are widely considered to be subcomponents in nutritional support. However, proteins and amino acids are fundamental to recovery and survival, not only for their ability to preserve active tissue (protein) mass but also for a variety of other functions. Understanding the optimal amount of protein intake during nutritional support is therefore fundamental to appropriate clinical care. Although the body adapts in some ways to starvation, metabolic stress in patients causes increased protein turnover and loss of lean body mass. In this review, we present the growing scientific evidence showing the importance of protein and amino acid provision in nutritional support and their impact on preservation of muscle mass and patient outcomes. Studies identifying optimal dosing for proteins and amino acids are not currently available. We discuss the challenges physicians face in administering the optimal amount of protein and amino acids. We present protein-related nutrition concepts, including adaptation to starvation and stress, anabolic resistance, and potential adverse effects of amino acid provision. We describe the methods for assessment of protein status, and outcomes related to protein nutritional support for critically ill patients. The identification of a protein target for individual critically ill patients is crucial for outcomes, particularly for specific subpopulations, such as obese and older patients. Additional research is urgently needed to address these issues.
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Affiliation(s)
- Peter J M Weijs
- Department of Nutrition and Dietetics, Internal Medicine, VU University Medical Center Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands. .,Department of Intensive Care Medicine, VU University Medical Center Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands. .,Department of Nutrition and Dietetics, Amsterdam University of Applied Sciences, Wibautstraat 2-4 1091 GM, Amsterdam, the Netherlands. .,EMGO+ Institute of Health and Care Research, VU University Medical Center Amsterdam, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands.
| | - Luc Cynober
- Clinical Chemistry Department, Cochin and Hôtel-Dieu Hospitals, APHP, 1 place du Parvis Notre-Dame 75004, Paris, France. .,Nutrition Lab, EA 4466, Department of Experimental, Metabolic and Clinical Biology, Faculty of Pharmacy, Paris Descartes University, 12 rue de l'Ecole de Médicine 75270, Paris, France.
| | - Mark DeLegge
- Baxter Healthcare, Deerfield, IL, 60015-4625, USA.
| | - Georg Kreymann
- Baxter Healthcare SA Europe, CH-8010, Zürich, Switzerland.
| | - Jan Wernerman
- Department of Anesthesiology and Intensive Care Medicine, Karolinska University Hospital, Huddinge, Karolinska Institutet, 141 86, Stockholm, Sweden.
| | - Robert R Wolfe
- Center for Translational Research in Aging & Longevity, Department of Health & Kinesiology, Texas A&M University, 4243 Ireland St #336, College Station, TX, 77843, USA.
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Martindale RG, DeLegge M, McClave S, Monroe C, Smith V, Kiraly L. Nutrition delivery for obese ICU patients: delivery issues, lack of guidelines, and missed opportunities. JPEN J Parenter Enteral Nutr 2012; 35:80S-7S. [PMID: 21881018 DOI: 10.1177/0148607111415532] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The most appropriate enteral formula for the severely obese population has yet to be determined. The obese patient in the intensive care unit (ICU) creates numerous difficulties for managing care, one being the ability to deliver appropriate and timely nutrition. Access for nutrition therapy, either enteral or parenteral, can also create a challenge. Currently, no specific guidelines are available on a national or international scale to address the issues of how and when to feed the obese patient in the ICU. A bias against feeding these patients exists, secondary to the perception that an enormous quantity of calories is stored in adipose tissue. Making a specialty enteral formula for obesity from existing commercial formulas and other modular nutrient components is not practical, secondary to difficulty with solubility issues, dilution of the formula, and safety concerns. Using today's concepts and current metabolic data, a formula could be produced that would address many of the specific metabolic derangements noted in obesity. This formula should have a high-protein, low-carbohydrate content with at least a portion of the lipid source coming from fish oil. Specific nutrients that may be beneficial in obesity include arginine, glutamine, leucine, L-carnitine, lipoic acid, S-adenosylmethionine, and betaine. Certain trace minerals such as magnesium, zinc, and selenium may also be of value in the obese population. The concept of a specific bariatric formulation for the ICU setting is theoretically sound, is scientifically based, and could be delivered to patients safely.
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Affiliation(s)
- Robert G Martindale
- Department of Surgery, Oregon Health and Sciences University, Portland, OR 97239, USA.
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McClave SA, Kushner R, Van Way CW, Cave M, DeLegge M, Dibaise J, Dickerson R, Drover J, Frazier TH, Fujioka K, Gallagher D, Hurt RT, Kaplan L, Kiraly L, Martindale R, McClain C, Ochoa J. Nutrition Therapy of the Severely Obese, Critically Ill Patient. JPEN J Parenter Enteral Nutr 2011; 35:88S-96S. [DOI: 10.1177/0148607111415111] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Stephen A. McClave
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky
| | - Robert Kushner
- Department of Medicine, Northwestern University, Chicago, Illinois
| | | | - Matt Cave
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky
| | - Mark DeLegge
- Department of Medicine, Medical University of South Carolina, Charleston
| | - John Dibaise
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota
| | | | - John Drover
- Department of Surgery, Queen’s University, Kingston, Ontario, Canada
| | | | - Ken Fujioka
- Center for Weight Management, Scripps Clinic, Del Mar, California
| | - Dympna Gallagher
- Department of Medicine and Institute of Human Nutrition, Columbia University, New York, New York
| | | | - Lee Kaplan
- Department of Medicine, Harvard University, Cambridge, Massachusetts
| | - Lazlo Kiraly
- Department of Surgery, Oregon Health and Sciences University, Portland, Oregon
| | - Robert Martindale
- Department of Surgery, Oregon Health and Sciences University, Portland, Oregon
| | - Craig McClain
- Department of Internal Medicine, University of Louisville Medical Center, Louisville, Kentucky
| | - Juan Ochoa
- Department of Surgery, University of Pittsburg, Pittsburg, Pennsylvania
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Gallagher D, DeLegge M. Body composition (sarcopenia) in obese patients: implications for care in the intensive care unit. JPEN J Parenter Enteral Nutr 2011; 35:21S-8S. [PMID: 21807929 DOI: 10.1177/0148607111413773] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The study of body composition is a rapidly evolving science. In today's environment, there is a great deal of interest in assessing body composition, especially in the obese subject, as a guide to clinical and nutrition interventions. There are some strikingly different compartments of body composition between the obese and the lean patient. We do have the ability to measure body composition accurately, although these techniques can be labor intensive and expensive. The recognition of patients with sarcopenic obesity has identified a potential high-risk patient population. These body composition abnormalities may have even greater importance in the intensive care patient.
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Affiliation(s)
- Dympna Gallagher
- Department of Medicine and Institute of Human Nutrition, Columbia University and St. Luke's-Roosevelt Hospital New York, New York, USA.
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Affiliation(s)
| | - Mark DeLegge
- Medical University of South Carolina, Charleston
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Martin K, DeLegge M, Nichols M, Chapman E, Sollid R, Grych C. Assessing Appropriate Parenteral Nutrition Ordering Practices in Tertiary Care Medical Centers. JPEN J Parenter Enteral Nutr 2010; 35:122-30. [DOI: 10.1177/0148607110362992] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Kelley Martin
- Digestive Disease Center, Medical University of South Carolina, Charleston, South Carolina
| | - Mark DeLegge
- Digestive Disease Center, Medical University of South Carolina, Charleston, South Carolina
| | - Michele Nichols
- Center for Research in Nutrition and Health Disparities, University of South Carolina, Columbia, South Carolina
| | - Emily Chapman
- Digestive Disease Center, Medical University of South Carolina, Charleston, South Carolina
| | - Ronald Sollid
- Digestive Disease Center, Medical University of South Carolina, Charleston, South Carolina
| | - Catherine Grych
- Digestive Disease Center, Medical University of South Carolina, Charleston, South Carolina
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DeLegge M, Wooley JA, Guenter P, Wright S, Brill J, Andris D, Wagner P, Filibeck D. The State of Nutrition Support Teams and Update on Current Models for Providing Nutrition Support Therapy to Patients. Nutr Clin Pract 2010; 25:76-84. [DOI: 10.1177/0884533609354901] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Mark DeLegge
- American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), Silver Spring, Maryland
| | - Jennifer A. Wooley
- American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), Silver Spring, Maryland
| | - Peggi Guenter
- American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), Silver Spring, Maryland
| | - Sheila Wright
- American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), Silver Spring, Maryland
| | - Joel Brill
- American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), Silver Spring, Maryland
| | - Deb Andris
- American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), Silver Spring, Maryland
| | - Pam Wagner
- American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), Silver Spring, Maryland
| | - Don Filibeck
- American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), Silver Spring, Maryland
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Abstract
BACKGROUND Asymmetric dimethylarginine (ADMA) is an emerging biomarker that has been associated with oxidative metabolism and increased cardiovascular risk. Little information is available regarding the effect of diet on ADMA. METHODS The authors studied 86 overweight/obese adults as part of a clinical trial of psyllium supplementation to determine whether 3 months of such supplementation would affect ADMA levels. Forty-one people in the intervention group received 14 g/day of psyllium in addition to their usual diet compared with 45 controls who followed their usual diet alone. The 2 groups were comparable at baseline in demographic characteristics and body mass index. RESULTS Baseline ADMA levels were elevated in this overweight/obese population compared with published reference values in healthy individuals (0.75 vs 0.50 micromol/L). The change in ADMA levels over 3 months was not different in the psyllium group compared with the control group (-.03 vs -.01 micromol/L, P=.73). CONCLUSIONS These findings do not support a significant effect of psyllium fiber supplementation on ADMA.
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Affiliation(s)
- Dana E King
- Digestive Disease Center, Medical University of South Carolina, Department of Family Medicine, 295 Calhoun Street, Charleston, SC 29425, USA.
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Abstract
Irritable bowel syndrome accounts for approximately 2.7 million physician office visits yearly, although only 10%-30% of affected patients seek treatment. The disease is predominantly found in women 20-50 years of age. The etiology of irritable bowel syndrome is likely multifactorial: environmental factors, genetics, gut flora alterations, nervous system alterations (visceral hypersensitivity and motility abnormalities), and psychosocial stressors are thought to contribute. Treatment options are also quite diverse, including both pharmacologic and nonpharmacologic modalities. This article summarizes the proposed pathophysiology of and treatment options for irritable bowel syndrome.
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Affiliation(s)
- Christian Clark
- Division of Gastroenterology and Hepatology, Digestive Disease Center, Medical University of South Carolina, Charleston, South Carolina 29425, USA
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Dixon J, DeLegge M, Morgan KA, Adams DB. Impact of total pancreatectomy with islet cell transplant on chronic pancreatitis management at a disease-based center. Am Surg 2008; 74:735-8. [PMID: 18705576 DOI: 10.1177/000313480807400812] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Because of poor outcomes with traditional surgical management, total pancreatectomy with autologous islet transplantation (TPAIT) has been heralded as a breakthrough in the management of severe chronic pancreatitis intractable to medical management. To assess the impact of TPAIT on a pancreatobiliary disease-based center, a retrospective review and analysis of patients who underwent TPAIT after failing traditional surgical management was undertaken. Seven patients who underwent TPAIT were identified. Patient hospitalizations, emergency department visits, and clinic visits in the year pre- and post-TPAIT were tabulated. Average body weights and serum prealbumin were recorded during the year pre- and post-TPAIT. Based on the number of hospitalizations, clinic visits, and emergency department visits as an indicator of overall symptom severity, patients experienced an improvement in symptoms during the 12 months after TPAIT. Prealbumin values remained stable during the postoperative year. An observed decrease in weight suggests that other factors may be impacting the overall state of nutrition. The impact of TPAIT on the surgical management of chronic pancreatitis is limited in scope and benefit and continues to require careful analysis to identify appropriate candidates.
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Affiliation(s)
- Jennifer Dixon
- Medical University of South Carolina, Charleston, South Carolina, USA.
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Harvin G, DeLegge M, Garrow DA. The impact of race on weight loss after Roux-en-Y gastric bypass surgery. Obes Surg 2007; 18:39-42. [PMID: 18080726 DOI: 10.1007/s11695-007-9278-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2007] [Accepted: 07/25/2007] [Indexed: 12/17/2022]
Abstract
BACKGROUND Gastric bypass surgery for morbid obesity has dramatically increased in volume over the past decade. Caucasian patients have been noted previously to lose more weight after bariatric surgery than African-Americans patients. Data regarding predictors of maintaining weight loss after surgery are minimal. We sought to determine predictors of long-term weight loss after bariatric surgery. METHODS Retrospective analysis using a multivariate logistic regression model of all patients undergoing Roux-en-Y gastric bypass surgery at the Medical University of South Carolina from May 1993 to December 2004 for whom 2 years of follow-up data was available. Our dependent variable was the percentage of weight lost from baseline, dichotomized at +/-35%. Our primary independent variable was race, defined as Caucasian, African-American, or other. Relevant covariates were added to the model to control for their potential effects on outcome. RESULTS One hundred eleven patients (17 male/94 female; 85% Caucasian, mean age 44 years (range 18-68 years). In our model, Caucasian subjects (adjusted odds ratio [OR] = 7.60, 95% confidence intervals [95%CI] = 1.83-31.5) and late post surgical complications (adjusted OR = 2.67, 95%CI = 1.05-6.80) significantly predicted weight loss at 2 years, after controlling for relevant confounders. Other covariates did not significantly impact the model. CONCLUSION Race and late post surgical complications significantly impacted the percentage of weight loss at 2 years for patients undergoing Roux-en-Y gastric bypass surgery at our institution. Future research should be directed at determining potential genetic and/or social reasons for these differences.
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Affiliation(s)
- Glenn Harvin
- Department of Medicine, Division of Gastroenterology and Hepatology, Digestive Disease Center, Medical University of South Carolina (MUSC), 96 Jonathon Lucas Street, CSB #210, P.O. Box 250 327, Charleston, SC, USA
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DeLegge M, Alsolaiman MM, Barbour E, Bassas S, Siddiqi MF, Moore NM. Short bowel syndrome: parenteral nutrition versus intestinal transplantation. Where are we today? Dig Dis Sci 2007; 52:876-92. [PMID: 17380398 DOI: 10.1007/s10620-006-9416-6] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2006] [Accepted: 04/30/2006] [Indexed: 01/19/2023]
Abstract
Current management of short bowel syndrome (SBS) revolves around the use of home TPN (HPN). Complications include liver disease, catheter-related infections or occlusions, venous thrombosis, and bone disease. Patient survival with SBS on TPN is 86% and 75% at 2 and 5 years, respectively. Surgical management of SBS includes nontransplant surgeries such as serial transverse enteroplasty and reanastomosis. Small bowel transplant has become increasingly popular for management of SBS and is usually indicated when TPN cannot be continued. Posttransplant complications include graft-versus-host reaction, infections in an immunocompromised patient, vascular and biliary diseases, and recurrence of the original disease. Following intestinal-only transplants, patient and graft survival rate is 77% and 66% after 1 year. After 5 years the survival figures are 49% and 34%, respectively. Future improvements in survival and quality of life will enhance small bowel transplant as a viable treatment option for patients with SBS.
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August D, DeLegge M, Ireton-Jones C, Steiger E. An evidence-based approach to optimal management of vascular and enteral access for home parenteral and enteral nutrition support. JPEN J Parenter Enteral Nutr 2006; 30:S5-6. [PMID: 16387911 DOI: 10.1177/01486071060300s1s5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- David August
- Division of Surgical Oncology, UMDNJ/RWJMS and Cancer Institute, New Brunswick, New Jersey, USA.
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Ireton-Jones C, DeLegge M. Home parenteral nutrition registry: a five-year retrospective evaluation of outcomes of patients receiving home parenteral nutrition support. Nutrition 2005; 21:156-60. [PMID: 15723743 DOI: 10.1016/j.nut.2004.04.024] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2003] [Revised: 05/05/2003] [Accepted: 03/21/2004] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Few data are currently reported on home parenteral nutrition (HPN) patient outcomes, which makes evaluating comparative outcomes in HPN difficult. This study describes outcomes of consecutive HPN patients collected retrospectively over a 5-y period by one HPN support provider. METHODS Retrospective data from the HPN support provider was aggregated yearly from 1997 to 2001. Length of therapy, demographics, diagnosis, rehospitalizations, catheter infection rate, catheter occlusion rate, and mechanical complication rate data were reported. RESULTS The mean age of HPN patients ranged from 42 y to 45 y. The average length of HPN therapy was 100 d. There were more female than male HPN patients. Nutritional deficiency and malabsorption were the most common International Classification of Diseases, Ninth Revision codes for HPN use and reflects a focus on nutritional diagnosis rather than on disease state as the criterion for HPN use. Catheter infection rates ranged from 0.44 to 0.84 per 1000 catheter days, a lower than anticipated number. Mean catheter occlusion rates were lower than 7% and mean mechanical complication rates were approximately 5%. Known termination of therapy was secondary to completion of therapy (50% to 56%) or death (17.3% to 22%). CONCLUSIONS Overall, time on HPN therapy in the United States has increased. Nutritional diagnoses are currently used to justify HPN. Catheter infection and occlusion rates, in general, are low. Termination of therapy and death are the most common reasons for HPN discontinuation. Standardization of HPN data collection is necessary to obtain a historical snapshot of the efficacy and safety of patients treated outside the hospital with nutritional support.
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Abstract
The aim of this study is to determine if the endoscopic presence of esophagitis predicts aspiration pneumonia after the initiation of enteral feedings in a newly placed PEG tube. A retrospective analysis of 278 patients who received a PEG tube from November 1999 to June 2002 was performed. All PEG procedures performed by a single endoscopist were reviewed from the GI Trac database at the Medical University of South Carolina. Eleven of the procedures were aborted due to technical difficulties. Nine patients received the PEG for gastric decompression only. Seven patients died within 14 days of PEG placement from non-PEG-related complications and were excluded. The resulting 251 patients included for our analysis successfully had PEG tube placement and had at least 14 days of enteral feeding. Esophagitis was defined macroscopically by the endoscopic presence of mucosal edema, friability, or obscurity of the normal vascular pattern in the distal esophagus. Aspiration was defined as the witnessed regurgitation of or tracheal suctioning of PEG feedings. Pneumonia as a consequence of aspiration was defined by development of fever and new infiltrate on chest radiograph within 14 days of PEG placement. Two hundred fifty-one patients had PEG placement (M, 127; F, 124; average age, 62.4 year; age range, 18-95 years) performed by a single endoscopist over a 32-month period. Fourteen (5.6%) of these patients had clinically evident pulmonary aspiration, with seven of them developing pneumonia. Thirteen (93%) of these patients had normal esophageal mucosa. One of the 24 patients (4%) with esophagitis or esophageal ulceration present endoscopically had an aspiration event with subsequent pneumonia. None of the 20 patients found to have some other form of esophageal pathology had an aspiration event. The overall incidence of aspiration pneumonia after the initiation of PEG feedings was 2.7% (7/251). The odds ratio that the presence of esophagitis would predict the development of aspiration pneumonia was 1.60, with a 95% confidence interval of 0.18 to 13.89. This study argues that the presence of esophagitis alone does not increase the risk of aspiration pneumonia from PEG feedings. Other factors apart from esophagitis play an important role in the incidence of aspiration pneumonia with PEG feeding
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Affiliation(s)
- Matthew L Carnes
- Medical University of South Carolina, Department of Medicine, Division of Gastroenterology and Hepatology, Digestive Disease Center, Charleston, South Carolina 29425, USA
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Abstract
OBJECTIVE During laparotomy, jejunostomy tubes (J tubes) are often placed to provide access for enteral nutrition in the immediate postoperative period. However, the placement of such tubes may be associated with potentially devastating intra-abdominal complications possibly related to the tenuous security of a tube through the small bowel wall. An alternative method for enteral nutrition access is to surgically place a "PEG-J" tube (i.e., surgical G/J tube) thus providing for jejunal feedings via a gastrotomy without a jejunotomy. The purpose of this study is to assess whether surgically placed G/J tubes reduce the postoperative complications in comparison to feeding J tubes. METHODS Over the past 18 months, 92 J tubes and 56 G/J tubes were placed during laparotomy at a single institution and the method chosen by surgeons' preference. The frequency of complications associated with each tube was determined by review of the postoperative medical records. RESULTS There was no enteric leakage in those patient given G/J tubes (p < 0.05). Furthermore 10% of the patients receiving J tubes required operative repair of a J tube complication while no patient with an access complication following G/J tube placement required surgical repair (p < 0.05). CONCLUSIONS These results demonstrate that operative positioning of a jejunal feeding tube through a gastrostomy tube (surgical G/J tube) provides a safer route for enteral nutrition than does direct tube placement via the jejunal wall, by significantly reducing both the incidence of enteric leakage and the requirement for operative repair.
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Affiliation(s)
- D C Gore
- Medical College of Virginia, Richmond 23298-0475, USA
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21
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DeLegge M, Murthy KS, Grider JR, Makhlouf GM. Characterization of distinct receptors for the peptidyl leukotrienes LTC4 and LTD4/LTE4 coupled to the same signaling pathway in isolated gastric muscle cells. J Pharmacol Exp Ther 1993; 266:857-63. [PMID: 8394921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Receptors for the peptidyl leukotrienes, (LT)C4, LTD4 and LTE4, and the signaling pathways to which they are coupled were characterized in isolated guinea pig gastric muscle cells. The three LTs were equipotent contractile agonists (EC50 values = 0.10-0.12 nM), but they elicited their responses by interacting with distinct receptors. The contractile responses to LTD4 and LTE4, but not LTC4, were inhibited by the LTD4 antagonist, SKF 104353 [2-(S)-hydroxy-3-(R)-[(2-carboxyethyl)thiol]-3-[2-(8- phenyloctyl)phenyl]-propanoic acid]. Similar Ki estimates for SKF 104353 suggested interaction of LTD4 and LTE4 with a common receptor. Decisive evidence for distinct LTC4 and LTD4/LTE4 receptors was obtained by applying a receptor protection technique. Cells in which LTC4 was used as a receptor protective agent while other receptors were inactivated by N-ethylmaleimide retained their responses to LTC4 only. Cells in which LTD4, LTE4 or SKF 104353 were used as a receptor protective agent retained their responses to LTD4 and LTE4 only. Both LTC4 and LTD4/LTE4 receptors were coupled to Pl hydrolysis: all three LTs stimulated similar increases in inositol 1,4,5-trisphosphate (IP3) levels (3.9-4.3 pmol/10(6) cells), protein kinase C activity (85-94 pmol/mg/min) and cytosolic-free Ca++ ([Ca++]i) (278-306 nM). Contractile responses were abolished: 1) when Pl hydrolysis was inhibited by neomycin and 2) when Ca++ stores were depleted by pretreatment of muscle cells with caffeine in Ca(++)-free medium, but not when muscle cells were incubated in Ca(++)-free medium or with Ca++ channel blockers, suggesting that contraction and [Ca++]i were mediated by IP3-dependent Ca++ release.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- M DeLegge
- Department of Medicine, Medical College of Virginia, Richmond
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