Could gut-liver function derangements cause chronic venous insufficiency?

Upregulation of adhesion molecules and neutrophil infiltration of venous valve cusps may be risk factors for chronic venous insufficiency. But studies that focus on the target organ (vein) fail to consider the influence of systemic inflammation on WBC behavior in the microcirculation. This study probes the gut-liver axis as a potential source of gut-derived oxidative stress and free radical production leading to white blood cell activation in chronic venous insufficiency. Venous hemodynamics (ambulatory venous pressure, air plethysmography, duplex) and gut-derived oxidative stress markers were studied in nine patients with chronic venous insufficiency (group I) and nine age- and sex-matched control subjects with no venous disease (group II). Group I had healed venous ulcers (class 5, CEAP) but near-normal ambulatory venous pressure, to eliminate high ambulatory venous pressure as a chronic venous insufficiency risk factor. Markers of gut-derived oxidative stress included: stool analysis; intestinal permeability; hepatic detoxification challenges with caffeine, salicylate, and acetaminophen; and urine lipid peroxides. Ambulatory venous pressure did not significantly differ (group I, 42.5 +/- 5.3 mm Hg; group II, 35.5 +/- 5.5 mm Hg; p = NS). Candida overgrowth in stool distinguished group I from group II (7/9 pts vs 1/9 pts, respectively; p = 0.015). Increased intestinal permeability (lactulose/mannitol ratio) was prevalent in both groups (group I 0.07 +/- 0.02, group II 0.17 +/- 0.08, p = NS; normal range, 0.01-0.03). Both groups showed similar incidence of elevated urine lipid peroxides (5/9 pts vs 6/9 pts, respectively; p = NS), yet group I exhibited underfunction of both sulfation (group I 16.8 +/- 2.9%, group II 43.3 +/- 11%, p<0.03; normal acetaminophen recovery 16-36%) and glucuronidation (group I 30.4 +/- 4.1%, group II 64.1 +/- 14.4%, p<0.04; normal acetaminophen recovery 27%-56%) relative to oxidative stress, perhaps an indicator of diminished antioxidant capacity in patients with chronic venous insufficiency. Gut dysbiosis (as indicated by stool yeast) and hepatic detoxification challenge pathway exhaustion may lead to subclinical, systemic inflammation and peripheral white blood cell adhesion in chronic venous insufficiency. Further exploration of the relationship between oxidative stress and venous disease is needed.

Fat transfer to the face: technique and new concepts.

The minimally invasive technique of using autologous fat transplantation has become a standard procedure in facial rejuvenation. It is simple, in-expensive, permanent, and effective. This article describes the technique and new concepts of fat transfer to the face.

Impact of nutrition support on patient outcome and hospital costs.

Outcome data for patients malnourished due to gastrointestinal problems requiring surgery show that morbidity and mortality are improved when nutrition support is provided. The effect is greatest for those patients whose prognostic nutrition index is high. For these individuals in particular, this support is mandatory for the other therapies provided to be effective. The principle underlying this support is the fact that protein deficit cannot be repaired by carbohydrates or fat, whether from body stores or an external source. Instead, protein has to be provided, either enterally or parenterally. Providing protein as part of nutrition support before, rather than after, the patient deteriorates is the key to improved outcome and cost efficiency. The small percentage of hospital patients who require this intervention can be identified by routine measuring of serum albumin levels and are those with levels below 3.5 g/dL.

Effect of peptide chain length on amino acid and nitrogen absorption from two lactalbumin hydrolysates in the normal human jejunum.

A double lumen jejunal perfusion technique has been used in man to study the effect of peptide chain length on absorption of amino acid nitrogen from two partial enzymic hydrolysates of lactalbumin. Copper-chelation chromatography showed that one lactalbumin hydrolysate (LH2) contained 98% peptides with a chain length greater than 4, whilst the other (LH1) contained a more even spread of chain lengths with 55% less than 4. Absorption of total nitrogen and of 14 amino acid residues occurred to a significantly greater extent from the low molecular weight LH1 than from the higher molecular weight LH2. The results suggest that the pattern of nitrogen and amino acid absorption from partial enzymic hydrolysates of whole protein is markedly influenced by peptide chain length and that brush border peptide hydrolysis has an important rate limiting effect on absorption rates.

Increasing malnutrition during hospitalization: documentation by a nutritional screening program.

Nutritional status can change during hospitalization. To evaluate the degree of change, a nutrition screening program (NSP) that included admission and 3-week reassessment was implemented. NSP parameters were weight for height, percentage of weight loss, arm muscle circumference, triceps skinfold, serum albumin, and total lymphocyte count. Nutritional risk factors (NRF) were also recorded: cancer, nothing by mouth (NPO) for 3 or more days, loss of appetite, difficulty chewing or swallowing, persistent fever, and cancer chemotherapy or radiation therapy. Of 15,876 patients admitted during the period of March 1982 through December 1982, 583 (3.67%) were found to be suffering from malnutrition or to have NRFs. Of the 583 patients, 182 received nutritional support and were excluded from the study. The remaining patients were reassessed after 3 weeks and had significant decreases in nutritional parameters; 622 patients with deficits in one parameter (visceral or somatic) on admission had a significant decrease in all parameters (p less than .001) on 3-week assessment. There was a deterioration in nutritional status in those patients entering the hospital with NRFs only or with one low parameter.

The efficacy of nutritional support in the elderly.

One hundred two consecutively nutritionally supported patients were studied to determine the effect of age on the response to nutritional support and outcome of hospital stay. The patients were divided into two groups: group 1 (n = 37) consisted of all patients under 65 years of age, and group 2 (n = 65) consisted of patients 65 years of age and older. All patients underwent a complete nutritional assessment prior to the initiation of nutritional support and weekly thereafter. The patients' somatic compartments were assessed using weight, arm muscle circumference, creatinine height index, and triceps skinfold thickness. The visceral compartments were assessed using serum albumin level, transferrin total iron binding capacity (TIBC) level, and total lymphocyte count. Nitrogen balance was evaluated and cell-mediated immunity was determined using a standard battery of antigens. The patients' nutritional assessment parameters at the start of therapy were compared with those at discharge or death and correlated with outcome of hospital stay. The difference in crude mortality rates between the two groups was statistically significant; however, there was no significant difference between the type and degree of nutritional depletion and mean length of nutritional therapy between the two groups. There was also no significant difference between the degree of improvement or maintenance of somatic or visceral parameters, nitrogen balance, or cell-mediated immunity between the two groups. It is therefore concluded that age alone is not a deterrent to the use of aggressive nutritional support in the elderly.

Enteral hyperalimentation.

Parenteral hyperalimentation, when used free of associated morbidity, usually produces a dramatic reversal in the deteriorating clinical course of the patient. However, most patients who need nutritional support have at least a minimally functioning gastrointestinal tract. By using a continuous enteral gavage of a chemically defined diet through a 4F tube, the same positive nitrogen balance, weight gain and accelerated wound healing can be achieved. As with parenteral hyperalimentation, there are avoidable iatrogenic morbidities. A policy and procedure for safe and effective enteral hyperalimentation, results of clinical experience and a simplified method for assessing achievement of a therapeutic goal are presented.