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1.
J Trauma Acute Care Surg ; 87(3): 630-635, 2019 09.
Artículo en Inglés | MEDLINE | ID: mdl-31205220

RESUMEN

BACKGROUND: Adhesive small-bowel obstruction (SBO) is a common surgical condition accounting for a significant proportion of acute surgical admissions and surgeries. The implementation of a high-osmolar water-soluble contrast challenge has repeatedly been shown to reduce hospital length of stay and possibly the need for surgery in SBO patients. The effect of low-osmolar water-soluble contrast challenge however, is unclear. The aim of this study is to evaluate the outcomes of an SBO pathway including a low-osmolar water-soluble contrast challenge. METHODS: A prospective cohort of patients admitted for SBO were placed on an evidence-based SBO pathway including low-osmolar water-soluble contrast between January 2017 and October 2018 and were compared with a historical cohort of patients prior to the implementation of the pathway from September 2013 through December 2014. The primary outcome was length of stay less than 4 days with a secondary outcome of failure of nonoperative management. RESULTS: There were 140 patients enrolled in the SBO pathway during the study period and 101 historic controls. The SBO pathway was independently associated with a length of stay less than 4 days (odds ratio, 1.76; 95% confidence interval, 1.03-3.00). Median length of stay for patients that were successfully managed nonoperatively was lower in the SBO pathway cohort compared with controls (3 days vs. 4 days, p = 0.04). Rates of readmission, surgery, and bowel resection were not significantly different between the two cohorts. CONCLUSION: Implementation of an SBO pathway using a low-osmolarity contrast is associated with decreased hospital length of stay. Rates of readmission, surgery, and need for bowel resection for those undergoing surgery were unchanged. An SBO pathway utilizing low-osmolarity water-soluble contrast is safe and effective in reducing length of stay in the nonoperative management of adhesive small-bowel obstructions. LEVEL OF EVIDENCE: Therapeutic study, level IV.


Asunto(s)
Medios de Contraste/uso terapéutico , Vías Clínicas , Obstrucción Intestinal/diagnóstico por imagen , Yohexol/uso terapéutico , Anciano , Femenino , Estudio Históricamente Controlado , Humanos , Obstrucción Intestinal/cirugía , Obstrucción Intestinal/terapia , Tiempo de Internación , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Radiografía Abdominal , Resultado del Tratamiento
2.
J Surg Res ; 191(1): 148-55, 2014 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-24793452

RESUMEN

BACKGROUND: As low bone mineral density is a risk factor for fracture in childhood, optimizing age appropriate bone mass is recommended and might lower the impact of bone loss related to age. Consumption of omega-3 polyunsaturated fatty acids (PUFAs), including eicosapentaenoic and docosahexaenoic (DHA) acids have been shown to beneficially modulate bone metabolism. The objective of this study was to determine the incidence of fracture in neonates receiving a fish compared with soybean oil-based intravenous lipid emulsion and evaluate the effect of varying dietary omega-3 PUFA consumption on growing bone in young mice. MATERIALS AND METHODS: Eligibility criteria for the clinical study included gestational age ≤37 wk and parenteral nutrition-dependence for ≥4 wk. Radiographs were reviewed after lipid initiation to identify radiologic bone fracture. The animal study evaluated female C57/Bl6 mice randomized into one of five groups from age 3-12 wk, at which time femurs were harvested for micro-computed tomography and light microscopy analysis. RESULTS: A lower incidence of bone fracture was found in neonates maintained on fish compared with soybean oil. In the animal study, findings suggest the DHA diet provides the best protection against trabecular bone loss as evidenced by increased bone volume fraction, increased trabecular number, and decreased trabecular separation on micro-computed tomography. These protective effects appeared to affect the bone microstructure alone. CONCLUSIONS: The lower fracture risk observed in fish oil fed neonates in combination with the protective effects of DHA observed in the femurs of young C57/BL6 mice suggest an important role for omega-3 PUFAs on bone growth.


Asunto(s)
Densidad Ósea/efectos de los fármacos , Desarrollo Óseo/efectos de los fármacos , Ácidos Docosahexaenoicos/farmacología , Fracturas Óseas/prevención & control , Animales , Ácido Eicosapentaenoico/farmacología , Ácidos Grasos Omega-3/farmacología , Femenino , Fémur/diagnóstico por imagen , Fémur/efectos de los fármacos , Aceites de Pescado/farmacología , Fracturas Óseas/diagnóstico por imagen , Fracturas Óseas/etiología , Enfermedades Gastrointestinales/complicaciones , Edad Gestacional , Humanos , Recién Nacido , Ratones Endogámicos C57BL , Osteoblastos/efectos de los fármacos , Osteoblastos/patología , Estudios Retrospectivos , Aceite de Soja/farmacología , Microtomografía por Rayos X
3.
JAMA Surg ; 149(7): 663-70, 2014 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-24827450

RESUMEN

IMPORTANCE: The introduction of hepatoprotective strategies and multidisciplinary management has significantly improved the outcome of neonates with short bowel syndrome (SBS) who require parenteral nutrition (PN). OBJECTIVE: To determine the probability of weaning from PN based on intestinal length in neonates with SBS amidst the new era of hepatoprotective strategies and multidisciplinary management. DESIGN, SETTING, AND PARTICIPANTS: Retrospective medical record review at a single-center academic institution. Neonates with no more than 100 cm of small intestine at a corrected gestational age of no more than 30 days who were diagnosed with a surgical gastrointestinal disease and PN dependent for at least 2 weeks were included. Data were collected from January 1, 2004, through June 1, 2012. EXPOSURE: Neonates with SBS requiring PN. MAIN OUTCOMES AND MEASURES: The probability of wean from PN without reinitiation for at least 1 year, as determined by logistic regression. Predictors of wean were evaluated using exact conditional logistic regression. Predictors of time to wean were determined by Cox proportional hazards regression. RESULTS: Sixty-three patients with a median (25th percentile, 75th percentile [interquartile range (IQR)]) gestational age of 31 (27, 35) weeks, birth weight of 1423 (895, 2445) g, small intestinal length of 41.0 (24.0, 65.0) cm, and predicted length of 29.0% (17.1%, 45.5%) underwent analysis. Fifty-one patients (81%) received a fish oil-based lipid emulsion (1 g/kg/d), 40 (63%) were weaned, 11 (17%) remained PN dependent, 4 (6%) underwent transplant, and 8 (13%) died while on PN. Excluding patients who underwent transplant or died, the median (IQR) small intestinal length was 55.0 (28.0, 75.0) cm in weaned and 26.0 (14.0, 41.0) cm in PN-dependent patients (P = .006), with 40 of 51 (78%) weaned by study end. The cumulative probability of wean for patients with at least 50 cm of small intestine was 88% after 12 and 96% after 24 months. Patients with less than 50 cm of small intestine had a cumulative probability of wean of 23% after 12, 38% after 24, and 71% after 57 months. Small intestinal length was found to be the primary predictor of wean. Notable predictors of time to wean included the amount of small intestine remaining (hazard ratio, 1.94 [95% CI, 1.45-2.58] per 20 cm of intestine; P < .001), entirety of care within our institution (3.27 [1.59-6.72]; P = .001), and intestinal lengthening procedure (0.19 [0.04-0.84]; P = .03). CONCLUSIONS AND RELEVANCE: The majority of patients will wean from PN despite short intestinal length, likely as a result of new management strategies combined with a multidisciplinary team approach.


Asunto(s)
Nutrición Parenteral/estadística & datos numéricos , Síndrome del Intestino Corto/terapia , Prestación Integrada de Atención de Salud , Femenino , Edad Gestacional , Humanos , Recién Nacido , Masculino , Probabilidad , Estudios Retrospectivos , Síndrome del Intestino Corto/complicaciones , Tasa de Supervivencia , Factores de Tiempo , Resultado del Tratamiento
4.
JPEN J Parenter Enteral Nutr ; 38(6): 693-701, 2014 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-23770843

RESUMEN

OBJECTIVE: To assess the safety and efficacy of a fish oil-based intravenous fat emulsion (FIFE) in reducing the incidence of cholestasis in neonates compared with the traditional soybean oil-based intravenous fat emulsion (SIFE). METHODS: A double-blind randomized controlled trial was conducted. Nineteen neonates were enrolled (10 SIFE; 9 FIFE). Nutrition assessments and laboratory studies were serially obtained for the duration of PN support or until 6 months' corrected gestational age. Neurodevelopmental outcomes were assessed at 6 and 24 months' corrected age. RESULTS: There were no differences between groups in demographic characteristics, with an overall median age of 2 days, gestational age of 36 weeks, and birth weight of 2410 g. There were no differences between groups in baseline laboratory values other than alkaline phosphatase (lower in the FIFE group) or in the duration of parenteral nutrition (PN), amount of enteral intake, or the number of operative procedures. The incidence of cholestasis among enrolled patients was significantly lower than expected, resulting in early study termination and an inability to assess for differences in the incidence of cholestasis. The FIFE was associated with no increased risk of growth impairment, coagulopathy, infectious complications, hypertriglyceridemia, or adverse neurodevelopmental outcomes. No patient developed essential fatty acid deficiency. CONCLUSION: The FIFE at 1 g/kg/d was well tolerated in the neonates recruited for this study. Given the necessary early termination of this study, a follow-up trial with revised eligibility criteria is necessary to determine whether the provision of FIFE decreases the incidence of PN-cholestasis compared with the traditional SIFE.


Asunto(s)
Colestasis/prevención & control , Emulsiones Grasas Intravenosas/uso terapéutico , Aceites de Pescado/uso terapéutico , Aceite de Soja/uso terapéutico , Peso al Nacer , Estudios Cruzados , Método Doble Ciego , Ácidos Grasos Omega-3/administración & dosificación , Ácidos Grasos Omega-3/análisis , Femenino , Humanos , Incidencia , Lactante , Recién Nacido , Masculino , Nutrición Parenteral , Factores de Riesgo , Resultado del Tratamiento , Triglicéridos/sangre
5.
JPEN J Parenter Enteral Nutr ; 37(5): 570-98, 2013 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-23685349

RESUMEN

BACKGROUND: Premature infants are at increased risk for metabolic bone disease, with resulting delayed bone growth, osteopenia, and rickets. METHOD: A systematic review of the best available evidence to answer a series of questions regarding neonatal patients at risk of metabolic bone disease receiving parenteral or enteral nutrition was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development and Evaluation working group. A consensus process was used to develop the clinical guideline recommendations prior to external and internal review and approval by the American Society for Parenteral and Enteral Nutrition Board of Directors. QUESTIONS: (1) What maternal risk factors predispose the neonate to metabolic bone disease? (2) What is the optimal type of feeding to promote neonatal bone health? (3) When and how should vitamin D supplements be administered? (4) Does parenteral nutrition (PN) predispose a neonate to metabolic bone disease, and if so, are there PN formulation recommendations to minimize this risk?


Asunto(s)
Enfermedades Óseas Metabólicas/prevención & control , Enfermedades Óseas Metabólicas/fisiopatología , Recien Nacido Prematuro/crecimiento & desarrollo , Apoyo Nutricional/efectos adversos , Enfermedades Óseas Metabólicas/etiología , Ensayos Clínicos como Asunto , Suplementos Dietéticos , Humanos , Lactante , Micronutrientes/administración & dosificación , Estudios Observacionales como Asunto , Factores de Riesgo , Vitamina D/administración & dosificación
6.
JPEN J Parenter Enteral Nutr ; 37(4): 498-505, 2013 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-22767698

RESUMEN

BACKGROUND: One of the most common and severe complications of long-term parenteral nutrition (PN) is PN-associated cholestasis. The soybean oil-based lipid emulsion administered with PN has been associated with cholestasis, leading to an interest in lipid reduction strategies. The purpose of this study was to determine whether the provision of a soybean oil-based lipid emulsion at 1 g/kg/d compared with 2-3 g/kg/d is associated with a reduced incidence of cholestasis. METHODS: Retrospective review of neonates admitted between 2007 and 2011 with a gastrointestinal condition necessitating ≥ 21 days of PN support. Neonates were divided into 2 groups based on the intravenous lipid emulsion dose: 1-g group (1 g/kg/d) and 2- to 3-g group (2-3 g/kg/d). The primary outcome measure was the incidence of cholestasis. RESULTS: Sixty-one patients met inclusion criteria (n = 29, 1-g group; n = 32, 2- to 3-g group). The 2 groups did not differ in any baseline characteristics other than associated comorbidities that were more common in the 2- to 3-g group. The duration of PN, the number of operative procedures and bloodstream infections, and enteral nutrition (EN) were similar between groups. The incidence of cholestasis was not different between groups (51.7%, 1-g group; 43.8%, 2- to 3-g group; P = .61), and there was no difference between groups in the time to cholestasis (32.6 ± 24.1 days, 1-g group; 27.7 ± 10.6 days, 2- to 3-g group; P = .48). Overall, 44.8% of patients with cholestasis were transitioned to full EN, and 55.2% were transitioned to a fish oil-based lipid emulsion after which the direct bilirubin normalized in all patients. CONCLUSION: Lipid reduction to 1 g/kg/d does not prevent or delay the onset of cholestasis in neonates.


Asunto(s)
Colestasis/prevención & control , Emulsiones Grasas Intravenosas , Nutrición Parenteral/efectos adversos , Aceite de Soja , Bilirrubina/sangre , Colestasis/sangre , Colestasis/etiología , Nutrición Enteral , Emulsiones Grasas Intravenosas/administración & dosificación , Emulsiones Grasas Intravenosas/efectos adversos , Femenino , Aceites de Pescado/administración & dosificación , Humanos , Recién Nacido , Masculino , Nutrición Parenteral/métodos , Estudios Retrospectivos , Aceite de Soja/administración & dosificación , Aceite de Soja/efectos adversos
9.
Aging Cell ; 11(6): 1046-54, 2012 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-22978268

RESUMEN

Women approaching advanced maternal age have extremely poor outcomes with both natural and assisted fertility. Moreover, the incidence of chromosomal abnormalities and birth defects increases with age. As of yet, there is no effective and practical strategy for delaying ovarian aging or improving oocyte quality. We demonstrate that the lifelong consumption of a diet rich in omega-3 fatty acids prolongs murine reproductive function into advanced maternal age, while a diet rich in omega-6 fatty acids is associated with very poor reproductive success at advanced maternal age. Furthermore, even short-term dietary treatment with a diet rich in omega-3 fatty acids initiated at the time of the normal age-related rapid decline in murine reproductive function is associated with improved oocyte quality, while short-term dietary treatment with omega-6 fatty acids results in very poor oocyte quality. Thus, omega-3 fatty acids may provide an effective and practical avenue for delaying ovarian aging and improving oocyte quality at advanced maternal age.


Asunto(s)
Envejecimiento/efectos de los fármacos , Grasas de la Dieta/administración & dosificación , Ácidos Grasos Omega-3/administración & dosificación , Aptitud Genética/efectos de los fármacos , Oocitos/efectos de los fármacos , Reproducción/efectos de los fármacos , Administración Oral , Envejecimiento/fisiología , Animales , Cruzamiento , Aceite de Coco , Ácidos Grasos Omega-6/administración & dosificación , Ácidos Grasos Omega-6/efectos adversos , Femenino , Aptitud Genética/fisiología , Humanos , Tamaño de la Camada/efectos de los fármacos , Masculino , Ratones , Ratones Endogámicos C57BL , Oocitos/citología , Oocitos/fisiología , Aceites de Plantas/administración & dosificación , Reproducción/fisiología , Aceite de Soja/administración & dosificación
10.
JPEN J Parenter Enteral Nutr ; 36(5): 506-23, 2012 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-22753618

RESUMEN

BACKGROUND: Necrotizing enterocolitis (NEC) is one of the most devastating diseases in the neonatal population, with extremely low birth weight and extremely preterm infants at greatest risk. METHOD: A systematic review of the best available evidence to answer a series of questions regarding nutrition support of neonates at risk of NEC was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development and Evaluation working group. A consensus process was used to develop the clinical guideline recommendations prior to external and internal review and approval by the A.S.P.E.N. Board of Directors. RESULTS/ CONCLUSIONS: (1) When and how should feeds be started in infants at high risk for NEC? We suggest that minimal enteral nutrition be initiated within the first 2 days of life and advanced by 30 mL/kg/d in infants ≥ 1, 000 g. (Weak) (2) Does the provision of mother's milk reduce the risk of developing NEC? We suggest the exclusive use of mother's milk rather than bovine-based products or formula in infants at risk for NEC. (Weak) (3) Do probiotics reduce the risk of developing NEC? There are insufficient data to recommend the use of probiotics in infants at risk for NEC. (Further research needed.) (4) Do nutrients either prevent or predispose to the development of NEC? We do not recommend glutamine supplementation for infants at risk for NEC (Strong). There is insufficient evidence to recommend arginine and/or long chain polyunsaturated fatty acid supplementation for infants at risk for NEC. (Further research needed.) (5) When should feeds be reintroduced to infants with NEC? There are insufficient data to make a recommendation regarding time to reintroduce feedings to infants after NEC. (Further research needed.).


Asunto(s)
Suplementos Dietéticos , Nutrición Enteral/métodos , Enterocolitis Necrotizante/terapia , Recién Nacido de Bajo Peso/crecimiento & desarrollo , Enfermedades del Prematuro/terapia , Animales , Arginina/administración & dosificación , Ácidos Grasos Insaturados/uso terapéutico , Glutamina/administración & dosificación , Humanos , Lactante , Recien Nacido Extremadamente Prematuro/crecimiento & desarrollo , Recién Nacido , Leche , Leche Humana , Probióticos/uso terapéutico , Ensayos Clínicos Controlados Aleatorios como Asunto , Factores de Riesgo
11.
Pediatr Res ; 71(2): 168-78, 2012 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-22258128

RESUMEN

INTRODUCTION: We investigated the use of dietary omega-3 (ω-3) polyunsaturated fatty acids (PUFAs) in the treatment of neuroblastoma both as a sole agent and in combination with sunitinib, a broad-spectrum tyrosine kinase receptor inhibitor. RESULTS: Substitution of all dietary fat with menhaden oil (ω-3 PUFA rich) resulted in a 40-70% inhibition of tumor growth and a statistically significant difference in the levels of several PUFAs (18:2 ω-6, 20:4 ω-6, 22:4 ω-6, 20:5 ω-3) as compared with a control diet. Furthermore, tumors from animals on the ω-3 fatty acid (FA)-enriched diet had an elevated triene/tetraene ratio suggestive of a change in local eicosanoid metabolism in these tissues similar to that seen with essential fatty acid deficiency. The ω-3 FA-enriched diet also decreased tumor-associated inflammatory cells and induced mitochondrial changes suggestive of mitochondrial damage. Combination treatment with sunitinib resulted in further reduction in tumor proliferation and microvessel density. DISCUSSION: These findings suggest a potential role for ω-3 PUFAs in the combination treatment of neuroblastoma. METHODS: We used a murine model of orthotopic and subcutaneous human neuroblastoma and diets that differ in the FA content to define the optimal dietary ω-3/omega-6 (ω-6) FA ratio required for the inhibition of these tumors.


Asunto(s)
Inhibidores de la Angiogénesis/farmacología , Proliferación Celular/efectos de los fármacos , Dieta , Ácidos Grasos Omega-3/administración & dosificación , Aceites de Pescado/administración & dosificación , Indoles/farmacología , Neuroblastoma/dietoterapia , Neuroblastoma/tratamiento farmacológico , Inhibidores de Proteínas Quinasas/farmacología , Pirroles/farmacología , Animales , Ácido Araquidónico/metabolismo , Línea Celular Tumoral , Relación Dosis-Respuesta a Droga , Ácidos Grasos Omega-3/metabolismo , Aceites de Pescado/metabolismo , Humanos , Metabolismo de los Lípidos , Masculino , Ratones , Ratones SCID , Microvasos/efectos de los fármacos , Microvasos/patología , Mitocondrias/efectos de los fármacos , Mitocondrias/patología , Neuroblastoma/irrigación sanguínea , Neuroblastoma/enzimología , Neuroblastoma/patología , Sunitinib , Factores de Tiempo , Carga Tumoral/efectos de los fármacos , Ensayos Antitumor por Modelo de Xenoinjerto
12.
Surg Clin North Am ; 91(3): 543-63, 2011 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-21621695

RESUMEN

Intestinal Failure Associated Liver Disease (IFALD) is a common and potentially life-threatening problem for pediatric patients receiving long-term parenteral nutrition (PN). Risk factors for IFALD include premature birth, low birth weight, long-term PN, intestinal stasis and sepsis. Preventative strategies are the cornerstone of improving outcomes in IFALD and include enteral feeding, weaning of PN, reduced dose lipid emulsions and the early recognition and treatment of sepsis. Recent work also demonstrates the efficacy of fish-oil based lipid emulsions in the prevention and treatment of IFALD. Transplantation is an option for end-stage liver disease but is associated with significant morbidity and mortality.


Asunto(s)
Hepatopatías/etiología , Hepatopatías/terapia , Síndromes de Malabsorción/complicaciones , Nutrición Parenteral/efectos adversos , Nutrición Enteral , Humanos , Intestinos/trasplante , Hepatopatías/epidemiología , Hepatopatías/prevención & control , Trasplante de Hígado , Pronóstico , Factores de Riesgo , Síndrome del Intestino Corto/terapia
13.
AJNR Am J Neuroradiol ; 23(9): 1445-56, 2002 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-12372731

RESUMEN

BACKGROUND AND PURPOSE: Conventional MR imaging findings of human brain development are thought to result from decreasing water content, increasing macromolecular concentration, and myelination. We use diffusion-tensor MR imaging to test theoretical models that incorporate hypotheses regarding how these maturational processes influence water diffusion in developing gray and white matter. METHODS: Experimental data were derived from diffusion-tensor imaging of 167 participants, ages 31 gestational weeks to 11 postnatal years. An isotropic diffusion model was applied to the gray matter of the basal ganglia and thalamus. A model that assumes changes in the magnitude of diffusion while maintaining cylindrically symmetric anisotropy was applied to the white matter of the corpus callosum and internal capsule. Deviations of the diffusion tensor from the ideal model predictions, due to measurement noise, were estimated by using Monte Carlo simulations. RESULTS: Developing gray matter of the basal ganglia and developing white matter of the internal capsule and corpus callosum largely conformed to theory, with only small departures from model predictions in older children. However, data from the thalamus substantially diverged from predicted values, with progressively larger deviations from the model with increasing participant age. CONCLUSION: Changes in water diffusion during maturation of central gray and white matter structures can largely be explained by theoretical models incorporating simple assumptions regarding the influence of brain water content and myelination, although deviations from theory increase as the brain matures. Diffusion-tensor MR imaging is a powerful method for studying the process of brain development, with both scientific and clinical applications.


Asunto(s)
Encéfalo/anatomía & histología , Imagen de Difusión por Resonancia Magnética , Ganglios Basales/anatomía & histología , Ganglios Basales/crecimiento & desarrollo , Ganglios Basales/metabolismo , Agua Corporal/metabolismo , Encéfalo/crecimiento & desarrollo , Encéfalo/metabolismo , Niño , Preescolar , Simulación por Computador , Cuerpo Calloso/anatomía & histología , Cuerpo Calloso/crecimiento & desarrollo , Cuerpo Calloso/metabolismo , Humanos , Lactante , Recién Nacido , Cápsula Interna/anatomía & histología , Cápsula Interna/crecimiento & desarrollo , Cápsula Interna/metabolismo , Tálamo/anatomía & histología , Tálamo/crecimiento & desarrollo , Tálamo/metabolismo
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