Reducing Antacid Use in a Level IV NICU: A QI Project to Reduce Morbidity.

INTRODUCTION: Gastroesophageal reflux is a physiologic occurrence in infants. Clinicians caring for neonates use histamine-2 receptor antagonists (H2As) or proton pump inhibitors (PPIs) for symptomatic reflux, apnea/bradycardia/desaturations, or irritability. Recent studies have shown that there is an increased incidence of infection, fracture, and mortality in neonates who receive antacids. METHODS: A multidisciplinary team aimed to decrease nonindicated antacid use in the NICU by 50% by April 2019. Outcome measures include the median number of inappropriate antacid prescriptions and patient-days on acid-suppressants. Interventions include education regarding use and risks of antacids, development of a list of indications deemed "appropriate" for starting an H2A or PPI, mandatory discussion on rounds when considering antacids, documentation of treatment goal, and indication, and an automatic drop-off in the electronic medical record. RESULTS: Baseline data (June-December 2017) showed 19 prescriptions of H2As or PPIs. Of those, 10 orders were deemed "inappropriate," according to our indicated uses. There were 407 total patient-days of medication-use (median: 51 patient-days). After the implementation of the interventions (October 2018-May 2019), there were 11 prescriptions of antacid medications, 3 of which were deemed "inappropriate." There were 206 total days of medication-use (median: 18.5 patient-days). CONCLUSIONS: A multidisciplinary agreement on indications for antacid use in neonates stimulates discussion and creates more purposeful use. Overall, we successfully decreased nonindicated antacid prescriptions in the NICU. For the next steps, we hope to educate physicians on the risks of antacid use and reduce prescriptions in other areas of the hospital and the outpatient setting.

Malassezia Pneumonia: A Rare Complication of Parenteral Nutrition Therapy.

Malassezia species (formerly known as Pityrosporum) are part of normal human skin flora and have been associated with benign dermatologic conditions, such as seborrheic dermatitis and tinea versicolor. In rare cases, however, Malassezia has been associated with systemic disease in immunocompromised patients and infants in the neonatal intensive care unit. Malassezia species require long-chain fatty acids for growth and therefore have a known predilection for individuals receiving lipid containing intravenous parenteral nutrition (PN). Systemic infections are characterized by prolonged fevers and illness but can include nonspecific signs and symptoms. We present the diagnosis and management of a rare case of an immunocompetent, nonneonatal, PN-dependent child with Malassezia furfur pneumonia.

Short-term fish oil supplementation improved innate immunity, but increased ex vivo oxidation of LDL in man--a pilot study.

BACKGROUND: Fish and fish oils are rich in the two long-chain polyunsaturated fatty acids (LCPUFAs) eicosapentaenoic acid (EPA, 20:5n-3) and docosahexaenoic acid (DHA, 22:6n-3). The n-3 LCPUFAs have been reported to have beneficial effects on cardiovascular functions, but their role in relation to immune functions is still controversial. AIM OF THE STUDY: The objectives of this study were to determine the effects of supplementation with fish oil on immune cell functions in human subjects. We have also assessed the effects on plasma lipids, antioxidant status and susceptibility of low-density lipoproteins (LDL) to oxidative stress. The antioxidant status was determined by measuring plasma vitamin C, tocopherols and carotenoids in plasma and LDL, and superoxide dismutase (SOD) in red blood cells. DESIGN: For 30 days, 10 volunteers ingested 25 g/d of either fish oil, providing n-3 LCPUFAs (7.5 g), or high-oleic sunflower oil, providing monounsaturated fatty acids mainly as oleic acid (22 g). The oils contained similar profiles of tocopherols. At day 0 and day 30, blood samples were drawn by venipuncture for plasma lipid and antioxidant analyses and lipoprotein isolation, and for isolation and functional tests of mononuclear cells and granulocytes. Fatty acid profiles of im mune cells and LDL were also determined. RESULTS: Fish oil supplementation resulted in an accumulation of n-3 LCPUFAs (EPA, DHA) in LDL and immune cells. The phagocytic activity, a measure of immune cell activity, was increased in both groups. Whereas the plasma and LDL antioxidant status do not appear to be affected by fish oil supplementation, an increased susceptibility of LDL to oxidation was observed in these healthy volunteers. CONCLUSIONS: The optimal amounts of n-3 fatty acids required to modulate immune functions remain to be established. In addition, adequate levels of antioxidant protection need to be provided during fish oil supplementation.

Comparison of the antioxidant activity of commonly consumed polyphenolic beverages (coffee, cocoa, and tea) prepared per cup serving.

In this study, the in vitro low-density lipoprotein oxidation model was used to assess the relative antioxidant activity of the polyphenolic beverages tea, coffee, and cocoa on a cup-serving basis. The beverages were prepared as 0.7-2.5% soluble coffee and 1.5-3.5% cocoa; teas (green, black, or herbal) were prepared as one tea bag infused over 5 min in 220 mL of hot water. Under these standard cup serving conditions, the antioxidant activity as determined by the lag time was in the range of 292-948 min for coffee, 217-444 min for cocoa, 186-338 min for green tea, 67-277 min for black tea, and 6-78 min for herbal tea. Addition of milk did not alter the antioxidant activity. The influence of coffee bean source and degree of roasting was further investigated. Green coffee beans of Robusta coffee exhibited a 2-fold higher antioxidant activity than Arabica coffee, but after roasting this difference was no longer significant. In conclusion, these commonly consumed beverages have a significant antioxidant activity, the highest being soluble coffee on a cup-serving basis.

Effect of vitamin supplementation on cytokine response and on muscle damage after strenuous exercise.

The present double-blinded, placebo-controlled study investigated whether antioxidant vitamin supplementation was able to modulate the cytokine and lymphocyte responses after strenuous eccentric exercise. Furthermore, muscle enzyme release was examined to see whether antioxidant treatment could reduce muscle damage. Twenty male recreational runners randomly received either antioxidants (500 mg of vitamin C and 400 mg of vitamin E) or placebo for 14 days before and 7 days after a 5% downhill 90-min treadmill run at 75% .VO(2 max). Although the supplemented group differed significantly with regard to plasma vitamin concentration before and after exercise when compared with the placebo group, the two groups showed identical exercise-induced changes in cytokine, muscle enzyme, and lymphocyte subpopulations. The plasma level of interleukin (IL)-6 and IL-1 receptor antagonist increased 20- and 3-fold after exercise. The plasma level of creatine kinase was increased sixfold the day after exercise. The concentrations of CD4+ memory T cells, CD8+ memory and naïve T cells, and natural killer cells increased at the end of exercise. The total lymphocyte concentration was below prevalues in the postexercise period. In conclusion, the present study does not support the idea that exercise-induced inflammatory responses are induced by free oxygen radicals.

Effect of dietary supplementation with fish oil on cyclosporine A-induced vascular toxicity.

We wished to determine whether dietary supplementation with fish oil prevents the vascular toxicity of cyclosporine (Cx). In a first set of experiments, we assessed the endothelial function of aortas isolated from rats supplemented for 6 weeks with fish oil (FO), administered by gavage, and providing 150 mg/kg/day of eicosapentaenoic acid and 100 mg/kg/day of docosahexaenoic acid. FO treatment altered neither acetylcholine- and histamine-induced relaxations, nor serotonin-induced contractions (NS vs. control group). Thereafter, three groups of rats were treated in parallel. Group 1 received FO supplementation (by gavage) for 6 weeks, and Cx (10 mg/kg/day po) was added during the last 2 weeks, group 2 received Cx only (10 mg/kg/day po) for 2 weeks, and group 3 served as a control. Both acetylcholine-and histamine-induced relaxations were reduced in group 2 compared with the control group, as indicated by the area under the curve (AUC), which was significantly higher: 296 +/- 17 vs. 138 +/- 32, and 392 +/- 38 vs. 318 +/- 25 for acetylcholine and histamine, respectively. In group 1, AUC for acetylcholine remained significantly different from the control (241 +/- 31 vs. 138 +/- 32), whereas AUC for histamine was 367 +/- 28 (NS vs. control). The serotonin-induced contractions were also enhanced in group 2 compared with those of the control group, and this alteration was not attenuated in group 1. After mechanical removal of the endothelium, the increased responsiveness to serotonin persisted in groups 1 and 2, suggesting this functional alteration to be located in the smooth muscle cells. Thus, in the rat the attenuation of Cx-induced vascular toxicity by fish oil supplementation is only partial, that is, it involves a slight improvement in endothelial function, but with persistence of functional changes in smooth muscle.

Manipulation of tissue fatty acid profile by intravenous lipids in dogs.

This study was undertaken to determine the effects on the fatty acid (FA) composition of various dog tissues of 4 different lipid emulsions (a 100% long-chain triacylglycerol (LCT) derived from soya bean oil emulsion, a mixed 50% medium-chain triacylglycerol (MCT)/50% LCT emulsion as well as both these emulsions supplemented with 10% fish oil (FO) triacylglycerols), when daily infused over 15 days as a substantial component of total parenteral nutrition. Lipids represented 55% of the non-protein energy. Blood samples as well as biopsies from liver, muscle and adipose tissue were taken 15 days before, and again immediately after TPN. In addition, the spleen was also removed immediately after TPN. Tissue FA composition was analysed by gas liquid chromatography of each lipid component after separation by thin layer chromatography. No differences in either safety or tolerance were detected between the different TPN preparations. In particular, infusion over 2 weeks of fat emulsions containing 10% fish oil was tolerated as well as conventional LCT and MCT/LCT emulsions. Relative linoleate content of tissue triacylglycerol (TG) was markedly increased in animals that received the LCT emulsions (e.g. from 22.6 +/- 2.5% to 32.2 +/- 0.6% in the liver), this effect being markedly reduced with MCT/LCT preparations. n-3FA were slightly incorporated into liver TG (from 0.0 +/- 0.0% to 2.3 +/- 0.7% and 1.2 +/- 0.4% for eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) respectively, with LCT + FO), but remained undetectable in extrahepatic tissue TG. Of interest, medium chain FA were found in tissue TG after infusion of the mixed MCT/LCT emulsions. As expected, changes of tissue phospholipid (PL) composition involved only long-chain FA. Infusion of soya bean oil emulsion was associated with an increased content of linoleate in liver PL (from 13.6 +/- 0.4% to 17.7 +/- 0.4%), but not in other tissues. MCT/LCT did not markedly affect PL/FA pattern in any tissue. Supplementation with fish oil was associated with an efficient incorporation of n-3FA into tissue PL, particularly in the liver (from 0.4 +/- 0.1% to 2.5 +/- 0.3% for EPA and from 3.9 +/- 0.8% to 9.1 +/- 0.4% for DHA, with the LCT + FO emulsion).

Plasma lipid and plasma lipoprotein concentrations in low birth weight infants given parenteral nutrition with twenty or ten percent lipid emulsion.

Because 10% and 20% intravenously administered lipid emulsions (intralipid preparations) differ in their phospholipid/triglyceride ratio (0.12 and 0.06, respectively), 28 low birth weight infants requiring parenteral nutrition for at least 1 week were selected at random to receive either emulsion to determine the effects on plasma lipids and lipoproteins. Triglyceride intake was progressively increased to reach 2 gm/kg per day between days 4 and 7. During that period, all plasma lipids in samples taken 6 hours after infusion were higher in the 10% intralipid group. In comparison with day 0 values, triglyceride concentrations decreased (63 +/- 7 to 45 +/- 4 mg/dl; p less than 0.05) in the 20% group. Cholesterol levels increased in both groups, but the rise was more than twofold higher in the 10% group. Phospholipid increase was approximately 25% in the 20% group but more than 125% in patients receiving the 10% emulsion (p less than 0.005). The changes in plasma cholesterol and phospholipid levels were almost entirely in low-density lipoproteins. After 7 days, eight infants from each group were given the alternate emulsion, which resulted in a reversal of lipid patterns in each patient. We conclude that the higher phospholipid intake in 10% than in 20% intralipid is associated with higher plasma triglyceride concentrations and leads to accumulation of cholesterol and phospholipids in low-density lipoproteins. Emulsions with lower phospholipid content may be preferable for low birth weight infants and perhaps other patient populations with impaired removal of parenteral fat emulsions.