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.

Metabolic and nutritional support of the intensive care patient. Ascending the learning curve.

The learning curve of nutritional support in the critically ill began with the amelioration of the effects of starvation in patients with a disabled intestine. Next, there was an appreciation that feeding formulas could be tailored to support patients with specific organ insufficiencies. Then it was realized that feeding enterally has distinct advantages over feeding parenterally. In addition to a decrease in catheter-related sepsis, there was noted a distinct decrease in "remote site" sepsis. In fact, good scientific reasons have been identified to explain why this occurs, such as maintaining the competency of the intestine against a translocation of endotoxin and bacteria and "turn-on" of the stress response. Further, we now know that specific nutrients can produce desirable pharmacologic effects. In the future, feeding formulae will be devised that continue to modify the patient's response to illness favorably. Another important consideration is to begin nutritional support as soon as possible--i.e., on the day of admission, if appropriate. The critical care specialist should be expert in these techniques, with the goal of eliminating malnutrition as a confounding variable in the clinical course of the intensive care unit patient.

The case for nutritional support. Eliminating hospital-acquired malnutrition improves outcomes and reduces costs.

Taking steps to eliminate hospital-acquired malnutrition in patients with disease or trauma significantly improves treatment outcomes. Patients' ability to recover from trauma or illness and respond to therapy depends on how well they synthesize proteins necessary to regain homeostasis. It is possible for patients to die from complications of progressive hospital-acquired malnutrition. Hospital executives and clinical personnel must understand that timely intervention with nonvolitional feeding in appropriately selected patients will decrease morbidity and length of stay. Hospitals that ignore nutritional support therapy for patients may be in violation of quality-of-care standards. And hospitals that do not have hyperalimentation or nutritional support teams, or that have disbanded such teams for economic reasons, are putting their critically ill patients at risk for malnutrition.

Albumin and colloid osmotic pressure implications for fluid resuscitation.

This article reviews basic physiologic principles governing fluids in spaces. Starling's law is presented, and its interpolation into a dynamic clinical setting is discussed. These principles are further described through a case presentation.

Review of the rapid normalization of serum albumin with modified total parenteral nutrition solutions.

The theoretical basis for the rapid normalization of hypoalbuminemia is contingent on recognition of those clinical circumstances requiring rapid and prolonged repair of colloid oncotic pressure. Standard total parenteral nutrition (TPN) solutions repair serum protein only after prolonged periods of therapy. Nutritionists have empirically observed that adding albumin to TPN solutions can quickly normalize hypoalbuminemia for sustained periods. Infusion of similar quantities of albumin without TPN results in no prolonged normalization. The mechanism of the rapid normalization of serum albumin with albumin-modified TPN solutions has yet to be determined, as has its relationships to prevention of hypoalbuminemia-associated morbidity and mortality.

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.

Incidence of protein calorie malnutrition in the nursing home population.

That nutritional parameters change with age is a well-known phenomenon. Physical activity, lean body mass, and metabolic rate all decline with increasing age. There has been little work regarding the nutritional assessment of geriatric nursing home patients to determine their nutritional status and to focus attention on their nutritional needs. The purpose of this study was to assess the nutritional status of the residents of two urban nursing homes. The nutritional status of 227 nursing home residents (mean age 72.2 years) was evaluated using biochemical and anthropometric measurements. Midarm muscle circumference, triceps skinfold thickness, weight, height, serum albumin, serum pre-albumin, serum retinol binding protein, and a complete blood count with differential were obtained. The evaluation of this data indicated that there was a 52% incidence of malnutrition. This can be broken down to: 24% hypoalbuminemic malnutrition, 19% Kwashiokor-Marasmus mix, and 9% Marasmus. Twenty-eight percent of all patients were anergic, and 76% of the patients were anemic. In conclusion, there appears to be far more documentable malnutrition than anticipated or previously reported in this population.

Efficacy of enteral diets in the prevention of stress-induced gastric erosions in rats.

This study compares the prophylactic effects of two different diets and routes of feeding on restraint stress-induced gastric erosions in the rat. Thirty male Sprague-Dawley rats were food-deprived and immobilized for 24 hours using a steel wire mesh. A small silicone tube was placed into either the proximal jejunum or the stomach via a laparotomy. There were three groups of ten rats (five jejunum-fed, five stomach-fed), receiving infusions (50 ml/24 h) of: (A) normal saline; (B) free amino acids (Vivonex HN, Norwich Eaton Pharmaceuticals) (60 cal and 0.318 G nitrogen); or (C) a peptide diet, with the nitrogen source as lactalbumin hydrolysate, otherwise identical to B. Gastric acidity was measured every 4 hours. At 24 hours, blood was collected and serum gastrin levels determined. The animals were then sacrificed and the stomachs examined. The results were analyzed using one-way analysis of variance. Fewer gastric erosions and lower serum gastrin levels and gastric acidity were found in animals fed diets B and C, versus animals fed normal saline (p less than 0.05). There was no difference between groups B and C. Our results also show that enteral diets using the jejunal route are better than those using the gastric route in reducing the incidence of stress-induced gastric erosions in rats.

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.

Correlation of pressure sores and nutritional status.

As life expectancy increases, so do the problems of the elderly population. One major problem is that of protein calorie malnutrition; another is the susceptibility of this population to pressure sores. The purpose of this study was to determine if a correlation exists between deteriorating nutritional status and the development of pressure sores. The nutritional status of 232 nursing home patients (mean age 72.9 +/- 12 years) was determined using biochemical and anthropometric measurements. Overall, the incidence of some degree of malnutrition was 59%. Seventeen of the patients were found to have pressure sores and were all malnourished. When classified as mild, moderate, or severe malnutrition, the patients with pressure sores were in the severe group. There was a significant difference (P less than .001) between the nutritional status of pressure sore patients and the malnourished patients. It appears that the development of pressure sores correlates with nutritional deficiencies. The authors' findings suggest a need for more aggressive nutritional support in the elderly, especially those with pressure sores.

Cholesterol: an antidiarrheal agent in rats with short-bowel syndrome fed elemental diets.

Studies show that bile acids and long-chain fatty acids are responsible for diarrhea in certain malabsorption syndromes. Recent reports indicate that substances such as dietary cholesterol, when moderately consumed, can reduce bile-induced excessive mucosal fluid and electrolyte output. This study explores the antidiarrheal effect and dosage of dietary cholesterol in rats following massive bowel resection, co-fed elemental diet. Thirty-five male Sprague-Dawley rats weighing 248-253 g underwent 75% resection of the small bowel and were fed ad libitum for 21 days with 1 of 5 diets (n = 7) of Vivonex HN, supplemented by 0, 2.5, 5, 10 or 15 mM cholesterol/1,000 g of the powdered elemental diet. Parameters measured included daily food and water consumption, daily changes in weight, volume of excrement and stool consistency graded by the same individual (water, semiformed or formed). It was found that 5 mM dietary cholesterol in 1,000 g of the elemental diet produced the most formed stool and significantly improved weight gain in rats with short-bowel syndrome.