Narrowing the Protein Deficit Gap in Critically Ill Patients Using a Very High-Protein Enteral Formula.

BACKGROUND: Protein deficits have been associated with longer intensive care unit (ICU) stays and increased mortality. Current view suggests if protein goals are met, meeting full energy targets may be less important and prevent deleterious effects of overfeeding. We proposed a very-high protein (VHP) enteral nutrition (EN) formula could provide adequate protein, without overfeeding energy, in the first week of critical illness. METHODS: This was a retrospective study of medical/surgical ICU patients receiving EN exclusively for ≥5 days during the first week of ICU admission. Twenty participants received standard EN; 20 participants received the VHP-EN formula (1 kcal/mL, 37% protein). Protein and energy prescribed/received, gastrointestinal tolerance, and feeding interruptions were examined. RESULTS: Forty ICU patients [average Acute Physiology and Chronic Health Evaluation II score of 20.1] were included. Protein prescribed and received was significantly higher in the VHP group vs the standard EN group (135.5 g/d ± 22.9 vs 111.4 g/d ± 25; P = .003 and 112.2 g/d ± 27.8 vs 81.7 g/d ± 16.7, respectively; P = .002). Energy prescribed and received was similar between groups (1696 kcal/d ± 402 vs 1893 kcal/d ± 341, respectively; P = .101 and 1520 kcal/d ± 346 vs 1506 ± 380 kcal/d; P = .901). There were no differences in EN tolerance (P = .065) or feeding interruptions (P = .336). CONCLUSIONS: Use of a VHP formula in ICU patients resulted in higher protein intakes without overfeeding energy or use of modular protein in the first 5 days of exclusive EN.

[SURGICAL COMPLICATIONS IN ACUTE POISONING AND PROTEIN--ENERGY DYSFUNCTION].

The article presents a review of acute surgical pathology and the frequency of its occurrence, complicating alcohol poisoning, cauterizing liquids, narcotic and psychotropic drugs and acute emerging metabolic (protein-energy). The development of surgical complications in poisoning was observed in patients in severe and very severe condition and is accompanied by a sharp increase in mortality (75%) and severe energy dysfunction. The most diverse and difficult flowing surgical complications were encountered in alcohol poisoning and cauterizing liquids.

Fluid, electrolytes, and nutrition: minutes matter.

Historically, in very low-birth-weight infant care, nutritional support was delayed during the first postnatal days because of fear of toxicity and harm with immature metabolic systems and intestinal function. Recent evidence demonstrates that early nutritional support is not only safe but likely necessary to optimize infant growth and neurodevelopment. In fact, nutrition management is a critical factor in very low-birth-weight infant golden hour support. Contemporary studies in protein and lipid intravenous support and early feeds as minimal enteral nutrition exhibit safety and some efficacy. We will present analysis of this evidence and development of potential better practices on the basis of these data as well as a review of golden hour fluid and glucose management. In addition, we provide several outcomes following our adoption of potentially better golden hour nutrition practices.

[Correction of protein metabolism violations in patients with malabsorption syndrome].

It is established that a heightened nitrogen balance is defined by a dysabsorbtion syndrom. Proved that the optimal quota of protein at albuminous insufficiency is about 135 g/day. Parenteral introduction of aminoacidic mixes (Infesol) led to clinical improvement, normalization of an aminoacidic spectrum of blood. Use of mixes for an enteral nutrition (Nutridrink) provides a reduction of symptoms of albuminous deficiency.

Modular protein supplements and their application to long-term care.

Modular protein supplements are added to either the diet or enteral formula to increase the protein or amino acid intakes of people who are nutritionally compromised. Protein supplements are aggressively marketed to long-term care clinicians because protein energy malnutrition and wounds are a common problem in this care setting. It can be challenging for clinicians to distinguish one product from another and to determine the best product for a specific application or nutrition care goal. Modular protein products can be sorted into 4 categories: (1) protein concentrates derived from a complete protein such as milk, soy, or eggs; (2) protein concentrates derived from collagen, either alone or in combination with a complete protein; (3) doses of 1 or more dispensable (nonessential) amino acids; and (4) hybrids of the complete or collagen-based proteins and amino acid dose. Modular protein supplements are generally provided either as a substrate for protein synthesis or as a source of 1 or more amino acids that may be conditionally indispensable (conditionally essential) under certain disease conditions. This review provides guidelines for the use of modular protein supplements according to their intended physiologic function and the assessment and nutrition care goals of the long-term care resident.

Effect of infections and environmental factors on growth and nutritional status in developing countries.

Despite numerous advances and improvements in child health globally, malnutrition remains a major problem and underlies a significant proportion of child deaths. A large proportion of the hidden burden of malnutrition is represented by widespread single and multiple micronutrient deficiencies. A number of factors may influence micronutrient deficiencies in developing countries, including poor body stores at birth, dietary deficiencies and high intake of inhibitors of absorption such as phytates and increased losses from the body. Although the effects of poor intake and increased micronutrient demands are well described, the potential effects of acute and chronic infections on the body's micronutrient status are less well appreciated. Even more obscure is the potential effect of immunostimulation and intercurrent infections on the micronutrient distribution and homeostasis. The association therefore of relatively higher rates of micronutrient deficiencies with infectious diseases may be reflective of both increased predisposition to infections in deficient populations as well as a direct effect of the infection itself on micronutrient status indicators. Recently the association of increased micronutrient losses such as those of zinc and copper with acute diarrhea has been recognized and a net negative balance of zinc has been shown in zinc metabolic studies in children with persistent diarrhea. It is also recognized that children with shigellosis can lose a significant amount of vitamin A in the urine, thus further aggravating preexisting subclinical vitamin A deficiency. Given the epidemiological association between micronutrient deficiencies and diarrhea, supplementation strategies in endemic areas are logical. The growing body of evidence on the key role of zinc supplementation in accelerating recovery from diarrheal illnesses in developing countries supports its use in public health strategies.

Electroporation for targeted gene transfer.

The utilisation of nonviral gene delivery methods has been increasing steadily, however, a drawback has been the relative low efficiency of gene transfer with naked DNA compared with viral delivery methods. In vivo electroporation, which has previously been used clinically to deliver chemotherapeutic agents, also enhances the delivery of plasmid DNA and has been used to deliver plasmids to several tissue types, particularly muscle and tumour. Recently, a large number of preclinical studies for a variety of therapeutic modalities have demonstrated the potential of electrically mediated gene transfer. Although clinical trials using gene transfer with in vivo electroporation have not as yet been realised, the tremendous growth of this technology suggests that the first trials will soon be initiated.

Gene therapy for lympho-hematopoietic disorders.

Inherited lympho-hematopoietic disorders are considered to be some of the most amenable targets for development of gene therapy because of their defined molecular biology and pathophysiology and the potential for corrected cells to exhibit profound growth and survival advantages. Recently, several clinical studies have shown that conventional gene transfer technology can produce major beneficial therapeutic effects.

Presentación clínica infrecuente de infección por VVZ en un paciente inmunocompetente / Infrequent clinical outbreak of VZV in an immunocompetent patient

Se presenta el caso de un paciente masculino, de 49 años de edad, con un alcoholismo crónico y desnutrido. El paciente desarrollo una infección cutánea por VZV caracterizada por ampollas hemorrágicas diseminadas, similar a las observadas en pacientes inmunodeprimidos. Cuando se hospitalizó tenía un compromiso metabólico severo con un balance proteico negativo a causa de su estado nutricional. Con el tratamiento con drogas antivirales, nutrición parenteral y pulso de metioprednisolona se obtuvo una remisión rápida de las lesiones cutáneas y una recuperación completa de su estado nutricional las primeras cuatro semanas. La desnutrición y el alcoholismo son condiciones relacionadas entre ellas y ambas pueden ser causa de déficit de la respuesta inmune. El déficit por esas causas no es el caso del paciente desde que ocurrió una remisión completa de su infección viral y una evolución favorable del síndrome metabólico. El interés del caso es la presentación clínica de la infección por VZV en un paciente no inmunodeprimido que clínica mente simuló ese estado

We present a male patient, 49 year old, that had a chronic alcoholism and a malnourished condition. The patient developed a skin VZV infection characterised by disseminated bullous and haemorrhagic lesions similar to those observed in immune-compromised hosts. When hospitalized, he had a severe metabolic impairment with a negative protein balance secondary to his nutritional status. Treatment included antiviral therapy, intravenous nutrition and metilprednisolone pulse. There was an early and quick improvement of the skin lesions and a complete recovery of the nutritional status in one month. Malnutrition and alcoholism are related conditions, and both of them can cause impaired immune responses. This was not the case in our patient where a complete remission of the viral infection and the favourable evolution of the metabolic syndrome occurred. The case is interesting due to the rare clinical picture induced by the VZV infection in a non immune-compromised host that clinically mimicked this state

Molecular basis of red cell protein antigen deficiencies.

Blood group antigens reside on cell surface molecules of wide structural and functional diversity. Although all are serologically detectable on red blood cells, most are also expressed in non erythroid tissues, but with a few exceptions their biological role on erythrocytes and tissues often remains elusive. Deficiencies of these molecules seen either in rare blood group "null" phenotypes and/or associated with red cell membrane disorders, offer the opportunity to clarify their role in the cell membrane and to correlate their molecular abnormalities with cell dysfunctions. This review will summarize some of the present knowledge on these defects and on gene targeting studies developed to analyze the function of these molecules in animal models.

[Nutrition and chronic liver disease]. / Nutrición y hepatopatía crónica.

The prevalence, causes, and consequences of energy-protein malnutrition (EPM) are reviewed in cirrhosis and its treatment, with special emphasis on those aspects that can be carried out in the ambulatory regime. EPM is a highly prevalent situation in advanced cirrhosis, but it probably already occurs in early stages of the disease. EPM has an important prognosis in cirrhosis. Specifically, the nutritional status could be a better predictor of the evolution after a liver transplant than the conventional prognostic indicators. The increase in the oxidation of fats and proteins is the most important mechanisms in EPM in these patients. The hypermetabolism and the deficit in ingestion are also relevant factors in the EPM in cirrhosis. Conventional diet therapy is the most important tool in the long term nutritional treatment in cirrhosis. The administration of nightly carbohydrate supplements could partially revert the alteration in the oxidation of the energetic substrates in these patients. Also, oral supplements of chemically defined diets could improve the quality of life and the long term survival of these patients. When artificial nutrition is indicated, enteral nutrition is the modality of choice in these patients. Enteral nutrition in cirrhosis is safe, nutritionally effective (as it guarantees an adequate energetic-proteineic ingestion), and in some studies it has been associated with a better short term survival. Adding branched chain amino acids to the diets or enteral supplements meant for cirrhotics would only be essential in patients who show intolerance to the conventional protein. Other changes in the components of the diet formulae meant for cirrhotics are open to further research.

Nucleoside-nucleotide mixture increases bone marrow cell number and small intestinal RNA content in protein-deficient mice after an acute bacterial infection.

The aim of this study was to determine if intraperitoneal administration of a nucleoside-nucleotide mixture would affect small intestinal morphology, bone marrow cell number, and DNA content in protein-deficient mice subjected to acute bacterial infection. Mice were randomized into two groups and orally fed protein-free diet or nucleotide-free 20% casein diet for 10 d. The mice in each group were divided into two subgroups and intraperitoneally administered 0.35 mL saline or nucleoside-nucleotide mixture (17.5 mL/kg body weight) for 10 d. On day 10, one subgroup from each major dietary group was either inoculated intravenously with methicillin-resistant Staphylococcus aureus or saline. Three days later, small intestinal morphology, bone marrow cell number, and DNA content were evaluated in infected and noninfected mice. Protein-deficiency in association with infection significantly (P < 0.05) reduced body weight, small intestinal weight, crypt depth, villous height, and wall thickness. All dietary groups exhibited similar small intestinal DNA and protein contents (protein:DNA ratio, RNA:DNA ratio) at 3 d postinfection. However, small intestinal RNA content in the infected protein-free dietary group administered nucleoside-nucleotide mixture was higher (P < 0.05) and tended to be higher relative to the infected nucleotide-free 20% casein group administered nucleoside-nucleotide mixture compared with the rest of the groups. In the infected protein-free dietary group administered nucleoside-nucleotide mixture, bone marrow cell number and bone marrow DNA content were higher (P < 0.05) relative to the infected protein-free dietary group, nucleotide-free 20% casein diet administered saline, or nucleoside-nucleotide mixture, respectively. We conclude that intraperitoneal administration of nucleoside-nucleotide mixture may stimulate bone marrow cell proliferation, DNA content, and small intestinal RNA content during periods of relative deficiency such as protein-deficiency in combination with infection.

Estusio de los valores de hemoglobina, hierro sérico, transferrina, proteínas totales y fraccionadas y su relación con el estado nutricional en niños con neumonía / Study of the valors of hemoglobin silken iron, transferrin, proteins totals and fractionals and its relations with the state nutritional in the children with pneumonia

Se realizó un estudio descriptivo prospectivo para explorar las modificaciones en parámetros bioquímicos durante la fase aguda y de convalecencia en niños con Neumonía y la relevancia del estado nutricional en el proceso infeccioso. Se estudiaron 51 niños (1 a 6 años de edad) que ingresaron al Hospital Pediátrico "Dr. Elías Toro", en el período abril 1994-febrero 1995, con diagnóstico de neumonía según criterios IRA-OMS. Los niños se clasificaron nutricionalmente empleando indicadores antropométricos OMS. Se determinó al ingreso y egreso; concentración de Hemoglobina (Hb), hierro sérico (Fe), capacidad total de enlazamiento de hierro por la Transferrina (TIBC), proteínas séricas totales y fraccionadas. Al ingreso 73.6 por ciento de los niños poseía valores de Hb menores a 10 g/dL, 98 por ciento presentaron Fe menor al 11 µmol/L. Los valores TIBC de todos los niños estaban en el rango de referencia tanto al ingreso como al egreso. No se encontraron diferencias estadísticamente significativas en las concentraciones de proteínas séricas totales respecto a la condición nutricional. La variación en la fracción proteica Alfa-1, observada al ingreso respecto al egreso, mostró diferencia estadística en los grupos de nutridos y desnutridos agudos. El proceso infeccioso pareciera modular los cambios bioquímicos descritos en el grupo de niños nutridos y desnutridos leves incluidos en el presente estudio

[Nutritional status of patients with HIV infection. Spontaneous evolution during the hospital stay]. / Estado nutricional de pacientes con infección por VIH. Evolución espontánea durante un ingreso hospitalario.

UNLABELLED: BASICS: Evaluate the nutritional status of HIV positive patients who are admitted to hospital for some acute process, and their evaluation, without nutritional support, during the admission. METHODS: Prospective study in HIV positive patients. Nutritional evaluation (on admission and on release); (1) anthropometric (weight, size, triceps, fold, circumference of the arm, and muscular circumference of the arm, and (2) biochemical (albumin, cholesterol, triglycerides, lymphocytes, pre-albumin, and transferrin). Statistical study: comparison of the paired means and chi squared test. RESULTS: 60 patients. Mean age 32 +/- 4.8 years, 76% men and 23% women. Staging: AIDS 84.8%, non-AIDS 15.2%. Main reason for admission: Infection (80%). Mean stay: 14 days +/- 9.5. Initial nutritional evaluation: normal: 1.7%, protein malnutrition: 5.3%, caloric malnutrition: 38.5%, mixed malnutrition: 54.3%, 85% of the patients refer weight loss. 21 patients (35%) were followed up. There were no significant differences in the anthropometric nor in the biochemical parameters, except in the levels of pre-albumin and transferrin, which improved (p < 0.001). Nutritional evaluation on release: normal: 9.5%, caloric malnutrition: 66.5%, mixed malnutrition: 23.7%. There were no cases of protein malnutrition. CONCLUSIONS: The vast majority of the HIV+ patients who are admitted, are malnourished, and after curing the acute process, 90.5% of them remain malnourished. The anthropometric measurements, albumin, cholesterol, and triglycerides do not vary during the hospital admission, despite the treatment and the clinical improvement. The increase of proteins with a short half life is due to controlling the infection, which is why these are not good parameters for the nutritional evaluation in these patients.