Journal of Parenteral and Enteral Nutrition Volume 35 Number 1 … · 2016. 8. 24. · 2 Journal of Parenteral and Enteral Nutrition / Vol. 35, No. 1, January 2011 fasting of 8h (control

1

Clinical Nutrition Week 2011.Vancouver, B.C., Canada

Vars Candidate

M20-2 - Preoperative fasting of 2h with maltodextrine combined with glutamine improves insulin resistance, nitrogen balance and serum glutathione early after laparoscopic cholecystectomy. A double-blind randomized trialDiana B. Dock-Nascimento, RD,MSc1; Jose E. Aguilar-Nascimento, MD, PhD2; Dan L. Waitzberg, MD, PhD3

1Department of Food and Nutrition, Federal University of Mato Grosso, Cuiabá, Brazil; 2Department of Surgery, Federal University of Mato Grosso, Cuiabá, Brazil; 3Department of Gastroenterology, University of Sao Paulo, Sao Paulo, Brazil.

Introduction: The main reason for traditional 6-8h of preoperative fast-ing is to reduce the volume and acidity of stomach contents, thus decreas-ing the risk of regurgitation/aspiration. Recently, various societies of anesthesia and nutrition have changed their guidelines to propose a reduction of the time for preoperative fasting for to 2 h, with the con-sumption of clear fluids containing carbohydrates (CHO). GLN is con-ditionally essential amino-acid after trauma with a multiple beneficial systemic function such as the preservation of body lean mass. Further-more, GLN supplementation may reduce infectious morbidity and length of hospital stay in surgical patients. We speculated that glutamine (GLN) may improve the formula of beverages designed for preoperative fasting by reducing the loss of nitrogen derived from muscle catabolism after trauma. The aim of the present study was to investigate the influence a beverage containing CHO and GLN given 2h before anesthesia on the insulin resistance and nitrogen balance during early metabolic response after laparoscopic cholecystectomy. Methods: A group of 60 females (19-62 years-old) candidates to elective laparoscopic cholecystectomy were randomized to receive in a double-blinded fashion either traditional

Scientific Paper Sessions

Premier Paper Session. January 31, 2011.

Vars Candidate

M20-1 - Eicosapentaenoic acid and docosahexaenoic acid synergistically attenuate bile acid-induced hepatocellular apoptosisEmma M. Tillman, PharmD1,2; Richard A. Helms, PharmD2,3; Dennis D. Black, MD1,3

1Children’s Foundation Research Center, The University of Tennessee, Memphis, TN; 2Clinical Pharmacy, The University of Tennessee, Memphis, TN; 3Pediatrics, The University of Tennessee, Memphis, TN.

Introduction: Parenteral nutrition (PN)-associated liver disease (PNALD) is a common complication occurring in children receiving long-term PN. Clinical studies in infants with PNALD have demonstrated improvement and even reversal of PNALD with omega-3 polyunsaturated fatty acid supplementation containing both eicosapentaenoic acid (EPA) and doco-sahexaenoic acid (DHA). Preclinical evidences suggest that one possible mechanism is attenuation of apoptosis induced by high levels of retained hydrophobic bile acids. The aim of this study was to determine the effects of EPA and DHA on hepatocellular apoptosis induced by the hydrophobic bile acid, chenodeoxycholic acid (CDCA). Methods: Cultured HepG2 cells were treated with 50, 100, 200 μM CDCA in the presence and absence of 10 μM EPA, 10 μM DHA, or 5 μM EPA + 5 μM DHA. Controls included cells incubated with vehicle alone (EtOH). Apoptosis was evaluated after 4, 8, 12, 18, 24 hours using the Apo-ONE® Homogeneous Caspase-3/7 Assay. Specific apoptotic mediators (Fas and TRAIL-R2) were evaluated at 0.5, 1, 1.5, 2, 4 hrs using quantitative real-time RT-PCR. Results: Treatment of HepG2 cells with 200 μM CDCA resulted in peak caspase activity at 12 hours. Treatment with EPA alone and DHA alone resulted in 22 % and 9 % caspase-3/7 attenuation, respectively. Caspase-3/7 activity was attenuated by 52 % when cells were treated with a combination of EPA and DHA (p = 0.0034). Peak Fas and TRAIL-R2 mRNA expression was observed at 0.5 hours. There was a 4.7-fold increase in Fas mRNA levels when cells were incubated with CDCA 200μM alone, as compared to no increase in Fas mRNA le. Conclusions: The combination of EPA and DHA resulted in a synergistic attenuation of bile acid-induced hepatocel-lular apoptosis evaluated by caspase 3/7 activity, as compared to treatment with EPA and DHA separately, in HepG2 cells. The combination of EPA and DHA did not result in a synergistic attenuation of the up-regulation of Fas or TRAIL-R2 by CDCA. These data suggest that EPA and DHA may be exerting an effect via additional pathways other than Fas and TRAIL-R2 to attenuate bile acid-induced apoptosis. More studies are needed to further evaluate the appropriate dose and the most effective ratio of EPA to DHA and to translate these results to the clinical setting.

Journal of Parenteral and Enteral Nutrition

Volume 35 Number 1January 2011

© 2011 American Society for Parenteral and Enteral Nutrition

10.1177/0148607110395865http://jpen.sagepub.com

hosted athttp://online.sagepub.com

2 Journal of Parenteral and Enteral Nutrition / Vol. 35, No. 1, January 20112 Journal of Parenteral and Enteral Nutrition / Vol. 35, No. 1, January 2011

fasting of 8h (control group, n=15 ) or three different beverages contain-ing either water (placebo group, n=15), or maldextrine plus GLN (GLN group, n=15 ), or pure maltodextrine (CHO group, n=15 ). Beverages were given 6h (400mL; GLN group: 50g maltodextrine, 40g GLN, 639.2 mOsm; and CHO group: 50g maltodextrine; 240 mOsm) and 2h (200 mL; GLN group: 25g maltodextrine, 10g GLN; 219.8 mOsm; and CHO group: 25g maltodextrine; 120 mOsm) before general anesthesia. The local ethics committee approved the study, and all patients gave written, informed consent for inclusion. Blood samples were collected both at induction of anesthesia and 10h after the operation (before the patient had received a meal). Urea nitrogen was assayed from the urinary output. The main endpoints of the study were the insulin resistance assessed by the HOMA-IR equation (Homeostasis Model Assessment-Insulin Resistance) and the nitrogen balance (NB). Secondary endpoints were the measurements pro-inflammatory markers (IL-6, C-reactive protein (CRP), pre-albumin, albumin), and glutathione (GSH) levels. A 5% level was adopted for significance. Results: There were no deaths, regurgitation during induc-tion of anesthesia nor postoperative complications. Gastric residual volume measured intraoperatively was similar between groups (p>0.05) varying from 0 to 80 mL (mean=9 mL). Postoperative HOMA-IR was greater in fasting subjects (4.0±3.6) than in the other three groups (placebo = 1.9±0.33, p=0.03; CHO=1.7±0.8, p=0.02; and GLN=1.5±0.6, p=0.01). All patients presented with negative NB. However, in GLN group the NB was significantly less negative (-1.30± 1.08 gN) than in the other three groups (placebo = -9.69±2.83gN, p=0.001; control= -7.25±0.44gN, p=0.01; and CHO= -5.87± 0.56, p=0.05). GSH increased in GLN group when compared to control group (p=0.04). All other results were similar among the groups. Conclusions: The abbreviation of preoperative fasting to 2h with either CHO or GLN beverages is safe. GLN added to CHO drink improves insulin resistance, nitrogen balance and increase the serum GSH levels in early postoperative period after laparoscopic cholecystectomy.

Vars Candidate

M20-3 - Early Arginine Depletion by Arginase after Trauma is Associated with Increased Susceptibility to InfectionsJohn P. Pribis, BS1; Xinmei Zhu, MD, PhD1; Juan B. Ochoa, MD1,2

1Department of Surgery, University of Pittsburgh, Pittsburgh, PA; 2Critical Care, University of Pittsburgh, Pittsburgh, PA.

Introduction: Systemic levels of arginine are reduced following injury and this may contribute to increased susceptibility to infection in injured patients, as arginine supplementation in patients correlates with a decrease in infectious complications. We have previously shown that increased arginase-1 induced in a heterogeneous population of Myeloid Derived Suppressor Cells contributes to arginine deficiency in a murine model of surgical trauma and prevents T-cell proliferation. We hypothesized a systemic release of arginase and arginine depletion early after injury may contribute to increased susceptibility to infection. Methods: Male, 6-8 week-old C57BL/6 mice were anesthetized and a midline laparotomy with large bowel manipulation was used as a model of surgical trauma. Plasma was collected at time points up to 72h for analysis of arginase activity (colorimetric assay that measures accumulation of L-Ornithine) and amino-acid quantification by HPLC. Liver-type arginase was inhibited in some mice using intraperitoneal nor-noha given immediately before and at 24 and 48h post surgery. Mice were infected 1h post-surgery with 5x105 CFU of Listeria monocytogenes (LM). Spleens and livers were homogenized 72h after infection and bacterial levels determined. Group comparisons were made using a one-way analysis of variance with Bonfer-roni post-hoc test or Student’s T-test. Pearson correlation coefficients were determined for arginase activity and amino acid levels. P<0.05 con-sidered significant. Results: Arginase activity in plasma maximally increased to 75 fold relative to baseline control at 2h after trauma and remained elevated at 72h (8.3 fold increase vs. control, p<0.05). Arginine

plasma levels in naïve mice were 39μM, and dropped significantly to 2μM at 2h after injury. Arginine levels remained significantly decreased at 6μM up to 4h but were recovered by 8h, 42μM, p>0.05 vs. control. Arginase and arginine levels in plasma had a correlation coefficient of -0.95. Bacterial loads after LM infection in liver and spleen were significantly increased in surgical trauma mice compared with non-injured mice (spleen 267-fold, liver 21,242-fold increase, injured vs non-injured, p<0.001), Nor-noha treatment of surgically-injured mice significantly reduced bacterial burden to 2.9-fold in spleen and 228.5 fold in liver relative to uninjured infected mice (p<0.001 injured vs. injured and nor-noha). Conclusions: Early depletion of systemic arginine in this model of injury contributed to an increased bacterial burden which was abrogated by administering an arginase inhibitor. These data are consistent with evidence that trauma patients supplemented with dietary arginine show a decrease in infectious complications. Modulation of arginine metabolism after surgical injury may also help maintain arginine homeostasis and decrease infectious complications.

Vars Candidate

M20-4 - Optimal protein and energy nutrition decreases 28 day mortality in mechanically ventilated critically ill patients: a prospective observational cohort studyPeter J. Weijs, PhD1,2; Armand R. Girbes, PhD MD2; Albertus Beishuizen, PhD MD2

1Nutrition and Dietetics, VU University Medical Center, Amsterdam, Netherlands; 2Intensive Care Medicine, VU University Medical Center, Amsterdam, Netherlands.

Introduction: Optimal nutrition for intensive care patients has been proposed to be the provision of energy as determined by indirect calorimetry, and protein provision of at least 1.2 grams/kg pre-admission weight per day. To achieve optimal intake an algorythm was developed (Strack van Schijndel et al. e-SPEN 2007;2:69-74) and implemented in the ICU (Strack van Schijndel et al. Neth J Med. 2009;67:388-93). After implementation the percentage of patients reaching adequate protein intake of 1.2 g/kg on day 4 after admission, a National Health Care Inspectorate indicator, increased from 30% to almost 60% (Neth J Med 2009). We previously have shown beneficial effects of optimal nutrition in female ICU patients (Strack van Schijndel et al. Crit Care 2009 Aug 11; 13(4):R132). Methods: Prospective observational cohort study in a mixed medical-surgical intensive care unit in an academic hospital. In total 886 consecutive mechanically ventilated patients were enrolled and included on day 3-5 after admission. Nutrition was guided by indirect calorimetry (Deltatrac) and provision of at least 1.2 grams of protein/kg pre-admission weight per day. Cumulative protein and energy balances were calculated for the period of mechanical ventilation and presented as intake per day. The main outcome parameter was 28 day mortality, analyzed by Cox regression with independent variable nutritional target reached (both energy and protein target) or energy target reached, both versus no target reached. Energy target reached was defined as at least 90% of measured resting energy expenditure + 10% for activity. Protein target reached was defined as intake of at least 1.2 g protein/kg pre-admission weight. Adjustments were made for sex, age, BMI, Apache II score, diagnosis, and hyperglycemic index. Results: Patient mean age was 63+16 years, BMI 26+6, Apache II 23+8. The Hazard ratio in the table shows a 50% reduction in 28 day mortality when both protein and energy target are reached. Post-hoc subgroup analysis per diagnosis revealed that patients with sepsis showed increased HR’s, therefore HR’s are also presented without sepsis patients. Conclusions: Optimal nutritional therapy, when both protein and energy targets are reached, leads to a marked reduction of 28 day mortality in mechanically ventilated ICU patients. Reaching energy targets alone is not enough. Outcome may depend on diagnosis.

CNW 2011 Scientific Abstracts 3

permeability preservation and reduction of bacterial translocation in this experimental model.

Figure 1. Histological analysis of terminal ileum: Sham (A), IO (B) and CIT (C) groups, presenting different grades of injury, espe-cially in IO group (arrows). The Sham group did not show impor-tant alteration (A). Pretreatment with CIT preserved intestinal epithelium after intestinal obstruction (C).

Scientific Paper Session: Critical Care. January 30, 2011.

Abstract of Distinction

S31-1 - Impact of Vitamin D Deficiency on Outcome in Critically Ill PatientsDavid Higgins, MS1; Kelly Queensland1; Paul Wischmeyer1; Alexandra Sufit1; Daren K. Heyland2,3

1University of Colorado School of Medicine, Denver, CO; 2Department of Medicine, Queen’s University, Kingston, ON, Canada; 3Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada.

Introduction: It is estimated that as many as 1 billion people worldwide have a deficiency in the essential nutrient vitamin D and this deficiency has been associated with a myriad of disease conditions. However, the impact of vitamin D deficiency on outcome in critically ill patients is still unclear. We hypothesize that vitamin D deficiency in ICU patients is a common condition and is associated with negative outcomes. Methods: We conducted a prospective multi-center study of 195 patients admitted to the ICU to evaluate the incidence of vitamin D deficiency and any association between vitamin D deficiency and mortality, infection status, length of ICU, SOFA scores, pneumonia status or creatinine. Serum samples where collected from a heterogeneous group of ICU patients and analyzed vitamin D levels via radioimmunoassay kit (DiaSorin) on admission day and 3 days later. Patients were followed for 28 days after admission and infection status and clinical outcomes were

Vars Candidate

M20-5 - Citrulline supplementation improves gut barrier after intestinal obstruction in miceMarina A. Batista, RD, MSc1; Maria Isabel Correia, MD, PhD2; Valbert N. Cardoso, Pharm, PhD1

1Pharmacy, Post-graduation Program in Food Science, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil; 2Surgery, Medical School and Post-graduation Program in Food Science, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.

Introduction: Previous studies have shown that citrulline decreases bacterial translocation and preserves intestinal permeability in mice undergoing intestinal obstruction. Gut barrier must be intact to prevent pathogenic invasion. Both physical and immune com-partments exhibit important functions in gut barrier. Immuno-globulin secretory A (sIgA) plays the first barrier against luminal agents. This study aimed at investigating the effects of a diet supple-mented with L-citrulline on intestinal morphology and local immune response. Methods: Intestinal permeability study - Thirty six Swiss male mice (5 weeks old) were randomized into three groups and pre-treated for 7 days either with conventional chow diet or a special diet containing L-citrulline (30mg/day), accordingly: Sham group - median laparotomy + conventional diet; intestinal obstruc-tion group (IO) - intestinal obstruction + conventional diet; and CIT group - intestinal obstruction + supplemented diet with 30 mg/day of L-citrulline. All the animals received isocaloric and isoproteic chow. On the 8th day, mice were gavaged with 0,1 mL of diethy-lenetriamine pentaacetic acid (DTPA) labeled with 18,5 MBq of technetium 99m (99mTc-DTPA). After 90 min, the animals were anesthetized and the terminal ileum was isolated and ligated. The Sham group underwent laparotomy only. After 18h the animals were sacrificed and the terminal ileus was harvested for histological analyses. Bacterial translocation study - Bacterial translocation was verified in another group of 24 mice, divided into similar groups with the same nutrition and surgical procedures as described above and gavaged on day 8th, with 0,1 mL of a suspension con-taining 108 CFU/mL of E. coli labeled with technetium 99m (99mTc-E. coli). After 18h of the surgical procedure, the small intestine was removed and 500 mg intestinal contents per 2mL PBS were suspended. After centrifugation at 2000 g for 30 min, the supernatant fluid was collected and kept frozen at -80°C until use. The levels of sIgA in the intestinal fluid were assessed by ELISA. ANOVA was used to evaluate sIgA data, with p<0.05 accepted as significant. Results: Citrulline preserved intestinal epithelium after intestinal obstruction (Figure 1). CIT group showed the highest levels of sIgA in intestinal fluid (2414.78 ± 828.24 mg/mL), when compared with Sham (921.50 ± 182.06) and IO groups (876.62 ± 136.49) (p<0.05). Conclusions: Citrulline protected the gut barrier by reducing intestinal injury and increas-ing local immune response, which may be responsible for intestinal

Nutrition (SD) and Hazard Ratio’s (95% CI) for different target groups.

No target reached (n=421)

Protein and energy target reached (n=216)

Energy target reached (n=234)

Energy intake (kcal/d) 1579 (403); 75% 1864 (352); 99% 1859 (347); 96% Protein intake (g/kg.d) 0.83 (0.23); 70% 1.35 (0.15); 112% 1.05 (0.13); 89% HR for all patients - 0.503 (0.319, 0.793) 0.821 (0.674, 1.000) HR for all patients minus sepsis patients - 0.351 (0.207, 0.595) 0.758 (0.604, 0.951)

n=886, n=15 patients only protein target reached

4 Journal of Parenteral and Enteral Nutrition / Vol. 35, No. 1, January 2011

documented. Patients who were expected to stay less than 24 hours, had elective surgery or overdoses were excluded. For mortality and length of ICU stay variable a Cox Proportional Hazard model with adjustment for age, BMI and APACHE II score was used. For infection status and secondary variables logistic regression and ANOVA models were used. Results: Vitamin D deficiency (<30 nmol/L) was observed in 50 patients (26%), insufficiency (>30 and <60 nmol/L) in 109 (56%) and sufficiency (>60 nmol/L) in 36 patients (18%). Mean vitamin D levels decreased from 47.0 (+/- 1.7) nmol/L on admission day to 44.4 (+/- 2.0) nmol/L on 3 days post admission. Vitamin D status was not associated with 28-day Conclusions: In conclusion, this is largest prospective cohort trial to date showing vitamin D insufficiency is a common condition in the ICU (82% of patients), and the first data showing a significant cor-relation of Vitamin D deficiency with longer length of ICU stay, increased risk of pneumonia, and elevated organ failure scores. This may be due the vital role of vitamin D in regulating immune surveillance and function.


S31-2 - Plasma Motilin Concentrations Fall with Erythromycin but Not Metoclopramide Treatment in Feed Intolerant Critically Ill PatientsRobert Fraser, MBBS FRACP PhD1,2; Laura K. Besanko, BHSc1; Nam Q. Nguyen, MBBS(Hons) FRACP PhD3; Carly M. Burgstad, BHSc(Hons)3; Marianne Chapman, BMBS FANZCA FJFICM4; Spencer Clarke, BSc(Hons)5; Richard H. Holloway, BSc(Hons) MBBS FRACP MD3,2; Arduino Mangoni, MBBS FRACP PhD6

1Investigation and Procedure Unit, Repatriation General Hospital, Adelaide, SA, Australia; 2Discipline of Medicine, University of Adelaide, Adelaide, SA, Australia; 3Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, SA, Australia; 4Intensive Care Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia; 5Pharmacology, University of South Australia, Adelaide, SA, Australia; 6Pharmacology, Flinders Medical Centre, Adelaide, SA, Australia.

Introduction: Prokinetic therapy with either metoclopramide (MCP) or low dose erythromycin (EM) reduces the gastric residual volume in feed-intolerant critically ill patients, but both become less effective during ongoing administration. The motor effects of EM are dose dependent and higher plasma EM concentrations are associated with less successful prokinetic treatment, possibly reflecting down regula-tion of motilin receptors. There are, however, no data on the effects of prokinetic therapy on plasma motilin concentrations in these patients. The aim of this study was to determine the effects of MCP and EM on plasma motilin concentrations in feed intolerant critically ill patients. Methods: Plasma motilin concentrations were measured in 55 mechanically ventilated, critically ill patients (37M, 50±2 yrs; APACHE II: 22.9±0.7) who were feed-intolerant (gastric residual volume (GRV) >250ml). Success of enteral feeding (6hrly GRV ≤250ml; feeding rate ≥40ml/h) was determined in patients receiving either IV MCP 10mg QID (n=27) or EM 200mg BD (n=18) over 7 days. Plasma motilin concentrations, measured by radioimmunoassay, were deter-mined at 1 and 7 hr after the first prokinetic dose. Data mean ± SEM; comparison t-test. Results: At 7hr post injection, plasma motilin con-centrations had increased with MCP administration on Day 1 (1 vs. 7 hr post-dose: 89±15 vs. 111±19 pg/ml; P=0.02), but not erythromycin (64±8 vs. 65±6 pg/ml). Plasma motilin concentrations 7h post-dose were higher in patients treated with MCP when compared to EM (P=0.02). Interestingly, plasma motilin concentrations were higher in patients at 1hr who failed to respond to either drug within 24h,

compared to successfully treated patients (116±28 vs. 69±9 pg/ml, P=0.05). A similar trend was seen at 7hr (120±30 vs. 76±10 pg/ml, P=0.09). There was a negative correlation between plasma motilin concentration 7hr post-treatment and time to loss of prokinetic effect (P=0.04, r= -0.28). Conclusions: Treatment with erythromycin, but not metoclopramide, in feed-intolerant critically ill patients is associ-ated with a fall in plasma motilin concentrations. The elevation in motilin concentrations with metoclopramide could contribute to the rapid tachyphylaxis seen with this agent.


S31-3 - Volume-Based Feeding in the Critically Ill PatientStephen McClave, MD1; Mohamed Saad, MD1; Alice Jotautas, RD1; Glen Franklin, MD1; Daren K. Heyland, MD2; Mary Anderson, RD1

1University of Louisville, Louisville, KY; 2Queens University, Kingston, ON, Canada.

Introduction: Critically ill patients placed on enteral nutrition (EN) are usually underfed. Increased caloric deficit correlates with worse patient outcome. A volume-based feeding (VBF) protocol designed to adjust the infusion rate to make up for interruptions in delivery should provide a greater volume of EN than the more common fixed hourly rate-based feeding (RBF) method. Methods: This single center, pro-spective study randomized critically ill patients on mechanical ventila-tion expected to receive EN for>3 days into a VBF versus a RBF protocol. Block randomization was performed with concealed opaque envelopes, initially by a 1:1 and later by a 3:1 ratio of study to control patients. Goal rate or volume was determined by weight-based equa-tions or indirect calorimetry. Once patients were at goal rate, their randomized feeding strategy was implemented. For VBF study patients, physicians used a total goal volume of feeds per day to determine an hourly rate, with interruptions necessitating recalculation at a higher rate by nurses to make up for lost time. For RBF controls, physicians determined a constant hourly rate of infusion to meet goal, with inter-ruptions necessitating nurses restarting at same rate. Primary outcomes included %goal calories infused and cumulative caloric deficit. Analysis was done by one-tailed Student’s T test. Results: 63 patients were enrolled in the study, 41 into the study group randomized to the VFB protocol, 22 to the control group randomized to the standard hourly RBF protocol. Six patients were excluded after randomization, four from the study group and two from controls, because of early extuba-tion within the first 24 hours or because the family requested withdrawal of care. Overall, study patients in the VBF group (n=37) received 92.9% of their caloric goal requirements for the study period and had a mean caloric deficit of -776.0 kcal, compared to control patients in the RBF group (n=20) who received 80.9% of goal calories (p=0.01) and sus-tained a mean caloric deficit of -1933.8 kcal (p=0.01). Uninterrupted sufficient (>95% goal calories) EN was delivered for 51.7% (88/170) of all EN days in study patients and 54.5% (60/110) of all EN days for controls. On those days when feeding was interrupted, study patients overall received a mean 77.6% goal calories (n=82 days) while control patients received 61.5% of goal calories (n=50 days), p=0.001. Nursing compliance with the VBF protocol was low at 33.2%. If nurses were compliant with the VBP strategy when EN was interrupted, then study patients received 96.2% of goal calories (n=26 days), versus receipt of only 69.0% of goal calories (n=56 days) when they were noncompliant. There were no instances of feeding intolerance due to use of the pro-tocol. Conclusions: A volume-based feeding strategy for provision of EN is feasible and safe, and improves delivery to better meet caloric requirements than the standard more commonly used rate-based strategy in critically ill patients.


IBW (AS-IBW), Harris-Benedict using adjusted body weight and a 1.5 stress factor (HB), and the Ireton-Jones for obesity (IJ). The latter two equations were multiplied by 0.65 to bring them in line with guidelines recommending underfeeding at 60-70% of needs. The correlation of PREE to MREE, predic-tive accuracy (percent of patients whose PREE was within 55-75% MREE), and the statistical precision and bias relative to 65% MREE were determined. Analyses were done for the whole cohort (n=31), those with simple obesity (n=20, BMI 30-50 kg/m2), and super obesity (n=11, BMI > 50 kg/m2). Results: Although the predictive equations had statistically significant correlations with MREE, they performed poorly in predicting 65% MREE when analyzing the whole cohort. These equations had unacceptable predictive accuracy, and were statistically imprecise and biased. The one exception was the AS-IBW formula which was unbiased. However, in subgroup analyses, the AS-ABW equation had acceptable predictive accuracy, and was statistically unbiased and nearly precise when used for predicting 65% MREE for the simple obesity group. The other three equations performed less well. For those with super obesity, the AS-IBW formula performed well with acceptable predictive accuracy, and was statistically both precise and unbiased. The other three equations performed poorly. Conclusions: The A.S.P.E.N./SCCM equations achieve the goal of predicting 65% MREE, but not for all degrees of obesity. Assuming feeding at 65% MREE is appropriate, patients with a BMI of 30-50 should receive 11-14 kcal/kg/day using ABW. Those with a BMI >50 should receive 22-25 kcal/kg/day using IBW. These formulas generally perform better than other popular predictive equations. Nutrition management may vary greatly across the range of obesity. Hence, future nutritional studies and guidelines should consider this important factor. Finally, indirect calorimetry remains the “gold standard” for determining energy needs of the obese as even the best predictive equations can be unreliable. Future studies are needed to clarify if underfeeding this patient population truly improves outcome.


S31-4 - Validation of the American Society for Parenteral and Enteral Nutrition Recommendations for Caloric Provision to Critically-Ill Obese Patients with Indirect Calorimetry.Kris M. Mogensen, MS,RD,LDN,CNSD1; Jasmine C. Corona, BA student2; Malcolm K. Robinson, MD2,3

1Department of Nutrition, Brigham and Women’s Hospital, Boston, MA; 2Department of Surgery, Brigham and Women’s Hospital, Boston, MA; 3Department of Surgery, Harvard Medical School, Boston, MA.

Introduction: In recently-published joint guidelines, A.S.P.E.N. and the Society of Critical Care Medicine (SCCM) recommend that obese, critically-ill patients receive 11-14 kcal/kg/day based on actual body weight (ABW) or 22-25 kcal/kg/day based on ideal body weight (IBW). Although underfeeding the obese at 60-70% of maintenance needs may improve outcome, it is unknown if these predictive formulas achieve this calorie target when validated against indirect calorimetry, perform equally well for all degrees of obesity, or if they compare well to other predictive equations. Our objectives: 1) determine if the A.S.P.E.N./SCCM formulas reliably predict 65% of measured resting energy expenditure (MREE); 2) determine if the formulas perform equally well at the low and high ends of the obesity range; and 3) compare the formulas to other predictive equations. Methods: MREE was measured with a metabolic cart in obese (BMI ≥ 30 kg/m2), critically-ill patients. REE was predicted (PREE) using several equations: 12.5 kcal/kg ABW (AS-ABW), 23.5 kcal/kg

Study Results

Protocol Group

Control Group

Demographics Mean Age 54.08 47.52 P=NSSex 62.16%

Male 52.38% Male

P=NS

Mean BMI 29.31 31.15 P=NSMean SAPS 19.46 21.67 P=NS

All Patients (n=37)

All Patients (n=20)

Mean % Goal Calories infused over entire period all patients

92.9% 80.9% P=0.01

Mean Cumulative Caloric Balance over entire period all pts

-776.0 Kcal -1933.8 Kcal P=0.01

Mean Daily % Goal Calories for each EN Day

All EN Days

(n=170)

All EN Days (n=110)

Uninterrupted EN Days

103.5% (n=88)

102.1% (n=60)

P=0.17

Interrupted EN Days 77.6% (n=82)

61.5% (n=50)

P=0.001

EN Days Protocol Used

96.2% (n=26)

[Same EN days if protocol had not been used]

[71.0%]

EN Days Protocol Not Used

69.0% (n=56)

Correlation, Accuracy, Precision, and Bias for PREE compared to MREE

Obesity Class

Prediction Equation

Correlation with MREE

Predictive Accuracy

Precision(%, 95%C.I.)

Bias (kcals,

95%C.I.)

All (BMI > 30)

AS-ABW 0.46* 45% 15-34 48 to 385

AS-IBW 0.70* 58% 10-16 -87 to 82***

HB 0.77* 61% 11-16 1 to 151 IJ 0.67* 55% 15-26 115 to

333 Simple

Obese (BMI 30-50)

AS-ABW 0.49* 70%** 8-17 -170 to 66***

AS-IBW 0.72* 50% 11-18 -45 to 166***

HB 0.74* 55% 8-18 -47 to 141***

IJ 0.69* 70%** 10-19 -14 to 201***

Super Obese (BMI >50)

AS-ABW 0.46 0% 28-67 480 to 929

AS-IBW 0.75* 73%** 6-15^ -236 to 4***

HB 0.74* 73%** 10-19 3 to 254 IJ 0.63* 27% 20-43 295 to

625

*p<0.05; **>70% is acceptable; ^ range <15% is precise; ***overlapping zero is unbiased


S31-5 - Cytokine and Nutritional Parameters Post Traumatic InjuryLorraine S. Young, RD MS CNSD1; Sherman Bigornia, MS1; Stacey Bell, RD DSc4; Daniel Remick, MD3; Bruce Bistrian, MD, PhD4; Peter Burke, MD2

1Endocrinology Diabetes and Nutrition, Boston Medical Center, Boston, MA; 2Surgery, Boston Medical Center, Boston, MA; 3Pathology, Boston Medical Center, Boston, MA; 4Medicine, Beth Israel Deaconess Hospital, Boston, MA.

Introduction: The neuroendocrine response to traumatic injury has been recently explored through investigations into the role of inflam-mation and cytokine elaboration post trauma and consequent effects on outcome. This has been facilitated by the development of highly sensitive multiplex technologies to detect a large number of cytokines in a small volume sample. Inflammation greatly impacts nutritional status and is mediated to a large extent by oxidative metabolites, for which nutritional co-factors are essential. The interactions of trau-matic injury on nutritional parameters, antioxidant micronutrients, and their relationship to inflammatory mediators however, is largely unstudied. Methods: As part of a randomized blinded trial evaluating the role of an oral antioxidant supplement on inflammatory and nutritional parameters post trauma we obtained baseline plasma samples on 18 trauma patients within 48 hours of their injury after obtaining informed consent. Additional clinical information including outcome are listed in Table 1. A multiplex of 17 pro-inflammatory and inhibitory cytokines were measured as well as albumin, and prealbumin (PAB) to assess nutritional/ inflammatory status and selenium, vitamin C, and vitamin E α and β as oxidative co-factors. The patients were followed until discharge or day 28 whichever came

first. Results: Fifteen or 83% of the patients were male, with an average age of 39.5 (range19-69). Their average BMI was 28.6, and thirteen (72%) sustained blunt trauma. There were no deaths. Table 1 depicts the average baseline data for the 18 patients As expected, cytokine elaboration post trauma was significantly enhanced. However mean IL-6 and IFNg were substantially more elevated than other cytokines at about 40 times above the upper limit of normal. Anti-oxidant co-factor levels were either low (selenium) or low normal at baseline. Spearman’s correlations were determined between the cytokine and antioxidant levels and with measures of injury, illness and outcomes. As expected inflammatory cytokines such as IL 6 and IL8 had significant correlations with lactate and SOFA scores but also of note, negative correlations with selenium and vitamin E beta. IL1b also showed negative correlations with albumin and vitamin E beta as well as expected associations with longer LOS and vent days. Selenium showed a significant negative correlation with SOFA scores and vitamin E alpha with SIRS. Serum lactate had the most signifi-cant correlations at the p<.01 level, with IL6, IL8, IL12p70, TNFA, and TNFR2, while VIT E β had the next most, with IL8, TNFR1, TNFR2, and Alb. Only IL1β and Alb were significantly associated at this level with outcome, Hospital LOS and Vent Days respectively. Conclusions: We have shown there are substantial relationships between antioxidant micronutrients levels and a variety of inflam-matory mediators as well as injury/illness score post trauma. Whether administration of antioxidants post trauma could modify the inflam-matory response remains to be determined. Through the use of multiplex cytokine analysis, both pro and inhibitory cytokines can be measured at multiple times and along with nutritional co-factors serve perhaps to help define what, if any, nutritional perturbations, and their timing, might favorably influence the outcome following post traumatic injury.

pg/ml Normal range Normal range

IL1ra* 9171±18620 40-250 Adm Alb 3.6±.6 g/dl 3.5-4.8 IL1R2* 8221±5447 2100-6000 CRP 14±10 mg/dl <1 IL4 2885±3223 179-413 PAB 15±5 mg/dl 18-38 IL6 2840±6584 14-75 Vit C 0.29±0.2 mg/dl 0.2-1.9 IL6R* 7723±4381 509-2200 Vit E α 5.9±1.6 mg/dl 5.7-19.9 IL8 228±261 4-91 Vit E β 1.2± .69 mg/l ≤ 4.3 IL10* 378±339 72-183 Selenium 79±16 mcg/l 110-160 IL12p70 194±309 2-70 WBC 10.9±3.9 K/Ul 4-11 GROa1 566±691 6-70 Lactate 2.2±1.1 MMol/L 0.5-2.0 IFNg1 6814±9587 28-150 APACHE II 12.7±4.6 MCP1 337±465 2-60 SIRS 0.4±0.4 MIP1a 130±84 54-220 SOFA 5.3±1.9 MIP1b 1439±695 68-225 ISS 23.9±17.9 TNFR1* 8274±5051 578-2920 Hospital LOS Days 21±9.5 TNFR2* 105816±64433 1712-5529 ICU LOS Days 14.7±10.1 TNFA 164±251 8-33 Vent Days 10±10.3 ILb 36±36 1-16

*inhibitory cytokines

S31-6 - Prospective, Randomized Double Blind Placebo Controlled Trial to Test High Dose Vitamin A Treatment in Patients with Sepsis

Kristoffer Osea, High School Student who is now at University of Irvine as a college student.; John A. Tayek, M.D., Professor of Medicine In- Residence, David Geffen School of MedicineHarbor-UCLA Medical Center, Torrance, CA.

Introduction: The purpose of the study was to test if Vitamin A treatment to patients with sepsis reduces the Length of Time in ICU, Days on Ventilator, Days on Pressors and 28-Day Mortality. In septic patients, more than the recommend daily requirements of 5000 IU of Vitamin A (retinol) can be lost in the urine per day. Many patients with sepsis have vitamin A deficiency. In a recent study approximately 65% of patients with sepsis have vitamin A deficiency (Hosp Nutr 2009). In addition, it has been suggested


that Vitamin A treatment may improve infection outcomes in pre-mature neonates (Cochrane Rev 2008). Methods: The trial was prospective, randomized and double-blind. As part of a larger sepsis trial, 63 patients with sepsis were randomized to receive either 50,000 IU of Vitamin A or placebo intramuscularly daily for 7-days. Data analysis was by ANOVA with two tailed test and p <0.05 as significant. Results: The mean age of the patients was 51+2 (mean+ SEM) and 54% were female. All patients had an ACTH stimulation test using 250 mcg of ACTH IV and serum cortisol was measured at time 0, 30 and 60 minutes. Baseline cortisol of 24.6+1 mg/dl increased to 41+2 mg/dl at 30 minutes and 49+2 at 60 minutes. There was no significant difference between the groups. All cortisol responses were greater than 12.9 mg/dl. Serum Vitamin A concen-tration was below normal in 54% of the patients tested (n=35). Table 1 describes the two groups with regard to baseline APACHE III score, baseline WBC and percent of patients with bacteremia. The average number of days in the ICU prior to entry into the study

Scientific Paper Session: Pediatric/ Neonatal. January 30, 2011.

Encore abstract: Presented at the American Association for the Study of Liver Diseases, November 2010. Reprint withheld at request of the author.

S32-1 - How does a high saturated fat/low polyunsaturated meal influence postprandial lipid metabolism in children and adolescents with nonalcoholic fatty liver disease?Diana Mager, PhD RD1,2; Carla Rodriguez-Dimitrescu, BaSc1; Jason Yap, MD FRACP1,3; Vera Mazurak, PhD1; Mary Jetha, MD FRCPC2; Geoff Ball, PhD RD1,2

1Agricultural, Food & Nutritional Science, University of Alberta, Edmonton, AB, Canada; 2Pediatrics, University of Alberta, Edmonton, AB, Canada; 3Pediatric Gastroenterology and Nutrition, Stollery Children’s Hospital, Edmonton, AB, Canada.


S32-2 - Assessing Tolerance of Increased Amino Acid Administration in Extremely Low Birth Weight Infants on the First Day of LifeChristin Moggio, MA, RD, CNSD; Mary Fogleman, MS, RD; Aloka L. Patel, MD; Gretchen Witowich, MS, RD, CNSCRush University Medical Center, Chicago, IL.

Introduction: Maximizing parenteral amino acid (AA) intake on the first day of life to more closely match fetal AA concentrations in utero has been associated with enhanced protein deposition and improved growth in premature infants. However, practitioners are often hesitant to provide higher levels of AA in those first

Groups (n) WBC (1,000) Bacteremia Days in ICU Days on Pressors Days on Ventilator 28-Day Mortality

Placebo 31 19.3+2.8 17% 7.6+1.1 1.5+1.0 4.5+1.0 34+9Vitamin A 32 14.7+1.5 20% 5.6+1.0 1.7+0/8 5.0+1.0 42+9

(mean+sem)

was similar for both groups (5.8+2.8 vs 4.0+1.1 days; placebo vs Vitamin A, respectively). Days on the ventilator prior to entry into the study were also similar (3.8+1.9 vs 3.2+1.0; placebo vs Vitamin A, respectively). Vitamin A was given to 32 patients and placebo was given to 31 patients. High dose Vitamin A treatment for 7-days slightly, but not significantly reduced the length of stay in the ICU (p = 0.13; See Table 1 below). The average number of days on pres-sors, the number of days on the ventilator and the 28-day mortality rate were not significantly different between the treatment and placebo groups. Conclusions: Vitamin A treatment for 7-days in septic adult patients failed to significantly reduce the number of days in the ICU, days on the ventilator, days on pressor agents or 28-day mortality. High dose Vitmain A treatment appeared to have no clinical benefit in adult patients with sepsis. A much larger sample size would need to be studied to test if vitamin A treatment in sepsis reduces length of stay in the ICU by two days. A reduced length of stay would have profound cost savings with such an inexpensive treatment.

days of life due to the risk of metabolic complications such as azotemia and acidosis. This study hypothesized that extremely low birth weight (ELBW) infants, defined as infants weighing <1000 grams at birth, would tolerate a parenteral AA intake of 3.0 gm/kg on the first day of life without an increase in metabolic complications. Methods: A retrospective review was performed of medical records from 67 ELBW infants who were born during 2008-2010. The infants born between October 2008 and June 2009 received a lower early AA (LEAA) parenteral nutrition solution containing 2.0 gm/kg AA (n=33), and the infants born between July 2009 and January 2010 received a higher early AA (HEAA) parenteral nutrition solution containing 3.0 gm/kg AA (n=34). Blood urea nitrogen (BUN), serum bicarbonate, base deficit, pH, glucose levels, and sodium bicarbonate and insulin administration were evaluated in the first 72 hours of life. Sta-tistical analysis was performed using Chi-square and t-tests. The study was approved by the Rush Institutional Review Board. Results: Infants were similar in gestational age (25.4±1.9 vs. 25.9±1.3 weeks, p=0.25) and birth weight (711.6±126.9 vs. 766.4±135.7 grams, p=0.09) in the LEAA and HEAA groups, respectively. Highest BUN (34.1±12.4 vs. 39.4±13.3 mg/dl), p=0.09), lowest serum bicarbonate (14.2±2.3 vs. 15.2±2.7 mEq/L, p=0.13), highest base deficit (-10.0±2.9 vs. -9.1±3.6, p=0.25), lowest pH (7.16±0.11 vs. 7.20±0.12, p=0.09), and sodium bicar-bonate administration (4.1±2.6 vs. 3.1±2.2 mEq/kg, p=0.10) were not found to be significantly different between the LEAA and HEAA group in the first 72 hours of life. Infants in the LEAA group received significantly less protein than the HEAA group on the first day of life (2.2±0.34 vs. 2.9±0.37 gm/kg, p=<0.001) and in the first 72 hours of life (8.7±1.3 vs. 9.8±1.3 gm/kg, p=0.001) as well as significantly fewer calories in the first 72 hours of life (43.2±7.7 vs. 47.1±6.9 kcals/kg, p=0.03). Highest blood glucose (242.8±101 vs. 183.1±56.8 mg/dl, p=0.004) and insulin administration in the first 72 hours of life (36% vs. 15%, p=0.04) were significantly greater in the LEAA group than in the HEAA group. Conclusions: ELBW infants in


the HEAA group tolerated 3.0 gm/kg AA as well as infants in the LEAA group receiving 2.0 gm/kg AA without an increase in metabolic complications. In addition, infants in the HEAA group

S32-3 - Micro Preemies Experience Prolonged Ventilator Days When Receiving Higher Infusions of IVFE During the First 48 Hours of LifeDouglas Drenckpohl, MS, RD, CNSC, LDN1; Huaping Wang, Ph.D2; Kamlesh S. Macwan, MD3,1

1Neonatal, Children’s Hospital of Illinois, Peoria, IL; 2Internal Medicine, University of Illinois College of Medicine at Peoria, Peoria, IL; 3Department of Pediatrics, University of Illinois College of Medicine at Peoria, Peoria, IL.

Introduction: Micro premature infants with a birthweight (BW) <750 grams (gms) are at greater risk for developing chronic long disease (CLD). Premature infants who develop CLD have a higher energy expenditure and therefore, are at risk for growth failure. To maintain their nutritional status and improve their length of stay (LOS) premature infants with CLD, often require increased calories. Objective/Hypothesis The hypothesis is that there is a relationship between ventilator days and LOS determined by the amount fluid and caloric intake and of intravenous fat emulsions (IVFE) given. To compare how these nutrients affected ventilator days, LOS, and incidence of CLD between the control group and the experimental group. Methods: This was a randomized, non-blinded, controlled trial of Appropriate for Gestational Age (AGA) premature infants <750 gms at birth. The control group started at 0.5 gm/kg/d of 20% IVFE and the experimental group was started at 2 gms/kg/d of 20% lVFE. The IVFE present in the parenteral nutrition was advanced by 0.5 grams daily, until both groups achieved 3 gms/kg/d of IVFE. Normality was checked with the continuous variables. Spearmen rho was used to check the correlation between variables. T-test and chi square were used to compare the group dif-ference. P value <0.05 was considered significant. Results: Nineteen infants were eligible for analysis. Four infants expired during the first week of life and were excluded from analysis. The Spearman rho analysis showed premature infants with a higher infusion rate of IVFE on Days of Life (DOL) 1 & 2 had increased days on ventilators (p=0.031; p=0.011), while those infants who had a higher infusion of IVFE on DOL 7, had fewer ventilator days (p=0.04). Also, the Spearman rho analysis showed premature infants receiving a higher total calorie intake on DOL 6 & 7 had a decreasednumber of ventilator days (p=0.039;p=0.016). Premature infants who received increased total calorie intake by DOL 6 & 7 had a decreased LOS (p=0.05; p=0.016). When infants were divided into the different study groups (Table 1), the experimental group had a longer duration of ventilator days 56.5 + 5.09 days vs. 38 + 18.12 days in the control group (p=0.031). The experimental group average LOS was

Low (n = 33) High (n = 34) p-value

Gestational age (weeks) 25.4 ±1.9 25.9±1.3 t-test p=0.25 Birth weight (grams) 711.6±126.9 766.4±135.7 t-test p=0.09 Small for gestational age 8 (24%) 8 (24%) Chi-square p=0.95 Indomethacin administration in the first 72 hours of life 7 (21%) 7 (21%) Chi-square p=0.95 Amino acid intake on the first day of life (gm/kg) 2.2±0.34 2.9±0.37 t-test p<0.001 Amino acid intake in the first 72 hours of life (gm/kg) 8.7±1.3 9.8±1.3 t-test p=0.001 Calorie intake in the first 72 hours of life (kcals/kg) 43.2±7.7 47.1±6.9 t-test p=0.03 Highest BUN in the first 72 hours of life (mg/dl) 34.1±12.4 39.4±13.3 t-test p=0.09 Lowest serum bicarbonate in the first 72 hours of life (mEq/L) 14.2±2.3 15.2±2.7 t-test p=0.13 Highest base deficit in the first 72 hours of life -10.0±2.9 -9.1±3.6 t-test p=0.25 Lowest pH in the first 72 hours of life 7.16±0.11 7.20±0.12 t-test p=0.09 Bicarbonate administration in the first 72 hours of life (mEq/kg) 4.1±2.6 3.1±2.2 t-test p=0.10 Highest blood glucose in the first 72 hours of life (mg/dl) 242.8±101 183.1±56.8 t-test p=0.004 Insulin administration in the first 72 hours of life 12 (36%) 5 (15%) Chi-square p=0.04

received significantly higher calories, experienced less hypergly-cemia and, as a result, received less insulin in the first 72 hours of life.

109.17+18.34days, while the control average LOS was only 98.33 + 15.29 days, which was not significant (p=0.236). There was no significant differences in CLD between the control group and the experimental group, 55.6% vs. 100% (p=0.103). Conclusions: Micro preemies may not benefit from early higher infusion rates of 2 gm/kg/day of IVFE. Premature infants with BW <750 gms may benefit from starting IVFE at 0.5 gms/kg/day on DOL 1 & 2.

Outcomes for Ventilators Days and Length of Stay

Control n=9(%) Experimental n=6(%)

Ventilator Days 38±18.12 56.5±5.09 0.031*LOS 98.33±15.29 109.17±18.34 0.236CLD 0.103

Yes 5(55.6) 6(100)

No 4(44.4) 0(0)

*Acheived statistical significance of p<0.05

S32-4 - Higher Infusion Rates of Intravenous Fat Emulsions During the First Week of Life for Micro Preemies Causes Increased Incidence of HypertriglyceridemiaDouglas Drenckpohl, MS, RD1; Huaping Wang, Ph.D3; Kamlesh S. Macwan, MD2

1Neonatal, Children’s Hospital of Illinois, Peoria, IL; 2Department of Pediatrics, Univeristy of Illinois College of Medicine at Peoria, Peoria, IL; 3Internal Medicine, Univeristy of Illinois College of Medicine at Peoria, Peoria, IL.

Introduction: Premature infants with a birthweight (BW) <750 grams (gms) are at great risk for growth failure, upon discharge from the Neonatal Intensive Care Unit (NICU). Research has shown higher infusion rates of intravenous fat emulsions (IVFE), 2 grams/kilogram/day (gms/kg/day) on the first day of life, has reduced growth failure and improved clinical outcomes such as lower incidence of necrotizing enterocolitis (NEC) and retinopathy of prematurity (ROP), for premature infants with BW between 750-1500 gms. Objective/Hypothesis Our hypothesis was premature infants with a BW <750 grams would tolerate higher infusion rates of IVFE within the first week of life, as evidenced by maintaining


a serum triglyceride level of ≤200 milligrams/deciliter (mg/dl). Methods: This was a randomized, non-blinded, controlled trial of Appropriate for Gestational Age (AGA) premature infants <750 gms at birth. The control group started at 0.5 gm/kg/d of 20% IVFE and the experimental group was started at 2 gms/kg/d of 20% lVFE. The IVFE present in parenteral nutrition was advanced by 0.5 grams daily, until both groups achieved 3 gms/kg/d of IVFE. Fisher’s test, t-test, and repeated measures ANOVA were used for statistical analysis. Kolmogorov-Smirnov test was used to determine the normality of variables. All tests with a p value of <0.05 was considered statistically significant. Results: Twenty-one infants completed this study. Three infants were excluded from analysis due to not meeting study criteria. Significantly more infants in the experimental group experienced hypertriglyceridemia (201 gm/dl or greater) than infants in the control group, 100% vs. 50.0% (p=0.033). Repeated ANOVA (Table 1) showed the experimental group higher average serum triglyceride levels (p=0.007. The largest variation of mean triglyceride levels occurred on study day 5. On study day 1 the experimental group started with higher infusion rates of IVFE, but by study day 7 the control group had higher infusion rates of IVFE. Initial higher infusion rates of IVFE did not have an affect on clinical outcomes such as initia-tion of insulin, chronic lung disease, NEC, ROP, growth failure, and mortality. Conclusions: Micro Preemies with a BW <750 gms do not benefit from early higher infusion rates of IVFE during the first week of life. Micro premature infants with a BW <750 gm would benefit starting at 0.5 gm/kg/d of IVFE and advance as tolerated to 2 gm/kg/d of IVFE maximum during the first week of life.

Introduction: Subjective Global Nutritional Assessment (SGNA) is composed of a parental interview questionnaire, which includes information about the child’s growth history and recent feeding habits, and a nutrition-related physical examination to assess fat and muscle wasting, as well as edema. SGNA has been validated for the assessment of nutritional status in pre-operative pediatric patients; however, no validated tool exists for assessing the nutritional status of patients admitted to the pediatric intensive care unit (PICU). The objective of this study was to determine if SGNA could identify patients with malnutrition in the PICU. Methods: We prospectively evaluated the nutritional status of 156 consecutive children (aged 1 month to 5 years) admitted to a PICU (surgical, medical, and cardiac patients) using SGNA, and standard anthro-pometric measurements, including weight, length, triceps skinfold (TSF), and mid-upper arm circumference (MUAC). At admission to the PICU, 1 of 2 dietitians executed SGNA while 1 of 3 physi-cians obtained anthropometric measurements. To test inter-rater reproducibility, 76 children had SGNA performed by 2 dietitians. Mid-upper arm muscle area (MAMA), percent ideal body weight (%IBW), and appropriate z-scores for the anthropometric measure-ments were calculated. Parametric (t-test, ANOVA) and nonpara-metric (Kruskal-Wallis, Wilcoxon-Mann-Whitney) tests were used for comparison of anthropometric measurement z-scores across the SGNA groups. Spearman’s rank correlation was computed to inves-tigate the relationship between the measures and the SGNA ratings. Kappa statistics was computed to assess inter-rater reliability. Results: There were 59 females and 87 males enrolled in the study with a median age of 17 months (range, 1-60). 115 were judged normal (N), 24 were moderately malnourished (M), and 7 were severely malnourished (S) as per the SGNA. Comparisons across SGNA groups showed that MAMA, MUAC, TSF, length and weight z-scores-for-age, weight-for-length z-scores and %IBW were highly significantly different across the groups. The pairwise comparisons showed that the differences were significant across the M and N groups and N and S in all these cases. MUAC-for-age z-score, length-for-age z-score, and weight-for-age z-score were significantly different across M and S as well. Weight-for-length z-score was marginally different across M and S. The Spearman’s rank correla-tions suggested that MAMA, MUAC, TSF, length and weight z-scores-for-age, weight-for-length z-scores and %IBW were significantly correlated to the SGNA scores (Concurrent Reliability). Also, nega-tive correlations suggested that these measurements decreased with worsening SGNA ratings. Inter-rater agreement occurred in 66 (87%) of 76 children having duplicate SGNA assessments. The Kappa value of 0.671 indicates moderate reliability between the two raters. Conclusions: SGNA is able to differentiate between well-nourished and malnourished children aged 1 month to 5 years admitted to the PICU. SGNA can be used as a screen to identify malnutrition at admission to the PICU. SGNA ratings between dietitians are reproducible.

Serum Triglyceride Levels

Control n=10 Experimental n=9 P value

mean±sd mean±sd Day 1 81.80±46.28 137.67±79.97 0.076 Day 2 114.80±48.75 163.78±71.57 0.096 Day 3 147.90±72.28 145.89±47.62 0.944 Day 4 120±30.44 165±66.53 0.090 Day 5 123.89±20.42 252.44±146.84 0.031* Day 6 131.67±48.58 127.56±55.84 0.870 Day 7 142.89±57.51 121.29±51.33 0.422 Incidence of Hypertriglcyridemia

n(%) n(%)

≥201 mg/dl 5(50) 9(100) 0.033*

*Achieved statistical significance p<0.05

S32-5 - Subjective Global Nutritional Assessment in Critically Ill ChildrenSarah Vermilyea, RD, CSP, CD, CNSD1; Julie Slicker, RD, CSP, CD, CNSD1; Khalil El-Chammas, MD2; Mutaz Sultan, MD2; Mahua Dasgupta, MS2; Raymond G. Hoffmann, PhD2; Martin K. Wakeham, MD2; Praveen S. Goday, MD, CNSC2

1Children’s Hospital of Wisconsin, Milwaukee, WI; 2Medical College of Wisconsin, Milwaukee, WI.

Variables

Concurrent Reliability: Spearman Rank Correlation (p)

Comparison Among Groups. (Kruskal-Wallis)

Multiple comparisons

M vs. N N vs. S M vs. S

Weight-for-age z score2 -0.58(<0.0001) <0.0001 <0.001 <0.0001 0.007 Length-for-age z score2 -0.35(<0.0001) <0.0001 0.002 0.0008 0.04 Weight-for-length z score1 -0.57(<0.0001) <0.0001 <0.0001 0.0006 0.05 % ideal body weight1 -0.57(<0.0001) <0.0001 <0.0001 <0.0001 0.08 Triceps skinfold-for-age z score1 -0.42(<0.0001) <0.0001 <0.0001 <0.0001 0.25 Mid-upper arm circumference-for-age z score1 -0.34(0.002) 0.006 0.03 - 0.17 Mid-upper arm muscle area-for-age z-score1 -0.56(<0.0001) <0.0001 <0.0001 <0.0001 0.007

1 ANOVA for overall comparisons, t-test for pairwise comparisons 2 Kruskal-Wallis test for overall comparisons, Mann-Whitney Wilcoxon test for pairwise comparisons


S32-6 - Achieving Normal Growth in Patients with Hypoplastic Left Heart Syndrome and Variants through Intensive Interstage Nutrition InterventionJulie A. Slicker, RD CSP CD CNSD1; David A. Hehir, MD2,3; Nancy Rudd, RN, MS, CPNP2,3; Praveen S. Goday, MBBS, CNSC4; Kathy Mussatto, PhD, RN3; Pippa Simpson, PhD2; Nancy Ghanayem, MD2

1Clinical Nutrition, Childrens Hosptial of Wisconsin, Milwaukee, WI; 2Pediatrics, Medical College of Wisconsin, Milwaukee, WI; 3Herma Heart Center, Childrens Hosptial of Wisconsin, Milwaukee, WI; 4Pediatric Gastroenterology & Nutrition, Childrens Hosptial of Wisconsin, Milwaukee, WI.

Introduction: Malnutrition is common in patients with congenital heart disease. In chronic disease, and specifically in patients with hypoplasic left heart syndrome (HLHS), growth failure has been associated with poor outcomes. The causes are multifactorial: increased metabolic demands, insufficient oral intake, increased work of breathing, as well as additional acquired and genetic comorbidities. We previously reported improved interstage survival outcomes in patients with HLHS and variants who had intensive home monitoring of oxygen saturation and weight between stage 1 (S1P) and stage 2 palliation (S2P). In this study, we sought to determine the prevalence of malnutrition and to describe the growth patterns in a cohort of home monitored patients with HLHS who had enhanced nutritional monitoring supported by a dietitian. Methods: We performed a retrospective chart review of 78 patients with single ventricle physiology who underwent S1P from August 2004 to January 2010. All patients who survived S1P and were discharged were enrolled in a home monitoring program in which daily weights and pulse-oximetry were recorded. Families were provided daily weight gain goals; failure to gain at least 20 grams over 3 days prompted immediate nutritional evaluation and intervention. Malnutrition was defined as a weight-for-age z-score (WAZ) < -2.0 at each time point in the study (birth, hospital discharge after S1P, and admission for S2P). Patients with a history of prematurity (<35 wk gestational age), chromosomal abnormalities, or other major noncardiac anomalies were excluded from the analysis. Results: Weight-for-age z score at each time point is shown in figure 1. There is a statistical difference in WAZ from birth-S1P discharge and S1P discharge-S2P (p<0.01). Median change in WAZ between discharge after S1P and S2P was +0.4 (range, -1.1 to 2.6) and 57/78 (74%) patients had a positive change in WAZ. The percentage of patients who were malnourished was 2.6% at birth, 15.4% at discharge after S1P and 3.8% at S2P. Median weight gain between discharge after S1P and S2P was 26 grams per day (range, 2-46), with 78% gaining ≥ 20gm/day; 17% 10-20gm/day; and 5% <10gm/day. Median caloric intake at discharge after S1P was 120 kcal/kg/day (range, 80-182 kcal/kg/day) and fell at S2P to a median of 109 kcal/kg/day (range, 67-162kcal/kg/day). At discharge, 65% of patients were exclusively oral fed, 26% of patients received a combination of oral/enteral tube feedings, and 9% were fed completely via enteral tubes. At the time of S2P, 44% of patients required supplemental tube feeding. Most children required concentrated formulas (77/78 patients at discharge after S1P and 72/78 patients at the time of S2P) to reach weight gain goals. Conclu-sions: Normal infant growth patterns can be achieved in patients with single ventricle physiology between S1P and S2P with a comprehensive interstage management plan that incorporates home monitoring of weight, goal-directed nutritional support and regular evaluation and intervention by a dietitian.

Scientific Paper Session: Assessment, Body Composition, Enteral Nutrition. January 30, 2011


S33-1 - Analysis of the variation in body composition of patients with lung cancer using computed tomography image analysis: implications for treatment toxicity and time to deathRachel A. Murphy, B.Sc1; Vera C. Mazurak, Ph.D1; Tony Reiman, S.M, M.D.2; Sami Antoun, Ph.D3; Vickie E. Baracos, Ph.D4; Marina Mourtzakis, Ph.D5

1Department of Agricultural, Food and Nutritional Sciences, University of Alberta, Edmonton, AB, Canada; 2Department of Oncology, Dalhousie University, Saint John, NB, Canada; 3Department of Supportive Care, Institut Gustave Roussy, Villejuif, France; 4Department of Oncology, University of Alberta, Edmonton, AB, Canada; 5Department of Kinesiology, University of Waterloo, Waterloo, ON, Canada.

Introduction: Cachexia was recently redefined as loss of muscle inde-pendent of fat loss. In concordance with this new concept, we reported a low incidence of underweight lung cancer patients (<8% with body mass index (BMI) <18.5kg/m2) but muscle depletion was present in nearly 50% of patients. In this population muscle depletion is an occult condition obscured by fat. One consequence of muscle depletion is a low proportion of lean to fat tissue. There is some evidence to suggest that these patients have excess toxicity from chemotherapy even when dose is adjusted to body surface area (BSA). Our current research continues to investigate variation in body composition of patients with lung cancer to determine the relationship with treatment toxicity and survival. We also aimed to develop normative data on skeletal muscle. Methods: We adopted a population based approach to prospectively study body composition in an international cohort of patients (n=811; 455 men, 366 women), who were referred to a regional medical oncol-ogy service in Alberta, Canada and Villejuif, France. Computed tomog-raphy (CT) images acquired for diagnostic purposes were used to measure skeletal muscle and adipose tissue area (cm2) at the 3rd lumbar vertebrae (L3), which was subsequently normalized for stature to give units of cm2/m2 (L3 skeletal muscle and adipose tissue index). Total body fat-free mass (FFM) was estimated from muscle area. BMI and BSA were calculated from height and weight. Low L3 muscle index was defined using previously published sex-specific cut-offs for mortal-ity. Results: At referral the mean age was 64 and 90% had stage III or IV cancer. Mean BMI was 25.2kg/m2, 48.5% of patients were overweight or obese and only 6.1% were underweight. There was high heterogene-ity of L3 muscle index within all classes of BMI (Figure 1). Conversely, adipose tissue was strongly correlated to BMI (r=0.89; P<0.001). The overall prevalence of muscle depletion was 45.5%. If patients in this study were to receive FFM-based doses of Cisplatin rather than con-ventional BSA-based doses, the estimated dose of Cisplatin per kg of FFM would be highly variable (Table 2). Compared to the median dose (3.0mg/kg), patients in the first and fourth quartiles of FFM/BSA would be given a 20% higher and 20% lower dose of Cisplatin respectively. This is approaching the magnitude of a typical dose change following chemotherapy toxicity. Reference ranges for L3 muscle index are shown in Table 1. Multivariate Cox proportional hazards analysis showed that independent of age, sex and stage of disease, L3 muscle index was a predictor of shorter survival for patients in the 25th percentile (hazard ratio, 1.3; P=0.007) and longer survival for patients in the 75th per-centile (hazard ratio, 0.8; P=0.03). Conclusions: Body composition is highly variable with prominent skeletal muscle depletion despite normal or heavy body weights. The development of reference ranges for muscularity provides normative data against which patients can be compared. This may help clinicians identify patients who are at an increased risk of treatment toxicity and death.


S33-2 - Clogged Feeding Tube Management now that Viokase is UnavailableKurt R. Stahlfeld, Program Director, UPMC Mercy; Laura E. Hiltner, General Surgery Resident, UPMC Mercy; Kurt W. Stahlfeld, Clinical Researcher, UPMC MercySurgery, UPMC Mercy, Pittsburgh, PA.

Introduction: Clogging of enteral feeding tubes is a frequent and time consuming clinical problem. Scientific trials analyzing methods to unclog feeding tubes are outdated, use unrealistic in vitro models, and favor a medication that is no longer available. To our knowledge, there is limited analysis of the pressures required to unclog feeding tubes, no standard model that simulates clinical feeding tube occlusions, and no documentation of the effectiveness of a currently available enzyme used to unclog feeding tubes. Objectives: To use a reproducible and realistic model with calibrated pressure measurements to compare the

effectiveness of a commercially available pancrelipase with Viokase (Axcan Pharma, Montreal, CA) in unclogging feeding tubes. Hypothesis: The pancrelipase slow release capsule on formulary would be as effec-tive as Viokase in unclogging feeding tubes. Methods: We developed a reliable model to occlude an 8 French 43 inch Dobbhoff Nasogastric Feeding Tube (Tyco, Mansfield, MA). Flushing the tube with 10 cc of 1.2 cal/cc Osmolite (Abbott, Columbus, OH), injecting 20 meq of KCl suspended in 2 cc of sterile water followed by injection of another 2 cc of osmolite, and then letting the tube sit for 24 hours reliably occluded the tube to pressures of 8 atmospheres. Using this model, we randomized 46 occluded tubes to pancrelipase or Viokase, aspirated each tube with a 20 cc syringe, and instilled approximately 3 cc of the slow release pancrelipase or Viokase enzyme suspension. The suspension was created by combining 325 mg of bicarbonate and 5 cc of water with either Viokase (lipase 8000 USP U, protease 30,000 USP U, amylase 30,000 USP U) or pancrelipase (lipase 6,000 USP U, protease 19,000 USP U, amylase 30,000 USP U). After 20 minutes, we attempted to flush the tubes using sterile water and a balloon catheter inflation device. If flow was restored, the pressure necessary to clear the tube was recorded. If this attempt was unsuccessful, additional attempts were made at 60 and 240 minutes. Chi-square test and two-sample t-test were used to compare the groups, and statistical significance was considered when P < .05. Results: At twenty minutes, the pan-crelipase group opened more feeding tubes (20/25) than the Viokase (10/21) group (p < .01) and at a lower mean pressure (3.02 atm vs 3.85 atm p = .17). Four of the remaining tubes in the pancrelipase group opened by 240 minutes (average 6.25 atm) whereas only one of the eleven tubes in the Viokase group opened (4 atm). Conclusions: The in vitro model described above accurately simulates a clogged feeding tube. Slow release pancrelipase is appropriate to use and is more effective than Viokase at unclogging feeding tubes.

Encore abstract: Presented at the American Heart Association Scientific Sessions, November 2010. Published: Arcand J et al. Circulation. 2010; 122: A21551. Republished with permission of Wolters Kluwer Health.

S33-3 - Evaluation of Two Methods for Sodium Intake Assessment in Cardiac Patients With and Without Heart Failure: the Confounding Effect of Loop DiureticsJoAnne Arcand, MSc, RD2,1; John S. Floras, MD, DPhil1; Eduardo Azevedo, MD1; Susanna Mak, MD1; Gary Newton, MD1; Johane P. Allard, MD1

1Heart Failure Clinic, Mount Sinai Hospital, Toronto, ON, Canada; 2Department of Nutritional Sciences, University of Toronto, Toronto, ON, Canada.

Introduction: Twenty-four-hour urine collections are considered the optimal method for sodium intake assessment. Loop diuretics (LD), a common medical therapy for heart failure (HF) patients, may confound the ability of a 24-hour urine collection to measure sodium intake based on their potent natriuretic effects. Whether a diagnosis of HF or the use of LD therapy for HF compromises the validity of 24-hour urine collec-tions as a surrogate marker for sodium intake is unknown.The objective of this study is to determine the strength of association between 24-hour urine collections and food records for sodium intake assessment in non-HF cardiac patients, and in HF patients stratified by LD usage. Methods: Weighted food records and 24-hour urine collections were simultaneously completed for two consecutive days in a group of medically stable HF patients and non-HF control patients with cardiovascular disease. Cor-relation coefficients and the Bland-Altman method of agreement described the relationship between the techniques for the estimation of sodium intake. Results: Non-HF cardiac patients (n=96, 65±11 years) and HF patients not taking LD (n=47, 62±11 years) and HF patients taking LD

Table 1. Percentiles of lumbar skeletal muscle index (cm2/m2) in patients with lung cancer

using computed tomography image analysis

5 25 50 75 95

Men Women Men Women Men Women Men Women Men Women 37.6 31.3 45.1 37.3 50.9 41.8 56.7 46.6 67.0 55.6

Table 2. Effect of variation in fat-free mass (FFM) on chemotherapy dosage.

Q1 Q2 Q3 Q4

FFM/BSA (kg/m2) 20.9a 24.2b 26.6c 30.1d BSA (m2) 1.79a 1.77a 1.84b 1.88b Cisplatin/BSA (mg/m2) 75 75 75 75 Cisplatin/FFM (mg/kg) 3.6a 3.1b 2.8c 2.5d

Means with different subscripts vary, P<0.05 (one-way ANOVA with Bonferroni comparisons).

Figure 1. Variation in skeletal muscle within BMI classes.


(n=62, 60±12 years) were included. The HF groups were similar with regards to medical therapies and clinical characteristics. Correlation coefficients for sodium intake between food records and urine collections were r=0.624 (p<0.001) for non-HF cardiac patients, and r=0.678 (p<0.001) for HF patients not taking LD. However no significant asso-ciation (r=0.132, p=0.312) was observed for HF patients taking LDs. The 95% limits of agreement between the non-HF cardiac patients and the HF patients not taking LD were similar; but were approximately 50% wider for HF patients taking LD suggesting poor agreement in this patient group. Conclusions: For assessing sodium intake, food records agree well with 24-hour urine collections in non-HF patients with cardiovascular disease and in HF patients not receiving LD therapy. The poor associa-tion between food records and urine collections in the HF patients taking LD suggests that the natriuretic effect of diuretics impairs the utility of urine collections in estimating sodium intake; therefore food records may provide the better estimate of sodium intake these patients. These findings have important implications in the measurement and surveil-lance of sodium intake in both HF and non-HF cardiovascular populations.

S33-4 - Low phase angle (PhA), determined by bioelectrical impedance, is significantly associated with malnutrition and hospital length of stay in patients at hospital admissionUrsula G. Kyle, MS, RD/LD1,2; Claude Pichard, MD, PhD3

1Pediatrics, Baylor College of Medicine, Houston, TX; 2Intensive Care Medicine, Texas Children’s Hospital, Houston, TX; 3Clinical Nutrition, Geneva University Hospital, Geneva, Switzerland.

Introduction: The biological meaning of PhA, determined by bioelec-trical impedance analysis (BIA), is not completely understood, but has been interpreted as an indicator of membrane integrity and water distribution between the intra- and extracellular spaces. PhA is one of the direct measures by BIA instrument. Low PhA has been associated with increased morbidity and mortality. The purpose of this study was to determine if there is a significant association between PhA and nutritional status, determined by Subjective Global Assessment (SGA) and Nutritional Risk Screening (NRS-2002), and hospital length of stay (LOS) in adults patients at hospital admission compared to healthy controls. Methods: PhA was determined in patients (n = 995, M/F 525/470, age 52.4±21.7 yrs, BMI = 24.3±3.4 kg/m2). A healthy control subject was age-, sex- and height-matched for each subject from our data base (n = 995, M/F 525/470, age 52.4±21.9 yrs, BMI = 23.9±4.2 kg/m2, p = 0.02). Phase angle was determined by BIA (Nutriguard-M, 50 kHz, DataInput GmbH, Germany) by standard 4-electrode method. Low PhA was set at <5.6° and <5.0° in men (M) and women (W), which corresponds to the 10th percentile for healthy subjects >35 yrs. Results: PhA was significantly lower in patients (M 6.0±1.4°, W 5.0±1.3°) than controls (M 7.1±1.2°, W 6.0±1.2°, un-paired t-test p <0.001). More patients (39.5%) had low phase angle than controls (11.5%, Chi2 p <0.001). Patients were significantly more likely to have low PhA than healthy controls: Well-nourished by SGA (OR 1.8, 95th CI 1.3-2.5); moderately malnourished (OR 6.0, 95th CI 4.5-79); severely malnour-ished (OR 15.3, 95th CI 10.9-21.3) and by NRS-2002: no risk (OR 2.2, 95th CI 1.7-3.0), moderate risk (OR 7.0, 95th CI 5.1-9.5) and severe risk (OR 18.4, 95th CI 12.8-26.4). Furthermore, patients with low PhA were more likely to have LOS >20 days (OR 4.0, 95th CI 2.4-6.8) and LOS 5-20 days (OR 3.2, 95th CI 2.3-4.5) than patients hospitalized <5 days. Conclusions: Patients had significantly lower PhA than age-, sex- and height-matched healthy controls. There is a significant association between low PhA and malnutrition and low PhA and LOS. Thus PhA is a independent indicator of nutritional status and can be used as a prognostic tool to evaluate nutritional status in patients at hospital admission.

S33-5 - Segmental Bioelectrical Impedance Measurement of Limb Skeletal Muscle Mass is Predicted by Total Body Protein using In Vivo Neutron Activation AnalysisBoyd J. Strauss, MBBS, PhD, FRACP1,2; Che Sam Lo, MD, PhD1; Karen M. Parisienne, RN2; Daniel B. Stroud, PhD1,2; Gisela Wilcox, MBBS, BMedSc, FRACP, FRCPA1,2

1Dept of Medicine, Monash University, Clayton, VIC, Australia; 2Body Composition Laboratory, Clinical Nutrition and Metabolism Unit, Monash Medical Centre, Clayton, VIC, Australia.

Introduction: Protein malnutrition in hospital patients is common, often undetected and a significant determinant of mortality and morbidity. Segmental bioelectrical impedance (SegBIA) provides a rapid method for the assessment of limb water content. Manufacturer proprietary software often provides a derived measurement of limb skeletal muscle mass (SMM) from limb water, using regression analysis against appendicular lean tissue mass (ALTM) measured by dual energy xray absorptiometry (DXA). Skeletal muscle mass is the body composition (BC) component containing the most significant component of total body protein (TBP). Prompt gamma in vivo neutron activation analysis (IVNAA) for the measurement of total body nitrogen is accepted as the criterion method for the measure-ment of TBP, but is now available in only a few locations internationally. We assessed the relationship between SegBIA derived limb SMM and TBP in adult hospital patients. Methods: Our IVNAA facility exists in a BC laboratory located in a major university teaching hospital in Melbourne, Australia. The CV for total body nitrogen by IVNAA in the laboratory is 3.5%. Using a Tanita BC-418 SegBIA body composition analyser under standardized conditions, we have simultaneously assessed SegBIA limb SMM, DXA ALTM (GE Lunar Prodigy) and IVNAA TBP in 89 individual adult clinical patients (F 60 M 29, 25 - 75 interquartile (IQ) age range 25-51 years). The patients were a mixed clinical sample (BMI IQ range 18.2 - 27.0 kg/m2, % DXA body fat IQ range 18.6 - 39.4), with conditions including metabolic disorders, malabsorption, obesity and others. Results: Measured SegBIA limb SMM IQ range was 15.5 - 23.4 kg, DXA ALTM IQ range was 12.74 - 20.41 kg and IVNAA TBP IQ range was 6.63 - 9.75 kg. Bland-Altman analysis of the relationship between SMM measured by DXA and SegBIA showed bias = 1.02 kg with 95% limits of agreement of -2.46 to +4.51 kg. The Pearson correlation between SegBIA limb SMM and IVNAA TBP was highly significant (r2 = 73.8%, p < 0.0001). Conclusions: Limb SMM measured by SegBIA appears to be well predicted by TBP, and gives confidence to the use of SegBIA manufacturer propri-etary software derived from DXA regression. Under standardized condi-tions, SegBIA measurement of limb SMM provides a rapid and useful method in the assessment of protein malnutrition in hospital patients.

S33-6 - Body weight increases after post-discharge nutritional support in malnourished elderly patientsFloor Neelemaat, PhD student, RD1; Judith Bosmans, PhD3; Abel Thijs, MD2; Jaap Seidell, Professor3; Marian van Bokhorst - de van der Schueren, PhD, RD1

1Nutrition and Dietetics, Internal Medicine, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, Netherlands; 2Internal Medicine, VU University Medical Center, Amsterdam, Netherlands; 3Department of Health Sciences, EMGO Institute for Health and Care Research, VU University, Amsterdam, Netherlands.

Introduction: Little is known about the effects of long-term nutritional support in malnourished elderly patients after discharge from the hospital. We studied the effect of nutritional support on body weight and fat free mass in malnourished elderly patients, from admission to hospital until three months after discharge. Methods: This RCT included malnourished


elderly (≥ 60 years) defined by a BMI < 20 kg/m2 and/or ≥ 5% unintentional weight loss in the previous month and/or ≥ 10% unintentional weight loss in the previous six months. Usual nutritional care (control group) was compared with the post-discharge nutritional intervention (energy and protein enriched diet, 2/day a package of an oral nutritional supplement (ONS), 1/day a calcium-vitamin D supplement, and 6x counselling by a dietician). Primary endpoints were changes in body weight (kg) and fat free mass (kg), analyzed by Student T-tests. Results: We included 210 patients, 105 in each group (mean age 74.4 ± 9.5 years). Patient charac-teristics did not differ significantly between groups at baseline. 35 patients withdrew from the study, 25 patients died (no significant differences between groups). Adherence to ONS, calcium-vitamin D supplement and dietetic counselling was high: 80%, 96% and 96%, respectively. Changes in body weight and fat free mass between baseline and follow-up are presented in Table 1. Body weight at baseline was found to be an effect modifier and therefore results are presented for different body weight categories (based on tertiles). Overall, patients in the intervention group tended to gain more weight than controls. This reached significance for the highest body weight category. For fat free mass no statistically signifi-cant differences could be demonstrated by the nutritional intervention. Conclusions: This randomized controlled trial shows positive effects on body weight of a three months nutritional intervention (energy and protein enriched diet, oral nutritional supplements, calcium-vitamin D supple-ment, counselling by dietician) to malnourished elderly patients. These effects were significant for the highest body weight category.

(TPN) to moderately restore the lymphocytes numbers from GALT and immunoglobulin A (IgA) level in gut. However, it was unknown whether these restorations would lead to improved outcome in sepsis. We observed effects of butyric acid addition to TPN on survival after Pseudomonas aeruginosa (P. aeruginosa) gavage in mice. Methods: Male ICR mice were randomized to standard TPN (S-TPN, n = 15), butyric acid supplemented TPN (Bu-TPN, n = 20), or Control (n = 17) group. After jugular vein catheter insertion, the S-TPN and Bu-TPN groups were advanced from 4.8 ml/day TPN solution to a target rate of 9.6 ml/day by the third day of feeding (day 1, 0.2 ml/hr; day2, 0.3ml/ hr, days 3-5, 0.4 ml/hr). The Control group received normal saline infusion with free access to chow. The Bu-TPN solution contained 47 mmol/L of butyric acid and 47 mmol/L of acetic acid, while the S-TPN solution included 94 mmol/L of acetic acid. After five days of respective diet, live P. aeruginosa (1×1011) were delivered by gavage. Survival was observed up to 14 days after bacterial challenge. Results: The survival time of the S-TPN group was significantly shorter than that of the control group (p<0.01). However, Bu-TPN significantly improved survival time in comparison with S-TPN (p<0.02). There was no significant difference in survival time between the Control and Bu-TPN groups. The survival rates at 14 days were as follows. Control group; 88%, S-TPN group; 42% and Bu-TPN group; 84%. Conclusions: Bu-TPN improves survival in a gut-derived sepsis model. New TPN formula con-taining butyric acid can be an option to restore impairment of host defense against infection during lack of enteral nutrition.

Table 1. Changes in body weight and fat free mass in mean (±SD)

Characteristic Intervention

group Δ Control group Δ

Difference (95% CI)

Body weight in kg - Total (n=146) - Tertiair <53.6 kg - Tertiair 53.6-63.9 kg - Tertiair > 63.9 kg

2.5 (3.8) 2.2 (3.4) 2.7 (3.8) 2.5 (4.2)

1.0 (5.8) 3.0 (4.2) 0.9 (5.6) -0.9 (6.8)

1.5 (-0.2 ; 3.1) -0.8 (-3.2 ; 1.5) 1.8 (-0.9 ; 4.4) 3.4 (0.2 ; 6.6)

Fat free mass in kg Total (n=79)

3.3 (4.3) 2.8 (4.1) 0.5 (-1.5 ; 2.4)

Scientific Paper Session: Parenteral Nutrition. January 30, 2011


S34-1 - Butyric acid supplementation restores total parenteral nutrition-induced reduction of survival in a murine gut-derived sepsis modelSatoshi Murakoshi, MD1,4; Kazuhiko Fukatsu, MD, PhD2; Tomoyuki Moriya, MD, PhD3; Jiro Omata, MD3; Koichi Okamoto, MD3; Midori Noguchi, Bachelor1; Hiroshi Yasuhara, MD, PhD2; Daizoh Saitoh, MD, PhD1; Isamu Koyama, MD, PhD4

1Division of Traumatology, National Defense Medical College Reserch Institute, Tokorozawa, Japan; 2Surgical Center, Tokyo University, Bunkyouku, Japan; 3Departoment of Surgery, National Defense Medical College, Tokorozawa, Japan; 4Departoment of Surgery, Saitama Medical University International Medical Center, Hidaka, Japan.

Introduction: Lack of enteral nutrition causes gut associated lymphoid tissue (GALT) atrophy, leading to impaired gut immunity. Our recent study demonstrated butyric acid addition to total parenteral nutrition

Fig. Survival curves for the Control, S-TPN, and Bu-TPN groups after gavage delivery of live P. aeruginosa. *p<0.01 vs. S-TPN. †p<0.02 vs. S-TPN.

S34-2 - Intravenous Fat Emulsion Is Associated with Negative Outcomes in Critically Ill Surgical Patients: A Retrospective ReviewVanessa J. Kumpf, PharmD, BCNSP1; John Oleis, DPh, BCNSP3; Rondi M. Kauffmann, MD, MPH3; Bryan Collier, DO, CNSP, FACS2; James C. Slaughter, DrPH3; Pennie Bell, RN, CCRP3; Jose Diaz, MD, CNS, FACS, FCCM2; Addison May, MD, FACS, FCCM2; Douglas Seidner, MD, FACG, CNSP1

1Center for Human Nutrition, Vanderbilt University Medical Center, Nashville, TN; 2Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN; 3Vanderbilt University Medical Center, Nashville, TN.

Introduction: Soy-based intravenous fat emulsion (IVFE) has been associ-ated with increased risk of morbidity and mortality in trauma patients when


used within the first 10 days of ICU admission. Based on this study, the SCCM and A.S.P.E.N. clinical guidelines in critically ill adults recommend that soy-based IVFE be withheld during the first week of hospitalization in the ICU. The purpose of this study is to evaluate the impact of IVFE exposure on outcomes in surgical intensive care unit (SICU) patients. Methods: A comprehensive database of patient characteristics, events and outcomes is prospectively captured and maintained for all SICU patients. This database was combined with a pharmacy billing database following IRB approval. The study included all patients admitted between June 2006 and September 2009 who were ≥ 18 years of age with an initial SICU admission ≥ 72 hours. Patients were divided into two groups based on IVFE exposure. IVFE exposure (IVFE+) was defined as administration of parenteral nutrition fat emulsion (PNFE) or propofol fat emulsion (PFE) that was given at any time during hospitalization. Baseline data was reported as median and 25th-75th inter-quartile range. Outcome measures included infections, hospital and ICU length of stay (LOS), ventilator days, and mortality. Wilcoxon and Pearson tests were used for unadjusted results. Multivariable linear and logistic regression were used to control for age, gender, and APACHE II score. Results: There were 5190 patients in the SICU database; 2415 of these patients met inclusion criteria and 1241 patients (51%) were exposed to IVFE (IVFE+ group). In the IVFE+ group, 812 (61%) were only exposed to PNFE, 164 (12%) were only exposed to PFE, and 356 (27%) were exposed to both. The majority of the IVFE+ patients (1154; 93%) were exposed within the first 7 days of SICU admission. Both groups were well matched based on age (60 years: [49, 69]), gender (59% male), BMI (26: [23, 32]), admis-sion SICU glucose level (166 mg/dL: [137, 211]), and APACHE II score (17: [13, 22]). IVFE+ vs. IVFE- patients had more infections (17% vs. 11%; p <0.001), had a longer LOS in the hospital (13.3 vs. 10.7 days; p <0.001) and the ICU (5.9 vs. 4.9 days; p <0.001), had a greater number of total ventilator days (6 vs. 3 days; p <0.001), and had a higher rate of mortality (11% vs. 8%; p = 0.003). Regression analysis revealed that the IVFE+ group were at a 2.53 fold increased odds of infection (95% CI: [1.77, 3.62]), experienced a 3.68 day longer hospital LOS (95% CI: [2.44, 4.92]), experi-enced a 2.83 day longer ICU LOS (95% CI: [2.15,3.51], experienced a 3.99 day longer time spent on the ventilator (95% CI: [2.57, 5.41]), and were at a 1.93 fold increased odds of death (95% CI: [1.29, 2.89]). All results are significant. Conclusions: Exposure to IVFE in critically ill surgical patients is associated with an increase in morbidity and mortality. These results support the SCCM./A.S.P.E.N. clinical guidelines regarding soy-based IVFE.

S34-3 - Epidermal Growth Factor and Glucagon-like peptide-2 actions on the loss of intestinal epithelial cell proliferation in a total parenteral nutrition mouse modelYongjia Feng, n/a1; Holst J. Jens, n/a2; Bolette Hartmann, n/a2; Daniel H. Teitelbaum, n/a1

1Pediatric Surgery Section,Department of Surgery, University of Michigan, Ann Arbor, MI; 2Endocrinology Research Section, Department of Biomedical Sciences, Universitet of Copenhagen, Copenhagen, Denmark.

Introduction: Total parenteral nutrition (TPN) results in a decline in intestinal epithelial cell (IEC) proliferation and increased EC apoptosis, resulting in profound intestinal mucosal atrophy in the mouse small intestine. Both epidermal growth factor (EGF) and glucagon-like peptide-2 (GLP-2) signaling have been reported to be involved in IEC proliferation in mice. However, the potential for an interaction between these two factors has not been well studied. We hypothesized that a loss of GLP-2 and EGF signaling are both related to the down-regulation of IEC proliferation in mice receiving TPN. Methods: 10 week old C57BL/6J male mice received enteral nutrition (Control) or TPN for 7-days. Exogenous EGF and GLP-2 were used in TPN mice (TPN+EGF and TPN+GLP-2) as additional groups. IEC proliferation was measured with PCNA expression, and 50mg/kg BrdU was injected i.p. 48 hours before mice were killed. IEC migration along crypt/villus axis was measured with immunofluorescent (IF) staining of BrdU. GLP-2R expression was measured with IF staining, EGF-R and its ligands were measured with western and real-time PCR. Circulating plasma GLP-2 level was measured by radioimmunoassay. Results: TPN administration decreased EGF-receptor (ErbB1) and ligand abundance in jejunal muscosa; and also decreased circulating plasma GLP-2 level 2-fold vs. Controls. GLP-2 receptor (GLP-2R) mRNA expression decreased 2.2-fold with TPN. Interestingly, in TPN+EGF mice, both EGFR and GLP2R decline was prevented (Table1). IF staining showed similar results; in controls most of GLP-2R was located in villi enteroendocrine cells, ~ 2 positive cells per villi. This declined 3-fold with TPN and GLP-2R loss was prevented in TPN+EGF mice (and GLP-2R cells were located in enteroendocrine cells and myofibroblasts in the submucosa(Fig1).We next examined the effect of exogenous GLP-2 (TPN+GLP-2); and interestingly, GLP2R expres-sion was also increased in enteroendocrine cells compared to Con-trols; but less so in myofibroblasts. IF staining with PCNA showed that TPN led to a loss of IEC proliferation (42% of Controls). In TPN+EGF and TPN+GLP-2 groups, this loss of proliferation was prevented to the same level as Controls(95.2% and 94.3% of Con-trol). In addition to gross measures of EC proliferation, TPN also dramatically reduced IEC migration up the crypt/villus axis. In Control mice, Brdu labeled cells migrated to between position 20-30, and reached the lower 1/3 of villi. In TPN mice BrdU label-ing position ranged between 0-10. In TPN+EGF loss of EC migration was not prevented, In TPN+GLP-2 mice a partial prevention of decreased EC migration was observed; and most BrdU poitive IEC were moved to positions 5-15(Fig2). This suggests that multiple mechanisms contribute to loss of TPN-associated atrophy. Conclu-sions: : It appears that the loss of both EGF and GLP-2 signaling contributed to TPN-associated loss of IEC proliferation. Interest-ingly, exogenous EGF or GLP-2 demonstrate a cross signaling between these two growth factor signaling pathways; an observation not previously documented. EGF may stimulate GLP2R to amplify GLP2 signaling, and conversely, GLP-2 may augment EGF signaling.

EGF TGFα Betacellulin Epiregulin Amphiregulin

1.28±0.68 EGFR EGFR GLP2R Plasma GLP2

mRNA(10-3) (protein) mRNA (10-2) (pmol/l) Control 10.43±5.20 10.74±1.94 2.65±1.70 10.44±5.20 27.31±11.51 4.01±1.46 0.75±0.18 23.23±10.90 33.3±8.80 TPN 2.99±2.45* 6.45±1.12* 2.27±0.90 3.00±2.45** 12.84±6.85* 1.65±0.40* 0.05±0.03** 9.07±3.03* 15.78±9.40* TPN+EGF 2.94±1.31* 6.18±1.64* 2.47±0.70 2.94±1.30** 20.42±4.50* 3.24±0.46^ 0.63±0.14& 26.79±12.30& n/a

*p<0.01, compared to control, **p<0.001, compared to control, ^p<0.01, compared to TPN , &p<0.001, compared tp TPN.


Fig 2


Encore Abstract: Presented at Digestive Disease Week (DDW), 2010.

S34-4 - Ethanol Lock Therapy Reduces Catheter-related Blood Stream infections in Home Parenteral Nutrition PatientsRex A. Speerhas, R.Ph., BCNSP, CDE1; Bijo John, MD2; Cindy Hamilton, MS, RD, CNSD2; Donald F. Kirby, MD, CNSP2; Ezra Steiger, MD, CNSP2

1Pharmacy, Cleveland Clinic, Cleveland, OH; 2Digestive Disease Institute, Cleveland Clinic, Cleveland, OH.

Introduction: Catheter-related blood stream infections (CRBSI) contribute significantly to morbidity, mortality and health care costs in home parenteral nutrition (HPN) patients. Despite improvements in the care of vascular access devices (CVAD) there is still a high prevalence of hospital admissions for CRBSI in HPN patients. The objective of this study is to investigate the efficacy of Ethanol Lock Therapy (ELT) in reducing the incidence of infections in patients with CRBSI in HPN patients. Methods: Medical records from the Cleveland Clinic database of HPN patients with CRBSI placed on prophylactic Ethanol Lock Therapy (ELT) were retrospectively studied from January, 2006 to August, 2009 (N=31). Data collected included demography, diagnosis and laboratory values. CRBSI rates and outcomes were compared pre- and post-ELT with the patients serving as their controls. Diagnosis of CRBSI was based on both clinical symptoms and positive blood cultures. ELT involved instilling sterile ethyl alcohol injection 70-98% daily into each lumen of the CVAD while on HPN. Comparative analysis was performed using McNemar’s test and Wilcoxon ranked tests. Results: 31 patients had 273 CRBSI related admissions (10 per 1000 catheter-days) prior to ELT in comparison to 47 CRBSI related admissions post ELT (6.5 per 1000 catheter-days, p=0.005). The rate of culture positive CRBSI were 3.53 versus 1.65 per 1000 catheter-days pre and post ELT (p=0.01). There was also a statistically significant decrease in the number of catheters removed for CRBSI pre and post ELT (p<0.001). ELT was also noted to decrease the recurrence of gram positive and Conclusions: This retrospective review supports the safety and efficacy of Ethanol Lock Therapy in reducing CRBSI related morbidity in HPN patients. This novel technique will also considerably decrease the burden of CRBSI related health care costs and may have utility also in treating CRBSI in the future.

Encore abstract: Presented at the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Conference, 2010 and the American College of Nutrition Conference 2010.

S34-5 - Aluminum Content Of Parenteral Nutrition Solution ProductsKevin Pieroni, M.D.1; Robert L. Poole, Pharm.D.2; Tessa K. Dixon, Pharm.D.2; Shabnam Gaskari, Pharm.D.2; K. T. Park, M.D.1; John A. Kerner, M.D.1

1Pediatric Gastroenterology, Hepatology, and Nutrition, Lucile Packard Children’s Hospital at Stanford, Palo Alto, CA; 2Pediatric Clinical Pharmacy, Lucile Packard Children’s Hospital at Stanford, Palo Alto, CA.

Introduction: Aluminum (Al) toxicity is associated with significant central nervous system, bone, liver, and hematologic damage. Al is a contaminant in products used to make parenteral nutrition (PN) solutions including calcium gluconate, sodium phosphate, potassium phosphate, and other additives. Premature infants are at a potentially high risk for toxicity due to prolonged courses of PN therapy and immature renal function. The Food and Drug Administration (FDA) has mandated standards for PN solution product labels and recommended a maximum patient Al daily exposure limit of 5 mcg/kg/day. The objective of this study is to compare the labeled Al content to the measured Al content of the PN solution products and determine which manufacturers have the least amount of Al contamination. Methods: A selection of products available in the United States from all manufacturers used in the production of PN solutions was identified and col-lected. Three lots were collected for each identified product. Samples were quantitatively analyzed by Mayo Laboratories. The products identified to have the lowest aluminum content were entered into the calculation engine of our PN software for a simu-lation analysis utilizing our patient database. All neonatal inpatients weighing less than 6 kg who received PN during 2009 at our institution were included. The total daily aluminum exposure was determined. Results: Comparing measured values, calcium glu-conate contains 20-30%, sodium phosphate contains 13-16%, and potassium phosphate contains 8-16% of the labeled Al content. Large lot-to-lot and manufacturer-to-manufacturer differences were noted for all products. Measured aluminum concentrations were significantly less than manufacturer-labeled values for all products. The PN patient database analysis found that the daily exposure to Al, using the least contaminated products, was 8.8-12.9 mcg/kg/day. Conclusions: The actual Al content of PN solu-tion products is significantly less than the labeled content. There is a significant difference between available manufacturers’ Al content. We previously found that neonates were receiving 28.3-47.6 mcg/kg/day Al exposure, using the labeled Al concentrations and 14.9-23.1 mcg/kg/day Al exposure when actually measuring the PN (JPGN 2010;50:208-11). When we look at the same patient population, using the measured Al concentrations of the least contaminated products that are currently available, the daily expo-sure is significantly less, 8.8-12.9 mcg/kg/day. Though still above the FDA recommended 5 mcg/kg/day, this study reveals that by using a combination of the least contaminated PN solution prod-ucts available, the Al exposure of patients at the highest risk can be significantly reduced.

Pre and Post ELT outcomes: Paired Analysis

Factor Pre-ELT Post-ELT p-value

Admissions 5 (2, 13) 1 (0, 2) <0.001Culture + CRBSI 3 (1, 4) 0 (0, 1) <0.001# catheters 4 (2, 8) 0 (0, 1) <0.001Removed for CRBSI 2 (1, 4) 0 (0, 1) <0.001GPC 18 (58.1) 4 (12.9) <0.001Yeast 9 (29.0) 3 (9.7) 0.058GNB 16 (51.6) 4 (12.9) <0.001

Values presented as N (%) for gram-positive cocci (GPC), Yeast and gram-negative bacilli (GNB) and Median (P25, P75) otherwise p-values correspond to McNemar’s tests for GPC, yeast and GNB and Wilcoxon singed rank tests otherwise (paired analysis)


changes occurred in B or T cells in Peyer’s patches or in any CD8+ T cell populations. Conclusions: PN reduces LP activated and regulatory T cells (CD4+CD25+) as well as naïve and memory B cells. The neu-ropeptide, bombesin, maintains these cell phenotypes at levels near chow levels when added to PN. The ENS appears intimately involved in mucosal immunity.

Table 1. Patient Demographics

Weight, kg

No. of Patients

No. of Patient Days

Average Parenteral

Nutrition Days/Patient

Range of Parenteral

Nutrition Days/Patient

0-<1 69 1112 16.1 1-41 1-<2 223 2532 11.4 1-79 2-<3 242 1778 7.3 1-97 3-<4 194 1784 9.2 1-130 4-<5 65 666 10.2 1-160 5-<6 27 350 13 1-173 Total 656 8222 12.5 1-173

Table 2. Measured Aluminum Exposure

Patient Weight, kg<b/>

Measured Average Aluminum Exposure, mcg/kg/day

0-<1 12.9 1-<2 11.2 2-<3 9.2 3-<4 9.5 4-<5 9.4 5-<6 8.8 Total 10.4

S34-6 - Bombesin Corrects Parenteral Nutrition (PN)-Induced Changes in Gut Lymphocyte PhenotypesMark A. Jonker, M.D.; Aaron F. Heneghan, Ph.D.; John Fechner, Ph.D.; Joseph F. Pierre, M.S.; Yoshifumi Sano, M.D., Ph.D.; Kenneth Kudsk, M.D.General Surgery, University of Wisconsin Hospital and Clinics, Madison, WI.

Introduction: PN reduces respiratory tract (RT) lymphocytes, gut associated lymphoid tissue (GALT) Peyer’s patch (PP) and lamina propria (LP) lymphocytes, lowers gut and RT sIgA levels and destroys established RT antiviral &antibacterial immunity. Bombesin (BBS), a neuropeptide of the enteric nervous system (ENS), reverses PN-induced sIgA and RT immune defects. We examined PN-induced lymphocyte phenotype changes in PP and LP with & without BBS. Methods: IV-cannulated ICR mice received Chow (n = 12), PN (n = 12), or PN + BBS injections (15 ug/kg TID, n =12) for 5 days. Lymphocytes isolated from PP and LP were analyzed with a LSR-II flow cytometer for hom-ing phenotypes (CD62L & LPAM-1) and state of activation (CD25, CD44, and Foxp3) in T cell (CD3) subsets (CD4 & CD8) as well as homing phenotype (CD62L & LPAM-1) in naive B (IgD+) and activated (IgM) B cells (CD45R/B220). Data are expressed as percent of specific phenotype/total lymphocytes. Results: PN significantly reduced LP 1) CD4+CD25+ (activated) T cells, 2) CD4+CD25+LPAM-1+ T cells (activated cells targeted to effector sites) and 3) T regulatory cells (Foxp3+) compared to Chow (Table). PN-BBS significantly increased each of these cell populations from PN levels to Chow levels. PN significantly reduced LP 1) IgD+ B cells (naïve B cells) and 2) IgD-LPAM-1+ (antigen activated) B cells from Chow levels while PN-BBS increased both B cell populations from PN to Chow levels. PN signifi-cantly reduced LP CD44+ (memory) B cells (memory) vs Chow while PN-BBS significantly increased memory from PN levels. No significant

LP specific lymphocyte phenotypes changes with PN and bombesin

Chow PN PN-BBS

CD4+CD25+ 43% 24% (a) 39% (b) CD4+CD25+LPAM-1+ 25% 12% (c) 27% (b) IgD+ 34% 23% (c) 30% (b) IgD-LPAM-1+ 6% 2% (c) 5% (b) CD44+ 38% 21% (c) 33% (b)

ap=0.01 vs Chow; b p<0.05 vs PN; c p<0.05 vs Chow

Scientific Paper Session: Pharmaconutrition. January 30, 2011


S35-1 - Use of an Immune-Modulating Enteral Formula in Post-Operative Cardiac Surgery Patients is Associated with Fewer Infectious Complications and Decreased Hospital Length of StayNicole M. Bedi, RD, LDN, CNSD1; Siobhan McGurk, BS2; Anne M. Burgess, MSHI, BSN2; James D. Rawn, MD2

1Department of Nutrition, Brigham and Women’s Hospital, Boston, MA; 2Division of Cardiac Surgery, Brigham and Women’s Hospital, Boston, MA.

Introduction: Immune-modulating diets (IMD) have been shown to decrease infectious complications and length of stay in high-risk patients undergoing elective operations. The role of IMDs for routine use con-tinues to be debated in the nutrition community. Cardiac surgery patients who do not progress to an oral diet and require tube feedings are at high risk for additional post-op complications. We sought to evaluate the impact of IMDs on the infection rates of patients following cardiac surgery. Methods: Patients who required tube feedings follow-ing cardiac surgery between 3/2008 and 6/2010 were fed a high-protein, peptide-based, immune-modulating enteral formula fortified with argi-nine, antioxidant vitamins, fish oil/MCT structured lipid, and short-chain fructooligosaccharide (FOS). A comparison group of patients who received a standard enteral feeding formula (including disease specific formulas, or fiber/FOS containing formulas, but without additi-tional arginine or fish-oils) between 10/2004 and 3/2008 were identified for the historical cohort. Tube feedings were started at any point during the patients’ initial post-operative when medically indicated. Patients who received less than 250kcal/d from tube feedings were excluded from analysis. Outcomes of interest included deep sternal wound infec-tion (DSWI), sepsis, leg infections, c. difficile infection, or multi-system organ failure (MSOF) during the index admission. The aggregate inci-dence of infectious complications was also compared. Continuous variables were compared using Student’s t-test (normal distributions)


or Mann-Whitney U tests (non-normally distributed). Dichotomous variables were compared using Fisher’s Exact test (SPSS 13.0, Chicago, IL). The criterion of statistical significance was p<=0.05. Results: The current study reports interim findings at two-thirds of planned enroll-ment. In total, 265 patients were identified in the historical period. These were compared to 172 patients in the IMD group. IMD patients were similar in age, gender, and daily caloric intake from tube feedings to the historical cohort. Due to the composition of the IMDs, the IMD group, on average, received significantly more protein. Median post-operative length of stay (LOS) was significantly lower at 27 days in the IMD group compared to 31 days in the historical group (p=0.002). The overall incidence of infectious complication was 26.4% in the historical

Arginine increased phospho-c-Jun expression (Fig.1A and 1B) but decreased PPARγ transcriptional activity (Fig. 1C and 1D) in a dose and time-dependent fashion. Phospho-c-Jun expression increased by one hour, remained increased at 4 hours, and was maximal at 10 mM arginine. The effect of arginine on PPARγ activity occurred later than for phosphor-c-Jun expression. PPARγ was repressed beginning at 2 hours, remained decreased thru 24 hours, and was maximally repressed by 10 mM arginine. PPARγ transcriptional activity was significantly decreased by arginine and GW9662 (Fig. 1E). The combination of arginine + GW9622 had a synergistic effect on the inhibition of PPARγ transcriptional activity (Fig.1E). Treatment of GW9662 did not alter phospho-c-Jun expression (Fig. 1F). However, silencing of c-Jun by siRNA significantly increased PPARγ activity which was only partially restored by GW9662 (Fig. 1G). Conclusions: GW9662 is an irrevers-ible antagonist that binds to the ligand-binding site of PPARγ. We demonstrated that GW9662 significantly decreased PPARγ activity by arginine, consistent with ligand-dependent binding. However, c-Jun silencing could not completely restore PPARγ. Our results therfore suggest that arginine regulates PPARγ activity via both ligand-dependent and -independent fashions . c-Jun is a main component of the AP-1 complex and is involved in pro-inflammation, whereas PPARγ possesses anti-inflammatory effects. Our findings can explain, at least in part, our previous observation that arginine supplementation enhanced inflammation in the post ischemic gut and suggest that targeting c-Jun inhibition in addition to activating PPARγ may enhance protection.

Historical IMD

Patients 265 172 p<= Age (yrs) mean (sd) 69.5 (14.2) 68.8 (14.1) 0.655 Females % (n) 41.5 (110) 37.8 (65) 0.250 Daily intake (kcal) mean (sd) 1,436 (460) 1,378 (469) 0.149

median 1,443 1,436 Daily protein (g) mean (sd) 63.7 (24.2) 75.3 (28.0) 0.001

median 65.3 77.3 Postop length of stay (d) mean (sd) 38.2 (26) 32.9 (26) 0.002

median 31 27 Operative mortality % (n) 20.8 (55) 16.3 (28) 0.263 Infectious complications DSWI % (n) 2.3 (6) 1.7 (3) 0.498 Leg infection % (n) 1.1 (3) 0.6 (1) 1.000 Sepsis % (n) 17.4 (46) 10.5 (18) 0.053 MSOF % (n) 2.6 (7) 1.7 (3) 0.746 c. diff positive culture % (n) 9.1 (24) 4.1 (7) 0.056 Any infectious complication % (n) 26.4 (70) 18.0 (31) 0.048

S35-2 - Arginine Decreases Peroxisome Proliferator-Activated Receptor Gamma Activity Via c-Jun in Both Ligand-Dependent And -Independent FashionsKechen Ban, PhD; Zhanglong Peng, MD, PhD; Rosemary Kozar, MD, PhDSurgery, University of Texas Health Science Center at Houston, Houston, TX.

Introduction: We have shown that enteral arginine can be injurious to the post ischemic gut. Arginine administered during gut ischemia/reperfusion enhanced c-Jun activity but inhibited peroxisome proliferator-activated receptor gamma (PPARγ, an anti-inflammatory mediator) activity. The objective of the current study was to further investigate the mechanism by which arginine regulates the activities of c-Jun and PPARγ in vitro. Methods: Rat intestinal IEC-6 cells were transfected with c-Jun siRNA by Lipofectamine 2000 or/and treated with 10 μM GW9662, (2-chloro-5nitrobenzanilide, an irreversible antagonist that covalently modifies a cysteine residue in the ligand binding site of PPARγ) and arginine 0- 20 mM for up to 8 hours. c-Jun and phospho-c-Jun protein expression were analyzed by Western blot. PPARγ activity was evaluated using a dual luciferase assay system by transiently co-transfecting the luciferase reporter construct pGAL3 Basic or PPRE X3-TK-Luc (luciferase reporter construct peroxisome proliferator response element) with the Renilla control vector in cells. Results:

group versus 18% in the IMD group (p=0.048, OR 0.612, 95% CI .381 - .985). The incidence of sepsis (17.4% in historical group, vs. 10.5% in the IMD group, p= 0.053) and c. difficile infection (9.1% vs 4.1% p=0.056) were also lower in the IMD group. Conclusions: Compared to historical counterparts who received standard enteral formulas, patients who received an IMD experienced fewer clinically important postoperative infections and also had significantly decreased LOS. In particular, the risks of sepsis and c. difficile were lower in the patients fed IMDs. Our preliminary findings suggest that use of IMDs in cardiac surgery patients may have significant impact in decreasing post-oper-ative infectious and other complications, warranting further investigation.


S35-3 - Prevention of Hypoxia/Reoxygenation Induced IEC-6 Cell Injury by Glutamine via Syndecan-1Zhanglong Peng, M.D, PhD; Kechen Ban, PhD; Rosemary Kozar, M.D, PhDSurgery, University of Texas Health Science Center at Houston, Houston, TX.

Introduction: Syndecan-1 is the major heparin sulfate proteoglycan (HSPG) found on epithelial cells, which functions as a co-receptor on the cell surface and helps maintain gut barrier function. Shedding of syndecan-1 is an innate host response to tissue injury and inflammation. We have shown clinically that syndecan-1 is shed after shock and reduced by resus-citation. Glutamine (Gln) is the primary metabolic fuel of small intestine and we and others have shown it is protective to the gut after shock, however the mechanisms of protection are not well elucidated. The objective of the current study was to investigate an association between glutamine’s gut protective effects and syndecan-1 shedding. As a first step, we hypothesized that glutamine would reduce injury induced by hypoxia/reoxygenation (H/R) in intestinal epithelial cells by minimizing loss of syndecan-1 from the cell surface. Methods: IEC-6 cells were cultured in Dulbecco’s modi-fied eagle media. Once confluent, cells were incubated in serum and glutamine free media overnight, then exposed to 24h hypoxia (1%O2)

followed by 4h of reoxygenation. Prior to hypoxia, 10mM Gln and 10mM arginine in final concentration were added into the media respectively with equal volume vehicle, and same volume vehicle only were added into the media of H/R alone and normoxia controls. Cell surface syndecan-1 was visualized by immunofluoresence staining and shed syndecan-1 in the medium was analyzed by ELISA. Cell proliferation was measured with MTT (3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyl tetrazolium bromid ). Cell migration was analyzed by measuring area of cell wound scratched along the cell well diameter and was expressed as percentage of recovered area in total wound area. Caspase 3/7 activity was measured using The Apo-ONE homogeneous caspase 3/7 assay kit. All data are presented as mean±SEM, n= 6/group. Results were analyzed by one-way ANOVA with Tukey post hoc. Means with different letters are significantly different. Results: H/R significantly reduced IEC-6 cell proliferation and migration, and increased caspase3/7 activity and syndecan-1 shedding (Table 1). Arginine significantly increased proliferation and reduced caspase 3/7 compared to H/R alone. Glutamine, however, reversed H/R-induced changes in proliferation, migration, and caspase3/7, comparable to normoxia con-trols. Importantly, glutamine’s protective effects correlated with a reduction in shed syndecan and preservation of cell surface syndecan (Figure 1). Conclusions: Our data suggests that glutamine may prevent H/R induced injury by minimizing loss of syndecan-1 from the surface of intestinal epithelial cells. This novel finding warrants further investigation.

Table 1. Association between shed syndecan and cell function

Groups Proliferation (Absorbance) Migration (%) Caspase 3/7(RFUs) Shed syndecan (Absorbance)

Normoxia 2.08 ± 0.01 a 0.95 ± 0.03 a 2574 ± 190 a 0.234 ± 0.016 a HR 0.75 ± 0.01 b 0.61 ± 0.05 b 20,938 ± 951 b 0.408 ± 0.006 b HR + glutamine 1.95 ± 0.01 a 0.82 ± 0.03 a 2753 ± 392 a 0.231 ± 0.002 a HR + arginine 1.25 ± 0.01 c 0.59 ± 0.07 b 5855 ± 532 c 0.375 ± 0.012 c

HR= hypoxia/reoxygenation


Syndecan-1 immunoflurosence after H/R and glutamine.

S35-4 - Phosphoinositide 3-Kinase Pathway Activity is Necessary for Glutamine Mediated Heat Shock Protein 70 Enhancement and Cellular Protection in Heat Stressed Intestinal Epithelial CellsLauren Zager, BS; Christine Hamiel, BS; Alyssa R. Kallweit, BS; Jonathan Levi, BS; Stefanie Niederlechner, MS; Paul Wischmeyer, MDAnesthesiology, University of Colorado Denver, Aurora, CO.

Introduction: Glutamine (GLN) treatment is protective in both experi-mental and clinical settings of critical illness and injury. The signaling pathways involved in GLN mediated protection remain to be elucidated. The phosphoinositide 3-kinase (PI3-K) pathway has been shown to decrease apoptosis by activation of other intermediates. It has also been implicated as a necessary component of cellular heat shock protein (HSP) expression although conflicting literature exists. The aim of this study was to determine if PI3-Kinase is essential for GLN mediated cellular protection and HSP70 expression in heat stressed (HS) intestinal epithelial cells (IEC). Methods: PI3-Kinase inhibitors, LY29400215 (50uM), or wortmannin (10uM), were added to IEC-18 cells for 45 minutes. Cells were then treated with and without GLN (10mM), and subsequent HS injury (either 44 degrees C for 50 min for lethal injury or 43 degrees for 45 min for non-lethal injury). Cells subjected to non-lethal HS were analyzed for HSP70 expression levels via western blot after a 3 hour recovery. Cells subjected to lethal HS were assayed for cell viability via MTS assay after a 24 hour recovery. All HS groups were normalized to their non-HS controls (CT) for survival experi-ments. All statistics were done via t-tests. Results: GLN increased cell survival in heat stressed IEC-18 cells more than 3 fold (p<0.001 vs. HS CT). PI3-K inhibition with LY29400215 and also wortmannin completely attenuated GLN’s protection (p<0.01 vs. HS GLN). HSP70 increased almost five fold in HS cells treated with GLN (p<0.001 vs. HS CT). Both PI3-Kinase inhibitors decreased GLN mediated HSP70 enhancement, (Ly29400215 by more than 63% (p=0.03 vs. HS GLN) and wortmannin

by 28% (p=0.04 vs. HS GLN). Conclusions: The mechanism of GLN mediated HSP70 enhancement and cellular protection appears to be depen-dent on PI3-K activation in HS IEC-18 cells.

S35-5 - The O-Linked-N-Acetylglucosamine Pathway Is Responsible For Glutamine Mediated Cellular Protection In Heat Stress But Not Oxidant InjuryAlyssa R. Kallweit, BS; Christine Hamiel, BS; Stefanie Niederlechner, MS; Alexandra Sufit, BS; Paul Wischmeyer, MDAnesthesiology, University of Colorado Denver, Aurora, CO.

Introduction: Glutamine (GLN) treatment can decrease mortality, length of hospital stay and infectious complication in critically ill patients. GLN protects via heat shock protein (HSP) enhancement although it’s mechanism of induction in different experimental injury models remains to be eluci-dated. GLN enhances HSP70 expression via the O-linked-N-acetylglucos-amine (O-GlcNAc) pathway during heat stress (HS) in fibroblast cells although no data exist in intestinal epithelial cells (IEC). Furthermore, it is unknown whether GLN’s mechanism of protection is consistent in HS vs. oxidant injury. GLN mediated effects on HSP25 and HSP32 expression via the O-GlcNAc pathway are also unknown. The purpose of our study was to determine if the O-GlcNAc pathway is the mechanism by which GLN protects in both heat and oxidant injury in the intestinal epithelium. Methods: Small interfering RNA (siRNA) knockdown of a key O-GlcNAc enzyme, O-linked-N-acetylglucosamine transferase (OGT), was used in IEC-18 cells to determine if GLN protects through this pathway. Cells were transfected with either no oligos, non-coding control oligos (NC), or OGT siRNA (OGTsi). Cells were then treated for 15min with 0mM GLN (CT) or 8mM GLN, and subjected to either lethal injury for cell survival (HS of 44 degrees for 50 min, or 4mM H2O2 for 30 min), or non-lethal injury for protein expression (HS of 43 degrees for 45 min, or 600uM H2O2 for 30 min). OGT, HSP25, 32 and 70 levels were evaluated via western blotting after a 3hr recovery. Survival was determined via MTS assays after 24hrs. All injured groups were normalized to non-injured controls to account for differences in cell proliferation and growth. Results:

Figure 1. Immunofluorescence localization of syndecan-1 on surface of IEC-6 cells.


MTS assays showed GLN increased survival 4-5 fold during lethal HS and oxidant injury (p<0.01 vs. HS CT or H2O2 only). OGTsi decreased GLN’s protection by 86% in HS cells (p<0.001 vs. HS GLN), however in oxidant injury, OGTsi did not decrease GLN mediated protection. NC oligos did not affect GLN mediated protection in either group. Western blot showed an increase in HSP25, 32, and 70 with HS in GLN-treated cells (p<0.01 vs. HS CT). OGTsi attenuated GLN’s enhancement of HSP25 by 48% (p<0.01 vs. HS GLN) and also showed a strong trend of decreasing GLN mediated HSP32 and 70 in HS cells. In oxidant injury, GLN only enhanced HSP32 (p<0.05), and OGTsi did not affect any of the HSPs evaluated. OGT levels were knocked down by 85-96% in the silenced groups vs. non-silenced controls (p<0.04). NC oligos did not change HSP expression in heat or oxidant injury. Conclusions: GLN protects intestinal cells from both heat and oxidant injury through different mechanisms. In HS, GLN’s mechanism of cellular protection and HSP expression is dependent on the O-glcNAc pathway. OGT silencing in oxidant injury did not affect GLN mediated cell survival, indicating that GLN is exerting an alternative mechanism of protection. This protection could be mediated via HSP32 through diverse regulation of transcription factors such as AP1, NRF2 or NFkB. These are the first data showing the O-GlcNAc pathway is essential for GLN mediated cellular protection and HSP25 expression in HS intestinal cells. Furthermore, this is the first report of GLN exerting an alternative protective effect in oxidant injury that is independent of the O-GlcNAc pathway.

S35-6 - Integrin/Src Inhibition Decreases Glutamine’s Cytoprotective Mechanism by Attenuating Cell Swelling, O-Glycosylation, Heat Shock Factor-1 and Heat Shock Protein Expression, and by Increasing Cleaved Caspase-3 LevelsStefanie Niederlechner, MS; Jonathan Levi, Bc; Christine Hamiel, Bc; Alyssa R. Kallweit, Bc; Paul Wischmeyer, MDUniversity of Colorado, Aurora, CO.

Introduction: Glutamine (GLN) is known to be an osmotically acting amino acid, which can be cytoprotective following injury. Furthermore, it is acknowledged that cell swelling and the integrin pathway can induce cellular protection and that GLN increases the activation of transcription factors, such as heat shock factor-1 (HSF-1), via the O-glycosylation (O-GlcNAc) pathway to induce the protective heat shock protein (HSP) response. Further, it has been implicated that GLN decreases cleaved caspase-3 expression during heat stress (HS) to prevent apoptosis. However, it is currently unknown if the integrin pathway is related to GLN’s cell protective mechanism in intestinal epithelial-6 cells (IEC-6). Methods: IEC-6 cells were treated for 15 min with increasing doses of GLN (up to 20 mM), with or without integrin inhibitor GRGDSP (50 μM), inactive control peptide GRGESP (50 μM) or Src-kinase inhibitor PP-2 (75 μM). Cell survival was measured via MTS assay 24h post-HS (44°Cx50min). O-glycosylated protein levels, HSF-1, HSP32, HSP70, Procaspase-3 and cleaved caspase-3 levels were determined via Western blot, and cell area size and cytoskeleton stabilization via fluorescence microscopy after non-lethal HS (43°Cx50min). Results: GRGDSP completely attenuated GLN-mediated increases in cell area size (p< 0.001 vs. HS GLN; n=3) and destabilized the F-actin cytoskeleton in non-HS and HS groups. GLN increased cell survival in a dose dependent manner after HS (p< 0.001 vs. HS CT; n=4). However, GRGDSP and PP2 attenuated GLN’s protec-tion by 70%-100% (p< 0.001 vs. respective GLN groups; n=4). GRGDSP also decreased GLN-mediated increases in HSF-1 levels by 79% after HS (p< 0.05 vs. HS 10 mM GLN; n=3). O-GlcNAc modified proteins increased 100% post-HS after 10 mM GLN treatment (p< 0.001 vs. HS C; n=5). GRGDSP attenuated GLN’s effect on O-GlcNAc protein modification by 84% (p< 0.05 vs. HS 10 mM GLN; n=5). GLN-mediated increases in HSP70 and HSP32 (2-3 fold) were attenuated by 70%-100% post-HS after GRGDSP and PP2 treatment (p< 0.05 vs. HS CT; n=4). Moreover,

GLN supplementation (10 mM) decreased the production of cleaved caspase-3 after HS. However, GRGDSP inhibited GLN’s decreasing effect on cleaved caspase-3 levels (p<0.05; n=3). GRGESP control peptide had no effect on any of the GLN-mediated cellular protection pathways. Conclusions: The integrin/Src pathway is an essential component of GLN’s molecular mechanism of cellular protection. It seems that GLN activates the integrin pathway via cell swelling leading to cytoskeletal stabilization, which can initiate the O-GlcNAc pathway leading to increased O-glycosylation, HSF-1 and HSP levels after HS injury. This leads to decreased cleaved caspase-3 levels and prevents apoptosis. (Supported: R01 GM078312)

Scientific Paper Session: Gastrointestinal / Hepatic. January 30, 2011.

Encore abstract: Presented at the Pancreas Society of Great Britain and Ireland. Published: J.J. Pancreatology, 2010;10:84-103. Reprinted with permission of Skarger AG Basel.

S36-1 - Are we underestimating the risk of osteopathy in patients with chronic pancreatitis?Sinead Duggan, BSc. Dipl. RD (Research)1,3; Sinead Feehan, RD2; Paul F. Ridgway, MD1,3; Kevin Conlon, MD1,3

1Centre for Pancreatico-Biliary Disease, Adelaide & Meath Hospital, incorporating the National Children’s Hospital, Dublin 24, Ireland; 2Nutrition & Dietetics, Adelaide & Meath Hospital, incorporating the National Children’s Hospital, Dublin 24, Ireland; 3Surgery, Trinity College Dublin, Dublin, Ireland.

Introduction: There are no bone health guidelines for chronic pancre-atitis, such as exist in other malabsorptive conditions including Coeliac Disease and Inflammatory Bowel Disease. Studies in Eastern Europe reported that osteopathy (osteoporosis and osteopenia) may exist in 39% of chronic pancreatitis patients. Chronic pancreatitis patients exhibit deterioration of exocrine function, resulting in nutrient malab-sorption and increasing the risk of malnutrition. Malabsorption of vitamin D affects the absorption of dietary calcium, increasing the risk of low bone-mineral density. In this first Irish study into malnutrition and bone health in chronic pancreatitis, we investigated the degree of osteopathy in chronic pancreatitis patients presenting to our centre. We also sought to evaluate the factors that are predictive of low bone mineral density, and to compare nutritional, smoking and alcohol status to controls. Methods: Study design was a prospective, cross-sectional study. To date, n=76 have been recruited (n=49 CP, n=27 controls). Nutritional assessment consisted of anthropometry; weight, height, body mass index, triceps skin fold, hand-grip strength, bone mineral density (using dual energy X-ray absorptiometry), 25-OH vitamin D, smoking (pack years), alcohol status, and pain (likhart scale). Statistics were performed using Minitab 5 (USA) and included regression to test factors predictive of low bone mineral density. Ethical approval was obtained from the Joint SJH/ AMNCH research ethics group. Results: Among chronic pancreatitis patients, 82.4% had osteopathy and 91% were vitamin D insufficient. Using linear regression, low body mass index (p=0.0077), smoking (p=00.76) and pain (p=0.015) were predic-tive of low bone mineral density. Compared to matched-controls, the chronic pancreatitis group had lower body mass index (P=0.04), lower mid upper-arm circumference (P=0.00), lower triceps skin fold (P=0.00), and among males, lower handgrip-strength (p=0.00). Conclusions: Osteopathy in this group far exceeds that described elsewhere. Low


S36-3 - Perioperative nutritional treatment is associated with improved postoperative outcome in patients with esophageal, gastric or pancreatic cancerGerdien C. Ligthart-Melis, PhD, Msc, RD1; Nienke D. te Boveldt, Msc1; Henk M. Verheul, PhD, MD3; Donald L. van der Peet, PhD, MD2

1Nutrition & Dietetics, VU University Medical Center, Amsterdam, Netherlands; 2Surgical Oncology, VU University Medical Center, Amsterdam, Netherlands; 3Medical Oncology, VU University Medical Center, Amsterdam, Netherlands.

Introduction: Esophageal, gastric and pancreatic cancer patients are prone to malnutrition, because they are not only subject to cancer-induced cachexia but also to impaired digestive functioning. The present study was conducted to explore how perioperative nutritional treatment affects nutritional status and postoperative outcome in patients with esophageal, gastric or pancreatic cancer. Methods: This exploratory study included forty-seven patients in the treatment group and fifty-six patients in the historical control group with mean age 64 ± 9.5 (41-82). Patients in the treatment group received nutri-tional treatment preoperatively, during admission for surgery and after dis-charge by a dietician (February 2009 to March 2010). Patients in the historical control group were only visited by a dietician after surgery and received limited follow up by phone (January 2006 to December 2008). The Mann-Whitney test and Chi-square test or Fisher’s exact test were used to compare nutritional status, postoperative complications, postoperative nutritional related problems and length of hospital stay. To assess predictor variables of postoperative complications univariate and stepwise forward multivariate linear regression analysis were conducted. Results are expressed as mean ± SD. A p<0.05 was considered significant. Results: Patients in the treatment group sustained weight (0.27 ± 2.9 kg; NS), whereas patients in the historical control group lost weight before surgery (-3.2 ± 3.7 kg; p=0.001) (treatment vs. control: p= 0.002). Postoperative weight loss (2 weeks until 3 months after surgery) was more limited in patients in the treatment group (-2.1 ± 3.6 kg; p=0.008), than patients in the historical control group (-3.6 ± 4.1 kg; p=0.001) (treatment vs. control: p=0.05). Patients in the treatment group experienced less postoperative complications (0.8 ± 0.8 vs. 1.6 ± 1.4; p=0.02),

body mass index, smoking and the presence of pain were associated with poor bone health. Chronic pancreatitis patients were thinner, with lower muscle stores and lower functional capacity. The development of assessment and monitoring guidelines is vital for this group.

S36-2 - Facilitating Bayesian Analyses of Clinical Trials of Novel Lipid Based Approaches to Pediatric Intestinal Failure Associated Liver Disease - An Expert Belief Elicitation StudyIvan Diamond, MD1,2; Robert Grant, BA MA1; Brian Feldman, MD MSc2; Paul Pencharz, MBChB PhD1; Simon Ling, MBChB1; Aideen Moore, MD MHSc1,2; Paul W. Wales, MD MSc1,2

1Group for Improvement of Intestinal Function and Treatment, The Hospital for Sick Children, Toronto, ON, Canada; 2Department of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.

Introduction: Parenteral omega-3 lipid emulsions as well as lipid mini-mization may play a role in the treatment and prevention of Intestinal Failure Associated Liver Disease (IFALD) in children. While the evidence base should ideally be derived from randomized trials, such studies are challenging due to the rarity of Intestinal Failure (IF) especially when a frequentist approach to data analysis is employed. An alternate strategy would be to employ a Bayesian approach to clinical trial analysis, which incorporates prior data in the analysis. The objective of this project was to elicit expert beliefs as to the probability of IFALD with various lipid approaches. These belief probability distributions can be used as prior distributions in Bayesian analyses of ongoing and future clinical trials. Methods: All 21 centers who participated in the Pediatric Intestinal Failure Consortium (PIFCON) NIH grant submission were invited to participate. Interviews were conducted using a validated approach to belief elicitation with 3 nominated experts (a surgeon, a pediatrician and a dietician) from each multi-disciplinary IF team. During the interview, participants were asked to estimate in an average population of infants (< 1 year) referred for management of IF with early IFALD [conjugated bilirubin (CB) 1 - 2 mg/dl] who were receiving a soy-based emulsion at the time of referral (dose 2-3 g/kg/day), the probability of advanced IFALD(CB > 6 mg/dl) at 3 months following referral in each of 3 scenarios: 1. Conventional Lipid:- soy-based emulsion (dose 2-3 g/kg/day), 2. Omega-3 Lipids:- child switched to an Omega-3 enriched lipid emulsion (dose 2-3 g/kg/day), 3. Lipid mini-mization:- soy-based emulsion but at a dose of <1g/kg/day. Belief probability distributions for each approach were developed. Participants were also asked to specify whether they believed based on their understanding the literature and their clinical experience whether the use of omega-3 emul-sions or lipid minimization could be routinely justified at this time in IF patients outside of clinical trials. Results: Seventeen centers plus the author’s institution participated in this study. One center declined partici-pation and three centers did not respond to the invitation (86% response rate). Sixty expert interviews were conducted. Median duration of experi-ence of participants managing patients with IF was 8.5 (range 2-35) years. The median point estimate for the probability of advanced liver disease using the Conventional Lipid was 32.5%, 17.5% for Omega-3 lipids and 13% Lipid minimization. Belief probability distributions for the various approaches are shown in Figure 1. While only 35% of experts felt that the routine use of Omega-3 lipid was justified in those with early IFALD (CB 1-3 mg/dl) 68% of experts felt that lipid minimization was routinely justi-fied in these patients. 85% of experts believed in routine use of omega-3 lipids and 92% in the routine use of lipid minimization in those with advanced IFALD (CB > 6 mg/dl). Conclusions: While there is significant variability in terms of expert belief as to the probability of advanced IFALD with conventional lipids, experts believe that both omega-3 lipid and lipid minimization will result in a lower incidence of IFALD. These specific belief probability distributions can be used to inform Bayesian analyses of ongoing clinical trials in this area. While experts believe that the use of both omega-3 emulsions and lipid minimization are routinely justified in those with advanced IFALD, the discrepant views in early liver disease highlights the need for clinical trials in this setting.

Belief Probability Distributions for each of Conventional Lipid, Omega-3 Lipid, and Lipid Minimization. The x-axis specifies the proportion of patients who develop advanced IFALD within 3 months. The y-axis provides the weight of expert belief for the proportion who develop advanced IFALD. The area under each curve equals 1. Whereas expert opinion suggests that both Omega-3 Lipids and Lipid Minimization are associated with lower incidences of advanced IFALD than Conventional Lipid, there was significant variation in expert belief as to the probability of advanced IFALD with Conventional Lipid.


less postoperative nutritional related problems (2.1 ± 1.2 vs. 2.6 ± 1.3; p=0.03) and a shorter hospital stay (16 ± 19.7 days vs. 22.5 ± 19.6 days; p=0.05) than patients in the historical control group. Linear regression analysis confirmed the association between perioperative nutritional treat-ment and decreased number of postoperative complications (β: -0.72 ± 0.24 (95%CI: -1.19, -0.26); p=0.003). Conclusions: The results of this exploratory study support the hypothesis that perioperative nutritional treatment by a dietician improves nutritional status and postoperative outcome in esophageal, gastric and pancreatic cancer patients. A large prospective randomized, controlled trial would be warranted to confirm these results. However, such a study may be unethical to conduct.

Encore abstract: Presented at ESPEN Conference, 2010. Published: Clinical Nutrition, September 2010. Reprint withheld at request of author

S36-4 - Parenteral Nutrition Outcomes of Patients with Short Bowel Syndrome after Discontinuing TeduglutideCharlene Compher, PhD, RD1; Richard Gilroy, MD2; Marek Pertkiewicz, MD, PhD3; Thomas Ziegler, MD4; Sarah J. Ratcliffe, PhD5; Francisca Joly, MD, PhD6; Fedja Rochling, MD7; Bernard Messing, MD, PhD6

1School of Nursing, University of Pennsylvania, Philadelphia, PA; 2Gastroenterology, University of Kansas Medical Center, Kansas City, KS; 3General Surgery and Nutrition, Medical University of Warsaw, Warsaw, Poland; 4Gastroenterology, Emory University, Atlanta, GA; 5Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA; 6Gastroenterology and Nutrition Support, Hospital Beujon, Paris, France; 7Gastroenterology, University of Nebraska Medical Center, Omaha, NE.

S36-5 - Sustained Glucagon-like Peptide-2 Infusion is Required for Intestinal Adaptation and Cessation Reverses Increased Cellularity in Rats with Intestinal FailureMatthew C. Koopmann, MD1,2; Xueyan Chen, MB, PhD3; Jens J. Holst, MD, PhD4; Denise M. Ney, PhD1

1Nutritional Sciences, University of Wisconsin, Madison, WI; 2Surgery, University of Wisconsin, Madison, WI; 3Pathology, University of Wisconsin, Madison, WI; 4Medical Physiology, the Panum Institute, University of Copenhagen, Copenhagen, Denmark.

Introduction: Glucagon-like peptide-2 (GLP-2) is a nutrient-dependent proglucagon-derived hormone that is a proposed treatment for human short bowel syndrome (SBS). Clinical studies evaluating GLP-2 in adults with SBS indicate that the effects of GLP-2 are not sustained after discontinuation of therapy. The objective was to determine how the timing, duration and cessa-tion of GLP-2 administration affect intestinal adaptation and enterocyte kinetics in a rat model of human SBS that results in intestinal failure requir-ing total parenteral nutrition (TPN). Methods: Rats underwent 60% jejunoileal resection plus cecectomy and jugular vein cannulation and were maintained exclusively with TPN for 18d in these treatments: TPN control (no GLP-2); sustained GLP-2 (1-18d); early GLP-2 (1-7d, killed at 7d or 18d); and delayed GLP-2 (12-18d). Enterocyte kinetics, including mitosis, apoptosis and crypt fission, were quantified by a pathologist based on evaluation of hematoxylin-and-eosin-stained jejunal sections. Results: Body weight gain was similar across groups and plasma bioactive GLP-2 was significantly increased with co-infusion of GLP-2 (100 μg/kg/d) with TPN. GLP-2 treated rats showed significant increases in duodenum and jejunum mucosal dry mass, protein, DNA, and sucrase activity compared with TPN control. The increased jejunum cellularity reflected significantly decreased apoptosis and increased crypt mitosis and crypt fission due to GLP-2. When GLP-2 infusion stopped at 7d, these effects were reversed at 18d. Sustained GLP-2 infusion significantly increased duodenum length and decreased 18d mortality to 0% from 37.5% deaths in TPN control (p=0.08). Colon proglucagon expression quantified

by real-time RT-PCR was increased in TPN controls and attenuated by GLP-2 infusion; jejunal expression of the GLP-2 receptor did not differ among groups. Conclusions: Early sustained GLP-2 infusion reduces mortality, induces crypt fission, and is required for intestinal adaptation whereas cessation of GLP-2 reverses gains in mucosal cellularity in a rat model of intestinal failure. Treatment with GLP-2 holds promise for patients with SBS, especially those with resection of ileum and colon and limited capacity to secrete endogenous GLP-2. This study furthers the role of exogenous GLP-2 as hormonal replace-ment therapy in intestinal failure, and demonstrates that early initiation and sustained duration of treatment is most effective.

S36-6 - Synergistic Effects of Glucagon-like Peptide-2 and Early Enteral Nutrition Permit Near Complete Independence from Total Parenteral Nutrition in a Rat Model of Human Short Bowel SyndromeAdam S. Brinkman, MD1,2; Patrick M. Solverson, BS1; Sangita G. Murali, PhD1; Denise M. Ney, PhD1

1Nutritional Sciences, University of Wisconsin-Madison, Madison, WI; 2Surgery, University of Wisconsin Hospitals and Clinics, Madison, WI.

Introduction: Short Bowel Syndrome (SBS) affects ~30,000 individuals in the United States and often necessitates total parenteral nutrition (TPN) due to inadequate intestinal adaptation. TPN is fraught with serious com-plications including recurrent episodes of bacteremia, sepsis, venous throm-bosis, and liver dysfunction. Glucagon-like peptide-2 (GLP-2) is a nutrient-dependent, proglucagon-derived gut hormone that stimulates intestinal adaptation. Provision of a small volume of enteral nutrition in the form of a low residue, liquid, semi-elemental diet, potentiates the intes-tinotrophic action of GLP-2 in parenterally fed rats with SBS. Our objective was to investigate whether early enteral nutrition in combination with GLP-2 allows independence from TPN in a rat model of SBS, and thus help clinicians liberate patients with SBS from TPN. Methods: Male, 175 gram, Sprague-Dawley rats underwent 60% small bowel resection (including ileum and cecum) with resultant jejunocolic anastomosis and placement of a jugular catheter. Animals were randomly assigned to TPN alone (TPN) or TPN with GLP-2 (100ug/kg BW/d) and enteral nutrients (TPN+GLP-2+EN). In both groups the rate of TPN was advanced from 1mL/hr to a nutritionally sufficient rate of 2.5mL/hr over the 72 hrs following surgery. Starting on post-operative day (POD) #4, rats in the TPN+GLP-2+EN group were allowed ad libitum access to diet. Enteral nutrition consisted of a rodent formulation of a commercial low residue, liquid, semi-elemental diet. Starting on POD #6, the rate of TPN in the TPN+GLP-2+EN group was reduced by 0.25mL/hr/day while following diet intake and daily body weight. Assessment of intestinal adaptation of residual bowel includes: length, mass, mucosal concentrations of protein and DNA, sucrase activity and histology. Results: Initial body weight was similar among groups on the day of surgery. Animals in both groups lost weight during the first 48 hours following surgery although both groups regained their pre-operative weight by POD #6. TPN+GLP-2+EN animals showed a steady gain in body weight after the introduction of EN and maintained body weights, as the TPN rate was decreased from 2.5mL/hr to 0.5mL/hr by day 15. The TPN+GLP-2+EN group showed a significantly greater gain in body weight compared with TPN alone, +46 vs +27 gm/18 days, despite similar total energy intake. The wet weight of jejunal mucosa was three-fold greater and the length of residual jejunum was ~20% longer in the TPN+GLP-2+EN group compared with the TPN group. TPN+GLP-2+EN animals were unable to be liberated from TPN during this 18-day study. Conclusions: Early EN in combination with GLP-2 following small bowel resection allowed for a safe 80% reduction of TPN rate with positive increases in body weight as well as mass and length of residual jejunum. These results indicate that early introduction of EN in combination with GLP-2 mediates intestinal adaptation of residual bowel such that near complete indepen-dence from TPN can be achieved in a rat model of SBS. In conclusion, strategies of early EN in combination with growth factors may help clini-cians liberate patients with SBS from TPN.


Author Index: Orally Presented Abstracts

Aguilar-Nascimento, J – M20-2Allard, J – S33-3Anderson, M – S31-3Antoun, S – S33-1Arcand, J – S33-3Azevendo, E – S33-3Ball, G – S32-1Ban, K – S35-2, S35-3Baracos, V – S33-1Batista, M – M20-5Bedi, N – S35-1Beishuizen, A – M20-4Bell, P – S34-2Bell, S – S31-5Besanko, L – S31-2Bigomia, S – S31-5Bistrian, B – S31-5Black, D – M20-1Bosmans, J – S33-6Brinkman, A – S36-6Burgess, A – S35-1Burgstad, C – S31-2Burke, P – S31-5Cardoso, V – M20-5Chapman, M – S31-2Chen, X – S36-5Clarke, S – S31-2Collier, B – S34-2Compher, C – S36-4Conlon, K – S36-1Corona, J – S31-4Correia, M – M20-5Dasgupta, M – S32-5Diamond, I – S36-2Diaz, J – S34-2Dixon, T – S34-5Dock-Nascimento, D – M20-2Drenckpohl, D – S32-3, S32-4Duggan, S – S36-1El-Chammas, K – S32-5Fechner, J – S34-6Feehan, S – S36-1Feldman, B – S36-2Feng, Y – S34-3Floras, J – S33-3Fogleman, M – S32-2Franklin, G – S31-3Fraser, R – S31-2Fukatsu, K – S34-1Gaskari, S – S34-5Ghanayem, N – S32-6Gilroy, R – S36-4Girbes, A – M20-4Goday, P – S32-5, S32-6Grant, R – S36-2Hamiel, C – S-35-4, S35-5, S35-6Hamilton, C – S34-4Hartmann, B – S34-3

Hehir, D – S32-6Helms, R – M20-1Heneghan, A – S34-6Heyland, D – S31-1, S31-3Higgins, D – S31-1Hiltner, L – S33-2Hoffmann, R – S32-5Holloway, R – S31-2Holst, J – S34-3Holst, J – S36-5Jetha, M – S32-1John, B – S34-4Joly, F – S36-4Jonker, M – S34-6Jotautas, A – S31-3Kallweit, A – S-35-4, S35-5, S35-6Kauffmann, R – S34-2Kerner, J – S34-5Kirby, D – S34-4Koopmann, M – S36-5Koyama, I – S34-1Kozar, R – S35-2, S35-3Kudsk, K – S34-6Kumpf, V – S34-2Kyle, U – S33-4Levi, J – S35-4, S35-6Ligthart-Melis, G – S36-3Ling, S – S36-2Lo, C – S33-5Macwan, K – S32-3, S32-4Mager, D – S32-1Mak, S – S33-3Mangoni, A – S31-2May, A – S34-2Mazurak, V – S31-3McGurk, S – S35-1Messing, B – S36-4Mogensen, K – S31-4Moggio, C – S32-2Moore, A – S36-2Moriya, T – S34-1Mourtzakis, M – S33-1Murakoshi, S – S34-1Murali, S – S36-6Murphy, R – S33-1Mussatto, K – S32-6Neelemaat, F – S33-6Newton, G – S33-3Ney, D – S36-5, S36-6Nguyen, N – S31-2Niederlechner, S – S-35-4, S35-5, S35-6Noguchi, M – S34-1Ochoa, J – M20-3Okamoto, K – S34-1Oleis, J – S34-2Omata, J – S34-1Osea, K – S31-6Parisienne, K – S33-5

Park, K – S34-5Patel, A – S32-2Peironi, K – S34-5Pencharz, P – S36-2Peng, Z – S35-2, S35-3Pertkiewicz, M – S36-4Pichard, C – S33-4Pierre, J – S34-6Poole, R – S34-5Pribis, J – M20-3Ratcliffe, S – S36-4Rawn, J – S35-1Reiman, T – S33-1Remick, D – S31-5Ridgway, P – S36-1Robinson, M – S31-4Rochling, Fedja – S36-4Rodriguez-Dimitrescu, C – S32-1Rudd, N – S32-6Saad, M – S31-3Saitoh, D – S34-1Sano, Y – S34-6Seidell, J – S33-6Seidner, D – S34-2Simpson, P – S32-6Slaughter, J – S34-2Slicker, J – S32-5, S32-6Solverson, P – S36-6Speerhas, R – S34-4Stahfeld, K – S33-2Steiger, E – S34-4Strauss, B – S33-5Stroud, D – S33-5Sufit, A – S31-1, S35-5Sultan, M – S32-5Tayek, J – S31-6te Boveldt, N – S36-3Teitelbaum, D – S34-3Thijs, A – S33-6Tillman, E – M20-1van Bokhorst-de van der Schueren, M – S33-6van der Peet, D – S36-3Verheul, H – S36-3Vermilyea, S – S32-5Waitzberg, D – M20-2Wakeham, M – S32-5Wales, P – S36-2Wang, H – S32-3, S32-4Weijs, P – M20-4Wilcox, G – S33-5Wischmeyer, P – S-31-1, S35-4, S35-5, S35-6Witowich, G – S32-2Xinmei, Z – M20-3Yap, J – S32-1Yasuhara, H – S34-1Young, L – S31-5Zager, L – S35-4Ziegler, T – S36-4


Clinical Nutrition Week 2011. Vancouver, B.C., Canada

gastric bypass (GB) surgery. There is little consensus about how much VitD should be supplemented after GB. The objective of this analysis was to determine how fat mass loss and VitD intake are related to circulating serum 25-OH VitD levels after GB. Results may yield a better understand-ing of optimal VitD treatment recommendations after GB. Methods: Twenty women (body mass index: 47.8±6.7 kg/m2; age: 48.0±10.3 years) were studied before GB and 1-year post-GB. Blood was collected in the fasted state and later analyzed for 25-OH VitD using the Diasorin Liaison method. Three-day diet records were collected for assessment of dietary and supplemental VitD intake prior to visits. Results: At baseline, 10 subjects were VitD insufficient (serum VitD <30 ng/mL) and 10 were deficient (serum VitD <20 ng/mL). At 1-year, 6 subjects had VitD>30 ng/mL, 10 subjects were insufficient and 3 were deficient. On average, fat mass decreased by 37±10 kg (p<0.01) and serum 25-OH VitD increased by 8±13 ng/mL (p<0.01) from baseline to 1-year. Average VitD intake from diet and supplements at baseline was 312±357 IU and increased to 604±410 IU at 1-year (p=0.02). Serum 25-OH VitD change from baseline at 1 year was predicted by fat mass loss and VitD intake (p=0.03 for the overall model). Although VitD intake was significantly associated with baseline serum 25-OH VitD, it was not a significant predictor of change in VitD. Conclusions: VitD status improved after GB, however insuffi-ciency remained a problem. Fat mass loss was a better predictor of serum 25-OH VitD levels than VitD intake. VitD intake in this study may not have been sufficient to promote optimal serum 25-OH VitD levels and future work regarding recommendations is warranted.

TOPIC: Body Composition

S2 - Protein Supplementation in the Early Post-Operative Period Following Gastric Bypass SurgeryLauren M. Beckman, MS, RD1; William Thomas, PhD2; Shalamar D. Sibley, MD, MPH3; Tiffany R. Beckman, MD, MPH3; Jennifer R. Mager, PhD, RD1; Todd A. Kellogg, MD4; Sayeed Ikramuddin, MD4; Carrie P. Earthman, PhD, RD1

1Food Science and Nutrition, University of Minnesota, Twin Cities, MN; 2School of Public Health, University of Minnesota, Twin Cities, MN; 3Medicine, University of Minnesota, Twin Cities, MN; 4Surgery, University of Minnesota, Twin Cities, MN.

Introduction: Following gastric bypass (GB) surgery, substantial changes in body composition occur, including loss of body weight and fat mass, which has a beneficial effect on overall morbidity. Fat free mass is also lost, but this could be disadvantageous because it contains the metaboli-cally active tissue compartment, termed body cell mass (BCM). Adequate protein intake is needed for optimal BCM maintenance and consequently the focus of this study was to determine if protein supplementation soon after GB has an impact on BCM. Methods: Twenty extremely obese women (BMI: 47.9±6.8 kg/m2; age: 48.0±10.3 years) were studied before GB and approximately 2 weeks, 6 weeks, 6 months, and 1 year postopera-tively. In a double-blinded manner, subjects were randomized to consume either a protein containing beverage (20g protein, 0g fat, 2g carbohydrate, 90kcal) or placebo (0g protein, 9g fat, 3g carbohydrate, 90kcal) twice a day immediately after surgery for 6 weeks. Fifteen women completed the 6 week supplementation period. BCM was estimated from intracellular fluid measured by multiple dilution. Group’s BCM values were compared in mixed-effects linear models with a random subject effect to model the

Scientific Poster Exchange. January 30, 2011

Sorted by topic

Bariatrics: S1Body Composition: S2-S6Cachexia: S7 (withdrawn)Catheters/Care: S8Critical Care: S9-S29Diabetes: S30-S32Enteral Nutrition: S33-S36Gastrointestinal Disease: S37-S39Glycemic Control: S40-S42Inflammation: S43Lipids: S44-45Liver Disease: S46-S47Malnutrition: S48-S50Neonatal: S51-S57Neurological Disorders: S58Nutrition Assessment: S59-S67Nutrition and Chronic Disease: S68Parenteral Nutrition: S69-S74Pediatrics: S75-S79Pharmaconutrition: S80Prebiotics: S81Quality Improvement: S82Surgery: S83-S87Trauma: S88

TOPIC: Bariatrics

Encore abstract: Reprinted from Clinical Nutrition Supplements, Vol 5, L.M. Beckman, C.W. Compher, J. Muniz, et.al., PP405 Serum 25-OH Vitamin D Improves After Gastric Bypass Surgery, 2, 2010, with permission from Elsevier.

S1 - Serum 25-OH Vitamin D Improves after Gastric Bypass SurgeryLauren M. Beckman, MS, RD1; Charlene Compher, PhD, RD, FADA, CNSC, LDN2; Juan Muniz, PhD2; Shalamar D. Sibley, MD, MPH3; Tiffany R. Beckman, MD, MPH3; Jennifer R. Mager, PhD, RD1; Sayeed Ikramuddin, MD4; Todd A. Kellogg, MD4; Carrie P. Earthman, PhD, RD1

1Food Science and Nutrition, University of Minnesota, Twin Cities, MN; 2School of Nursing, University of Pennsylvania, Philadelphia, PA; 3Medicine, University of Minnesota, Twin Cities, MN; 4Surgery, University of Minnesota, Twin Cities, MN.

Introduction: Vitamin D (VitD) insufficiency and obesity appear to be associated. Although it is thought that VitD may be sequestered in adipose tissue, VitD status does not greatly improve with weight loss following


correlation of repeated measurements. In addition, protein intake was assessed throughout the 1-year period. Results: Although the percentage of calories from protein and protein grams per kilogram were significantly greater during the supplementation period (weeks 2 and 6) in the protein group, there were no differences in BCM between the protein and placebo groups at any visit. BCM significantly decreased after surgery in both groups, with no differences in the amount of BCM lost between groups at any visit. Protein supplementation in the early post-operative period did not result in greater BCM preservation at 6 weeks through 1 year. Protein intake recommendations after GB are 60-80g/day and the percent of subjects consuming at least 60 g protein/day, regardless of treatment, was 6.7% at 6 weeks, 0% at 6 months, and 0% at 1 year. Conclusions: We found that the protein supplement augmented protein intake during the supplementation period but did not have a positive effect on BCM loss at any time point after GB. Perhaps the amount of protein in the protein supplement (i.e. 20g per supplement) was not suf-ficient to mitigate BCM losses and it is clear that future work should evaluate a higher protein dosage considering what is known about the beneficial effects of dietary protein on BCM during weight loss. Based upon dietary records, it is evident that neither group was consuming the recommended amount of protein and this further underscores the impor-tant role of the dietitian for post-GB nutrition management.

S3 - DXA Appendicular Lean Tissue Mass is a Good Surrogate for Total Body Protein in Hospital PatientsBoyd J. Strauss, MBBS, PhD, FRACP1,2; Daniel B. Stroud, PhD1,2; Che Sam Lo, MD, PhD1; Gisela Wilcox, MBBS, BMedSc, FRACP, FRCPA1,2

1Dept of Medicine, Monash University, Clayton, VIC, Australia; 2Body Composition Laboratory, Clinical Nutrition and Metabolism Unit, Monash Medical Centre, Clayton, VIC, Australia.

Introduction: Protein malnutrition in hospital patients is common, often undetected and a significant determinant of mortality and morbid-ity. Dual energy xray absorptiometry (DXA) is often used as an available reference method to assess body composition (BC). DXA appendicular lean tissue mass (ALTM) can be used to assess skeletal muscle mass, the BC component containing the most significant component of total body protein (TBP). We have assessed the relationship between DXA ALTM and TBP in hospital patients. Methods: We have used prompt gamma in vivo neutron activation analysis (IVNAA) to measure total body nitrogen, a direct TBP surrogate, for over 20 years. IVNAA nitrogen is accepted as the criterion method for the measurement of TBP, but is now available in only a few locations internationally. Our IVNAA facility exists in a BC laboratory located in a major university teaching hospital in Melbourne, Australia. Over that time, we have simultane-ously assessed DXA ALTM and IVNAA TBP in 1775 individual clinical patients (F 1072, M 703, 25 - 75 interquartile (IQ) age range 31 - 57 years). The patients are a mixed clinical sample (BMI IQ range 20.1 - 31.8 kg/m2, % DXA body fat IQ range 20.4 - 42.2), with conditions including short bowel syndrome, metabolic disorders, malabsorption, renal failure, cirrhosis, obesity and others. Two DXA units have been used during the 20 years (Lunar DPX and GE Lunar Prodigy). The CV for total body nitrogen by IVNAA in the laboratory is 3.5%. Results: Measured ALTM IQ range was 15.13 - 22.46 kg, and TBP was 7.19 - 10.75 kg. Gender, age and ALTM each were significant (p < 0.0001) independent predictors of TBP. Using multiple linear regression, TBP was significantly predicted by a combination of gender, age and ALTM (r2 = 81.76%, p < 0.0001). Conclusions: ALTM measured by DXA is a good surrogate measure of TBP, and can be used with confidence in the assessment of protein malnutrition in individuals across a wide range of clinical conditions. The wide availability of DXA in hospitals suggests that this method could be routinely used in the assessment of protein malnutrition.

Encore abstract: Presented at ESPEN 2010. Published : Clinical Nutrition Supplements. 2010, Vol.5;No.2:348. Reprinted with permission from Elsevier Ltd.

S4 - Determinants of bioelectrical phase angle in hospitalized patientsNicole Stobäus, MSc1; Matthias Pirlich, MD PhD2; Kristina Norman, PhD2

1Dept. of General Medicine, Charité - University medicine, Berlin, Germany; 2Dept. of Gastroenterology, Hepatology and Endocrinology, Charité - University medicine, Berlin, Germany.

Introduction: Phase angle, a parameter of bioelectrical impedance analysis is a well-known predictor of morbidity and mortality in various disease settings. The reasons for decreased phase angle are however not yet com-pletely understood. We therefore investigated determinants of phase angle in hospitalized patients. Methods: 770 patients (364 male; 53.6±16.7 years) were included in a retrospective analysis. Phase angle was assessed by bioelectrical impedance analysis at 50 KHz. Subjective Global Assess-ment (SGA) was used to evaluate nutritional status. Age, gender, body mass index (BMI) as well as nutritional status (SGA), diagnosis (benign or malignant) and C-reactive protein (CRP) were investigated as potential determinants of phase angle in a general linear model regression analysis. Results are given as estimates of effect size in percent. Results: 66.1% of patients were suffering from benign disease and 54.8% were classified moderate or severely malnourished (SGA B or C). Phase angle ranged from 1.6° to 8.4° (mean: 4.9±1.2°). Next to age (58.1%), SGA (24.8%) emerged as major determinant for phase angle in our study population. Moreover, gender (6.6%), CRP (5.5%) and BMI (5%) exhibited a significant influence on phase angle whereas diagnosis showed no significant effect. Conclusions: Next to established determinants like age, gender and BMI, malnutrition and inflammation have a strong impact on phase angle in sick individuals which partly explains its prognostic power.

S5 - Phase angle and body composition of patients undergoing liver transplantationLucilene R. Anastácio, RD,MS1; Lívia G. Ferreira, RD,MS2; Hélem S. Ribeiro, RD3; Agnaldo S. Lima, MD,PhD4; Eduardo G. Vilela, MD,PhD4; Maria Isabel Correia, MD,PhD4

1Adult Health Postgraduate Program, Medical School, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil; 2Surgery Postgraduate Program; Medical School, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil; 3Food Science Post Graduation Program; Pharmacy School, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil; 4Alfa Institute of Gastroenterology; Hospital of Clinics, Medical School, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.

Introduction: Phase angle (PA) is obtained by the ratio between resistance and reactance assessed by bioelectric impedance measurement. PA is related to body cell mass, function of cell membrane and it is considered a prognostic marker in various disease conditions, including cirrhosis. While the excess weight is well documented in patients who undergo liver transplantation (LTx), there are no available data on PA values in this population. Methods: From March to October of 2008, patients who underwent LTx were transversaly studied on body composition by Quantum XL bioelectric impedance. PA values were stratified according to reference values for Brazilian population considering sex and age. Excessive weight or obesity by percentage of body fat (PBF) were defined based on Lohman’s definition. Age, sex, income, schooling, self reported habitual sleeping hours, smoking, ex-smoking, familiar history of excessive weight, tacroli-mus or cyclosporine use, time on and cumulative dose of steroids use, indication for transplantation, donor age, sex and body mass index (BMI)


were assessed in order to identify associated factors with excessive PBF or lower PA levels. Mann-whitney, Qui-square and Exact Fisher tests were used (SPSS program version 17.0). Results: We assessed 162 patients (median age of 51 ± 13; 61.7% male). Data on PA, body composition and BMI are depicted in table 1. Although most patients were classified as overweight and obese both by BMI (59% and 21%, respectively) and PBF (91% and 65% respectively), many patients presented with PA values below percentile 5 (35%). Associated factors to excessive PBF were: smoking (p <0.01, OR: 0.11, CI: 0.03 to 0.37); familiar overweight history (p = 0.02, OR: 3.88; CI:1.14 to 13.17); tacrolimus use (p = 0.04, OR: 5.3; CI:1.56 to18.08); greater BMI immediately after LTx (p = 0.02). Associated factors to obesity according to PBF were: smoking (p = 0.01, OR: 0.18, CI: 0.06 to 0.53); family overweight reports (p <0.01, OR: 3.32; :1,68 CI-6, 56); male donor (p = 0.03, OR: 2.16; :1,09 CI-4.3); increased BMI before liver disease (p <0.01) and immediately after transplantation (p <0.01). No associated factors were identified for low values of phase angle. Conclusions: Almost all assessed patients who underwent liver transplantation presented with excess body fat and several factors were associated with this morbidity. On the other hand, decreased PA values in this population were high. This aspect needs to be further assessed, given the implications associated with it.

(BH; N=7/time point). Percent change was calculated using data from a sham group (Sham; n=4/time point). The burn groups received a 40% total body surface area (TBSA) full-thickness scald burn. Disuse by HLU was initiated immediately following injury. Urine was collected daily for determination of corticosterone. At the conclusion of the study, overall body fat mass was determined by visceral fat measurements and plasma was collected and stored at -80°C for analysis of plasma leptin. Data are presented as a percent change from sham and significance at p<0.05 was determined using a student’s t-test. Results: Fat mass was reduced in BA and BH on day 1 in response to the injury/disuse, but showed a non-significant increase at day 3. By day 7 fat mass was significantly reduced from sham in BA and BH, which continued until day 14. In addition, BH was significantly reduced from BA by day 7 (p<0.005). Percent leptin in BH was significantly elevated on day 1 and significantly decreased in BA and BH on days 3,7 and 14 (Table 1). We found significant increases in urinary corticosterone the day immediately following injury in BA and BH (p<0.005), followed by decreases in both groups through day 14. Conclusions: Burn injury, accompanied by long-term disuse causes com-plex metabolic changes. An acute phase of inflammation and ‘stress’ results from burn injury and disuse as illustrated by the dramatic increase in leptin and corticosterone during the ebb phase (day 1). Following this phase, the hypermetabolic response becomes apparent, leading to a loss of fat mass and dramatic decrease in leptin. The acute treatment of burn patients is a challenge due to the immediate metabolic changes, which vary over time and may involve multiple factors such as injury and disuse.

Table 1. Phase angle, body fat, lean body mass, hydration and body mass index values of patients

undergoing liver transplantation

Phase angle

Body fat (%)

Lean body

mass (%) Hydration

(%)

Body Mass Index

(kg/m2)

Mean 5.8 30.2 69.8 52.1 26.6 Standard Deviation 1.2 8.6 8.6 6.7 5.4 Median 5.7 31.0 69.0 51.5 26.1 Minimum 3.3 7.3 50.3 37.2 16.7 Maximum 11.4 49.7 92.7 69.4 56.8

S6 - Fat Metabolism Responses to Severe Burn and Disuse in RatsLisa A. Baer, MS1,2; Xiaowu Wu, MD2; Steven E. Wolf, MD2,3; Charles E. Wade, PhD1,2

1University of Texas Health Science Center-Houston, Houston, TX; 2US Army Institute of Surgical Research, Fort Sam Houston, TX; 3University of Texas Health Science Center-San Antonio, San Antonio, TX.

Introduction: Severe burn and disuse result in endocrine responses that are associated with substantial and sustained metabolic changes. A pro-found increase in the inflammatory response ultimately leads to hyper-metabolism with increased energy expenditure, thus resulting in a loss of fat and lean body mass. The metabolic response resulting from burn injury has been defined as biphasic, including the initial ebb phase, occurring within the first 24 hours of injury, followed by the flow phase, which can last for years. Hypermetabolic and catabolic responses to the injury are pronounced due to the reduction in tissue perfusion and altered metabo-lism. Previously we observed significant reductions in overall fat mass and metabolic hormones after 14 days of disuse following burn injury using a combined severe burn/hindlimb unloading (HLU) rodent model. The purpose of this study was to determine how metabolic indices are affected by HLU and severe burn during the acute ebb phase (1day) and flow phase (3 day,7 day, 14 day) as a percent change from sham. Methods: Male, Sprague-Dawley rats (~ 300g) were randomized into two groups: Burn Ambulatory (BA; N=7/time point), and Burn/Hindlimb unloaded

Table 1. Fat mass, leptin and corticosterone as a percent of sham.

% of Sham (Mean±SEM)

Fat Mass 1 day 3 day 7 day 14 day BA 87±5 105±5 83±3+ 74±3+ BH 88±3 91±5 65±5+* 56±2+*

Leptin BA 131±24+ 62±21+ 24±4+ 26±8+ BH 480±76+* 45±5+* 10±2+* 10±2+*

Urinary Corticosterone

BA 377±68 200±26 267±24 174±18+ BH 630±127+ 304±31+* 521±82+* 186±16+

+significant from sham; *significant from BA; p<0.005

TOPIC: Cachexia

S7 - Withdrawn

TOPIC: Catheters/Care

S8 - Taurolidine lock: British Columbian experience in Home Total Parenteral Nutrition patientsAlbert Chang, MD1,2; Elizabeth Bremner, MHA2; Sheila Sakich, RN2; Suzanne Idle, RD2; Scott Whittaker, MD1,2

1Medicine, University of British Columbia, Vancouver, BC, Canada; 2Medicine, St Paul’s Hospital, Vancouver, BC, Canada.

Introduction: Current literature suggests repeated antibiotics and catheter removal in a certain subset of patients suffering from multiple catheter-related bloodstream infections (CRBI) is unlikely to prevent recurrence. Line sepsis is the most common complication in home total parenteral nutrition (HPN). The purpose of this study was to examine if taurolidine lock in a group of


HPN patients prone to CRBI would help reduce infection rates and thus improve morbidity and mortality. Methods: HPN patients enrolled for greater than 1 year whom were identified to have multiple CRBI were enrolled in this study. They were given 2% Taurolidine lock instilled into the central line following TPN infusion and remained in-situ until the next TPN infusion. Nursing training and demonstration was given and a take-home brochure reminding of proper aseptic technique and proper Taurolidine lock use. These patients utilized the Taurolidine lock for at least 1 year. CRBI rates were calculated based on 1000 catheter days, and compared as pre-and post-Taurolidine infection rates. Data collection included number of line changes, taurolidine complications and incidences of bactermia. Results: Nine patients were identified with multiple CRBI. Four patients were excluded: two were already on Taurolidine prior to study, one patient was on Taurolidine only for 6 months and the last one refused to participate. All five of remaining patients have been on HPN for at least 2 years (range: 2-13 years) and using the Taurolidine lock for at least one year. CRBI rates ranged from 1 to 5 per 1000 catheter days pre-Taurolidine, which reduced to 0 infection post-Taurolidine. Central line changes were performed for all patients who had CRBI infections. Bactermia was noted in greater than >95% of CRBI infections with the Methicillin-sensitive Staph aureus as the most common species. There were no Taurolidine related complications. Conclusions: Taurolidine may improve line sepsis rates in HPN patients suffering from CRBI. Further studies will include greater recruitment, complication monitoring and cost analysis.

TOPIC: Critical Care

S9 - A Retrospective Review of Feeding Practices in the Intensive Care Unit Following Abdominal Aortic Aneurysm RepairMelanie R. Ksienski1; Tanis R. Fenton1,3; Kevin B. Laupland2,3; Dan Zuege2,3; Paul Petrasek4,3; Reza Shahpori21Nutrition Services, Calgary Area, Alberta Health Services, Calgary, AB, Canada; 2Critical Care, Peter Lougheed Centre, Alberta Health Services, Calgary, AB, Canada; 3Faculty of Medicine, University of Calgary, Calgary, AB, Canada; 4Division of Vascular Surgery, Peter Lougheed Centre, Alberta Health Services, Calgary, AB, Canada.

Introduction: Abdominal aortic aneurysm (AAA) repair often involves substantial post-operative morbidity, admission to the intensive care unit (ICU) and long hospital stays. Early enteral feeding (EN) (within 48 hours of ICU admission) is recommended for the general ICU population and is associated with improved outcomes. Prior local qual-ity improvement studies suggested post operative AAA repair patients had delayed initiation of EN compared to other medical and surgical patients in the ICU. Our objectives were to describe the times to initia-tion of feeding (EN & oral diet), identify variables associated with early feeding, determine if early EN is achievable and well tolerated and determine if early feeding was associated with reductions in mortality and durations of mechanical ventilation and ICU stay. Methods: A retrospective cohort design was used to review records of post-surgical AAA repair patients admitted to ICU within 48 hours of surgery. Fac-tors associated with early feeding were identified. Feasibility, tolerance to early feeding and nutritional adequacy were evaluated. Results: Preliminary results revealed that of 162 patients included, only 23.5% received early feeding. A description of feeding practices is shown in Figure 1. Patients were at higher risk of not being fed early if they had an open versus endovascular AAA repair (RR = 1.5, 95% CI = 1.2 to 1.9, p = 0.0001) and large blood losses (>4L) during surgery (RR = 1.3, 95% CI = 1.1 to 1.5, p = 0.007). However, emergency versus elective surgery was not associated with early feeding (RR = 1.1, 95% CI = 0.91 to 1.3, p = 0.338). Patients who were fed early had a shorter ICU length of stay compared to those who were not fed early (4.7 vs. 10.0 days; p=0.0007). Vascular surgeons were noted to have varying practice regarding early feeding, by feeding early between 4 and 33% of their AAA patients (p = 0.043). Of the 48 patients fed via EN, 28 achieved nutrition adequacy (> 80% of EN goal rate received) during ICU admission. Feed intolerance was not significantly different between the early and the delayed fed group (RR = 1.8, 95% CI = 0.65 to 5.1, p = 0.26). Conclusions: Early feeding was achieved in a minority of patients and was related in part to patient surgical characteristics and individual healthcare provider practices. Further studies are needed to determine whether early enteral feeding is safe and beneficial in this patient group.

Description of feeding practices once admitted to ICU post AAA repair


S10 - A Safety and Dose-Escalation Study of Parenteral Zinc Supplementation in Critically Ill Children-Stage 1Natalie Cvijanovich1; Heidi R. Flori1; Ginny Gildengorin1; Janet King1; Hector R. Wong2

1Critical Care, Childrens’ Hospital & Research Center Oakland, Oakland, CA; 2Critical Care, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.

Introduction: Zinc (Zn) is an essential trace element required for the function of multiple enzymes and transcription-related factors. It plays important roles in immune function, both innate and adap-tive, wound healing, and glucose homeostasis. Plasma Zn levels drop in the setting of critical illness, and urinary excretion increases, potentially resulting in the net effect of functional Zn deficiency. Low Zn levels are associated with increased organ failure in critically ill children. We postulate that the known association of glucose dysregulation and immunosuppression associated with critical illness is due in part to, and potentially ameliorated by, Zn supplementation. There are no known studies of intravenous (IV) Zn supplementation in the critically ill. Our objective is to assess the safety and phar-macokinetics of IV Zn supplementation in step-wise escalating doses, starting with 250 mcg/kg/day. We will simultaneously evaluate glucose homeostasis, markers of inflammation, and development of lympho-penia. The ultimate goal of this study is to inform a future inter-ventional trial of Zn supplementation in critically ill children. Methods: This is a prospective, Phase I/II trial of IV Zn supple-mentation in critically ill children < 10 years old presenting to a pediatric intensive care unit (PICU), with PRISM III score > 5 or

at least one new organ failure. After consent was obtained, plasma and urine Zn levels on Days 1 through 7 were measured, as well as lymphocyte subsets and markers of inflammation (interleukin-6 [IL-6] and C-reactive protein [CRP]) on Days 1 and 3 of illness. Glucose levels and requirement for insulin were monitored. The first 6 enrolled subjects (“control” group) received no supplemental Zn, but underwent all laboratory testing. The second group of 6 patients (Zn 250 group) received 250 mcg/kg/day IV Zn sulfate, divided into 3 doses daily for 7 days. All clinical data were collected. The next phase of the study will be to increase the supplementation dose to 500 mcg/kg/day. If this is tolerated and plasma Zn levels are not supratherapeutic, the dose will be increased to 750 mcg/kg/day. Results: Twelve patients have been enrolled to date, six in the “control” group and six in the Zn 250 group. Mean age was 40 ± 41 months in the controls, and 22 ± 21 months in the Zn 250 group (p=0.42). PRISM and PIM scores were not significantly different between groups (PRISM 10.5 ± 7.4 control, vs. 9.5 ± 7.8 Zn 250, p=0.82; PIM 10.6 ± 12.2 control, 15.1 ± 12.1 Zn 250). Day 1 mean plasma Zn was low (43.1 ± 13.6 mcg/dL), with no signficant differ-ence between groups. In the Zn 250 group, plasma Zn levels increased over the 7-day period of supplementation, but remained below normal (Day 1: 36.6 ± 14.7; Day 7: 67.1 ± 10.4; mean ± SD)-see Figure 1. There were no changes in lymphocyte subsets, IL-6, or CRP during the supplementation period in either group. There were no adverse events in any patients. Conclusions: Supplementation of critically ill children with 250 mcg/kg/day IV Zn is well-tolerated and feasible. However, at this dose normalization of plasma Zn does not occur. It is therefore reasonable to continue dose escalation to 500 mcg/kg/day

Figure 1. Average zinc levels per day for controls and zinc supplemented patients. Data are expressed as the means per day ± sem. The day 1 values for zinc supplemented patients represent the 8 am level, prior to the first dose.


S11 - Plasma Motilin Concentrations are Not Suppressed by Small Intestinal Nutrient Infusion in Critically Ill PatientsLaura K. Besanko, BHSc1; Robert Fraser, MBBS FRACP PhD1,2; Nam Q. Nguyen, MBBS(Hons) FRACP PhD3; Carly M. Burgstad, BHSc(Hons)3; Marianne Chapman, BMBS FANZCA FJFICM4; Spencer Clarke, BSc(Hons)5; Richard H. Holloway, BSc(Hons) MBBS FRACP MD3,2; Arduino Mangoni, MBBS FRACP PhD6

1Investigation and Procedure Unit, Repatriation General Hospital, Adelaide, SA, Australia; 2Discipline of Medicine, University of Adelaide, Adelaide, SA, Australia; 3Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, SA, Australia; 4Intensive Care Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia; 5Pharmacology, University of South Australia, Adelaide, SA, Australia; 6Pharmacology, Flinders Medical Centre, Adelaide, SA, Australia.

Introduction: During fasting, gastric and small intestinal motility under-goes cyclical phase III activity associated with increased plasma motilin concentrations. In health, this fasting motor activity is terminated by small intestinal nutrient infusion and replaced by a fed motor pattern. In critical illness, however, phase III-like activity persists in the small intestine, but not stomach, during enteral feeding. Plasma motilin con-centrations in critically ill patients are unknown, as is the response to intestinal nutrient. The aim of this study was to determine fasting and nutrient-stimulated plasma motilin concentrations in critical illness. Methods: In 21 critically ill patients (13 male; 49±4 yr) and 18 healthy subjects (10 male; 27.7±2.9 yr) plasma motilin concentrations were determined (using radioimmunoassay) at baseline (fasting) and at 20, 40 and 60 min during separate intra-duodenal (ID) nutrient (Ensure®) infusions of 1 and 2 kcal/min. Data mean ± SEM; comparison 2-way ANOVA. Results: Fasting plasma motilin concentrations in critically ill patients and healthy subjects were similar (94±11 vs. 82±11 pg/mL; P=0.46). In healthy humans, plasma motilin concentrations fell during ID nutrient infusion (P<0.001), with a greater reduction during 2kcal/min (P=0.03). However, in critical illness, plasma motilin concentrations increased during ID nutrient infusion (P=0.001) with a peak at 20min, with no difference in response between caloric loads. Plasma motilin concentrations were higher in critically ill patients during both 1kcal/min (P=0.07) and 2kcal/min (P=0.003) infusions compared to healthy subjects. There was a trend for increased motilin concentrations during 2kcal/min infusion in feed intolerant patients (n=10), compared to patients tolerant of enteral feeding (P=0.09). Conclusions: In critical illness, fasting plasma motilin concentrations are normal, but do not suppress with SI nutrient infusion as occurs in health. This appears to be more predominant in feed-intolerant patients, and may contribute to the per-sistence of small intestinal phase III activity during enteral feeding in critically ill patients.

S12 - How are we Feeding the Critically Ill Elderly? A Multicenter Observational StudyNaomi E. Cahill, MSc1,2; W. Ting Lim, BSc1; Rupinder Dhaliwal, RD BASc2; Miao Wang, MSc2; Daren K. Heyland, MD, FRCPC2,3

1Department of Community Health and Epidemiology, Queen’s University, Kingston, ON, Canada; 2Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada; 3Department of Medicine, Queen’s University, Kingston, ON, Canada.

Introduction: The proportion of elderly patients being admitted to our Intensive Care Units (ICU) is increasing. Currently, there is a paucity

of information about the nutrition care received by this vulnerable subgroup of patients. This study aimed to describe the baseline personal demographics, nutritional practices and clinical outcomes of octogenar-ians (80+ years old) admitted to the ICU. The secondary objective was to examine if there is an association between the nutritional status of and nutrition received by octogenarians on admission to ICU and their 60-day clinical outcomes. Methods: Three multi-centre, international prospective observational studies of nutritional practices in 355 ICUs were conducted in 2007, 2008 and 2009. Each participating ICU aimed to collect data on 20 mechanically ventilated critically ill adult patient who stayed in the ICU for a minimum of 72 hours. Patient character-istics, nutrition status on ICU admission (i.e. BMI), nutrition received for the first 12 days of ICU admission, and 60-day clinical outcomes were recorded for each patient. Results: Data were collected on 8838 patients, of these, 946 were octogenarians and had at least 3 days in the ICU prior to exclusive oral feeding. The mean age of patients included was 84.0±3.4 years with a mean BMI of 25.6±5.2 kg/m2. A total of 483 (51.6%) were classified to be at nutritional risk with a BMI <25 kg/m2. Of all patients, 66.8% received enteral nutrition (EN) alone, 9.4% received parenteral nutrition (PN) alone, 15.8% received EN and PN combined, and 8% received no artificial nutrition during the first 12 days of their ICU stay. The mean time to start of EN was 1.7±1.8 after admission to ICU. Of all patients who had EN interrupted due to intol-erance (n=168), 90.8% received motility agents and 2.5% had small bowel feeds. The mean head of bed elevation was 32.3±10.7 degrees. Overall, patients received 56.4%±29.5% of the energy and 52.8%±29.9% of protein prescribed from total nutrition. Forty two percent of patients died within 60 days of ICU admission, and of the surviving patients, 75.2% were still in the hospital at day 60. The proportion of patient who died or remained in hospital was significantly higher for patients with a low BMI <25 compared to those with a BMI of 25-30 (adjusted hazard ratio (HR) = 0.73, 95% confidence interval (CI) 0.56-0.94, p=0.02). An increase in the provision of nutrition of 1000 Kcals per day was associated with a reduction in the proportion of patients who died or remained in hospital (unadjusted HR = 0.77, 95% CI 0.62-0.95, p=0.02). However this difference did not remain significant (p=0.14) after adjusting for significant baseline characteristics including nutri-tional status. Conclusions: In this study we observed that octogenarians are being admitted to the ICU with poor nutritional status, are not adequately fed, have a high mortality rate, and remain in hospital care long after ICU discharge. This study with help to identify opportunities for improving the quality of nutrition care provided to malnourished elderly patients.

S13 - Barriers to Feeding Critically Ill Patients: A Survey of Critical Care NursesNaomi E. Cahill, RD MSc1,3; Lauren Murch, MSc3; Rupinder Dhaliwal, RD BASc3; Daren K. Heyland, MD MSc2,3

1Department of Community Health and Epidemiology, Queen’s University, Kingston, ON, Canada; 2Department of Medicine, Queen’s University, Kingston, ON, Canada; 3Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada.

Introduction: Despite the publication of evidence-based clinical practice guidelines (CPGs) for nutrition therapy in the intensive care unit (ICU), delivery of optimum nutrition remains difficult to achieve in most ICUs. Recent literature suggests that for guidelines to be successfully imple-mented into practice we first need to understand the barriers to changing practice. Recognizing that critical care nurses are key stakeholders in facilitating adequate and safe provision of nutrition in the ICU, before we can successfully implement the recommendations of critical care nutrition guidelines we need to gain an understanding of the barriers


that critical care nurses face when enterally feeding critically ill patients. The objective of this study was to describe barriers to enterally feeding critically ill patients. Methods: A cross-sectional survey of barriers to enterally feeding critically patients was conducted between April and June 2010. Seven ICUs from 5 hospitals in Canada and the USA who are participating in a quality improvement initiative were involved in this survey. At each ICU, a random sample of 60 full and part-time nurses were invited to complete the questionnaire. If the total number of nurses employed in the ICU was less than 80, the questionnaire was sent to all nurses. The questionnaire was composed of 49 items divided into four parts. Part A consisted of general questions about the imple-mentation of nutrition guidelines (9 items). Part B asked respondents about their level of agreement with the recommendations of the nutri-tion guidelines pertaining to enteral feeding (8 items). Part C focused on specific barriers to delivering adequate amounts of enteral nutrition (26 items). Important barriers were identified as more than a third of nurses responding “fully disagree” and “disagree” to the positive framed questions, or “important” and “very important” to negative framed ques-tions. Results: A total of 154/420 critical care nurses completed the barriers questionnaire, for a response rate of 36.7%. None of the respon-dents disagreed with the statement that nutrition therapy was very important for mechanically ventilated critically ill patients, and that they are responsible for ensuring that patients receive adequate nutrition while in the ICU. Overall, the nurses agreed with the recommendations of critical care nutrition CPGs. The most important barriers were identi-fied as ‘no or not enough feeding pumps on the unit’ (51.2%), ‘other aspects of care take priority over nutrition’ (51.2%), ‘enteral formula not available on the unit’ (49.2%), ‘delays and difficulties obtaining small bowel access’ (44.4%), ‘no or not enough dietitian coverage at weekends and holidays’ (42.8%), ‘no feeding tube in place to start feed-ing’ (41.2%), ‘delay in physician ordering initiation of EN’ (41.0%), ‘non-ICU physicians requesting patients not be fed enterally’ (40.2%), ‘delays in initiating motility agents in patients not tolerating EN’ (38.8%), ‘waiting for the dietitian to assess the patient’ (36.1%), ‘current national guidelines not readily accessible when needed’ (35%), and ‘feeding being held too far in advance of procedures’ (33.1%). Conclusions: Overall, nurses attitudes towards nutrition therapy and critical care nutrition CPGs recommendations were positive. However, we identified important barriers to feeding critically ill patients. Future quality improvement programs should include a barriers assessment and tailor implementa-tion strategies to overcome the identified barriers to feeding critically ill patients.

S14 - Title: Epidermal Growth Factor is Depleted and Predicts Sequential Organ Failure Assessment Score in Adult ICU PatientsLindsay B. Weitzel, PhD1; Ludmila Khailova, MS1; Kelly Queensland, BA1; Daren K. Heyland, MD2; Paul Wischmeyer, MD1; Jessica A. Dominguez, PhD1

1Antesthesiology, University of Colorado Denver, Aurora, CO 80045, CO; 2Medicine, Kingston, Ontario, ON, Canada.

Introduction: Epidermal growth factor (EGF) is a peptide that has been shown to be protective against organ injury in preclinical models of critical illness. However, the role of EGF in critically ill patients is unknown. The goal of this study was to investigate the relationship of serum EGF levels to mortality, infection, and organ failure in adult ICU patients. Methods: 111 patients had blood drawn on Day 1 of their ICU stay as part of a prospective observational ICU trial. Blood was also collected from 10 healthy controls. Serum from the non-selected sub-groups was analyzed for EGF using Quantikine Human EGF ELISA kit. Statistical analyses were carried out using SAS version 9.2. Results: All

patients were mechanically ventilated and 43 (45%) patients were diag-nosed with infection during their ICU stay. Patients admitted to the ICU had significantly lower (p ≤ 0.001) levels of EGF (30.14 ± 3.29 pg/ml) compared to healthy controls (367.21 ± 44.19pg/ml). There is no rela-tionship between EGF levels and age, gender, infection or mortality. EGF levels were significantly related to maximum SOFA score when tested via simple regression (p=0.0356). Conclusions: Our data reveals serum EGF levels are depleted in critically ill patients. We also show EGF levels correlate with the sequential organ failure score. EGF is known to protect organs such as the intestine, kidney, and lung. There-fore, systemic administration of EGF may be a novel therapeutic agent for critically ill patients.

S15 - Thrombocytopenia is not a contraindication to feeding tube placement in critically ill oncology patientsRina P. Patel, Pharm.D.1; Todd Canada, Pharm.D., BCNSP, FASHP1; Joseph L. Nates, MD, MBA-HCA, FCCM2

1Division of Pharmacy, University of Texas M. D. Anderson Cancer Center, Houston, TX; 2Department of Critical Care, University of Texas M. D. Anderson Cancer Center, Houston, TX.

Introduction: Current guidelines recommend that enteral nutrition be initiated in critically ill patients who are unable to maintain volitional intake. Existing trials have not evaluated the feasibility of feeding tube (FT) placement in the critically ill thrombocytopenic oncology population. Thrombocytopenia (TCP) may be considered a “contraindication” to FT placement due to the potential risk of bleeding complications. Primary Objective: To compare the incidence of overt and clinically important gastrointestinal (GI) and point-of-entry bleeding complications within 72 hours of attempted FT placement among critically ill oncology patients with and without TCP. Secondary Objectives: To compare the number of attempts for FT placement, number of aborted FT placements, number of displaced FT requiring replacement/readjustment, number of blood product transfusions, and number of patients that reach enteral feeding goal by ICU day 7 or discharge. Methods: Medical intensive care unit oncology patients > 18 years old with attempted FT placement were evaluated in a 52-bed ICU at a 550-bed comprehensive cancer center. Endpoints were compared between patients with and without TCP. TCP was defined as a platelet count < 150,000/μL. Overt bleeding was pres-ence of hematemesis, gross blood, coffee-ground material in FT aspirate, hematochezia or melena. Clinically important bleeding was overt bleeding plus 1 of the following: decrease in hemoglobin (Hgb) by ≥ 2 g/dL in a 24-hour period within 72 hours of FT placement, failure of Hgb to increase by number of units of RBCs administered minus 2 within 72 hours of FT placement or decrease of systolic blood pressure by ≥ 20 mmHg within 24 hours of symptoms. Patient demographics, baseline and follow-up laboratory data, bleeding complications, units of blood products trans-fused, and patient disposition were collected. Thirty-eight subjects were needed to detect a 45% difference in bleeding complications for a 90% power. Results: Fifty-nine patients (TCP=42, no TCP=17) were enrolled between December 2009 and May 2010. Baseline characteristics are shown in Table 1. The mean age was 57 years, and 58% were female. TCP patients were more likely to have a hematologic malignancy, lower baseline hemoglobin and platelet count (p <0.01). As expected, more TCP patients received blood products 24 hours prior to FT placement (p <0.01). Overt (0 vs 7.1%) and clinically important (2.4% vs 5.9%) bleeding complications were not associated with the presence of TCP (p=0.55 and p=0.50, respec-tively). Secondary outcomes are shown in Table 2. Conclusions: Critically ill oncology patients with TCP do not appear to be at a higher risk for overt or clinically important point-of-entry or GI bleeding complications after FT placement compared to those without TCP if they are transfused prior to FT placement.


S16 - Predictive Equations of Caloric Needs in Traumatic Brain Injury: How Good Are They?Merin M. Kinikini, RD,FNP,CNSC; Thomas W. White, MD,FACS,CNSC; Holly Keller, RD,CD,CNSC; Kristine Douglass, RD,CD,CNSD; Lorraine Linford, RN,BS,CNSCNutrition Support Service, Intermountain Medical Center, Salt Lake City, UT.

Introduction: Traumatic Brain Injury (TBI) is a devastating diagnosis which consists not only of the primary insult, but also an insidious secondary injury cascade. Patients with severe TBI have a disruption in metabolic homeostasis that increases energy expenditure and protein catabolism. Inappropriate feeding of these patients is associated with increased morbidity and mortality. Estimating energy requirements for TBI patients continues to be problematic. Previous studies in various ICU patient populations have compared caloric needs generated by predictive equations with Indirect Calorimetry (IDC). These studies consistently demonstrate poor correlation. We hypothesize that standard energy prediction equations underestimate the caloric needs of TBI patients with multi-system injury. Our study aim was to compare several predictive equations, commonly used in the ICU patient population, with IDC-generated REE in severely injured patients with TBI. Methods: IDC was used to measure REE in mechanically ventilated ICU patients with a diagnosis of TBI. Estimated energy requirements were calculated using the following instruments: Harris-Benedict Equation, Harris-Benedict x 1.7, Penn State Equation, Ireton-Jones Equation with and without burn factor, Mifflin-St. Jeor Equation, Mifflin St.-Jeor x 1.7, and 35 kcal/kg. Additionally, an individualized caloric recommendation was rendered for each patient by an experienced nutrition support clinician. Mean values were compared to mean REE using Student’s t-test. Results: Forty three IDC studies were obtained in 37 patients at a mean of 9 days from ICU admission. All prediction models significantly underpredicted caloric needs except for Harris-Benedict X 1.7, Mifflin-St Jeor X 1.7, and Ireton-Jones with burn factor. Mean Ireton-Jones with burn factor significantly exceeded REE. See table. Conclusions: Com-monly used predictive equations for energy requirements are suspect in this

patient population and consistently underpredict caloric needs. In the absence of IDC, Harris Benedict X 1.7 and Mifflin St. Jeor X 1.7 appear to most closely predict the hypermetabolism of severely injured patients with TBI.

Table 1. Baseline characteristics and bleeding complications

TCP (n=42) No TCP (n=17) p-value

Age 58 ± 12.9 53.3 ± 16.1 0.66 APACHE-II score 28.8 ± 6.5 25.7 ± 6.4 0.11 Hematologic malignancy* 34 (81) 2 (12) <0.001 Baseline hemoglobin (g/dL) 8.3 ± 1.1 9.7 ± 1.6 0.003 Baseline platelet count (x 103/μL) 40.9 ± 47.7 248.6 ± 84.8 <0.001 Baseline PT 18.3 ± 3.2 18 ± 4.7 0.82 Transfusion of blood products before FTP* 36 (86) 2 (12) <0.001 Transfusion of RBC 24 h prior to FTP (mL) 498 ± 260 577 ± 280 0.68 Transfusion of platelets 24 h prior to FTP (mL) 457 ± 235 0 NA Overt bleed* 3 (7.1) 0 0.55 Clinically important bleed* 1 (2.4) 1 (5.9) 0.50

TCP: thrombocytopenia, APACHE-II: acute physiology and chronic health evaluation, PT: prothrombin time, FTP: feeding tube placement, RBC: red blood cells, NA: not applicable Data presented as mean ± SD unless otherwise indicated *n (%)

Secondary outcomes

TCP (n=42) No TCP (n=17) p-value

TF goal by ICU day 7 or discharge 17 (40) 8 (47) 0.64 Number of total FTP attempts* 3 ± 2 (1-12) 3 ± 2 (1-7) 0.62 Patients with repeat attempts 32 (76) 11 (65) 0.52 Patients with aborted attempts 5 (12) 3 (18) 0.68 Displaced FT requiring adjustment 6 (14) 6 (35) 0.09

TCP: thrombocytopenia, TF: tube feed, ICU: intensive care unit, FTP: feeding tube placement Data presented as n (%) unless otherwise indicated *Mean ± SD (Range)

Results

Method Mean Kcal/day ± Std p-value

Indirect Calorimetry/REE 3025 ± 573 Harris-Benedict 1781 ± 237 <0.0001 Harris-Benedict x 1.7 3025 ± 408 <0.9909 Penn State 2202 ± 292 <0.0001 Ireton-Jones 2501 ± 213 <0.0001 Ireton-Jones w/ burn factor 3348 ± 213 <0.0007 Mifflin-St Jeor 1726 ± 176 <0.0001 Mifflin-St Jeor x 1.7 2934 ± 305 <0.367 35 kcals/kg 2793 ± 524 <0.056 Nutrition Assessment Recommendation

2336 ± 329 <0.0001

S17 - Parenteral Nutrition in the Intensive Care Unit: Risk of Bias in Randomized TrialsRonald L. Koretz, Emeritus Professor of Clinical Medicine Department of Medicine Olive View-UCLA Medical Center Sylmar, CA, USA1; Timothy O. Lipman, Chief Division of Gastroenterology, Hepatology, and Nutrition Veterans Affairs Medical Center Washington, D.C., USA2

1Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA; 2Division of Gastroenterology, Hepatology, and Nutrition, Veterans Affairs Medical Center, Washington, DC.

Introduction: The current gold standard for making any therapeutic recommendation is a demonstration of benefit in one or more


randomized clinical trials (RCTs) with low risk of bias. (The reason for emphasizing low risk of bias is the fact that a lack of attention to certain methodologic details tends to demonstrate a more favor-able estimate of efficacy.) A recommendation to use parenteral nutrition (PN) in patients in the intensive care unit (ICU) is not based on such convincing evidence. Since current guidelines usu-ally do not even consider the issue of bias, this systematic review was undertaken to assess the utility of PN in the ICU from the perspective of risk of bias. Methods: RCTs assessing the utility of PN in patients who were explicitly known to be in ICUs were sought via computer searches of MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials. In addition, hand-searches of specific journals, Index Medicus, and abstracts of the annual meetings of ASPEN, ESPEN, and Digestive Disease Week were done. In order to qualify, the trial had to have been random-ized (quasi-randomized trials excluded), include a control group that, at least at the time when the PN was begun in the treated group, received no artificial nutrition, and report at least one clini-cal outcome (mortality, infectious or non-infectious complications, days on the ventilator, in the ICU, or in the hospital, or cost). The data were combined with meta-analysis. Risk of bias was determined by Cochrane criteria (adequate or unclear/inadequate 1] generation

of the randomization sequence, 2] concealed allocation, 3] blind-ing, 4] baseline similarities, 5] ability to do intent-to-treat analysis/accounting for dropouts, 6] selective outcome reporting, 7] early stopping, and 8] vested interest). One point was given for each criterion met. Since none of the RCTs met most of these criteria, after the scores were calculated, but before any analyses were done, “lower” risk of bias was defined as adequacy in at least 4 of these criteria or in 3 if none of the others was assessed as inadequate. Results: Nine RCTs were identified; 5 were conducted in adults and 8 were reported as full papers. Four were at lower risk of bias. The estimated effect (relative risk [RR] or weighted mean differ-ence [WMD]) and 95% confidence intervals (CI) for the various analyses are displayed in the table; RR < 1.0 or WMD < 0.0 favors PN. A significant difference is present when the 95% CI does not cross the line of equivalence. While there were only a limited number of RCTs to assess, significant harms were identified with regard to infectious and non-infectious complications. These harms were present in the trials at lower risk of bias. Since all of the trials were at substantial risks of bias, the true effects may even be more detrimental. Conclusions: Until truly low risk of bias RCTs show benefit, the fact that only harm was demonstrated should lead to a recommendation not to use PN in the critically ill.

Clinical outcome All trials Lower risk of bias High risk of bias

Mortality 1.00 (0.73, 1.38)1 1.01 (0.69, 1.49)1 0.98 (0.56, 1.70)1

Infectious complications 1.46 (1.18, 1.80)2 1.45 (1.17, 1.83)2 1.44 (0.84, 2.46)2

Non-infectious complications 1.31 (1.17, 1.47)1 1.26 (1.13, 1.41)1 3.00 (1.11, 8.12)1

Days on ventilator3 +1.31 (-0.78, +3.40)3 No data +1.31 (-0.78, +3.40)3

Days in ICU -2.20 (-6.85, +2.45)4 No data -2.20 (-6.85, +2.45)4

Days in hospital +3.50 (-2.62, +9.61)1 No data +3.50 (-2.62, +9.61)1

Cost (\$1000) +2.2 (-0.8, +5.2)4 No data +2.2 (-0.8, +5.2)4

1Effect present or absent in both pediatric and adult trials 2Effect only seen in adult trials 3Data from two trials in adults; no pediatric data 4Data from one trial in adults

S18 - Enteral Nutrition in the Critically Ill: Benefit or Methodologic Bias?Ronald L. Koretz, Emeritus Professor of Clinical Medicine Department of Medicine Olive View-UCLA Medical Center Sylmar, California, USA1; Timothy O. Lipman, Chief Division of Gastroenterology, Hepatology, and Nutrition Veterans Affairs Medical Center Washington, D.C., USA2

1Department of Medicine, Olive View-UCLA Medical Center, Sylmar, CA; 2Division of Gastroenterology, Hepatology, and Nutrition, Veterans Affairs Medical Center, Washington, DC.

Introduction: The current gold standard for making any therapeutic recommendation is a demonstration of benefit in one or more random-ized clinical trials (RCTs) with low risk of bias. A number of guidelines use data from RCTs to recommend enteral nutrition (EN) for patients in the intensive care unit (ICU). However, the influence of bias was not considered in the formulation of these guidelines in spite of the fact that a lack of attention to certain methodologic details usually produces an overestimation of the size of the effect. The objective of this systematic review was to identify the RCTs assessing the use of EN in critically ill patients and to compare analyses of trials at high risk of bias with those at low risk of bias. Methods: RCTs assessing EN in patients explicitly known to be in ICUs were sought via computer searches of MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials. In addition, hand-searches of specific journals, Index Medicus, and abstracts of the annual meetings of ASPEN, ESPEN, and Digestive Disease Week were done. In order to qualify, the trial had to have been randomized (quasi-randomized trials

excluded), include a control group that, at least at the time when the EN was begun in the treated group, received no artificial nutrition, and report at least one clinical outcome (mortality, infectious or non-infectious complications, days on the ventilator, in the ICU, or in the hospital, or cost). The data were combined with meta-analysis. Risk of bias was determined by Cochrane criteria (adequate or unclear/inadequate 1] generation of the randomization sequence, 2] concealed allocation, 3] blinding, 4] baseline similarities, 5] ability to do intent-to-treat analysis/accounting for dropouts, 6] selective outcome report-ing, 7] early stopping, and 8] vested interest). One point was given for each criterion met. Since none of the RCTs met most of these criteria, after the scores were calculated, but before any analyses were done, “lower” risk of bias was defined as adequacy in at least 3 of these criteria. Results: Fifteen RCTs were identified; 14 were conducted in adults and 13 were reported as full papers. Five were at lower risk of bias. The estimated effect (relative risk [RR] or weighted mean differ-ence [WMD]) and 95% confidence intervals (CI) for the various analy-ses are displayed in the table; RR < 1.0 or WMD < 0.0 favors EN. A significant difference is present when the 95% CI does not cross the line of equivalence. The significant benefits that were identified (with regard to mortality and infectious complications) were only seen in trials with high risks of bias. One harmful effect (longer duration of hospitalization) was only seen in the trials with lower risk of bias.) Conclusions: The alleged benefits from EN in the ICU are likely due to methodologic limitations rather than a true effect. In fact, since all of the trials were at substantial risks of bias, we cannot be sure that EN does not actually cause harm. In the absence of truly low risk of bias RCTs that show benefit, the data are insufficient to support a recommendation for EN in critically ill patients.


S19 - Hospital Mortality in Elderly Veterans with a Reduced Serum Albumin Concentration; The Role of Energy Intake, Hyperglycemia and Severity of Illness ScoreSharon Foley, M.S., R.D., L.D., Ph.D.2; Katie Heintz-Miller, C.N.S.D., R.D.2; Dana Holland, R.D.2; John A. Tayek, M.D., Professor on Medicine-In Residence1

1Harbor-UCLA Medical Center, Torrance, CA; 2Hines Veterans Hospital, Chicago, IL.

Introduction: Nutritional factors such as hyperglycemia and energy intake may influence survival. The purpose of this study was to determine if energy intake and/or elevated blood glucose concentrations influences mortality in hypoalbuminemic (<2.5 gm/dl) patients. Methods: Documented dietary intake, a Simplified Acute Physiology Score (SAPS II) score and laboratory values were obtained in 233 hospitalized elderly (68±13 years old) Veterans. Adequacy of caloric intake was recorded as good, fair, or poor based on medical record entries made by Registered Dietitians, Registered Nurses, or Physicians. Logistic regression was used to determine the relationship between 30-day mortality, and the covariates of serum albumin, serum glucose, SAPS II score, and adequacy of dietary intake. Significance level was established at p < 0.05 for all two-sided tests. Data is represented as mean±SD. Results: The average serum albumin on admission was 2.3±0.5 gm/dl and the 30-day hospital mortality was 27%. The average length of stay for these patients with a reduced serum albumin (< 2.5 gm/dl) was approximately 4-weeks. Consistent with the reduced serum ablumin con-centration, the SAPS II score was elevated at 31±13. Energy intake was considered good in 50% of patients, fair in 22% and poor in 28%. Despite having a reduced serum albumin, patients with a good energy (calorie) intake only had a 13.4% hospital mortality (p<0.05). Mortality was doubled (26%) in those patients with a fair intake. Mortality was increased almost 4-fold (49%) in those with a poor energy intake. Of the 233 patients included in the study, 152 (65%) had at least one hyperglycemic event. Using the Mantel-Haenszel chi-square test, a non-fasting blood glucose (non-FBG) of 140-199 mg/dl was found to have a significant effect on mortality, whereas a FBG of 110-125, FBG >125, and non-FBG >199 were not associated with an increase in hospital mortality. In patients with a SAPS II score > 25 (n=144), hospital mortality was only 17.9% in those patients who had a “good” energy intake. In sharp contrast, hospital mortality was increased 3-fold (55% 30-day hosptial mortality) if the dietary intake was reported as fair or poor (p<0.01). Interestingly, for those who were less ill based on the SAPS II < 25 (n=98), the mortality rate was 7.3% in the good intake group and a 15.6% mortality if the intake was reported as fair or poor (p=0.26). The lack of signifiance may be due to the small sample size or due to the fact that energy intake may not influence mortality when patients are less ill. Overall, a poor energy intake was independently associated with an increased odds ratio for mortality (4.68-fold, p <0.001) using a multi-regression logestic model. Therefore, a poor oral intake is associated with an increase hospital mortality. Conclusions: Elderly hospitalized Veterans with a reduced serum albumin concentration on admission have a very high mortality rate (27%). A poor energy intake was associated with a 49% hospital mortality rate. In contrast, those with a good nutritional intake during the entire hospital stay had only a 13% hospital mortality rate. Earlier research has demonstrated that as little as an additional 300 Kcal intake per day in

underweight patients can significantly reduce hospital mortality (Potter 2001). Our study suggests that a good energy intake in elderly patients with a reduced serum albumin concentration may play a role in hospital outcome. A prospective randomized clinical trial is needed in elderly patients with a reduced admission serum albumin concentration to test if additional energy intake reduces mortality.

S20 - ICU malabsorption syndrome characteristics: faecal energy and macronutrient lossesNicolette Wierdsma, PhD-student, RD, MSc1; Peter Weijs, PhD1; Ad van Bodegraven, PhD, MD2; Bert Beishuizen, PhD, MD3

1Nutrition and Dietetics, VU University Medical Center, Amsterdam, Netherlands; 2Gastroenterology, Small Bowel Unit, VU University Medical Center, Amsterdam, Netherlands; 3Intensive Care Unit, VU University Medical Center, Amsterdam, Netherlands.

Introduction: Malabsorption is of clinical relevance in intensive care unit (ICU) patients. We therefore aimed to describe faecal composition as well as energy, fat, protein and carbohydrate intestinal absorption of ICU patients. Methods: This observational cross sectional study was conducted in a tertiary mixed medical-surgical ICU. Patients with previ-ously diagnosed intestinal failure were excluded. Faecal losses of energy (kcal/d using bomb-calorimetry), fat (g/d by van der Kamer method), protein (g nitrogen/d by Kjeldahl) and carbohydrate (calculated residual energy) were assessed by faeces collection for 72 hours. Intestinal absorp-tion capacity was calculated as difference between ingested energy (or macronutrients) and faecal losses, expressed as percentage of ingested energy (or macronutrients). A daily faecal production of >350 g faeces was classified as risk of malabsorption. Results: Fifty-seven consecutive fully enterally fed and haemodynamically stable adult ICU patients (63±14 yr, 56% male) were included. Patients in both groups (>350 faeces/d, n=47 vs <350 g faeces/d, n=10) were comparable for demographic data, but were worse for APACHE score in >350g faeces/d patients (31±12 vs 23±7, p=0.022). Mean daily fecal losses statistically significantly different (p<0.001) between both groups: faecal production 796±942 vs 153±74 g, energy 446±201 vs 147±87 kcal, fat 11±14 vs 2±2 g, nitrogen 2.2±1.3 vs 0.9±0.5 g and 57±25 vs 25±19 g carbohydrates, respectively. Calculated intestinal absorption capacities are presented in Table 1. Conclusions: Energy and macronutrient losses as well as energy and macronutrient intestinal absorption is markedly altered in ICU patients with excessive faecal loss (>350 g/d). Adaptation of diet with increased energy and protein content is necessary to supply enterally sufficient nutrients in these patients at risk for malabsorption.

Clinical outcome All trials Lower risk of bias High risk of bias

Mortality 0.63 (0.43, 0.92) 1.09 (0.56, 2.15) 0.51 (0.32, 0.81) Infectious complications 0.73 (0.63, 0.83) 0.81 (0.62, 1.06) 0.69 (0.59, 0.81) Non-infectious complications 0.97 (0.61, 1.53) 2.67 (0.77, 9.25)1 0.79 (0.47, 1.31) Days on ventilator -0.15 (-2.23, +1.92) -3.17 (-6.84, +0.51) +1.26 (-1.26, +3.77) Days in ICU -0.01 (-1.76, +1.74) -4.41 (-8.26, +0.57) +1.15 (-0.82, +3.11) Days in hospital +3.91 (-1.85, +9.66) +14.11 (+2.32, +25.89) +0.71 (+5.89, -7.31) Cost (\$1000) -3.2 (-10.9, +4.4) -3.2 (-10.9, +4.4) No data

1Only one trial (pediatric)

Table 1. Energy and macronutrient absorption in ICU patients

Absorption (%) <350 g faeces/d

>350 g faeces/d n

p-value (t-test)

Energy 93.1 ± 4.0 76.4 ± 10.7 47/10 <0.001 Fat 97.2 ± 2.7 85.6 ± 17.3 47/10 <0.001 Protein 94.3 ± 3.8 85.8 ± 7.6 39/5 <0.001 Carbohydrate 89.3 ± 7.2 71.9 ± 16.9 39/5 <0.001


S21 - Characteristics and feasibility of the citrulline generation test to assess intestinal mass in ICU patientsMartijn Keur, PhD student1; Nicolette Wierdsma, MSc, RD PhD student2; Job Peters, MD, PhD student3; Tom Teerlink, MD, PhD4; Bert Beishuizen, MD, PhD1; Ad van Bodegraven, MD, PhD3

1Nutrition and Dietetics, VU University Medical Center, Amsterdam, Netherlands; 2Intensive Care Unit, VU University Medical Center, Amsterdam, Netherlands; 3Department of Gastroenterology, Small Bowel Disease Unit, VU University Medical Center, Amsterdam, Netherlands; 4Department of Clinical Chemistry, Metabolic Laboratory, VU University Medical Center, Amsterdam, Netherlands.

Introduction: Small intestinal function is supposedly pivotal with regard to nutritional support and risk of SIRS/sepsis due to loss of the intestinal barrier function, in particular in ICU patients. The gold standard, intestinal absorptiometry, is too cumbersome; therefore we assessed characteristics of the recently proposed citrulline generation test (CGT) and its feasibility in ICU setting. Methods: CGT reference values were measured in 16 ‘stable’ ICU patients as described before. The loading dose Dipeptiven® (glutamine-alanine) was sequentially administered enterally and intrave-nously, with 10-time points sampling of venous and arterial plasma citrul-line, and 24 hours between each glutamine administration. Amino acid analysis was performed using reverse-phase high-performance liquid chro-matography. Results: Mean (± SD) age was 60.9 y ± 10, and BMI was 26.7 kg/m2 ± 7. Enteral administration of glutamine induced a 90-minutes generation of citrulline (iAUCT90) of 556 μmol/L/min (IQR = 192-1006) in venous samples, and 724 μmol/L/min (IQR = 267-1154) for arterial sampling. Intravenous glutamine resulted in 769 μmol/L/min (IQR = 576-950) for venous and 977 μmol/L/min (IQR 740-1084) for arterial citrulline sampling. Peak generation of citrulline was assessed at T=60 and T=75minutes, revealing correlation coefficients of r=0,99 and r=0,96 (both p<0.0001), respectively. Conclusions: In stable ICU patients, citrul-line generation following glutamine challenge is optimally assessed fol-lowing intravenous administration and using arterial sampling. Total citrulline generation is highly correlated with 2-points measurement at T=60 or T=90 minutes, which definitely increases test feasibility in vari-ous settings. Enteral routing of glutamine is probably hampered by gas-trointestinal motility disturbances, commonly observed in ICU patients.

S22 - Diagnostic accuracy of faecal weight to identify clinical significant malabsorption in critically ill patientsNicolette Wierdsma, MSc, RD, PhD-student1; Peter Weijs, PhD1; Ad van Bodegraven, PhD, MD2; Bert Beishuizen, PhD, MD3

1Nutrition and Dietetics, VU University Medical Center, Amsterdam, Netherlands; 2Gastroenterology, Small Bowel Unit, VU University Medical Center, Amsterdam, Netherlands; 3Intensive Care Unit, VU University Medical Center, Amsterdam, Netherlands.

Introduction: Malabsorption is of clinical relevance in critically ill patients, necessitating adaptation of enteral nutrient administration. However, malab-sorption is difficult to diagnose and probably underestimated in these patients. We aimed to assess and validate diagnostic accuracy of faecal weight as marker for faecal energy malabsorption in ICU patients. Methods: This observational cross-sectional study was conducted in a tertiary mixed medical-surgical ICU. Faecal loss of energy (kcal/day using bomb-calorimetry) was assessed by faeces collection for 72 hours. Intestinal absorption capacity was calculated as dif-ference between energy administration (calculated from ingested amount of enteral nutrition) and faecal losses, expressed as the percentage of ingested energy. Patients previously diagnosed with intestinal failure were excluded. Clinical significant malabsorption was a priori defined as an intestinal energy absorption capacity of <85%. Diagnostic accuracy of faecal weight to detect malabsorption was described as sensitivity (Se), specificity (Sp), positive

predictive value (PPV), negative predictive value (NPV) and ROC area under the curve (AUC). Results: A total of 57 haemodynamically stable ICU adult patients (63±14 yr, 56% male) on full enteral feeding was included. Since a faecal production of >350 gram/day had the largest AUC (0.879), it was the optimal cut-off value for detecting energy malabsorption in ICU patients (Figure 1). Se and PPV for 350 gram faeces versus < 85% energy absorption were 80%. Sp and NPV were both 96%. Faecal weight (gram/day) and intestinal energy absorption capacity (%) inversely correlated strongly (Spearman’s r = -0.778, p<0.001). Conclusions: A faecal weight of more than 350 g/d is in ICU patients a reliable marker for detecting clinical significant malabsorp-tion, expressed as >15% intestinal energy losses of ingested energy. Daily monitoring of faecal weight should be incorporated in the nutritional approach in the ICU, in order to correct for intestinal losses when necessary.

S23 - Enteral Nutrition in North American ICUs: What Formulas are Being Used?Rupinder Dhaliwal, RD, BASc1; Naomi E. Cahill, RD, MS1,2; Miao Wang, MSc1; Daren K. Heyland, FRCPC2,3

1Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada; 2Department of Community Health and Epidemiology, Queens University, Kingston, ON, Canada; 3Department of Medicine, Queens University, Kingston, ON, Canada.

Introduction: Enteral Nutrition is a standard component of nutrition therapy in intensive care units (ICUs). Enteral formulas range from poly-meric and elemental/semi-elemental formulas to those that are geared towards the unique needs of the ICU patient such as those supplemented with arginine, fish oils/borage oils and antioxidants. There is evidence from Clinical Practice Guidelines that supports the use of polymeric formulas and those containing fish oil, borage oils and antioxidants in critically ill patients while the use of arginine containing formulas is cautioned. How-ever, the current utilization of enteral formulas in North American ICUs is not well reported. The purpose of this study is to determine the type of enteral nutrition formulas being utilized in North American ICUs in order to compare current practice to the recommendations from Clinical Practice Guidelines. Methods: In 2009, we conducted an international, prospec-tive, observational cohort study of current nutrition practices in ICUs in Canada and the US. Consecutively enrolled mechanically ventilated adult patients that stayed in the ICU for at least three days were included. Sites collected data on nutrition practices (i.e. type of formula and duration) on enrolled patients from ICU admission to discharge for a maximum of 12 days. Data was reported as number (and %) of patients ever receiving the formula (at least on one day) and/or patient days. Results: A total of 1870 patients were enrolled from 33 ICUs in Canada and 73 ICUs in the US. A total of 1515/1870 (81%) patients received EN formulas during the first 12 days of ICU admission on 15003 patient days and 355/1870 (19%) did not. A total of 1293/1515 (85%) patients received polymeric formula on 8764/10725 (82%) patient days and 262/1515 (17%) received elemental/semi elemental formulas on 1550/10725 (14%) patient days while 91/1515 (35%) received both (on the same or different day) during the first 12 days of ICU admission. The average duration on elemental/semi-elemental formula was 5.9 days (range 1-12) per patient compared to 6.8 days (range 1-12) per patient for polymeric formula. A total of 171/1515 (11%) patients received an arginine containing formula on 1025/10725 (10%) patient days and 142/1515 (9%) received a formula containing fish/borage oils and antioxidants on 849/10725 (8%) patient days. The use of formulas containing fish/borage oils and antioxidants in patients with Acute Respira-tory Distress Syndrome (ARDS) was 68/209 (33%). The average duration on arginine containing formulas was 6.0 days (range 1-12) per patient and 6.4 days (range 2-11) per patient with ARDS for a formula containing fish/borage oils and antioxidants. Conclusions: Consistent with the recom-mendations from Clinical Practice Guidelines, the use of polymeric for-mulas compared to elemental/semi-elemental formulas is predominant in ICUs in North America, while arginine containing formulas are infrequently


used. Formulas containing fish/borage oils and antioxidants are not being used despite strong recommendations from Clinical Practice Guidelines. Efforts at improving the use of formulas containing fish/borage oils and antioxidants in ARDS patients are encouraged.

Encore abstract: Presented at the 25th Annual meeting of Japanese Society for Parenteral and Enteral Nutrition. Published Jomyaku Keichou Eiyou (the Journal of Japanese Society for Parenteral and Enteral Nutrition) Vol.25/Jan.2010/317. Reprinted with Permission of the Jeff Corporation Co, Ltd.

S24 - Plasma Glutamine as A Predictor of Mortality in Critically Ill PatientsTakae Tsujimoto, RPh, MS1,4; Kentaro Shimizu, MD, PhD3; Masafumi Wasa, MD, PhD2; Nobuaki Hata, BS3; Tatsuya Takagi, PhD1; Etsuko Uejima, PhD1

1Graduate School of Pharmaceutical Sciences, Osaka University, Suita, Japan; 2Graduate School of Medicine, Osaka University, Suita, Japan; 3Medical Hospital, Osaka University, Suita, Japan; 4Pharmaceutical Sciences, Kobe Gakuin University, Kobe, Japan.

Introduction: Plasma aminogram is an important parameter to understand kinetics and dynamics of amino acids in human body. Glutamine is a non-essential amino acid but is considered conditionally essential in patients with catabolic conditions. The purpose of the current study was to compare the plasma levels of glutamine in non-survived patients with those in survived patients in the emergency department of Osaka University Medical Hospital and to find if the plasma glutamine can be a factor to predict prognoses. Methods: Plasma aminogram was measured in the patients admitted to the emergency department from July, 2004 to January, 2009. One hundred eighty one patients were included in this study of the plasma aminogram. 62% (112) of the patients were male and median of their ages was 64 (range 20-90). The diagnoses of the patients were infection (87, 48%), trauma (27, 15%), endogenous diseases (26, 14%), fulminant hepatitis (15, 8%), burn (8, 4%), and others (18, 10%).The pattern of aminogram was compared between patients not survived and survived. The plasma aminogram was determined with high performance liquid chromatography. The nine essential amino acids and fourteen non-essential amino acids were quantified. Results: A mortality rate was 32%. Among the amino acids glutamine showed a unique relationship between its concentration and mortality. Unlike other amino acids, mortality was higher when the concentration of glutamine was not only high but also low. The patients were divided into 3 groups according to the concentration of plasma glutamine. The mortality in a group of patients with plasma glutamine more than 800 nmol/mL (Group H) was significantly higher than that of in a group of plasma glutamine between 300 and 800 nmol/mL (Group M) (57.1 % vs. 26.4 %, p<0.001). Also, the mortality in a group of patients with plasma glutamine less than 300 nmol/mL (Group L) was significantly higher compared to Group M (44.4 % vs. 26.4 %, p<0.05). Conclusions: The findings suggest that it is valuable to measure plasma glutamine in critically ill patients to predict the prognosis.

S25 - Association between Serum Prealbumin Levels and Systemic Infection on Admission , and Relationships with Sequential Organ Failure Assessment Scores in Critically Ill PatientsYasumasa Iwasaki, MD, PhD1,2; Midori Yamane, Nurse1; Kazuko Tsugawa, Clinical Laboratory Technician1; Hisako Oka, Dietitian1; Koichi Tanigawa, MD, PhD2; Susumu Tazuma, MD, PhD1,3

1Nutrition Support Team, Hiroshima University Hospital, Hiroshima, Japan; 2Advanced Emergency and Critical Care Center, Hiroshima University Hospital, Hiroshima, Japan; 3Department of General Medicine, Hiroshima University Hospital, Hiroshima, Japan.

Introduction: Prealbumin is one of the rapid turnover proteins, and it is not affected by exogenous intravenous administration of albumin. There-fore, prealbumin has been widely used as a clinical marker to evaluate nutritional status. However, it was pointed out that the serum prealbumin level may be altered by systemic dysmetabolism such as infection. The aim of this study was to determine the association between serum preal-bumin levels and systemic infection, and relationships between the pre-albumin levels and Sequential Organ Failure Assessment (SOFA) scores in critically ill patients. Methods: Two retrospective study protocols were designed as follows: Study1; Twenty-seven consecutive critically ill adult patients whose serum prealbumin were assessed within 5 days from admis-sion to our ICU from July 1st through August 31st of 2010, were enrolled.

Mortality associated with plasma concentration of glutamine

Conc. of Gln (nmol/mL)

No. of non-survivors Mortality p value

≦300 12(12/27) 44% <0.05* 300-500 22(22/70) 31% 0.1797 500-800 15(15/70) 21% - >800 8(8/14) 57% <0.0001** overall 57(181) 31%

*significantly different from 500-800 nmol/mL of Gln, **significantly different from 500-800 nmol/mL Fischer’s exact test

Concentration of plasma glutamine survivors vs. non-survivors


They were divided into two groups according to the prealbumin levels: the low prealbumin level (LP) (<11mg/dl) group and the high prealbumin level (HP) (≥11mg/dl) group. Patients’ backgrounds (age, sex), systemic inflammatory response syndrome (SIRS) score, acute physiology and chronic health evaluation II (APACHE II) score, WBC, C-reactive protein (CRP), and serum lactate levels, were compared between the two groups. Study2; Eighteen consecutive critically ill adult patients who stayed at our ICU for more than 10 days during the same period were enrolled. Serum prealbumin levels were measured three to six times for each patient during stay in the ICU. A total of 75 points of prealbumin levels were compared with SOFA scores. Results: Study1; No significant difference was found in patients’ backgrounds, APACHE II score, WBC and serum lactate levels between the two groups; however, CRP levels in the LP group were significantly higher than in the HP group (median; 5.1 vs. 0.8, p=0.01). The rate of positive for SIRS (fulfilling at least two SIRS criteria) was 94 % in the LP group and 50 % in the HP group (odds ratio, 16.0; 95 % confidence interval 1.50 to 171.2; p=0.015). Study 2; A nega-tive correlation was found between serum prealbumin levels and SOFA score (r=-0.63, p<0.001). Receiver operating characteristic curve analysis was used to evaluate the sensitivity, specificity and diagnostic accuracy of SOFA score less than 2. When the cut-off level for prealbumin were set as the closest point to 100% sensitivity and 100% specificity, the level was 13.9mg/dl (sensitivity, 74%; specificity, 79%; and diagnostic accuracy, 77%, respectively). Conclusions: The results of this study demonstrated that elevation of CRP and positive for SIRS in critically ill patients admit-ted to the ICU were strongly associated with lower serum prealbumin levels, indicating systemic infection may affect prealbumin metabolism. The elevation of the prealbumin levels (≥13.9 mg/dl) is associated with reducing severity of the multiple organ dysfunction syndrome (MODS). Thus, such a level of prealbumin should be a clinical target for critically ill patients.

S26 - Elderly Trauma Patients: Highest Risk, Fewest CaloriesRosemary Kozar, MD, PhD1; Carmel Dyer, MD5; Eileen Bulger, MD3; Marina Mourtzakis, PhD2; Charles E. Wade, PhD1; Daren K. Heyland, MD4

1Surgery, University of Texas Health Science Center at Houston, Houston, TX; 2Kinesiology, University of Waterloo, Waterloo, ON, Canada; 3Trauma Surgery, Harborview Medical Center, Seattle, WA; 4Medicine, Queen’s University at Kingston, Kingston, ON, Canada; 5Medicine, University of Texas Health Science Center at Houston, Houston, TX.

Introduction: The number of injured elderly admitted to ICU’s is increas-ing while their morbidity and mortality post injury remain high. Increased intakes of energy and protein appear to be associated with improved clinical outcomes in critically ill patients. The objective of the current study was to examine the relationship between the amount of energy and protein administered and clinical outcomes in the critically ill trauma patients and in particular, elderly trauma patients. Methods: From an international database involving 355 ICU’s and 8838 critically ill adult patients mechanically ventilated within 48 hrs that remained in ICU for >72 hrs, we identified patients admitted with a trauma diagnosis and compared the nutritional practices and clinical outcomes of patients < 65 to ≧ 65 years of age. Descriptive data are presented as mean ± SD or median with IQR. P values were calculated by using mixed model adjust-ing for ICU and year of data collection for continuous outcomes and Rao-Scott Chi-Squared method clustering by ICU for categorical out-comes. Results: Trauma patients comprised 10.2% (900/8838) of the study population. There were 742 patients < 65 and 158 patients ≧65. Elderly trauma patients had higher Apache II scores, longer ICU and days of mechanical ventilation, and higher mortality (Table 1). Body mass indexes (BMIs) were similar between groups yet the elderly were prescribed less calories and protein. (Table 2). Both groups received inadequate

energy and protein intake, though the elderly received a greater percentage of prescribed calories and protein. Overall, elderly patients received sig-nificantly less (p< 0.0001) total calories than younger patients during their ICU stay. Conclusions: Elderly trauma patients requiring ICU admis-sion experience worse clinical outcomes than their younger counterparts and receive inadequate nutritional support. Optimizing energy and protein intake in this high risk population may improve clinical outcomes. Further research in this area is warranted.

Table 1. Demographics and Outcomes

Variable < 65 years ≧ 65 years p value

Apache II 19.1 ± 7.2 23.6 ± 7.1 <0.001Mechanical ventilation (days)*

9.5 (4.7-17.2) 13.1 (6.7 - 25.0) 0.005

ICU length of stay (days)*

12.9 (7.9-20.6) 17.4 (11.5-24.6) 0.01

Mortality 89 (12.0%) 42 (26.8%) <0.001

*Median (IQR)

Table 2. Nutritional Parameters

Parameter < 65 years ≥ 65 years p value

BMI 26.9 ± 6.6 26.8 ± 4.9 0.77Enteral nutrition only 585 (78.8%) 126(79.8 %) 0.82Prescribed energy (kcal/kg) 25.7 ± 5.2 23.7 ± 4.9 0.0002Prescribed protein (kcal/kg) 1.3 ± 0.3 1.2 ± 0.3 0.0008Received calories (kcal/kg/day) 14.2 ± 7.3 14.1 ± 6.4 0.38Received protein (kcal/kg/day) 0.65 ± 0.36 0.69 ± 0.34 0.59Adequacy of calories % 55.6 ± 26.1 60.0 ± 24.9 0.45Adequacy of protein % 50.7 ± 26.6 57.9 ± 26.2 0.03

S27 - Does intolerance to enteral nutrition predict mortality in the critically ill patient?Niamh Smyth, RD1,2; Sinead Duggan, RD2; Sinead Feehan, RD2; Judy Hardt, RN1; Maria Donnelly, MD1

1Department of Intensive Care, Adelaide and Meath Hospital, Dublin, Ireland; 2Nutrition and Dietetics, Adelaide and Meath Hospital, Dublin, Ireland.

Introduction: Current international guidelines recommend that critically ill patients with a functioning gastrointestinal tract be fed early with enteral nutrition (EN). However, gastrointestinal dysfunction is common in critically ill patients and has a complex, multifactorial pathogenesis. In clinical practice, meeting nutrition targets with EN alone can be dif-ficult. The use of total or supplemental parenteral nutrition (PN) is rec-ommended in those who cannot be fed sufficiently via the enteral route. We sought to investigate if intolerance to enteral nutrition (EN) was a predictor of adverse clinical outcomes. Methods: The study design was a retrospective review of a prospectively recorded intensive care unit (ICU) database. Consecutive patients admitted to intensive care requiring arti-ficial nutrition support (ANS) over a twelve month time period were included in the study. ‘Intolerance’ was defined as requirement for PN once use of prokinetic agents had failed and placement of a post-pyloric feeding tube was deemed inappropriate or failed. Mortality was the out-come of choice. Results: The reason for admission was 60% medical and 40% surgical. The overall mortality rate was 28%(standardised mortality rate 0.8). Of total admissions, 52% (233) patients were deemed to require ANS. All patients were fed within 48 hours of admission to ICU, 44.5% patients were fed using EN alone, 19% were fed using PN only and 36.5%


required a combination of PN and EN. Mortality was highest in the patient group requiring a combination of EN and PN (48%) than in patients receiving EN only (23%) or PN only (23%). Twenty nine patients required PN due to intolerance to EN. This group had higher APACHE II scores than those who had PN for other reasons. We compared the “EN intoler-ant” group to the EN alone group and found the mean APACHE II score of the EN intolerant group was statistically higher than the EN alone group (p=0.007). We also found a strong statistical association between the type of nutrition received while in ICU and mortality (p=0.000). Conclusions: Intolerance to EN indicating dysfunction of the gastroin-testinal tract was an indicator of mortality in our patient group. The clinical significance of these findings are not entirely clear and require further investigation, however intolerance to EN indicating GI dysfunction may potentially serve as an important indicator of worsening clinical status so treatment can be more focused and targeted in this patient population.

S28 - Enteral feeding complications influence the goal for nutrients infusion in critically ill patientsCynthia R. Duarte, RD; Bruna V. Lopes, RD; Jose E. Aguilar-Nascimento, MD, PhD; Diana B. Dock-Nascimento, RD,MScFederal University of Mato Grosso, Cuiaba, Brazil.

Introduction: Nutritional therapy (NT) is an integral part of the treatment in critically ill patients. As these patients are at nutritional risk, it is essential to establish an appropriate provision of nutrients to achieve the improvement of malnutrition and its consequences. Guidelines of various societies recommend the use of enteral feeding (EF) as the first choice for these patients. However, complications that may occur during EF may interfere in the delivery of the planned amount of nutrients. The aim of this study was to evaluate whether the occurrence of complications influ-ences the daily infusion of EF in critically ill patients. Methods: We prospectively followed 72 (36 M and 36 F) critically ill patients (mean and range age= 66 [15-94] years old) who received a total of 289 days of EF. Nutritional status was assessed by subjective global assessment (SGA). End-points of the study were: 1) the ratios of the daily infused /prescribed volume, calories, and proteins; and 2) the influence of complications to achieve the planned target of nutrients. The infusion-related complica-tions were diarrhea, constipation, vomiting, abdominal distension, acci-dental removal, and obstruction of the tube. Results: Malnutrition at admission was high (92.2%) and severe malnutrition (SGA-C) accounted for 44.6% of the cases. The mean (SD) volume infused was 87.8 (21) % of the volume prescribed. However the volume (1138±445 vs 1281±403 mL), amount of calories (1482±564 vs 1677±485 kcal), and protein (67±29 vs 75±26 g) delivered was significantly lesser than the prescribed (p<0.001). The occurrence of complications significantly decreased the amount of both the volume (1069 ± 458 vs 1200± 425 ml; p=0.02) and calories (1406 ± 575 vs 1551± 546 kcal; p=0.05) infused per day. Diar-rhea was the main complication that impaired the delivery of nutrients. On the other hand either constipation or abdominal distension did not influence the results. Conclusions: EF complications impair the achieve-ment of the planned target of nutrients in critically ill patients.

S29 - Amino acid metabolism in critically ill patients: Tracer methodology in the fed and postabsorptive stateMechteld A. Vermeulen, MD1; Paul A. van Leeuwen, MD PhD1; Cornelis H. Dejong, MD PhD5; Pierre Bet, PharmD3; Albertus Beishuizen, MD PhD4; Nicolaas E. Deutz, MD PhD6; Gerdien C. Ligthart-Melis, RD PhD2

1Surgery, VU University Medical Center, Amsterdam, Netherlands; 2Dietetics and Nutritional Sciences, VU University Medical Center, Amsterdam, Netherlands; 3Pharmacy, VU University Medical Center, Amsterdam, Netherlands; 4Intensive Care Medicine, VU University Medical Center, Amsterdam, Netherlands;

5Surgery, Maastricht University Medical Center, Maastricht, Netherlands; 6Center for Translational Research on Aging & Longevity, Donald W. Reynolds, Little Rock, AR.

Introduction: Quantification of metabolic needs of critically ill patients is challenging. Steady state tracer methodology is a delicate tool to gain more insight in metabolic processes by means of a calculated ratio between infused tracer and the unlabeled counterpart (tracee). In this population common postabsorptive measurements might not be repre-sentative since the patient will not be fasted during his stay at the ICU. However steady state and enrichment may be difficult to achieve, due to possible loss of the small tracer quantities within the bulk of tube feeding. The aim of this pilot study, which was the start of a larger study with 10 vs. 10 critically patients, was to investigate how continuation of feeding during the tracer protocol would affect tracer enrichments of L-[2-15N]glutamine, L-[5-13C-4,4,5,5,2H4]citrulline, L-[guanidino-15N2]arginine, L-[ring-2H5] phenylalanine and L-[ring-2H2]tyrosine. Methods: Two critically non-septic patients received enteral nutrition based on indirect calorimetry for seven days with (n=1) or without alanyl-glutamine (n=1), isocalorically, isonitrogenously. In a crossover manner on four days (day 4-7), tracers were infused both intravenously and enterally, and nutrition was both stopped and continued. In the postab-sorptive experiments enteral feeding was discontinued 2 hours prior to the tracer protocol and until the protocol was finished. Patients received a primed, continues infusion of the mentioned GLN(M+1), CIT(M+5), ARG(M+2), TYR(M+2), TYR(M+4) (prime only) and PHE(M+5) (infusate only) tracers. Arterial blood was drawn every 30 minutes, for 2.5 hours after which tracer to tracee ratio (TTR%) was determined to observe if tracers reached steady state. Results: Significant arterial enrichments were observed for all tracers used (TTR% increase baseline vs. steady state level: GLN(M+1),CIT(M+5), ARG(M+2), TYR(M+2), PHE(M+5) paired T-test: p<0.000). Steady state was observed in both patients, in all experiments (see GLN(M+1)graph). Conclusions: These findings suggest that achievement of steady state of amino acid tracers is not affected by continuous enteral feeding. Meanwhile enteral tracers co-administered with enteral feeding still allows arterial tracer enrich-ment, which strengthens the clinical usefulness of the tracer methodology, in this case measurement of metabolism of critically ill patients.


TOPIC: Diabetes

S30 - Dietary Pattern and Glycemic Control of Diabetic Adolescents During Ramadan FastingNagat Eltoum1; Sidiga Washi2; Abdulaziz Al-Twaim3

1College of Nursing-Basic Sciences Department, King Saud Bin Abdulaziz University for Health Scieneces, Jeddah, Saudi Arabia; 2Nutrition and Health, United Arab Emirates University, Al Ain, United Arab Emirates; 3Pediatric, King Abdulaziz Medical city, Jeddah, Saudi Arabia.

Introduction: Ramadan fasting is one of the 5 pillars of Islam. Healthy adult Muslims around the world fast from dawn to dusk for 29-30 consecutive days every year. Individuals with chronic diseases such as diabetes mellitus are exempted from fasting to prevent complica-tions. Nevertheless, many diabetic adolescents insist on fasting during Ramadan, thereby creating a medical challenge for themselves and their health care providers. The effect of Ramadan fasting in diabetic adolescents has not been widely investigated. The main objective of the study is to investigate the effect of Ramadan fasting on diabetic adolescent’s glycemic control and dietary intake. Methods: A cohort study conducted during two Ramadan seasons (2007 & 2008) at King Abdulaziz medical city-Jeddah, KSA. Fifty four diabetic adolescents (13-18 years old), with no history of diabetes complications or other medical conditions participated in the study. All participants were permitted by their physicians to fast during Ramadan. They were evaluated at 3 points; before, during and after Ramadan. Validated questionnaires were completed by the participants. Further more the participants were asked to keep three days diet diary and, blood glucose records. Anthropometric measurements and glycated hemoglobin test were conducted before and after Ramadan. Results: All participants fasted a mean of 21.7±7 days. There was a slight significant loss in weight (-0.45 kg) and Body Mass Index by the end of Ramadan. Total daily insulin dose decreased significantly with a significant change in the type of insulin used during Ramadan. Hypoglycemia were more prevalent during Ramadan (p =.007). Sixty percent of the participants experienced hyperglycemia episodes either at night time or after midnight. .Glycated hemoglobin did not change significantly as com-pared to before Ramadan. None of the participants were hospitalized due to severe hypoglycemia or ketoacidosis during Ramadan. There was a significant increase in the energy and macronutrients intake during Ramadan. Conclusions: The increased episodes of hypergly-cemia and hypoglycemia during fasting might be due to the significant change in the administered insulin as well as the lack of adherence to dietary guidelines in type 1 diabetic adolescents. The results sug-gest the importance of adherence to dietary and medical guidelines to decrease the incidence of complications during Ramadan fasting.

Effect of Ramadan fasting on energy and nutrients intake (n=50).

Variable Before Ramadan During Ramadan P-value Target*

Energy (kcal/d) 1613±582 2137±571 .000 Varies according to age, sex & activity Carbohydrates (g/d) 217.7±86.7 256.8±69.2 .012 Carbohydrates (% kcal) 49.7±8.7 47.5±7.7 .458 50-55% Protein (g/d) 67.7±23.4 81.4±32.5 .026 Protein(% kcal) 16±3.9 15.1±4.4 .775 10-15% Fat (g/d) 67.4±31.1 90±37.8 .001 Fat (% kcal) 34.2±6.6 37.4±6.1 .244 30-35% Fiber (g/d) 14.6±8 17.3±5.9 .002 25-35 Cholesterol (mg/d) 301.5±268.6 305.2±174.2 .702 < 300

Data are means ±SD, and percentages unless otherwise indicated. P-value is significant at ≤ .05. *ISPAD Clinical Practice Consensus Guidelines 2006-2007: Nutritional management

S31 - Impact of carbohydrate counting in glycohemoglobin (A1c) of patients with type 1 diabetes in a public tertiary service

Marcella Consoli, RD, MS1,2; Débora Guimarães, RD2; Beatriz Gabriel, RD2; Rafael Mattos, RD, MS2; Janice Reis, RD, MS2; Saulo Purish, MD, PhD2; Maria Isabel Correia, MD, PhD1

1Instituto Alfa de Gastroenterologia, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil; 2Ambulatório de Diabetes tipo 1, Santa Casa de Belo Horizonte, Belo Horizonte, Brazil.

Introduction: Carbohydrate counting is an approach for patients with diabetes mellitus that focuses on carbohydrate as the primary nutrient affecting postprandial glycemic response. It’s known to be an importante strategy with significant impact on glycemic control in patients with type 1 diabetes (DM1) under insulin therapy. In the early 1990’s the Diabetes Control and Complications Trial (DCCT) used carbohydrate counting as one of the education tools for treatment of diabetes. In many countries this nutritional approach is not widely used, mainly in public health ser-vices. The aim of this study was to assess the impact of carbohydrate


counting on glycohemoglobin (A1c) of type 1 diabetes patients (DM 1) in a public tertiary clinic. Methods: Patients diagnosed with DM1 under insulin treatment who were on carbohydrate counting therapy for at least three months were included. A1c before, three months and 12 months after the beginning of carbohydrate counting was obtained from medical records. Nonparametric paired Wilcoxon and T tests were used to compare data before and after a minimum period of three months. All results were considered significant at a significance level of 5%. Results: Sixty-four patients diagnosed with type 1 diabetes under insulin therapy were assessed retrospectively. The mean age was 20 ± 8.9 years. Sixty-two percent of patients were female. There was significant decrease between A1c before and three months after the beginning of carbohydrate counting (median: 8.5% vs 8.0%; p=0.021). When comparing A1c before and 12 months after the beginning of the therapy this difference was not maintained (median: 8.5% vs 8.5%; p=0.6). Conclusions: Carbohydrate counting was effective in the first months of treatment, in this group of patients. How-ever, its long-term efficacy decreased, probably justified itself by a tendency of patients’ lack of adherence to exactly calculate the grams of carbohy-drates per meal. This result demonstrates the need for ongoing nutritional monitoring of these patients with constant assessment of therapy.

S32 - Effect of a Blend of Arginine, Glutamine and Beta-hydroxy beta butyrate Used For The Treatment of Diabetic Neuropathic Foot Ulcers on Blood Glucose ControlPatrizio Tatti, Department of Endocrinology and Metabolism ASL RMH (Rome) Italy1; Annabel Barber, University of Nevada Las Vegas NV (USA)2

1Diabetes and Endocrinology, ASL RMH, Marino (Roma), Italy; 2Annabel Barber, University of Nevada, Las Vegas, NV.

Introduction: Background and aims: Arginine has been suspected of increasing renal neoglucogenesis1. Since relatively high doses of this amino acid are used, in combination with glutamine and beta-hydroxy-beta-methylbutyrate (HMB) in an oral nutritional supplement for patients with diabetic foot ulcers, we chose to examine the effect of this blend on glycemic control in type 2 diabetic patients. Methods: Materials and methods: We compared the body weight, HbA1c level, the area under the curve (AUC) after a test meal and the mean blood glucose (MBG) calcu-lated from a 3 points/day home self monitoring of blood glucose (SMBG), one fasting and two 2 hours postprandial, in 14 type 2 diabetic patients receiving oral nutritional supplementation with the blend for neuropathic foot ulcers. These values were obtained prior to initiation of the therapy and at 4 months after the start of supplementation. All subjects were on combined therapy with bedtime insulin and oral hypoglycemic agents, or multiple daily insulin injections. The AUC was calculated with the trapezoi-dal rule from a six point curve. Data were analyzed by paired- T test (SPSS software version 17). When data were not normally distributed, logarithmic transformation was performed. Results: Results: The HbA1c decreased significantly during the treatment (HbA1c 8.95+1 vs 8.10, p=.000), body weight decreased (88.7 + 10 vs 87.1+11 Kg, p=.043) while the MBG (199+ 22 vs 190+ 16 mg/dl, p=.07) , the AUC (3.88+.35 vs 4.1+.21, p=.051) and the insulin dosage remained stable (33+5 vs 32.7+6 U/day, p=NS). A further analysis of the SMBG demonstrated a significant reduc-tion of the fasting blood glucose (163+32 vs 139+27, p=.001). The post-prandial values did not change significantly (post lunch 178+36 vs 184+ 31 mg/dl, p=NS; post dinner 181+36 vs 186+34 mg/dl, P=NS). With the multiple regression analysis appears that 67% of the variability of HbA1c can be attributed to the reduction in weight. Conclusions: Conclusions: The significant reduction in HbA1c while the MBG and the AUC remained stable or slightly increased might be explained with a reduction of the hepatic glucose output most probably secondary to the effect of these substances on the inflammatory process, as well as changes in body com-position, previously described using this blend. The slight increase in the AUC is of borderline statistical and biologic significance and may be offset by the anti-inflammatory effect and the concomitant decrease in weight.

Further evidence of the effect on the hepatic glucose output is seen in the analysis of the SMBG data as only the fasting blood glucose level that is highly dependent on the hepatic glucose output was decreased.

TOPIC: Enteral Nutrition

Encore abstract: Presented at the 5th Annual Convention of Philippine Society for Parenteral and Enteral Nutrition (PHILSPEN), Nov 12-13, 2009, Manila. S33 - Use of refractometry in interpreting gastric residual volumes in tube fed patients receiving peptide based vs intact protein enteral formula: a preliminary studyEliza Mei P. Francisco, Head, Nutrition Support Team1,2; Cristito B. Alea, Chief Resident, Internal Medicine1; Baby A. Permentilla, Chief Dietitian1

1Nutrition Support Team, Mary Mediatrix Medical Center, Lipa Batangas, Philippines; 2Asian Hospital and Medical Center, Muntinlupa, Philippines.

Introduction: In clinical practice, gastric residual volume is used as a parameter to determine feeding intolerance. Feeding is often interrupted when the gastric residual volumes are high. However, the traditional practice of gastric residual volumes is flawed in design, is poorly standard-ized in its technique, is not an accurate measure of gastric emptying, and is an insensitive marker for regurgitation and aspiration. The refractive index of a solution (like an enteral formula), measured by refractometry, is a physical property of that solution, which is remarkably constant and reproducible under varying conditions of concentration, pH and tempera-ture. Refractometry can determine whether the gastric fluid drained from a feeding tube is composed of a given enteral formula or endogenous secretions. This study aims to describe the refractometry readings (Brix value) of different enteral formulas with varying concentrations and to compare the gastric residuals of tube fed patients receiving intact protein formula versus peptide based formula according to volume and refrac-tometry reading. Methods: All tube fed patients admitted at two tertiary hospitals and referred from February to April 2009 were consecutively recruited in the study. Patients receiving intact protein were placed in Group 1 and patients receiving peptide based formula were placed in Group 2. The Brix value (BV) of each enteral formula was taken prior to feeding. As part of routine feeding protocol, the nurses checked for gastric residuals every 4 hours. If any gastric residual was obtained, the volume was recorded and a sample specimen was set aside for the researcher to do BV measurement. This procedure was done in both groups. Results: In Group 1, the mean volume of gastric residual after 4 hours was sig-nificantly less than the mean volume that was fed to the patient (91.70 + 139.40 vs 226.64 + 76.74; p<.01). The mean BV after 4 hours was significantly less than the BV of the original enteral formula (11.98 + 6.39 vs 19.28 + 7.64; p<.01). In Group 2, the mean volume of gastric residual after 4 hours was significantly less than the mean volume that was fed to the patient (28.21 + 39.39 vs 172.78 + 47.45; p<.01). The mean BV after 4 hours was significantly less than the BV of the original enteral formula (5.88 + 2.02 vs 23.71 + 3.24; p<.01). The mean GRV of patients receiving Peptamen formula was lower than that of patients receiving intact protein formula (28.21 + 39.39 vs 91.70 + 139.40; p>.01), although not significant. However, the mean BV of patients receiving peptide based formula (Peptamen) was significantly lower than that of patients receiving intact protein formula (5.88 + 2.02 vs 11.98 + 6.39; p<.01). Conclusions: Patients fed with peptide based formula have lower gastric residual volumes and lower Brix values compared to those patients fed with intact protein formula. Patients fed with peptide based formula may have better absorption, gastric emptying and feeding tolerance com-pared to those patients fed with intact protein formula as determined by refractometry. This is however only a preliminary study designed to intro-duce the concept of refractometry and its potential uses in tube feeding and further research studies are warranted.


S34 - Branched-chain amino acid and Glutamine rich formula diet has the potential to heal a pressure ulcerRyo Uchida, MS; Mio Fujimaki, MS; Tomoyuki Mine, PhD; Naoki Hayashi, PhDResearch Institute for Health Fundamentals, Ajinomoto Co., Inc., Shizuoka, Japan.

Introduction: Adequate nutritional support is required for healing a pressure ulcer early in assisting bedridden elderly people. However, the optimal nutritional approach to the wound is still unclear. We previously reported that oral administration of branched-chain amino acid(BCAA mixture; Val, Leu, Ile) promotes to heal a pressure ulcer in rats(Clinical nutrition week 2008). Using this model, we also found the decrease of some amino acids in plasma including glutamine(Gln). Gln is a condi-tionally essential amino acid which increases its demand by several surgical stresses. Therefore, the supplementation of BCAA and Gln into a diet is expected to have therapeutic effects on a pressure ulcer care in bedridden persons.The aim of this study is to evaluate effects of combined admin-istration of BCAA and Gln on healing a pressure ulcer in model rats. Methods: Male SD rats, aged 11weeks, fed the 1% casein diet based on AIN-93G nutrient formula ad libitum for 4weeks for developing malnutri-tion. Then, the stainless cylinder(φ15) was pressed to the shaved dorsal skin of rats at 0.8kgf/cm2 under the condition of anesthesia, heating and moisturization for 3 hours/day for 4days. After 4days, the rats had almost the same wound area. They were divided into 3groups; Control diet(Glycine 0.6g/100kcal), BCAA diet(BCAA 0.7g/100kcal) and BCAA+Gln diet(BCAA 0.7g+Gln 0.2g/100kcal) were given 60kcal/day to each group. These amino acids were displaced to a part of protein in the composition of control diet. All diets contained the same amount of protein(4.5g isoni-trogen), carbohydrate(14.2g) and vegetable oil(2.8g) in 100kcal. Vitamins and minerals were also the same. Wound area of each rat was measured at every day. Plasma was obtained by jugular vein at the pre- and post- injury point. Concentration of amino acids in the plasma was analyzed by amino acid analyzer. We also analyzed fibroblast growth factor(FGF), tumor necrosis factor-α(TNF-α), vascular endothelial growth factor(VEGF) and transforming growth factor-β(TGF-β) in site of wound area in each rat of BCAA+Gln and control group on 2nd and 5th day, for one of the explanations of these amino acids effects. Results: After development of a pressure ulcer at 4th day of pressurization, plasma level of BCAA and Gln decreased to 88% and 70%, respectively. Wound size of both of BCAA and BCAA+Gln groups reduced earlier than control. In particular, wound area in BCAA+Gln group was markedly lower than that of control until 3rd day. Wound area-time under the curve(AUC) in BCAA+Gln group was significantly lower than that of control to 8th day. In site of wound, FGF level in BCAA+Gln group was higher than that of control at 2nd and 5th day. On the other hand, TNF-α level in BCAA+Gln group was significantly lower than that of control at 5th day. VEGF was tendency to decrease in BCAA+Gln group than control at 2nd and 5th day, although it was not significant. Levels of TGF-β between BCAA+Gln and control group were almost the same at each point. Conclusions: These results indicate that a diet containing BCAA and Gln may has a potential to heal a pressure ulcer. BCAA+Gln may particularly have a possibility of healing the wound from early stage. Inhibition of excessive inflammation and proliferation of fibroblast were suggested as a mechanism for healing a pressure ulcer on BCAA+Gln, but further detail investigation is still interesting and required.

S35 - An Enteral Feeding Protocol for Mechanically Ventilated Pediatric PatientsEmily Burritt, RD, Miller Children’s Hospital1; Thienkim Ngo, MD, Children’s Hospital of Los Angeles4; Colleen E. Trupkin, RD, Miller Children’s Hospital1; Barry Steinmetz, MD, Miller Children’s Hospital3; Chris Babbitt, MD, Miller Children’s Hospital2

1Pediatric Nutrition, Miller Children’s Hospital, Long Beach, CA; 2Pediatric Critical Care, Miller Children’s Hospital, Long Beach, CA; 3Pediatric Gastroenterology, Miller Children’s Hospital, Long Beach, CA; 4Pediatric Critical Care, Children’s Hospital of Los Angeles, Los Angeles, CA.

Introduction: Mortality, morbidity and length of stay are all increased in malnourished intensive care patients.1-6 A pediatric study utilizing a feeding protocol demonstrated improved caloric support when compared to patients before the protocol was instituted.7 Our PICU has shown excellent results in achieving optimal nutrition in a select population of patients fed trans-pylorically.8 We hypothesized that mechanically ventilated PICU patients fed gastrically by protocol would have improved caloric delivery when com-pared to non protocol patients in a randomized controlled trial (RCT). Methods: A RCT was performed on patients who were likely to receive mechanical ventilation for greater than 48 hours at a 20 bed PICU. Patients were randomized to either the feeding protocol or control arm of the study. The feeding protocol assigned patients into one of three regimens based on age(table 2). The control group was fed according to the primary team’s plan using a goal provided by the registered dietician. Data collected included: age, LOS, length of ventilation, time to starting feeds, time to goal feeds, feeding days, goal kcal of order, goal kcal/vent days and complications. Statistical analyses were performed using Student’s t and Fisher’s exact test. Results: A total of 41 patients entered into the study. Seven patients were not included in the analyses (4 protocol and 3 control) because they were changed to nasojejunal feeds based on the attending physician’s preference (4) or because they were extubated in less than 48 hours (3). Therefore, 34 patients were included in the data analyses. When comparing patients that tolerated feeds without any complications in both groups (n=29), protocol patients reached goal feeds more rapidly after initiation (8 vs 19 hrs, p value <0.001) than non-protocol patients. Overall, 97 % of all patients were started on feeds within 48 hours of intubation and reached goal feeds while on the ventilator. On average, both groups received 59% of their goal kcal/day while ventilated. There was no difference in age, LOS, duration of ventilation, time to starting feeds, feeding days or complications between the two groups. Complications included abdominal distension, vomiting, pancreatitis, and one NEC scare and occurred in a total of 5 patients (15%). There was one death that was unrelated to the feeding protocol. Conclusions: All patients in this study received improved enteral nutritional support as compared to previous reports in both time to goal and average kcal received.9-10 Con-ducting a study on nutrition alone, may have led to increased emphasis and improved delivery of calories. Both groups had issues with gastric motility likely related to receiving narcotic infusions while on mechanical ventila-tion. However, no serious complications were seen. Protocol fed patients reached goal feeds more rapidly than non protocol patients, but overall there was no difference in the average caloric delivery per vent day. The protocol was well tolerated without any increase in complications and appears to be a safe way to feed mechanically ventilated pediatric patients.

Table 1. Demographics of Protocol and Non-protocol patients

Parameter Protocol Non-Protocol P Value

Patients 14 20 Age (months) 10 (1-168) 2.5 (0.5-192) NS PICU LOS (days) 12 (4-58) 10 (6-78) NS Duration of vent (days) 7.3 (2.6-54) 6.9 (3.8-37) NS Time to full feeds (hrs)* 8 (4.5-12) 19 (4-55) 0.0008 Reached goal feeds (n) 14 19 NS Kcal goal/Vent Day (%) 59 59 NS Complications 2 3 NS Parenteral Nutrition 1 2 NS

Data shown as median (range) *Calculated on patients that tolerated feeds without complications (29 patients)


S36 - Porcine Evaluation of Forces Required for Inadvertent Removal of PEG DevicesJohn C. Fang, MD; Kristen Hilden, RN, MSUniversity of Utah, Salt Lake City, UT.

Introduction: Solid mushroom type bolster or water filled balloons are the most common internal retention devices for PEG’s. It is these internal retention devices that resist accidental or inadvertant removal of PEG’s from external traction. For a balloon type replacement PEG’s the removal force may differ by differ by size (volume) of retention balloon or whether balloon bursts upon removal. The difference in forces required to remove these different retention devices have not been previously reported. Methods: Four solid internal bolster initial placement PEG’s were placed into 2 live pigs. Eleven days later the initial PEG’s were removed and replacement balloon PEG’s were placed and removed immediately. Force of external traction removal was mea-sured using strain gauge meter and measured in psi. The 4 initial placement solid internal bolster PEG’s (14-24F Endovive Standard PEG) and 26 balloon type replacement PEG’s (14-24F Endovive Stan-dard Profile Balloon Replacement Feeding Tubes (n=20), Kimberly Clark MIC Gastrostomy Feeding Tubes (n=6)) were tested. Balloons were inflated with sterile H2O to various volumes (5-20 cc) per manu-facturers directions. For balloon type PEG’s the balloons were left inflated when removal forces were tested. Results: The force to remove all retention balloons (burst and not burst) was significantly greater than the force required to remove the initially placed four solid internal bolster PEG’s (14.4 ± 0.6 vs.7.4 ± 0.9 respectively) (p=0.0004). Conclusions: Balloon type PEG’s required significantly more force to remove than solid internal bolster PEG’s. The force for removing bal-loon type replacement PEG’s did not differ by volume that the balloon was inflated to or whether retention balloons burst (vs. not bursting) during traction removal. This data has important implications for choosing and designing PEG’s in patients at risk for inadvertent removal.

TOPIC: Gastrointestinal Disease

S37 - How do you Feed? Results of a Transatlantic Survey of Nutrition Practice in Acute PancreatitisSinead Duggan, RD (Research), BSc. Dipl.1,3; Niamh Smyth, RD, BSc.2; Sinead Feehan, RD, BSc.2; Maria O’Sullivan, PhD4; Paul F. Ridgway, MD1,3; Kevin Conlon, MD1,3

1Centre for Pancreatico-Biliary Disease, Adelaide & Meath Hospital incorporating the National Childrens Hospital, Dublin 24, Ireland; 2Nutrition & Dietetics, Adelaide & Meath Hospital incorporating the National Childrens Hospital, Dublin 24, Ireland; 3Surgery, Trinity College Dublin, Dublin 24, Ireland; 4Clinical Medicine, Trinity College Dublin, Dublin 24, Ireland.

Introduction: Acute pancreatitis is a devastating disease in its most severe form. Despite much research, basic controversies still exist over the nutri-tional management of patients with severe disease. Many guidelines have been published, including ASPEN, ESPEN, the American Gastroenterol-ogy Association and the British Society of Gastroenterology, and while they broadly recommend ‘early’ feeding, they do not specify a time frame. Enteral feeding is unanimously recommended, however the preferred route of feeding (jejunal versus gastric) is less clearly defined. There is little direction on the provision of ‘additions’, such as pancreatic enzymes and probiotics. Little is known regarding practice and adherence to guide-lines. We conducted an international survey to examine nutrition practice in acute pancreatitis; including Canada, the United Kingdom (UK) and Ireland. We aimed to compare practice to guidelines, between countries and institution types. Methods: Study design was a cross-sectional descrip-tive survey. Electronic surveys were sent to dietitians who see acute pan-creatitis patients in the UK, Ireland and Canada. In total, 204 dietitians responded to the survey. Per country, n=117 dietitians in Canada, n=56 in the UK and n=31 in Ireland participated. Using Minitab 15 software, chi-square analyses examined differences in categorical variables. P<0.05 was considered significant. Results: When asked to define ‘early feeding’, 92.8% considered this to mean <48 hours after presentation. Over half (54.2%) reported opting to feed early in severe acute pancreatitis, less in obesity (42%) and more with pre-existing malnutrition (81.9%). There was a tendency to feed earlier in university hospitals (p=0.015), especially in the obese patient (p=0.01). Regarding parenteral nutrition, 15.2% reported ‘routine’ use. Most dietitians (92.1%) reported feeding enterally at least ‘occasionally’, more in university hospitals than in district/ general hospitals (p=0.00). Most prefer the jejunal route (64.2%), although less in the UK (43.8%) than in Canada (77.8%) or Ireland (54.2%). Seven in ten (73.5%) perceive barriers to enteral feeding, most commonly medic’s preference (57.8%). Probiotics are administered with feeds at least ‘some-times’ by 15.3% of dietitians, mostly in district/ general hospitals. Most dietitians (71.3%) administer pancreatic enzymes with feeds at least ‘some-times’. Conclusions: The survey underlines deficits in the nutritional management of acute pancreatitis. Although the aim to feed early is estab-lished among dietitians, it is less likely in obese patients. Parenteral nutri-tion is still prominent, and dietitians perceive medical opinion as a barrier to enteral feeding. Although the guidelines do not give direction on pro-viding pancreatic enzymes with feeds, this practice is common. Despite

Table 2. The Feeding Protocol

Plan A B C

Age Infants (0-11m) 12 months-9 years 10+ years

Formula Breast Milk or Home Formula

Standard pediatric formula with fiber

Standard adult formula with fiber

Caloric 24kcal/oz 30kcal/oz 32kcal/oz Initiation 5ml/hr 10ml/hr 15ml/hr

Advance 5ml/hr q 2 hours

10ml/hr q 2 hours

15ml/hr q 2 hours

Max 100ml/kg Maintenance Volume

Maintenance Volume

Goal RD determined RD determined RD determined

Force to remove replacement balloons by balloon volume

Balloon volume (cc) n

n (% Balloon burst)

Force (psi) mean ± SD p-value

5 4 3 (75) 12.8 ± 2.8 NS 6 4 0 (0) 15.6 ± 0.7 NS 10 4 0 (0) 16.4 ± 0.8 NS 20 14 9 (56) 15.4 ± 3.4 NS

Difference in force to remove replacement balloons that burst vs. balloons that did not burst

n Force (psi) mean ± SD p-value

Balloon burst 12 16.1 ± 3.0 NS Balloon did not burst 14 14.4 ± 2.7 NS


recent negative studies, probiotics are still administered. Differences in practice are apparent between countries; while jejunal feeding is favoured by the majority, it is used less in UK. Practice in university hospitals appears to be more compliant with guidelines than in district/ general hospitals. This study provides a platform for quality improvement inter-ventions. It allows the tailoring of education and research to overcome barriers to optimal practice, improve adherence to guidelines and ulti-mately advance nutritional management in acute pancreatitis.

S38 - Symptoms and Diet in Subjects with Irritable Bowel Syndrome: is Vitamin B6 the Missing Link?Solveig C. Ligaarden, MS, RD1,2; Per G. Farup, PhD, MD2,3

1Department of Medicine, Innlandet Hospital Trust, Gjövik, Norway; 2Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway; 3Department of Research, Innlandet Hospital Trust, Gjövik, Norway.

Introduction: Most subjects with irritable bowel syndrome (IBS) experi-ence an association between food consumption and IBS symptoms. Dietary intake of food groups has been the focus of some papers, but attention to nutrients is rare. The aim of this study was to investigate associations between dietary intake and the severity of IBS symptoms. Methods: This cross-sectional study was accomplished in the run-in period of a ran-domised controlled trial. Subjects with IBS, defined according to the Rome II criteria, were recruited from a hospital-based gastroenterology outpatient clinic. IBS symptoms were recorded (pain/discomfort, stool frequency, stool, urgency, bloating, straining and incomplete evacuation) on diary cards every evening for seven days and an IBS sum score was calculated (range 0-15). Food groups and food supplement intake was assessed from a food diary kept by the subjects in the same period. Asso-ciations between IBS sum score and dietary intake were explored with univariate and multivariate (with two covariates) linear regression analyses. Results are given as the median and range unless otherwise indicated. Results: Seventeen subjects (five men and 12 women) aged 52 (33-65) years were available for the study; one had constipation-predominant IBS, nine had alternating, and seven had diarrhoea-predominant IBS. The daily IBS sum score was 6.43 (3.86- 9.09). In univariate analyses, intake of vitamin B6 (B6) was the only component of the diet that was signifi-cantly associated with the IBS sum score. The daily intake of B6 was 0.9 (0.6-1.5) mg/day (recommended daily intake ≥ 1.2 mg/day). Low intake was associated with a high symptom score (R square = 0.609; β = -4.431, 95 % confidence interval, CI, -6.386 to -2.476, P = 0.00016). The results were confirmed by multivariate analyses. Consumption of more cereals implied higher intakes of B6. Conclusions: A low intake of B6 was sig-nificantly associated with increased IBS symptoms. Thus, B6 might be a factor in the complex immunology involved in the pathophysiology of IBS, or an indicator for a modified diet - for example, a less nutrient-dense diet - when symptoms are severe.

S39 - Glutamine enhances HSF-1 expression in experimental colitisHongyu Xue, MD, PhD; Paul Wischmeyer, MDUniversity of Colorado, Aurora, CO.

Introduction: Glutamine (GLN) is a key “pharmacologically-acting nutri-ent”. We have demonstrated that pharmacologic doses of GLN given via ‘bolus’ administration can confer therapeutic benefits in experimental inflammatory bowel disease (IBD). We further reveals for the first time that bolus GLN given in pharmacologic doses enhances colonic HSP expression in experimental IBD, suggesting this could be a key mechanism

underlying GLN’s action in this setting. However, the mechanisms by which GLN enhances HSP expression remain unclear. The heat shock transcription factor (HSF-1) is the master regulator for heat shock gene expression. It remains unclear whether GLN’s action is mediated by modu-lation of HSF-1’s transactivation activity or/and expression. We further related GLN’s modulation of HSF-1 to double-stranded (ds)RNA-dependent protein kinase (PKR), a vital stress-responsive protein governing the privi-leged expression of stress-related proteins during stress. Methods: In vivo, colitis was induced in male Sprague-Dawley rats by 5% dextran sulfate sodium (DSS) in drinking water for 7 days. GLN (0.75g/kg/day) or sham was administered to the rats by oral gavage during the 7-day DSS treat-ment. In vitro, conditionally immortalized YAMC colonic epithelial cells were treated with 0, 0.25, 0.5, 2, or 4 mmol/L GLN and cytokines (TNF-α (100ng/ml) and IFN-γ (200U/ml)) in a concurrent treatment model. HSF-1 knockout (HSF-1 -/-) mouse embryonic fibroblast cells were used to con-firm the specificity of HSF-1 expression in Gln’s protective effects. PKR expression and phosphorylation in YAMC cells were inhibited by siRNA and specific PKR inhibitor respectively. Results: GLN treatment mitigates experimental colitis both in vitro and in vivo, associated with enhanced HSP70 and HSP25 expression in colonic epithelial cells. In cytokine-injured YAMCs, GLN not only enhances HSF-1 transactivation activity by increasing its nuclear translocation and phosphorylation, but also up-regulates its expression in a dose-dependent manner. In in vivo DSS-colitis, GLN treatment also enhances HSF-1 expression in colonic mucosa. Fur-ther, GLN’s protective effects against inflammatory injury are lost in HSF-1 knockout cells. GLN increases steady-state HSF-1 mRNA level in both un-stressed and heat-stressed YAMC cells, suggesting that GLN’s upregula-tion of HSF-1 occurs at the transcriptional level. Further, inhibition of PKR phosphorylation abrogates GLN’s enhancement of HSF-1, HSP25 and HSP70 expression. PKR-specific siRNA, which blocks PKR expres-sion, also abrogates GLN’s induction of HSF-1 and HSP25. PKR phos-phorylation inhibition also blocks GLN’s enhancement of HSF-1 mRNA expression, which is consistent with finding that GLN’s modulation of HSF-1 expression occurs on the transcriptional level. Conclusions: Our data provides the first evidence showing that GLN may not only activate HSF-1’s transactivation activity, but also increases HSF-1 expression, which ultimately leads to up-regulated HSP expression and confers protec-tion to colonic epithelium in experimental colitis. GLN’s modulation on HSF-1 expression may occur at the transcriptional level. Further, GLN’s protection against inflammatory injury in the setting of IBD is dependent on HSF-1 expression. Lastly, we for the first time show that GLN’s enhance-ment of HSPs depends on PKR activation and expression.

TOPIC: Glycemic Control

S40 - Provision of Balanced Nutrition Protects Against Hypoglycemia in the Surgically Critically IllRondi M. Kauffmann, MD, MPH1; Rachel M. Hayes, BSN, PhD2; Judith M. Jenkins, MSN3; Patrick R. Norris, PhD3; Jose Diaz, MD, CNS, FACS, FCCM3; Addison May, MD, FACS, FCCM3; Bryan Collier, DO, CNSP, FACS3

1Surgery, Vanderbilt University Medical Center, Nashville, TN; 2Informatics Center, Vanderbilt University Medical Center, Nashville, TN; 3Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN.

Introduction: Intensive insulin therapy (IIT) lowers blood glucose (BG) levels and improves outcomes. Optimum target range remains controver-sial, due to concerns over hypoglycemia and associated increases in mor-tality with tight BG control (80-110 mg/dL). Typically, IIT protocols require a nutrition source, such as a dextrose solution, to guard against hypogly-cemia. We hypothesized that the provision of balanced nutrition (enteral


nutrition (EN) or total parenteral nutrition(TPN)) would be more protec-tive against hypoglycemia (<50 mg/dL) than carbohydrate, protein, or fat calories alone. Methods: A retrospective analysis was performed on SICU patients admitted to a tertiary care center from 06/06 to 9/09. The cohort included patients treated with a computerized IIT protocol, with at least 5 BG measurements, and surviving longer than 24 hours. The initial 12 hours on protocol was excluded, eliminating time to BG steady state. The protocol requires infusion of D10W at 30 ml/hr if the patient is not receiving either EN or TPN, to protect against hypoglycemia. Nutritional provision including carbohydrate, fat and protein calories were assessed in two hour increments, comparing periods of BG control with and without nutrition. Demographics, illness severity, BG measurements, laboratory values, adherence to IIT protocol, types of nutrition, and measures of BG variability were analyzed with multivariate logistic regression to determine their association with hypoglycemia. Robust covariance estimates were used to adjust for correlated data. Balanced nutrition was defined as the provision of TPN, either with or without lipids, or EN. Patients who received dextrose alone or fat alone (including propofol) were designated as not receiving balanced nutrition. Results: During the study period, 70,568 BG measurements were collected on 1482 patients. Hypoglycemia (<50 mg/dL) occurred in 168 (11.3%) patients and in 226 (0.32%) BG measurements. Forty-eight percent of patients received TPN or EN during their SICU stay. Baseline demographics including gender, race, age, and BMI did not differ between groups. Hypoglycemic events occurred in 5.7/1000 BG tests in patients not receiving balanced nutrition compared to 2.2/1000 BG tests in patients receiving balanced nutrition. In regres-sion models, provision of balanced nutrition was the strongest protective factor against hypoglycemia. Patients who did not receive balanced nutri-tion had a more than three-fold increase in odds of experiencing a hypo-glycemic event at their next BG check versus patients who were being provided EN or TPN (OR 3.6, p-value<0.0001). Age <65 years was also protective against hypoglycemia (OR 1.5, p-value= 0.02). Providing car-bohydrate, fat or protein calories alone did not protect against hypogly-cemia. Associations of APACHE II, history of diabetes, and time on protocol with hypoglycemia were not statistically significant. Conclusions: The provision of balanced nutrition, including carbohydrate and protein, guards against hypoglycemia regardless of the route of administration. From the standpoint of safer insulin therapy, balanced nutrition should begin when IIT is initiated. This data supports the use of a dextrose plus protein fluid source with IIT, rather than a dextrose fluid only. Future studies should evaluate the efficacy of EN versus TPN in preventing hypoglycemia, and associations between balanced nutrition and outcomes including mortality and infection risk.

S41 - Hypoglycemia from NPH Insulin during Continuous Enteral Nutrition is More Prevalent for Critically Ill Older PatientsVera Quallich, Pharm.D.1; Rex O. Brown, Pharm.D.1; George O. Maish, M.D.2; Martin A. Croce, M.D.2; Gayle Minard, M.D.2; Roland N. Dickerson, Pharm.D.11Clinical Pharmacy, University of Tennessee Health Science Center, Memphis, TN; 2Surgery, University of Tennessee Health Science Center, Memphis, TN.

Introduction: The intent of this study was to evaluate the safety and efficacy of subcutaneous NPH Insulin for hyperglycemic, critically ill trauma patients receiving intravenous (IV) regular human insulin (RHI) and continuous enteral nutrition (EN). Methods: Adult (> 18 years old), hyperglycemic critically ill trauma patients referred to the Nutrition Support Service for EN and glycemic management and who were transitioned from IV RHI therapy to subcutaneous NPH insulin given twice daily were retrospectively identified. Patients with renal failure or who received intermittent or bolus EN, had an ad-libitum oral diet intake > 500 kcal/d, given corticosteroids, or received < 48 hours of NPH insulin were excluded. A diabetic EN formula was provided when another specialized formula was not indicated. Sources

of dextrose from large volume parenteral fluids and IV medications were eliminated when possible. Target blood glucose concentration (BG) range was 60 to 150 mg/dL. BG was determined every 1 to 4 hrs. Patient data were obtained from the day prior to starting insulin therapy up to 14 days while receiving NPH Insulin. Results: Sixty-six patients from May, 2008 until April, 2010 met study entry criteria (Table 1). Thirty-two patients were transitioned to NPH insulin therapy from a continuous IV RHI infusion whereas 34 patients had NPH insulin added to their intermittent IV RHI sliding scale regimen. Target BG concentrations were maintained for 18 hrs/d. Nearly half of the total population had at least one BG < 60 mg/dL and 9% experienced at least one episode of BG < 40 mg/dL (Table 2). Those with BG < 60 mg/dL received a higher dose of NPH (44 ± 19 units/d vs. 33 ± 16 units/d, p < 0.01); supplemental IV RHI doses were similar(33 ± 26 units/d vs. 31 ± 21 units/d, p = NS). Older patients (≥ 60 yrs) were at increased risk for hypoglycemia from NPH insulin as twice as many older patients than younger patients (68% vs 31%) experienced hypoglycemia < 60 mg/dL (Table 2, p = 0.03). Five out of the six patients who experienced severe hypoglycemia (BG < 40 mg/dL) occurred within the older patient group. This difference in hypoglycemia between age groups could not be explained by dose of NPH, supplemental amount of RHI given, or carbo-hydrate intake (Table 2). Diabetic patients also tended to develop hypogly-cemia during NPH therapy (57% vs. 34%); however, this trend was not statistically significant (p = NS). Conclusions: Subcutaneous NPH insulin therapy, when used for hyperglycemic critically ill trauma patients receiving continuous enteral feeding, kept BG 60 to 150 mg/dL for most of the day. Older patients are at greater risk for developing hypoglycemia from NPH insulin. NPH insulin should be used with extreme caution for older criti-cally ill patients receiving continuous EN.

Table 1. Patient demographics

Variable Total

Population Age > 60

yrs Age < 60 yrs P

N 66 34 32 - Survived/Died (n/n) 61/5 31/3 30/2 NS Male/Female (n/n) 49/17 24/10 25/7 NS Age (yrs) 58 ± 15 71 ± 8 45 ± 8 0.001 Weight(kg) 92 ± 23 90 ± 23 95 ± 23 NS Diabetes mellitus (n) 37 (56%) 20 (54%) 14 (48%) NS Serum creatinine (mg/dL)

0.9 ± 0.3 0.9 ± 0.3 0.9 ± 0.3 NS

Albumin (g/dL) 2.1 ± 0.6 1.9 ± 0.5 2.2 + 0.6 0.01 Hospital LOS (d) 40 ± 27 38 ± 25 42 ± 28 NS

LOS, length of stay; n, number of patients; NS, not significant

Table 2. Glycemic response to NPH insulin

Variable Total

Population Age > 60 yrs

Age < 60 yrs P

N 66 34 32 - NPH dose (units/d) 33 ± 17 32 ± 15 35 ± 18 NS Supplemental RHI dose (units/d)

32 ± 23 29 ± 17 35 ± 29 NS

BG 60 - 150 mg/dL (hrs/d) 18 ± 4 17 ± 4 18 ± 4 NS BG > 150 mg/dL (hrs/d) 6 ± 4 5 ± 4 6 ± 5 NS BG < 60 mg/dL (hrs/d) 0 ± 1 1 ± 1 0 ± 1 0.001 Hypoglycemia < 60 mg/dL (n)

31 (47%) 21 (68%) 10 (31%) 0.03

Hypoglycemia < 40 mg/dL (n)

6 (9%) 5 (16%) 1 (3%) NS

CHO intake (g/d) 146 ± 51 142 ± 48 150 ± 55 NS

BG, blood glucose concentration; CHO, carbohydrate; N, number of patients; NS, not significant; RHI regular human insulin


S42 - Four-Hour Evaluation of a Medical Food in Subjects with Type 2 Diabetes Receiving Oral Hypoglycemic MedicationMenghua Luo, MD, PhD1; Anne C. Voss, PhD, RD1; Vikkie A. Mustad, PhD1; Lyudmila Ivanova, Prof2; Tatiana Morugova, Prof3; Elena Alexeeva, MD, PhD4; Lyudmila Ruyatkina, Prof5; Lyudmila Suplotova, Prof6; Natalia Vorokhobina, Prof7

1Abbott Nutrition, Columbus, OH; 2Kuban State Medical University, Central Okrug, Russian Federation; 3Bashkir State Medical University, Bashkortostan Republic, Russian Federation; 4Russian State Medical University of Federal Agency of Healthcare and Social Development based on City Clinical Hospital #68, Moscow, Russian Federation; 5Novosibirsk State Medical University, Novosibirsk, Russian Federation; 6Tyumen State Medical Academy, Tyumen, Russian Federation; 7City Clinical Hospital #3, St. Petersburg, Russian Federation.

Introduction: Postprandial hyperglycemia is an independent risk factor for diabetes-associated complications in individuals with type 2 diabetes. Dietary modification plays an important role in glycemic control. The purpose of the study was to demonstrate the efficacy of a diabetes specific formula (DSF) during a 4-hour postprandial meal tolerance test (MTT) in Russian subjects with controlled type 2 diabetes receiving oral hypoglycemic medication. Methods: In a randomized, two-treatment, two-period, cross-over design,168 eligible subjects from 11 study centers were asked to consume an average of 150 g of carbohydrate per day for 3 days before each study visit and to fast for 8-14 hours the night before the visit. On the study day, subjects took their routine oral hypoglycemic medication, and then received, in a random order, the diabetes specific formula (DSF) (230 mL) or a typical breakfast meal consisting of 30 gram white bread, 230 mL milk with 1.5% fat and 4 g butter

spread. The amounts of macronutrients were similar between the two meals providing ~200 kcal, 11 g protein, 26 g carbohydrate and 8 g fat. Capillary glucose levels, measured by a glucometer calibrated against to YSI, were determined at baseline (before meal consumption), and post-meal consump-tion at 30, 60, 90, 120, 180 and 240 (± 5) min. Data are presented as mean ± SEM. Results: DSF was well tolerated in all subjects. One hundred and eleven subjects completed the study per protocol (age: 58.6 ± 0.8 yr, BMI: 31.8 ± 0.42 kg/m2, waist circumference: 101 ± 1.3 cm, HbA1c: 8.0 ± 0.1%). Glucose levels reached to the peak values at 60 min (median) and the lowest levels at the end of the 240-min MTT test. The positive area under the curve (PAUC, primary outcome) was significantly smaller after consumption of DSF (mean ± SEM: 183.02 ± 18.74, median: 132.55) than the PAUC after consumption of the typical meal (mean ± SEM: 239.95 ± 23.11, median: 166.89; p = 0.0267). There was no difference in mean actual and adjusted capillary glucose concentrations at individual time points. The peak glucose values were 11.35 ± 0.25 and 10.90 ± 0.27 mmol/L after consumed the typical breakfast meal and DSF, respectively (p > 0.05). Conclusions: In patients with type-2 diabetes receiving oral hypoglycemic agents, compared to the typical breakfast meal, DSF improves postprandial glucose control. Combin-ing results from earlier studies, long-term use of DSF is beneficial to improve glucose management and decrease diabetes-associated complications.

TOPIC: Inflammation

S43 - Nutrition, Inflammation, and Quality of Life in Older Cardiac Surgery PatientsRose Ann DiMaria-Ghalili, PhD, RN1,2; Eileen Sullivan-Marx, PhD, RN, FAAN2; Charlene Compher, PhD, RD, FADA2

1Doctoral Nursing Dept, Drexel University, Philadelphia, PA; 2School of Nursing, University of Pennsylvania, Philadelphia, PA.

Blood glucose response to NPH insulin and supplemental RHI therapy in older versus younger patients.


Introduction: The purpose of this study was to examine nutritional, inflammatory, and quality of life (QOL) measures before and after cardiac surgery among community residing older adults (≥65 years). Since little is known about the relationship of nutrition, inflamma-tion, and quality of life following cardiac surgery, better understand-ing could potentially lead to improved outcomes and quality of life. Methods: Inflammatory and nutrition biomarkers were measured at T1 (preoperatively) and T2 (six weeks post-discharge) and included nutritional (weight, serum albumin, Mini-Nutritional Assessment™ [MNA], calf-circumference, grip-strength, appetite), inflammatory (serum IL-6 and hsCRP), and QOL (SF- 8 Health Status Survey). The SF-8 Health Status Survey measures 8 dimensions of self-reported health status. Corresponding subscales combine to yield a Physical and Mental Component Summary score. Twenty community residing older adults, without active cancer or immune compromise, scheduled to undergo elective coronary artery bypass surgery, with or without valve repair, were enrolled. Four patients were lost to follow-up. One patient was started on steroids postoperatively, and was not included in the final data analysis. Results: The mean age of participants was 72.25 ± 5.24 yrs, 70% male. At T2, 93% lost weight (3.34 ± 1.62 kg). Inflammatory response was categorized into low, intermediate and high using median IL-6 and hsCRP levels as cut-off. At T1, 42% were categorized as intermediate, and 28% as high. At T2, 79% were categorized as intermediate and 14% as high. QOL decreased at T2 ( Table 1). Except for Mental Health and Mental Component Summary score, all SF-8 scales were below the standard US mean of 50 at T2. T1 correlations (p ≤.05) between nutrition variables and SF-8 scales include: calf-circumference and, General Health (r=.623) and grip-strength and, Mental Component Summary score and Mental Health (r=.532, .728, respectively). T2 correlations (p ≤.05) between nutrition variables and SF-8 scales include: calf-circumference and, Social Functioning, General Health, and Bodily Pain (r=.541, .576, .538 respectively); grip-strength and, Mental Component Summary score and Mental Health (r=.635, .660, respectively); albumin and, Social Functioning and General Health (r=.664, .606, respectively); appetite and Vitality (r=.603), MNA and Bodily Pain (r=.526); weight loss and, Physical Health and Vitality (r=-.568, -.569, respectively). Conclusions: In the pres-ence of inflammation, lower levels of nutritional markers are related to lower levels of QOL in older adults before and after cardiac surgery. Examination of the impact of nutrition interventions on promoting QOL in older adults recovering from surgery is warranted.

TOPIC: Lipids

S44 - Fish oil reverses paclitaxel-induced atrophy of Peyer’s patches and decrease of immunoglobulin A levels in respiratory tractTomoyuki Moriya, M.D Ph.D1; Kazuhiko Fukatsu, M.D Ph.D2; Midori Noguchi, BA3; Koichi Okamoto, M.D1; Satoshi Murakoshi, M.D3; Hiroshi Yasuhara, M.D Ph.D2; Daizoh Saitoh, M.D Ph.D3; Kazuo Hase, M.D Ph.D1; Junji Yamamoto, M.D Ph.D1

1Department of Surgery, National Defense Medical College, Tokorozawa, Japan; 2Surgical Center, The University of Tokyo, Tokyo, Japan; 3Division of Traumatology, National Defense Medical College Research Institute, Tokorozawa, Japan.

Introduction: Chemotherapy remains the mainstay of treatment for cancer patients. However, anticancer drugs frequently have adverse effects on host defenses against infection. We recently demonstrated intravenous (IV) admin-istration of paclitaxel (PTX) to reduce gut associated lymphoid tissue (GALT) mass, which is a center of systemic mucosal immunity. Because PTX is increas-ingly used for the treatment of various malignancies,establishment of strategies to prevent PTX-related immunodeficiency may be needed. We examined the effects of infusion of fish oil (FO) or soybean oil (SO) on GALT cell number and immunoglobulin A levels in mice receiving PTX. Methods: Male ICR mice were randomized to four groups; Control (n=18), PTX (n=18), PTX+FO (n=14) and PTX+SO(n=15).The PTX, PTX+FO and PTX+SO groups received a single IV administration of PTX at 4 mg/kg on day 1. Then, the control and PTX groups received normal saline at 0.2 ml/hr, while the PTX+FO or SO group were given an infusion of 10 ml/kg of 10% fish oil or soybean oil emul-sion, respectively. After 7 days, the mice were killed and lymphocytes were isolated from Peyer’s patches (PPs), the lamina propria (LP) and intraepithelial (IE) spaces in the small intestine. Lymphocytes were counted and their phe-notypes (CD4,CD8,αβTCR,γΔTCR and B220) were determined by flowcy-tometry. Immunoglobulin A (IgA) level in small intestinal and respiratory tract washings was also measured by ELISA. Results: There were no significant differences in body weight change or white blood cell count in peripheral blood samples. With regard to the IgA levels, no significant change in intestinal IgA level was observed in the four groups. Respiratory tract IgA level was lower in the PTX and PTX+SO groups than in the control group. However, the PTX+FO group showed restoration of the respiratory tract IgA level to the control level. The PTX and PTX+SO groups showed a significantly lower PP lymphocyte number than the control group. However, fish oil infusion sig-nificantly restored the PTX-induced reduction of PP lymphocyte numbers. Absolute numbers of γΔTCR- and B220-positive cells in PPs were significantly lower in the PTX and PTX+SO groups than in the Control group. In addition, CD4- positive cells in PP were significantly decreased in the PTX group, as compared with the Control group. Absolute numbers of γΔTCR- and CD4- positive lymphocytes were significantly higher in the PTX+FO group than in the PTX group.The numbers of lymphocytes isolated from the IE and LP did not differ significantly among the 4 groups. Conclusions: IV infusion of FO reversed PTX-induced decrease in respiratory tract IgA level, in association with recovery of PP atrophy. Fish oil infusion after PTX injection may be an option for maintaining mucosal immunity and preventing untoward side effects.

Table 1. Quality of Life Scores at Preoperative and Post-discharge

Preoperative Mean ± SD

Post-discharge Mean ± SD

Physical Functioning 44.05 ± 8.88 41.15 ± 8.02 Role Performance 42.35 ± 9.49 39.04 ± 10.39 Bodily Pain 50.07 ± 9.86 45.68 ± 8.13 General Health 46.42 ± 5.75 48.47 ± 4.89 Vitality 49.26 ± 10.76 46.01 ± 5.93 Social Functioning 50.52 ± 6.61 42.33 ± 11.08* Role Emotional 48.76 ± 4.46 47.22 ± 6.60 Mental Health 50.14 ± 7.91 51.87 ± 5.44 Physical Component Summary Score

44.06 ± 8.18 39.46 ± 10.11

Mental Component Summary Score

52.61 ± 7.87 51.99 ± 7.90

*p=.005

Number of PP lymphocytes1)

Number of IE/LP lymphocytes1)

Intestinal IgA2)

Respiratory tract IgA3)

Control 38.0±2.3† 2.6±0.3/8.9±2.2 25.8±3.6 460±62†§PTX 23.7±2.1 2.5±0.2/10.5±0.5 23.3±3.1 291±27PTX+FO 36.3±6.2† 2.5±0.2/8.5±0.5 22.2±3.1 436±55†PTX+SO 24.0±2.8 3.0±0.5/10.1±1.9 26.3±2.8 326±46

1) (x106/body), 2) (μg/ml) 3) (ng/ml) (ANOVA †p<0.05 vs PTX, p<0.05 vs PTX+SO, §p=0.05 vs PTX+SO)


S45 - Relationship Between Hypertriglyceridemia and Body Mass Index in Patients Receiving Parenteral NutritionErin N. Frazee, PharmD1; Erin M. Koopman, PharmD, BCNSP1; M. Molly McMahon, MD2; John M. Miles, MD2

1Pharmacy Services, Mayo Clinic, Rochester, MN; 2Endocrine Research Unit, Mayo Clinic, Rochester, MN.

Introduction: Hypertriglyceridemia has been associated with adverse out-comes in patients receiving intravenous fat emulsions (IVFE), but little is known about its prevalence and causes. The objective of this study was to determine the association between body mass index (BMI) and serum tri-glyceride concentration during IVFE. We hypothesized that nutritionally depleted patients (arbitrarily defined as BMI < 16 kg/m2) have lower serum triglyceride concentrations during feeding than other individuals. Methods: Records of 287 hospitalized adult parenteral nutrition patients who had a triglyceride measurement during IVFE administration were reviewed. Patients receiving concurrent enteral nutrition, oral diet, or intravenous propofol infusion were excluded. Patients were stratified into four groups for analysis including very low BMI (VLBMI; < 16 kg/m2), low BMI (LBMI; 16-18.4 kg/m2), normal BMI (NBMI; 18.5-24.9 kg/m2) and overweight/obese patients (HBMI; ≥ 25 kg/m2). The Wilcoxon rank-sum test was used to assess the primary outcome of difference in serum triglyceride concentrations between VLBMI patients and all other patients. Secondary outcomes including dif-ference in triglycerides among the four BMI subgroups, correlation between triglyceride concentration and BMI in the aggregate cohort, and assessment of confounders such as lipid infusion rate, were analyzed using the Kruskal-Wallis test and the Spearman rank correlation coefficient. Results: A total of 44 VLBMI, 36 LBMI, 74 NBMI, and 133 HBMI individuals with a median (range) BMI of 24.2 (12.5-64.2) kg/m2 were included in the analysis. Patients received an average of 45 g/day of fat and calories equal to 103% of estimated basal energy requirement (Harris-Benedict equation). Median serum triglyc-eride concentrations were 107 (17-369) mg/dL in VLBMI patients and 124 (39-585) mg/dL in individuals with a BMI ≥ 16 kg/m2 (p = 0.016). Increasing BMI category was associated with increased median triglyceride concentra-tion during IVFE infusion (p = 0.016) and there was a weak but significant correlation between BMI and triglycerides in the aggregate cohort (R = 0.24, p < 0.0001). Hypertriglyceridemia (> 150 mg/dL) was present in 23%, 25%, 35% and 40% of VLBMI, LBMI, NBMI and HBMI patients, respectively. Lipid infusion rate was marginally higher in VLBMI patients compared with BMI ≥ 16 kg/m2, 1.25 (0.68-3.25) vs 1.01 (0.47-4.40) g•m2•h-1 (p = 0.056), and was inversely associated with BMI in the aggregate cohort (p < 0.0001). Because of surprising variability in triglyceride concentrations among VLBMI patients, abdominal computed tomography scans were reviewed where avail-able (n = 36) for determination of visceral fat (VF) and abdominal subcutane-ous fat (SF) using single-slice (L2-L3) analysis. Visceral and abdominal fat area were also found to be highly variable in these patients (VF median 24, range 7-208 cm2; SF median 22.7, range 2-134 cm2). In these VLBMI

patients, there was a significant positive correlation between triglycerides and both VF (R = 0.30, p < 0.05) and SF (R = 0.37, p < 0.05). Conclusions: Hypertriglyceridemia is common in parenterally fed patients. Despite higher lipid infusion rates, individuals with VLBMI have lower triglyceride concen-trations than individuals with BMI ≥ 16 kg/m2. There is remarkable variability in body fat (VF and SF) stores in VLBMI patients, indicating that BMI has very little value as an indicator of adiposity in this group. The mechanism for maintenance of substantial body fat stores in some VLBMI patients is unknown. Based on these findings, IVFE should be used with caution and lower infusion rates may be appropriate in certain patients.

TOPIC: Liver Disease

S46 - Improved Cholestasis Is Not Accompanied By Regression Of Fibrosis In Children Treated With OmegavenDavid F. Mercer, MD PhD; Steve C. Raynor, MD; Ruben E. Quiros-Tejeira, MD; Ryan T. Fischer, MD; Geoffrey A. Talmon, MD; Deb Perry, MD; Brandy D. Hobson, RD; Brandi K. Gerhardt, BScN; Wendy J. Grant, MD; Jean F. Botha, MD; Alan N. Langnas, DOUniversity of Nebraska Medical Center, Omaha, NE.

Introduction: Intestinal failure associated liver disease (IFALD) is a mul-tifactorial process which can culminate in cirrhosis and need for transplan-tation. Parenteral nutrition, most specifically soy-based lipid emulsions, are felt to be significant contributors to this process, perhaps through elevated levels of phytosterols. Many clinicians have turned to the use of a fish-oil based lipid preparation (Omegaven®, Fresenius Kabi, Bad Homburg, Ger-many) with reported success in reversing hyperbilirubinemia. There is no data, however, on whether Omegaven affects the pathology of IFALD. Methods: We have sequential biopsy data on five children receiving Ome-gaven, and had these biopsies reviewed blindly and separately by both a dedicated liver pathologist and a dedicated pediatric pathologist, with scor-ing of steatosis, cholestasis, inflammation, fibrosis and ductal proliferation based on standardized published scoring systems. This analysis was com-bined, correlated with laboratory data, and is summarized in the table, below. Results: In these five patients, we found that hyperbilirubinemia reversed, and hepatic synthetic function was preserved across timepoints. Histologic findings of cholestasis improved in all patients and inflammation improved in 3 of 5 children on Omegaven therapy. Fibrosis was either persistent (in 2 cases) or progressive (in 5 of 5 cases), and remained severe (grade 2 or higher) in all children at last biopsy. There were mixed effects on steatosis and ductal proliferation. Conclusions: From these data, we conclude that reversal of hyperbilirubinemia is not reflected by a similar histologic regression of fibrosis at the timepoints studied. An improvement in fibrosis might occur over time, but in the absence of any data, this finding prompts caution in focusing on resolution of jaundice alone as an endpoint in the treatment of IFALD.


S47 - Radiation Therapy Increases the Risk of Hepatobiliary Complications in Short Bowel SyndromeJon S. Thompson, MD; Rebecca Weseman, RD; Fedja Rochling, MB BCH; Wendy J. Grant, MD; Jean F. Botha, MB BCH; Alan N. Langnas, DO; David F. Mercer, MD PhDSurgery, University of Nebraska Medical Center, Omaha, NE.

Introduction: Patients developing the short bowel syndrome (SBS) are at risk for hepatobiliary complications, especially if receiving parenteral nutriton (PN). Radiation induced-liver disease (RILD) is a potential com-plication of radiation for abdominal tumors. We hypothesized that SBS patients with a history of abdominal radiation therapy would be at increased risk for developing hepatobiliary complications. Methods: We reviewed 92 adult patients developing SBS as a complication of operation for malig-nancy (n=37)and/or radiation treatment (n=35). SBS was defined as intestinal remnant <180cm in length with associated mlabsoption. Hepa-tobiliary diseae was evaluated by serum liver function tests, radiologic imaging, endoscopy, and histologic studies. End stage liver disease was defined as severe hyperbilirubinemia, hypoalbuminemia, and cirrhosis. Results: Rectal cancer was the most frequent tumor by both groups (36% vs 35%). There were significantly more ovarian cancers (18% v 3%, p<.05) in the radiaion group and fewer desmoid tumors (0% vs 24%, p<.05). There were more females(75% vs 51%, p<.05) in the radiation group. Intestinal remnant length was similar but radiation patients more frequetly had colon present (87% vs 62%, p<.05)and were less likely to have type I anatomy (33% vs 65% p<.05). Radiation patients were less likely to be weaned off PN (16% vs 41%, p<.05). Surgical rehabilitation (ostomy closure, intestinal lengthening and intestinal transplantation) had a similar occurrence in both groups. Cirrosis/portal hypertension was more frequent in the radia-tion group (35% vs 11%, p<.05). Radiographic evidence of fatty liver was similar in the two groups (2% vs 8%). End stage liver disease (ESLD) was also similar in both groups (18% vs 14%). The risk of cholelithiasis post SBS was not different in between groups(25% radiation vs 16% malignancy alone.) Conclusions: SBS patient with a history of radiation treatment for intra abdominal malignancy were more likely to develop cirrhosis and portal hypertension than SBS patients with malignancy alone. The risk of ESLD, however, was similar. Radiation SBS patients were less likely to wean from PN despite more favorable intestinal anatomy.

TOPIC: Malnutrition

S48 - Assessment of patient undernutrition using four different tools at admission in a Spanish hospitalJosefina Olivares, MD1; Luisa Ayala, RD1; Araceli Molina, NT1; Maria Jose Muñiz, NT1; Antoni Gamundi, PhD2; Lluís Masmiquel, MD, PhD1

1Endocrinology, Hospital Son Llatzer, Palma de Mallorca, Spain; 2Biologia Fonamental i Ciències de la Salut, University of the Balearic Islands, Palma de Mallorca, Spain.

Introduction: Background. About 10-85% patients are undernourished when admitted to the hospital and the majority of these develop worsening undernutrition during their hospitalization. Several data exist regarding undernourishment in Spanish hospitals. However, its relationship with anthropometrics and clinical variables is not well understood. Objectives. Determine the prevalence of undernutrition at admission in a sample of patients in our hospital. We also identify the factors most likely to influ-ence their nutritional status. Methods: We conducted a cross-sectional study at 24h of admission in medical and surgical departments during the period march-june 2010. After informed consent was obtained, trained dietitians assessed 537 adult patients using 4 screening tools: mininutri-tional assessment (MNA), nutritional risk score 2002 (NRS2002), sug-gestive global assessment (SGA) and malnutrition universal screening tool (MUST). Anthropometrics were also measured and comorbidities were

obtained by history and confirmed by medical records. Results: We studied 537 patients (56,4% males, n=303) with mean age of 61.27±17.67yo, weight 73.82±15.80, height 164,4±59.95 cm, BMI 27.27± 5.31 kg/m2 and recent weight loss 0.740±6.89%. The overall rate of undernutrition was 47.3%; 54.2% in patients >65yo vs 40.7% in patients <65yo (p=0.002). There was also significant difference between medical and surgical patients (63.4% vs 34.0%,p=0.000). Specific rates detected by each test were 29.9, 21.3, 19.6 and 18.8% for MNA, NRS2002, SGA and MUST respectively. The medical patients had higher rates than the surgical ones by all 4 tests: MNA: 35.5 vs 25.3%, SGA: 32.9 vs 8.6%, NRS2002: 33.7 vs 10.9%, MUST: 26.3 vs 12.6%. Undernutrition rates in the >65yo group were 31.8, 29.9, 28.4, 23.9% by MNA, SGA, NRS2002 and MUST. In the multivariate analysis, factors that influence the presence of undernourishment at admission were weight (OR 0.976 CI 95% 0.963-0.989,p=0,000) and heart disease (OR 1.739 CI 95% 1.161-2.605, p=0.007) for MNA (AUC 0.623); Liver disease (OR 4.450 CI 95% 1.938-10.218 p= 0.000), age >65yo (OR 2.1 CI 95% 1.194-3.929 p=0.011), medicine department (OR 3.579 CI 95% 1.934-6.623 p= 0.000) for SGA (AUC 0.965); lung disease (OR 3.345 CI 95% 1.447-7.734 p= 0.005), medicine department (OR 2.549 CI 95%1.086-5.984 p= 0.032) for NRS2002 (AUC 0.967). Recent uninten-tional weight loss was a common factor among all four tests. Conclusions: Undernourishment at hospital admission is frequent in our region. The rate varies depending on the test used. Significant differences were seen between medical and surgical departments. Multiple co-morbidities and medical conditions may contribute to the presence of undernutrition at admission and their effect can be assessed with different tools.

S49 - Oral nutritional support in malnourished elderly decreases functional limitations with no extra costsFloor Neelemaat, PhD student, RD1; Judith Bosmans, PhD3; Abel Thijs, MD2; Jaap Seidell, Professor3; Marian van Bokhorst - de van der Schueren, PhD, RD1

1Nutrition and Dietetics, Internal Medicine, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, Netherlands; 2Internal Medicine, VU University Medical Center, Amsterdam, Netherlands; 3Department of Health Sciences, EMGO Institute for Health and Care Research, VU University, Amsterdam, Netherlands.

Introduction: Older people are vulnerable to malnutrition which leads to increased health care costs. We evaluated the cost-effectiveness of nutri-tional supplementation in malnourished elderly patients for 3 months after hospital discharge in comparison with usual care. Methods: Hospital admitted malnourished elderly (≥60 years) patients were randomized to receive nutritional supplementation (energy and protein enriched diet, oral nutritional support, calcium-vitamin D supplement, telephone counselling by a dietician) for 3 months post discharge or usual care. Outcomes in this study were Quality Adjusted Life Years (QALYs), physical activities and functional limitations. Measurements were performed at hospital admission and at 3 months after discharge. Data were analyzed according to the intention-to-treat principle and multiple imputation was used for missing data. Cost-effectiveness was evaluated using bootstrapping. Results: In total 210 patients were included, 105 in each group. No statistically sig-nificant differences in quality of life and physical activities were observed between groups. Functional limitations decreased significantly more in the intervention group (mean difference -0.72, 95% CI -1.15 ; -0.28). No dif-ferences in costs between groups. Cost-effectiveness for QALYs and physical activities could not be demonstrated. For functional limitations there was a 0.95 probability that the intervention was cost-effective in comparison with usual care for ceiling ratios >€6500. Conclusions: Oral nutritional supplementation of malnourished elderly patients for 3 months after hospital discharge led to a significant improvement for functional limitations and is neutral in costs. Cost-effectiveness could not be demonstrated for QALYs and physical activities. The follow-up of 3 months was probably too short to detect changes in QALYs or physical activities in these patients.


Encore abstract: Presented at the 12th Congress of FELANPE, Oct 2-6, 2010. Published in Spanish: RNC Anales del XII Congreso de la Federacion Latinoamericana de Terapio Nutricional, Nutricion Clinica y metabolism, FELANPE RNC numero especial. October, 2010.

S50 - Malnutrition as an independent risk factor associated with surgical wound infectionLeticia R. Acosta, 1.845.2331; Maria E. Goiburu, 746.6801; Silvana Aveiro, 2.038.1511; Claudia Lawes, 524.3071; Ricardo Olmedo, 332.0462

1Nutrition, Hospital Central de IPS, Asunción, Paraguay; 2Surgery, Hospital Central de IPS, Asunción, Paraguay.

Introduction: The surgical wound infection is more often the nosocomial infection (NI), it causes increases in morbidity of the patient, in the stay (up to 4 days on average), and in mortality. It is obvious its direct impact on care costs and indirect as well as social and family impact. In the obese the surgical wound infection is two times more frequent than the general population. In addition, malnutrition is also a factor that has been associated with develop-ment of surgical site infection. The relationship of surgical wound infection, obesity, malnutrition has been insufficiently studied in our environment, which is why research in this regard could establish whether obesity and malnutrition are risk factors that enable the development of complications. The objective was to analyze the association between risk factors and surgical wound infection. Methods: Prospective, longitudinal, analytical studies in patients admitted to the general surgery department of the Instituto de Pre-visión Social - Hospital Central (IPS-HC) from January to June of 2010 of consecutive patients who met the inclusion criteria. The risk factors considered were: body mass index (BMI) was classified as malnourished (undernourished BMI <18.5 and obese BMI ≥ 30) and well nourished, personal medical his-tory (cardiovascular disease, diabetes mellitus, and cancer), kind of surgery (clean and clean contaminated or contaminated and dirty), age over 55 years. Data were loaded in an Excel spreadsheet and analyzed using Epi Info 2002 and SPSS. Results: 323 patients were evaluated of 55 ± 16.9 years old, 52% of them were male, with a principal diagnosis of biliary tract disease of 25.7% and most patients had a rate of Senic of 1 (0-4 .) The average hospital stay was 5 ± 6.7 days, overall mortality of 1.2%. The infected patients had an increased length of hospital stay of 14.1 ± 9.8 days versus 3.3 ± uninfected 2.7 days p <0.00001. After performing multivariate analysis to determine independent risk factors related to surgical wound infections, the significant factors found were: Malnutrition (undernutrition and obesity) p 0,02 RR 2 (1-3,7), presence of diabetes, cardiovascular diseases or cancer p 0,02 RR 3,2 (1,5-6,7). The kind of clean contaminated surgery were protective factors for the presence of infection p<0.00001 RR 0.07 (0.02-0.2). Conclusions: Risk factors for wound infection were malnutrition and the presence of comorbidities. The kinds of clean and clean contaminated surgery were protective factors for surgical infection.

TOPIC: Neonatal

Encore abstract: Presented at Canadian Pediatric Society, 2010. Published in Paediatrics and Child Health.

S51 - Institution of a Multidisciplinary Nutrition Team Affects Outcome of Infants with Complex Gastroschisis?Vikki Lalari, MSc, RD, CNSD1; Ayala Gover, MD1; Rebecca Sherlock, MD1,3; Sonia Butterworth, MD2,3; CAPSNet The Canadian Pediatric Surgery Network, N/A2,4; Susan Albersheim, MD, PhD1,3; Avash J. Singh, MD1,3

1Neonatology, BC Women’s Hospital, Vancouver, BC, Canada; 2General Surgery, BC Children’s Hospital, Vancouver, BC, Canada; 3University of British Columbia, Vancouver, BC, Canada; 4The Canadian Pediatric Surgery Network, Vancouver, BC, Canada.

Introduction: The management of patients with gastroschisis (GS) remains challenging as infants commonly have impaired intestinal func-tion causing feeding delays, parenteral nutrition (PN) dependence and increased length of hospital stay (LOS). Early categorization of infants into two subgroups, simple or complex, has been proposed to assist clini-cians in predicting outcomes and guide nutritional/medical care. We instituted a multidisciplinary nutrition team (MNT) in the NICU for patients with GS whom we categorized as simple (S-GS) or complex (C-GS) at birth. The objectives of the study were to determine whether the establishment of a MNT improves outcome for patients with GS and whether categorization of patients as simple or complex predicts outcomes. Methods: Outcomes and bowel characteristics were collected for pre-MNT (2005-2006) and MNT (2007-2009) periods. C-GS was defined as intestinal complications (atresia, perforation, necrosis, volvulus) or delay closure (>24h); S-GS defined as no complications and primary closure (<24h). Standard nutrition protocols for all infants with GS included a slow conservative feeding regime and individualized PN. Data was analyzed using Mann-Whitney U tests for continuous variables and tests for pro-portions where appropriate. Results: C-GS infants showed higher medical complexity than S-GS, in the pre-MNT period, with significantly increased LOS, PN days and time to full feeds (FF) (p<0.05). C-GS infants also showed higher complexity than S-GS during the MNT period, with increased LOS (p<0.05). Bowel appearance at birth revealed an increased number of intestinal complications (severe matting and necrosis) in C-GS infants compared to S-GS. S-GS infants had significantly increased LOS, days to FF and PN days during MNT period vs pre-MNT (p<0.05). C-GS infants showed a trend to reduced LOS and time to FF during MNT period. There were similar PN days for C-GS patients in the two periods and 2 MNT patients went home on PN. Both C-GS cohorts had 1 death; the pre-MNT death was at day 172 and the MNT death was at day 4. Conclusions: Implementation of a MNT with a conservative feeding approach appears to improve outcomes in complex GS, but prolonged hospitalization was observed for the simple GS group. Infants categorized as complex GS showed higher medical complexity than infants with simple GS. Categorization and bowel appearance at birth may help predict out-comes (favorable/unfavorable) and could be a useful tool in determining the appropriate nutritional and medical management for infants with simple or complex GS.

Characteristics and Outcomes of Infants with Gastroschisis

Simple Complex

Pre-MNT (n=10)

MNT (n=14)

Pre-MNT (n=14)

MNT (n=18)

Gestational Age1 (wks)

36 ± 2 36 ± 2 37 ± 1 36 ± 3

Birth Weight1 (g) 2552 ± 446

2603 ± 537

2760 ± 458

2369 ± 458

Primary Closure <24h (%)

100% 100% 14% 33%

Bowel Appearance at birth- severe matting &/or necrosis (%)

0 29% 21% *50%

LOS2 (d) 32∞Δ

(20-55) 47ΔΩ

(21-164) 84∞

(27-415) 75Ω

(4-323) PN2 (d) 22∞Δ

(15-47) 39Δ

(17-145) 61∞

(15-293) 63

(4-309) Time to FF 2,3(d) 11∞Δ

(6-24) 25Δ

(10-128) 41∞

(6-332) 31

(16-293) Cholestasis4 (%) 30% 50% 64% 67% Confirmed sepsis (%)

30% 29% 64% 78%

1mean±SD; 2median (range); 33 infants not on FF at discharge (not included); 4conjugated bilirubin >34umol/L; ∞ΔΩ p<0.05; *n=16


S52 - Bone Mineral Content in Born Preterm Children at Term Corrected Age and at 5-7 Years of AgeBeatriz S. Porto, MD1; Renato M. Fiori, MD2; Humberto H. Fiori, MD2; Beatriz N. Lago, MD2

1Pediatrics, Universidade Federal de Santa Maria, Santa Maria, Brazil; 2Pediatrics, Pontifícia Universidade Católica do Rio grande do Sul, Porto Alegre, Brazil.

Introduction: Preterm babies are at a greater risk of having stunted growth and insufficient bone mineralization than full-term infants; however, the long-term effects of this mineral deficiency have not been clearly estab-lished. The objective was to assess growth and bone mineralization using whole body densitometry in children aged around 6 years who were born prematurely. Methods: Bone mass and whole-body composition were measured by dual energy X-ray absorptiometry (DXA) in children aged around 6 years who had weighed ≤1750g at birth, with gestational age ≤34 weeks, and who had been submitted to densitometry at the time of discharge from the neonatal unit (preterm group). Anthropometric mea-surements were obtained at birth, at hospital discharge and at 5-7 years, as well as information about the type of milk used in the neonatal period. For comparison purposes, 20 healthy full-term or near-term infants (neo-natal control group) and 20 healthy children aged 5-7 years born to term (6-year-old control group) were assessed. Results: Birth weight and ges-tational age in the preterm group (n=39) were 1299g±266 and 31.7±2.2 weeks, respectively. These infants were discharged from the neonatal unit with a weight of 1961±118g and at a corrected gestational age of 38±3.2 weeks, comparatively to 2350g±306 and 36.8±1.3 weeks, respectively, in the neonatal control group. The bone mineral content (BMC) and the BMC adjusted for body weight (BMC/kg) were significantly lower in the preterm group than in the neonatal control group: 7.3±4.0g and 3.7±2.0g/kg versus 22.4±7.5g and 9.9±2.1, respectively (p<0.001). Around the sixth year of life, the BMC of the preterm group was significantly lower than that of the 6-year-old control group (614.4±102.7g versus 697.5±102.3g - p<0.05), but no difference was observed when the BMC was adjusted by body weight (30.2±3.5 versus 28.8±3.4g/kg, respectively - p=0.14). At the age of 6 years, patients in the preterm group had a lighter weight and were shorter than those in the 6-year-old control group (weight of 20.4±3.1kg versus 24.5±4.6kg - p<0.001 and height of 114.4±4.8cm versus 118.2±5.1cm - p<0.01). At this age, the group of infants who had been given unfortified breastmilk in the neonatal unit had a lower average weight than those infants fed fortified human milk or preterm formula who were included in the same group (19.3±2.2kg versus 21±3.4kg - p<0.005). Nevertheless, the BMC and the BMC/kg at 6 years were similar in these two groups (BMC of 566.4±99.5g versus 641.3±96 and BMC/kg of 29.3g±4.2 versus 30.7±3.1g, respectively). Conclusions: Preterm babies with evidence of low bone mass at the discharge from the neonatal unit showed recovery around the age of 6 years. However, at this age, their average growth was lower than that of healthy full-term infants. Likewise, at the age of 6 years, those infants who had been given unforti-fied breastmilk in the neonatal period had a lower average weight than those fed higher density of nutrients milk.

S53 - Parenteral Lipid Load, Enteral Nutrition, and Reversal of Total Parenteral Nutrition Associated Cholestasis in Neonates with Short Gut SyndromeJennifer M. Smith, MD1; Rebecca J. Wilhelm, RD3; Samuel Kocoshis, MD2

1Neonatology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 2Gastroenterology, Hepatology, and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; 3Nutrition Therapy, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.

Introduction: Cholestasis remains a significant problem for neonates who require long-term parenteral nutrition for short gut syndrome. Either drastic reduction in parenteral lipid load or aggressive transition to enteral feedings can halt and reverse the cholestasis. This study tested the hypoth-esis that successfully deriving a high percentage of calories from enteral feeds is more important than drastic parenteral lipid reduction. Methods: Data were collected from an existing “intestinal failure” database created at Cincinnati Children’s Hospital Medical Center. We retrospectively reviewed clinical data on infants treated at CCHMC with short gut syn-drome from April 2007- April 2009. Inclusion criteria were as follows: patients ages three weeks to one year who required total parenteral nutri-tion for >60 consecutive days and who developed TPN cholestasis (con-jugated bilirubin level greater than 3 mg/dL). Data captured included conjugated bilirubin, percentage enteral feeds, and amount of lipids in TPN at time of peak bilirubin. Cholestasis did not resolve in two sets of patients (they expired or underwent liver/small bowel transplants). These two groups were used as controls and compared to the group in whom cholestasis did resolve. Ten patients were identified who developed cho-lestasis that ultimately resolved . Six patients expired as a result of their cholestasis. Eight patients went on to liver and/or small bowel transplanta-tion. Results: Using a linear regression model, bilirubin levels and the percent of tolerated enteral feeds within the group of patients in whom cholestasis resolved showed a negative correlation (p= 0.07, r= -0.63) illustrating that as enteral feedings were increased, bilirubin levels decreased. In the control group no correlation was seen (p= 0.48, r= -0.2). Parenteral lipid load between 1 and 2.5 g/kg/day is not associated with the degree of cholestasis (p= 0.82, r= 0.08) in the group of resolved patients or the controls (p= 0.7, r= 0.11). Patients achieving >50% of calories enterally prior to bilirubin levels reaching 10 or greater, universally resolved their cholestasis. Bilirubin rose to greater than 10 in all patients who died or were transplanted. Only one control tolerated enteral intake of greater than 50%. Eighty percent of patients whose bilirubin normalized were tolerating >50% of calories enterally when the normalization began with median enteral intake of 68%. Conclusions: A dose dependent effect between increasing amounts of enteral feeds and resolution of cholestasis approaches significance despite a small sample size. Furthermore paren-teral lipid loads of 1 to 2.5 g/kg/day do not interfere with resolution of cholestasis if the tolerated enteral caloric load is >50% of total calories. Similarly, inability to advance feedings beyond 50% of the total caloric intake is associated with irreversibility of cholestasis, thereby mandating more aggressive hepatoprotective parenteral nutritional strategies.

S54 - Cholestasis and Total Lipid Provision Post Protocol Implementation in the Neonatal Intensive Care UnitCelina M. Scala, MS, RD, LDN, CNSC; Sarah J. Peterson, MS, RD, LDN, CNSDFood and Nutrition, Rush University Medical Center, Chicago, IL.

Introduction: The cause of parenteral nutrition (PN) associated liver disease (PNALD) remains unknown. Cholestasis is a manifestation of PNALD often seen in neonates requiring long term PN. Fish-oil based lipid emulsions have shown promise in improving PNALD; however, they are not yet widely available in the United States. This study hypothesized that implementing a protocol to reduce soy based intravenous (IV) lipids to 1.0 gram per kilogram from the usual dose of 3.0 grams per kilogram once cholestasis, defined as a direct bilirubin (dbili) above 2.0 milligrams per deciliter, develops would decrease duration and severity of cholestasis. Methods: A retrospective chart review was conducted for all patients admitted to the neonatal intensive care unit (NICU) of a large urban medical center during the first six months of 2009 and 2010. From January to June 2009, soy based IV lipids were provided at a goal of 3.0 grams per kilogram for babies receiving PN. Starting in January 2010, soy based IV lipids were provided at a goal of 3.0 grams per kilogram for babies


receiving PN; however, once babies had an elevated dbili, lipids were limited to 1.0 gram per kilogram. Patients who received PN and had an elevated dbili above 2.0 milligrams per deciliter were included. Exclusion criteria included transfer to the NICU after previously receiving more than three days of PN. Statistical analysis was performed using Mann-Whitney U and Chi-square tests. Results: A total of 22 infants were included in this study. Of the 86 total infants started on PN between January and June of 2009, nine developed cholestasis in the pre-protocol implementation group. Of the 95 total infants started on PN between January and June of 2010, 13 developed cholestasis in the post-protocol implementation group. Results [presented as medians (25th, 75th per-centiles)] indicated no significant differences in median days of PN [51.0

Characteristics of 22 Neonates Receiving Parenteral Nutrition

Total a (n=22) Pre-Protocol a (n=9) Post-Protocol a (n=13) Test

Gestation (weeks) 28.6 (26.2,33.8) 27.0 (25.9,34.2) 29.5 (26.0,33.7) Mann-Whitney U P=0.62 Male 15 (68%) 3 (33%) 12 (92%) Chi-square p=0.004 Birth weight (grams) 1090.0 (597.5,2885.0) 782.0 (592.5,2950.5) 1130.0 (775.0,2322.5) Mann-Whitney U P=0.87 Parenteral nutrition days 29.5 (12.8,56.3) 51.0 (12.5,108) 29.0 (11.0,43.0) Mann-Whitney U P=0.29 Lipid days 28.0 (10.8,54.0) 50.0 (10.5,98.5) 28.0 (10.5,43.0) Mann-Whitney U P=0.36 Cholestasis days 13.5 (4.8,34.8) 15.0 (5.0,53.0) 10.0 (4.5,34.0) Mann-Whitney U P=0.53 Max direct billirubin (mg/dL) 4.5 (2.9,8.2) 6.5 (3.0,11.1) 4.3 (2.8,6.0) Mann-Whitney U P=0.17 Max direct billirubin (mg/dL) on parenteral nutrition

10 (45%) 5 (56%) 5 (38%) Chi-square p=0.43

Total lipid given (grams per kilogram) 64.8 (21.3,148.0) 147.0 (24.0,284.5) 57.0 (17.2,106.5) Mann-Whitney U P=0.19 Ursodiol prescribed 12 (55%) 3 (33%) 9 (69%) Chi-square p=0.10 Surgery, GI complications, Necrotizing Enterocolitis

13 (59%) 8 (89%) 5 (38%) Chi-square p=0.02

apresented as medians (25th, 75th percentiles) or as percentage of total

(12.5,108) versus 29.0 (11.0,43.0), p=0.29] and days of lipids administered [50.0 (10.5,98.5) versus 28.0 (10.5,43.0), p=0.36] between the pre and post-protocol groups respectively. Additionally, no significant differences were found in total grams of lipid provided per kilogram [147.0 (924.0, 284.5) versus 57.0 (17.2, 106.5), p=0.19], peak dbili [6.5 (3.0,11.1) versus 4.3 (2.8,6.0), p=0.17], and median days of cholestasis duration [15.0 (5.0, 53.0) and 10.0 (4.5, 34.0), p=0.53] in pre versus post-protocol groups. Total grams of lipid given and total cholestasis days were signifi-cantly correlated (R=0.68, p<0.001). Conclusions: Additional research with a larger sample is needed to further explore whether decreasing soy based IV lipid provision helps reduce the duration of cholestasis in neo-nates on PN.

S55 - Light Exposure During Parenteral Nutrition Preparation and Infusion and its Effect on Amino Acid ConcentrationsCatherine M. Crill, PharmD, BCPS, BCNSP1,2; Emma M. Tillman, PharmD1,2; Richard A. Helms, PharmD1,2

1Clinical Pharmacy, The University of Tennessee Health Science Center, Memphis, TN; 2Le Bonheur Children’s Hospital, Memphis, TN.

Introduction: Components of parenteral nutrition (PN) solutions, specifically multivitamins, intravenous fat emulsions and amino acids, are thought to be affected by light exposure. The evidence has primarily focused on peroxide

formation in PN components and the attenuation of this process under light protected conditions. Multivitamins are the major contributor to peroxide formation, followed by fat emulsions. Manufacturers of commercial amino acid products recommend protection from light until use to prevent photo-degradation; some have added sulfites to minimize this potential. While some institutions photoprotect PN solutions infused to premature neonates, a popu-lation at particular risk from oxidative stress, practice varies between covering only during the infusion period or during both the preparation and infusion periods. The objective of this study was to evaluate the effect of light exposure during the preparation and infusion process specifically on amino acid con-centrations in PN solutions. Methods: PN solutions were compounded with a pediatric amino acid product containing sulfites (from the same lot), L-cysteine (40 mg/gram amino acid), and pediatric multivitamins. Intravenous fat emulsions were infused separately from dextrose/amino acid solutions. PN solutions were compounded and infused under light protected conditions (study solutions) and under non-light protected conditions (control solutions). For both solutions, the amino acid product and multivitamins were protected from light during storage (via manufacturer’s packaging). For the study solu-tions, the amino acid product, the multivitamins, and the compounded PN solution were protected from light during compounding and during 24 hour infusion at patient bedside using a dark opaque covering and amber light sensitive tubing. For the control solutions, the amino acid product and mul-tivitamins were exposed to light as soon as they were removed from the manu-facturer’s packaging and the PN solutions were compounded and infused under non light protected conditions. Two samples from each PN solution were sent for amino acid analysis (one sample taken immediately after com-pounding and another sample taken immediately after 24 hour infusion). PN samples were stored in opaque tubes at -80°C until amino acid analysis via automated ion-exchange chromatography. Results: Matched samples (post compounding and post infusion) were obtained from thirteen study solutions


and twelve control solutions. The data were normalized for each solution based on percent difference between the matched post compounding and post infu-sion concentrations of amino acids and ammonia. There was no significant difference between the study and control solutions with respect to any of the amino acids (alanine, arginine, aspartic acid, cystine, glutamic acid, glycine, histidine, isoleucine, leucine, lysine, methionine, phenylalanine, proline, serine, taurine, threonine, tryptophan, tyrosine, and valine) or ammonia concentra-tions. Conclusions: The results of this study suggest that amino acid photo-degradation of the parent compound is not prevented by photoprotection in sulfite-containing pediatric amino acid formulations during the preparation process or during 24 hour infusion. The results of this study support that there is no rate difference in the alteration of the amino acids that were measured; whether or not subtle degradative amino acid byproducts that were not mea-sured in this study exist under similar conditions remains to be elucidated.

S56 - Benefit of Elemental Formula in Neonatal Piglets with Short bowel SyndromeZheng Hua, BSc1; Justine Turner, MD PhD1,2; Patrick N. Nation, DVM MVSC PhD7; Pamela Wizzard, BSc1; Diana Mager, RD PhD2,1; David Sigalet, MD PhD5; Ronald Ball, PhD2; Paul Pencharz, MD PhD6,3; Paul W. Wales, MD MSc FRCSC FACS6,4

1Pediatrics, University of Alberta, Edmonton, AB, Canada; 2Agriculture, life & environmental sciences, University of Alberta, Edmonton, AB, Canada; 3Gastroenterology, Hepatology & Nutrition, Hospital for Sick Children, Toronto, ON, Canada; 4Surgery, Hospital for Sick Children, Toronto, ON, Canada; 5Surgery, University of Calgary, Calgary, AB, Canada; 6Pediatrics, University of Toronto, Toronto, ON, Canada; 7Pathology, University of Alberta, Edmonton, AB, Canada.

Introduction: Neonatal short bowel syndrome secondary to surgical resection or congenital diseases of the small intestine is the most common cause of intestinal failure in infants. After resection the remnant intestine will undergo adaptation, a process that increases nutrient uptake and enables autonomy from parenteral nutrition. This process is regulated by several factors, but enteral nutrients appear the most important. There is conflicting data, in both animals and humans, as to the benefit of elemental versus polymeric formula in promoting adaptation in this condition. The purpose of this study was to compare the benefits of elemental versus polymeric enteral formula, for growth and adaptation, using neonatal piglet models. We have previously shown that our novel piglet models of short bowel syndrome reflect the clinical severity of intestinal failure as seen in human neonates, with worse outcomes when ileum is resected. Methods: Three groups of neonatal piglets aged 5.0±0.15 days, and weighing2.3±0.05 Kg were studied. Two groups underwent 75% small intestinal resection: jejunoileal piglets (JI) (n=16) had mid-intestinal resection with jejunoileal anastomosis; jejunocolic piglets (JC) (n=17) had distal small intestinal resection with jejunocolic anastomosis; and a control group of sham piglets (n=15) had no resection. All piglets were fitted with a jugular catheter and a gastric feeding tube and were maintained for 14 days on parenteral nutrition, decreased as enteral nutrition was increased, to main-tain standard weight gain. In each group piglets were randomized to either an iso-caloric or isonitrogenous elemental (amino acid) formula or polymeric formula. Results: Between surgery groups, JI piglets showed most evidence for intestine growth and histological adaptation, where JC piglets not showing either. Comparison within surgical group showed, in JI or JC groups, weight gain did not differ by diet, but in the sham group weight gain was less for piglets given elemental formula compared to polymeric formula (2.0 vs 2.6 kg; p<0.05). However, within each surgical group, elemental or polymeric formula did not affect dry small intestine weight, colon weight, small bowel growth or histological evidence of adaptation. In the JC surgical group, piglets fed elemental formula had less diarrhea (9.9 vs 12.2 days; P<0.05) and shorter duration of parenteral nutrition support (12.0 vs 13.8 days; P<0.01) than those fed polymeric formula. These differences were not found in JI and Sham surgical groups. Conclusions: For JC piglets, without ileum and where notably adaptation is impaired, polymeric formula was associated with longer periods

of diarrhea and parenteral nutrition support. In regards to weight gain Poly-meric formula did perform better than elemental formula in piglets with intact gut, but this advantage was not apparent in piglets with short bowel length. Therefore, elemental formula is of benefit for neonates that have short bowel syndrome and extensive loss or complete absence of the ileum.

S57 - International Multicentre Validation of a Preterm Growth ChartTanis R. Fenton, PhD RD1,4; Roseann Nasser, MSc RD2; Misha Eliasziw, PhD4; Jae H. Kim, MD PhD3; Reg Sauve, MD MPH4,5

1Nutrition Services, Alberta Health Services, Calgary, AB, Canada; 2Clinical Nutrition Services, Regina Qu’Appelle Health Region, Regina, SK, Canada; 3Neonatology, University of California, San Diego, San Diego, CA; 4Community Health Sciences, University of Calgary, Calgary, AB, Canada; 5Pediatrics, University of Calgary, Calgary, AB, Canada.

Introduction: A preterm Growth Chart was developed in 2003, based on the Babson and Benda style of Fetal-Infant growth chart, for the assess-ment of growth of preterm infants as young as 22 weeks gestational age. The objective of this study is to determine the criterion validity of a Preterm Growth Chart, specifically to demonstrate the growth (weight, head cir-cumference, length) patterns of American and Canadian preterm infants. Methods: Infants (< 28 weeks gestation born between 2004 and 2009) growth was compared to the chart, divided into groups by: gestational age at birth (23-24 weeks, 25-26 weeks, 27-28 weeks); and: a) size for gesta-tional age (small, appropriate and large), b) gender, c) +/- morbidities (necrotizing enterocolitis, bronchopulmonary dysplasia, and/or cerebral palsy). Results: Preliminary results demonstrated that at 50 weeks post-menstrual age (10 weeks post term), the median weight of infants born at 23-24 weeks (n=95) was 4418 grams (n=21), which is equal to the 10th percentile, and ranged from <3rd percentile (z-score = -3.1) to the 65th percentile; 15/21 (71%) had weights greater than the 3rd percentile. Infants born at 27-28 weeks (n=346) at 50 weeks postmenstrual age (n=70) had median weight of 4749 grams (21st percentile), with a range of <3rd percentile (-3.9 z-score) to the 99th percentile; 62/70 (89%) had weights greater than the 3rd percentile at this age. Conclusions: The majority of infants’ weights at 50 weeks postmenstrual age were within the percentile curves of the 2003 Growth Chart. Further research is required to assess whether the Growth Chart assists in the identification of infants at higher risk of poor neurological outcomes.

Weight change patterns of 95 preterm infants born at 23-24 weeks on the 2003 Growth Chart, with the 3rd, 50th and 97th percentile curves.


TOPIC: Neurological Disorders

S58 - Body composition and energy expenditure parameters as predictors of mortality in Amyotrophic Lateral Sclerosis patientsIrene Breton, MD1; Cristina Velasco, MSc1; Cristina de la Cuerda, MD.PhD1; Miguel Camblor, MD1; Irene Catalina, MD2; Rosario Jimenez, RN2; Jose Luis Muñoz, MD2; Pilar García-Peris, MD.PhD1

1Nutrition Unit, Hospital General Universitario Gregorio Marañón. Madrid, Madrid, Spain; 2Neurology Unit, Hospital General Universitario Gregorio Marañón., Madrid, Spain.

Introduction: Changes in body composition and in energy expenditure have been described in patients with Amyotrophic Lateral Sclerosis (ALS). The aim of this study is to evaluate if any of these parameters can predict mortality in ALS patients. Methods: We performed a nutritional evaluation in ALS patients referred to a Nutrition Clinic as outpatients. We followed them for 24 months or until death. Body composition was assessed by anthropometry and BIA (Bodystat 1500®). Indirect calorimetry (Deltatrac®) was performed to evaluate resting energy expenditure (IC-REE). Values are expressed as median (P25-P75 range). Statistical analysis included Kaplan- Meier test.

Results: Fifty four patients were evaluated (27/27 F/M), aged 62.5 (47-71)y. Thirty eight patients had a spinal and 16 a bulbar onset. Time from diag-nosis was 14 months (7-24). Median time from evaluation to death was 11 m (5.5-15). BMI was 24.5 kg/m2 (23.2-26.9). Only two patients had a BMI< 18.5 kg/m2. Body composition study showed a FFM of 59.2% (56.4-65.9) in females and 65.3 % (58.6-68) in males. IC-REE was 1420 kcal/day (1262.5-1587.5) or 33 kcal/kg FFM (34.9-38.8). The difference between IC-REE and Harris-Benedict (HB) was -2.7 % (-10.3-5.9). In spinal onset ALS patients, IC-REE expressed in relation to FFM (IC-REE/FFM) was found to be lower as time to death was shorter (p=0,001 r=0.75) Fig 1. Patients with spinal onset and a BMI under 23 kg/m2 (p<0.001) and those with a FFM% below P50 had a worse outcome (p=0.034). IC-REE/FFM bellow 33 kcal/kg FFM was also associated with a higher mortality rate in spinal onset patients (p= 0.03); this was also observed in patients with a IC-REE lower than HB (p=0.007) Fig 2. We have not found any of these associations in bulbar onset patient. Conclusions: Low BMI and FFM may be related to a worse outcome in spinal onset ALS patients. In this study, spinal onset ALS patients with lower resting energy expenditure expressed in relation to FFM presented higher mortality rate. Body composition and energy expenditure alteration may have different consequences in both spinal and bulbar ALS patients. More studies are needed to determine what clinical variables can predict mortality in ALS patients.


TOPIC: Nutritional Assessment

S59 - Vitamin D Intake Patterns and Prevalence of Deficiency in Typical and High-Risk PregnanciesJenna Mastrobuono, BS1,2; Erin Jenks, MS, RD, LD2; Alison Steiber, PhD, RD, LD1

1Nutrition, Case Western Reserve University, Cleveland, OH; 2University Hospitals Case Medical Center, Cleveland, OH.

Introduction: Vitamin D deficiency during pregnancy has been associated with both maternal and fetal negative outcomes. This study sought to determine the vitamin D intake patterns and prevalence of vitamin D deficiency among pregnant women in Northeast Ohio, and to determine any association between vitamin D status and conditions of high-risk pregnancy. We hypothesized that there would be a high prevalence of vitamin D deficiency, attributed to both low dietary intake and limited sunlight exposure, and that vitamin D deficiency would be positively asso-ciated with conditions of high risk during pregnancy. Methods: Pregnant women receiving prenatal care were consented and enrolled at routine prenatal visits, and completed a validated food frequency questionnaire assessing dietary and supplemental vitamin D intake. Serum 25-hydroxy-vitamin D (25(OH)D) levels were requested during the pregnancy or at delivery. Primary outcome variables included mean daily dietary intake of vitamin D in IU and serum 25(OH)D in ng/ml. Secondary outcome vari-ables included vitamin D intake from supplements, sunlight exposure and tanning practices, and demographic characteristics. Descriptive analysis was reported in means and standard deviations for continuous variables

and frequencies for categorical variables. Statistical analyses (Mann-Whitney, Kruskal Wallis, and chi-square) were done using SPSS vs. 17.0 to compare serum 25(OH)D based on varying characteristics and to analyze vitamin D status based on risk category. Significance was defined as p<0.05. Results: Forty women with typical pregnancies and 25 women with high-risk pregnancies were enrolled. Mean age among the sample was 25.9 years; 77% of subjects were African American; 56% had completed high school or less. Mean dietary vitamin D intake was 264 IU per day, and 69% of subjects reported daily prenatal vitamin use. Among 37 women with vitamin D levels drawn, mean serum 25(OH)D was 16.4 + 8.9 ng/ml. Eighty-nine percent of women with vitamin D levels drawn were found to be either insufficient or deficient (25(OH)D <30 ng/ml). African-American subjects had significantly lower serum 25(OH)D levels than did non-African-Americans (p=0.043). Interestingly, women with typical pregnan-cies were significantly more likely to be deficient than those with high-risk pregnancies (x2=0.048). Older women were also significantly more likely to be deficient (p=0.000). Pre-pregnancy BMI and vitamin D intake from food and/or supplements were not significant predictors of vitamin D status. Conclusions: There was a high prevalence of vitamin D deficiency in this sample of pregnant women, despite a high prevalence of prenatal vitamin use and a mean dietary intake of vitamin D that exceeded the Adequate Intake (AI) of 200 IU per day. Race, but not high risk status, was a significant predictor of serum vitamin D levels. Serum 25(OH)D should be routinely tested on pregnant women, regardless of their risk category, and supplemented as needed. This study provides additional support for increasing the AI for vitamin D, and similarly designed, ade-quately powered studies should be conducted to more accurately assess the association between risk category and vitamin D deficiency.


S60 - Validation of predictive equation for weight in overweight and obese Mexican people using a metric tapeGabriela Quiroz, R.D.; Vianey Saldaña, R.D.; Jose Antonio Fonseca, PhDINCMNSZ, Mexico D.F., Mexico.

Introduction: Changes in nutritional status are important in clinical practice because they relate to an increase in morbidity and mortality. Weight measurement is important data for the evaluation of nutritional status. There are some situations in which these measurements cannot be made by standard methods, as is the case for bedridden patients and patients with difficulty in walking. Provision of adequate nutrition support is essential for decrease nutritional risk. The objective or this project was to design and validate a predictive equation for weight and evaluating their agreement with the equation proposed by Rabito. Methods: The following data were collected: sex (s), age and anthropometric measure-ments, i.e., weight in kg (wt), calf circumference in cm (cf), mid arm in cm (ma), waist (w), hip (hp) and wrist (wt) circumferences in cm, and half span (hs). Data were analyzed using multiple regression, actual weight was the dependent variable, independently corroborated using stepwise and obtained an equation to predict weight. This equation was validated in a different group with 17 patients and compared it with equation of Rabito and actual weight. The results were analyzed using regression fitted line plot. Results: 74 adults (mean age 47.8+14.7 years) with BMI >25 kg/m2 admitted to the Instituto Nacional de Nutrición Salvador Zubirán were evaluated. The regression equation was obtained (R2 adj. 96.5%, p<0.001): Wt=1.52(wr)+0.839(cf)+0.750(hs)+0.522(ma)+0.507(hp)+0.427(w)-4.96(s)-155. There was a correlation of 0.945 (0.92-0.97) between actual weight and our new equation (figure 1). The correlation was higher than equation of 0.825 (0.799-0-86). The coefficient of agree-ment for our new equation and equation of Rabito was 0.943 (0.91-0.967). Conclusions: There is a high correlation between the estimated weight of the new equation and the actual weight than that seen with the equa-tion of Rabito, although a larger sample is required. It must be validated in other populations.

Encore Abstract: Presented at the 32nd ESPEN Congress, 2010. Published: Clinical Nutrition Supplements Vol. 5, 2010. Re-publication withheld at the request of the author.

S61 - Adductor Pollicis Muscle: a Study about its Use as a Nutritional Parameter in Surgical PatientsMaria Cristina Gonzalez, MD, PhD; Rodrigo R. Duarte, MsC; Silvana P. Orlandi, MsCPost Graduation Program in Health and Behaviour, Catholic University of Pelotas, Pelotas, Brazil.

S62 - Is there a correlation between the new definition of disease-related malnutrition and muscular function?Maria Cristina Gonzalez, MD, PhD1; Carla A. Pastore, MsC1; Denise Halpern-Silveira, MsC2

1Universidade Católica de Pelotas, Pelotas, Brazil; 2Nutrition Department, Federal University of Pelotas, Pelotas, Brazil.

Introduction: Loss of fat-free mass (FFM) and a certain degree of inflam-mation are the components of disease-related malnutrition present in cancer, according to the new definition. In these patients, the loss of general functions, as consequence of FFM loss, decreases quality of life. Several parameters are used to perform nutritional assessment, but it is not well known how the correlation among them and with function assess-ment is. The aim of this study is to know the correlation among muscular function, assessed by handgrip strength (HS), and other nutritional param-eters and to show that the FFM is a significant determinant of muscular function. Methods: Cancer patients were studied before their first che-motherapy course. Nutritional status was assessed by Patient-Generated Subjective Global Assessment (PG-SGA) and body composition (presented as fat-free mass index - FFMI) and phase angle (PA) by BIA. Muscular function was evaluated by HS and the highest of three measurements was used in the analyses. Ultra-sensitive CRP and seric albumin was also evaluated. A pairwise correlation and a multiple linear regression were

Vitamin D Status of Study Participants.


performed to identify if malnutrition, CRP, albumin, FFM and PA were independent determinants of HS after adjustment for other variables. Results: Seventy three patients with gastrointestinal and lung cancer were studied. Most of them (56%) were male, and the mean age was 64 ± 11.9 years old. Colon cancer was the most prevalent type in this sample and 54.8% was receiving palliative chemotherapy. Only 12.3% of the patients were considered well nourished. The highest significant correla-tion was found between HS and PA (r = 0.59) and FFMI (r = 0.51). After controlling for sex, age and height, PA, CRP and FFMI were considered significant determinants factors for HS (Adj R2 = 0.71). Conclusions: Phase angle and parameters used in disease-related malnutrition, such as Inflammation (CRP) and muscle mass (FFMI), were considered sig-nificant factors to determine function. They can be considered as signifi-cant modifiers of muscle function, even after controlling for other confounding factors.

Encore Abstract: Presented at the 32nd ESPEN Congress, 2010. Published: Clinical Nutrition Supplements Vol. 5, 2010. Re-publication withheld at the request of the author.

S63 - Are C Reactive Protein and Phase Angle Determinant Factors for Handgrip Strength in Oncologic Patients?Maria Cristina Gonzalez, MD, PhD1; Carla A. Pastore, MsC1; M. Augusta B. Lang, Medical School student2; Rafael R. Glufke, Medical School student2; Caroline D. Penno, Medical School student2; Alessandra Formigheri, Medical School student2

1Post Graduation Program in Health and Behaviour, Catholic University of Pelotas, Pelotas, Brazil; 2Life and Health Sciences Center, Catholic University of Pelotas, Pelotas, Brazil.

S64 - Prevalence of low phase angle values in hospitalized patientsKristina Norman, PhD1; Nicole Stobäus, MSc2; Joerg Schulzke, MD2; Matthias Pirlich, MD1

1Dept of Gastroenterology, Charite University Medicine Berlin CCM, Berlin, Germany; 2Dept of General Medicine, Charite University Medicine Berlin, Berlin, Germany.

Introduction: A low bioelectrical phase angle has been shown to be predictive of morbidity and mortality in many disease settings. We recently demonstrated the 10th percentile of gender-, age- and BMI-stratified reference values to be a valid clinical cut-off value predictive of decreased quality of life and functionality and increased six month mortality in cancer patients (Am J Clin Nutr 2010;92(3):612-9).Objectives: In this study, we evaluated the prevalence of low phase angle (below 10th refer-ence percentile) in a large population of hospitalized patients. Methods: 1500 patients from different departments of the Charite University Hos-pital were recruited. Bioelectrical phase angle at 50 kHz was determined using a whole body impedance analyzer (Nutriguard M, Data Input, Ger-many), patients were then divided according to the 10th reference per-centile (JPEN 2006;30(4):309-16). Hand grip strength, peak flow and knee extension strength were measured as indicators of muscle strength. C-Reactive Protein was determined as inflammation marker, length of stay, comorbidity count and number of daily medications were recorded. Results: 1434 patients were included (51.8 % women, 40.7 % malignant disease). 684 patients (48.2%) had phase angle values below the 10th reference percentile. These patients had significantly lower muscle strength, increased length of hospital stay, higher comorbidity count and number of drugs. Conclusions: Low phase angle values are highly preva-lent in hospitalized patients. Assessment of phase angle should be incor-porated in the nutritional evaluation in order to detect patients at risk of decreased functional status and impaired outcome.

S65 - “Nutrition Screening -identifying children at risk” what is the level of agreement between the nursing nutrition screening tool and medical record data in identifying nutritional risk of pediatric patients for dietitian intervention?Anju Sharma, MS LRD CSP CNSDFood and Nutrition, Medical City Children’s Hospital Dallas, Dallas, TX.

Introduction: The incidence of malnutrition in hospitalized pediatric patients has always been a concern. Children have higher energy needs and limited energy reserves due to their continuous growth process. This physiological situation puts them at particularly high risk of malnutrition if they remain in the hospital for long periods of time. Recent research has indicated that nutritional status of the children declines during hospital stay. Therefore, it is crucial that nursing staff identify patients who are malnourished or are at risk for malnutrition upon hospital admission. Methods: Prospective chart audit study of patients admitted to a pediatric and pediatric intensive care unit at Medical City Children’s Hospital from June 1-June 23rd. All patients were screened by nurses at admission. This screening process generates a list of patients admitted in the pediatric and pediatric intensive care unit over a 24 hour period. An audit was performed comparing the nursing nutrition screening tool to medical record data. The nursing nutrition screen triggers include weight status, swallowing difficulty, oral intake, diagnosis, TPN/enteral nutrition, and food allergies/intolerances. Since the current nutrition screening tool is quick and easy to complete by nurses, the level of agreement should be high. So, strength of agreement level of 0.7 was chosen as a way to bal-ance the possible competing pressures toward higher and lower levels of agreement. Results: Three hundred fifty nine patients were screened by nurses over the three week period. At admission, nutrition screening was not completed for 31 children and 91 patients were discharged within 24 hours. The average age of patient was 21months and 46% of the patients were females and 53% were males. The kappa values for individual nutri-tion screening triggers (weight status 0.69 (p= 0.05), nutrition support 0.55 (p=0.01) chewing swallowing problem 0.42 (p=0.10), food allergies 0.66 (p=0.09), NPO status 0.49 (p=1.0) and diagnoses related to malnu-trition 0.05 (p=0.0001). The overall kappa values were (0.377, p= 0.0001) the nursing nutrition screening tool and medical record data in identifying nutritional risk of pediatric patients for dietitian intervention. All data will be presented at the meeting. Conclusions: There is low level of agreement for each nutrition screening triggers as well as overall kappa scores between nursing nutrition screening tool and medical record data. Nurses might benefit from nutrition screening education program to identify children who are at risk of malnutrition and need dietitian intervention.

Patients with phase

angle > 10th percentile

Patients with phase angle

< 10th percentile P value

hand grip strength (kg) 31.9 25.6 <0.0001 peak flow (l/min) 405.3 324.1 <0.0001 knee extension strength (kg)

29.6 25.0 0.007

C-reactive protein (mg/dl)

1.9 3.9 <0.0001

BMI (kg/m2) 25.4 23.7 <0.0001 age (years) 59.5 59.5 n.s. comorbidity count 4.4 3.7 0.001 drugs per day 5.9 4.1 <0.0001 length of stay (days) 11.1 13.6 <0.0001


S66 - Subjective Global Assessment Cannot be Reliably Validated in Critically Ill PatientsSarah Robbins, MD, MSc, FRCPC1; Lisa R. Jolicoeur, BSc2; Cathy Alberda, RD, MSc3; Leah Gramlich, MD, FRCPC1

1Gastroenterology, University of Alberta, Edmonton, AB, Canada; 2Agricultural, Food, and Nutritional Sciences, University of Alberta, Edmonton, AB, Canada; 3Nutrition Services, Alberta Health Services, Edmonton, AB, Canada.

Introduction: Malnutrition is recognized in critical care as a risk factor for adverse clinical outcomes including mortality, morbidity and increased hospital length of stay. Traditional nutrition assessment tools are not well validated in the critical care setting. The subjective global assessment (SGA) is a well-recognized technique that predicts nutrition-related com-plications in diverse populations. The purpose of the present study was to validate the SGA in a critically ill population. Methods: Patients admit-ted consecutively to a tertiary care intensive care unit (Royal Alexandra Hospital) were included in the study. The SGA was independently assessed by a registered dietitian and a physician nutrition specialist. Results: Fifty-one patients (33 men and 18 women; mean age 59) were identified. The weight history component of the SGA was obtained from five patients, family members in eight patients, and the medical record or unknown in 38 cases. Functional capacity was assumed from the chart or unknown in 23 cases. Physical examination of subcutaneous fat stores, muscle wasting, ankle edema and ascites was performed by both the dietitian and physician and were similar. We were unable to reliably assess sacral edema in the ventilated patient. An accurate measured weight was obtained in only 24% of patients. In spite of limitations in assessing both the weight history and anthropometrics, the dietitian and physician agreed on the degree of nutrition risk in over 80% of patients. Conclusions: We conclude that we are unable to reliably utilize the historical component of the SGA. Furthermore, anthropometrics are often inaccurate in the critical care setting. Experienced nutrition providers agree on nutrition risk based primarily on physical exam features and severity of illness, which may underestimate degree of nutrition risk in obese patients and patients that present with milder forms of malnutrition.

S67 - The Effect of Nutritional Assessment and Perioperative Total Parenteral Nutrition on Clinical Outcomes in Cancer Patients Undergoing Hyperthermic Intraperitoneal ChemotherapyPankaj Vashi; Carolyn Lammersfeld; Donald P. Braun; Rohan Vashi; Sadie Dahlk; Komen Brown; Digant GuptaCancer Treatment Centers of America, Zion, IL.

Introduction: The combination of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) is the treatment of choice for selected patients with peritoneal carcinomatosis. This retrospective study investigated the effect of baseline nutritional assessment and perioperative nutritional intervention on clinical outcomes in cancer patients undergo-ing HIPEC. Methods: Thirty six (36) cancer patients undergoing HIPEC at Cancer Treatment Centers of America between Jan 2009 and May 2010 were studied. Using Subjective Global Assessment (SGA), patients were classified prior to receiving HIPEC as well nourished (SGA-A), mildly to moderately malnourished (SGA-B), and severely malnourished (SGA-C). Patients who received total parenteral nutrition (TPN) were divided into 2 groups, those who received TPN postoperatively only and those who received it perioperatively (pre as well as post). The primary outcomes of interest were length of stay (LOS) and postoperative com-plications. LOS was calculated as the number of days patients stayed in the hospital. Postoperative complications were judged by the attending surgical oncologist and gastroenterologist and defined as any clinical event

not typically seen in patients who receive HIPEC. Results: Of 36 patients, 10 were males and 26 females. The mean age was 49.9 years (SD = 9.5). The most common cancer types were colon (n=17) and ovarian (n=11). Seventeen patients were SGA-A, 16 SGA-B and 3 SGA-C at admission. Fourteen patients received postoperative TPN only (3 SGA-A, 9 SGA-B and 2 SGA-C at admission) while 5 (1 SGA-C and 4 SGA-B at admission) patients received TPN perioperatively. Three SGA-A patients at admission who received postop TPN converted to SGA-B postop. The average dura-tion of preoperative TPN was <7 days while that of postoperative TPN was 23 days. Mean LOS for the study population was 17.8 days (SD=12.1). Mean LOS for SGA-A, SGA-B and SGA-C were 14.1, 17.3 and 41.7 days respectively (p<0.001). Overall incidence of complications was 36.1% (13/36). Complications were recorded in 5 of 17 (29.4%) SGA-A patients and 8 of 19 (42.1%) SGA-B+C patients (p=0.42). Most common compli-cations were sepsis, fever, bowel obstruction and wound dehiscence. There were no significant differences in mean LOS (p=0.32) and occurrence of complications (p=0.10) between perioperative and postoperative TPN patients. Conclusions: The SGA is an easy to use nutrition assessment tool that predicts LOS and the need for nutritional supplementation in cancer patients undergoing HIPEC. The average length of preoperative TPN (<7 days) was probably too short to have an impact on outcome in patients with a nutritional status of SGA-B and SGA-C. Future studies should investigate the benefits of perioperative TPN (with a longer pre-operative TPN component) in malnourished patients receiving HIPEC.

TOPIC: Nutrition and Chronic Disease

S68 - Differences in Metabolic Profile Between Young Obese Women with Polycystic Ovary Syndrome(PCOS)and Obese ControlsFotini Tsofliou, PhD; Aggeliki Apostolou, MSc; George Vlahavas, PhD; Labrini Kontopoulou, MSc; Vassiliki Magkou, BSc; Kiriaki Tafidou, BSc; Thomai Karagiozoglou-Lampoudi, MD, PhDClinical Nutrition Lab, Nutrition/Dietetics Dept, Technological Education Institute, Thessaloniki, Greece.

Introduction: Several studies point to increased cardiovascular risk among women with PCOS. The present study aimed to investigate whether meta-bolic disturbances in PCOS are an effect of obesity itself or associated to factors specific to the syndrome. Methods: Eighty six obese women (BMI=31.4±1.7 kg/m2, age=29.9±5.3 years) with PCOS and eighty six age and BMI matched control women (BMI =31.3±1.7 kg/m2, age=31.2±6.3 years) recruited from local OB/GYN offices participated in the study. Diag-nostic criteria for PCOS were clinical +/or biochemical evidence of hyper-adrogenism and polycystic ovaries on ultrasound. Dietary intake data were collected from a 24-h recall diary. Fasting blood samples were collected for the measurement of glucose, HbA1c and lipids. Statistical analysis of the data was carried out using two-tailed independent two-sample t-tests and Pearson correlations. Results: The PCOS group had a significantly greater waist/hip ratio (WHR) (0.87± 0.09 vs. 0.84±0.09, p = 0.047) than the control group. Fasting plasma concentrations of lipids, glucose and HbA1c were significantly higher in women with PCOS than the control group (Table 1). Consumption of total energy, protein and dietary fiber was similar between groups (p>0.05). Significant correlations were found between total cholesterol levels and dietary intake in PCOS group only (total energy (kcal) r=0.41, p<0.001; fat (% energy) r=0.24, p=0.03; fat (g) r=0.39, p < 0.001; cho (g) r=0.26, p= 0.02; pro (g) r=0.27, p=0.01). Central fat deposition (CFD) markers (waist circumference (WC), WHR, waist/height ratio (WHtR) correlated significantly with biochemical parameters in PCOS group only (Table 2). Conclusions: Obese women with PCOS represent a group with increased prevalence of disturbed metabolic profile associated with cardio-vascular risk. These disturbances might not be attributed to obesity per se, since obese women with PCOS had higher biochemical markers than their


found specifically in PCOS group, might suggest that it is not obesity but it is CFD that affects the cardiovascular risk in PCOS.

TOPIC: Parenteral Nutrition

Encore abstract: Presented at the 30th Annual Meeting of Surgical Infection Society, April 2010. Published: Republication withheld at request of the author.

S69 - Does Witholding Early Intravenous Fat Emulsion From Parenteral Nutrition Reduce Infections During Critical Illness?Sheela S. Thomas, MS,RD,CNSC; Anthony T. Gerlach, PharmD,BCPS; Lydia Pouzanjani, MS,RD,CNSC; Claire Murphy, PhamrD,BCPS; Melissa Whitmill, MD; Steven Steinberg, MD; Stanislaw Stawicki, MD; Charles Cook, MDNutrition Services, The OHio State University Medical Center, Dublin, OH.

S70 - Parenteral Nutrition (PN) suppresses polymeric immunoglobulin receptor (pIgR) expression in the Small Intestine though reduced JAK-STAT signalingAaron F. Heneghan, PhD.1,2; Jinggang Lan, PhD.1,2; Joseph F. Pierre, B.S.1; Yoshifumi Sano, M.D.2; Mark A. Jonker, M.D.2; Kenneth Kudsk, M.D.1,2

1Veterans Administration Surgical Services, William S. Middleton Memorial Hospital, Madison, WI; 2Surgery, University of Wisconsin Madison, Madison, WI.

Introduction: PN impairs mucosal immunity and increases infection in part via lower IgA levels. Transport of IgA across the mucosa to gut lumen depends on pIgR produced by mucosa. PN reduces pIgR levels in vivo. In vitro, IL-4 up-regulates of pIgR via JAK-STAT signaling. Since PN reduces gut IL-4 levels, we hypothesized that lower IL-4 decreases pIgR production via impaired JAK-STAT signaling in vivo. IL-4 regulates JAK-STAT by increasing phosphorylated JAK-1 and STAT-6 which was mea-sured in this work. Methods: : After 2 days recovery from IV cannulation, randomized male ICR mice received Chow (n=10) with saline or PN (n=8) for 5 days. Distal ileum tissue was collected, homogenized and protein extracted for JAK-STAT expression levels using a phospho-specific

Table 1

PCOS mean±SD, n = 86 Controls mean±SD, n = 86 p value

Glucose (mmol/lt) 112.9 ± 18.4 105.4 ± 10.8 0.001 HbA1c (%) 6.0 ± 1.0 (n=85) 5.4 ± 1.5 (n=39) 0.012 Total cholesterol (mmol/lt) 272.2 ± 32.6 219.5 ± 27.0 <0.001 LDL-C (mmol/lt) 179.5 ± 15.1 125.2 ± 28.3 <0.001 HDL-C (mmol/lt) 57.5 ± 8.2 62.3 ± 10.8 0.001 Triglycerides (mmol/lt) 217.8 ± 37.0 157.6 ± 42.7 <0.001

Table 2

PCOS Controls

WC(cm) WHR WHtR WC(cm) WHR WHtR r, p r, p r, p r, p r, p r, p

Glucose (mmol/lt) 0.48, <0.001 0.39, <0.001 0.50, <0.001 -0.26, 0.049 -0.01, 0.928 -0.24, 0.029 HbA1c (%) 0.31, 0.004 0.19, 0.080 0.32, 0.003 -0.19, 0.242 -0.51, 0.001 -0.18, 0.273 Total cholesterol (mmol/lt) 0.56, <0.001 0.37, 0.001 0.55, <0.001 -0.03, 0.772 0.02, 0.838 -0.18, 0.107 LDL-C (mmol/lt) 0.04, 0.710 0.08, 0.452 0.08, 0.464 -0.002, 0.983 -0.03, 0.788 -0.06, 0.526 HDL-C (mmol/lt) 0.23, 0.030 0.15, 0.184 0.21, 0.057 -0.06, 0.594 0.04 , 0.734 -0.12, 0.266 Triglycerides (mmol/lt) 0.31, 0.004 0.26, 0.015 0.28, 0.010 0.02, 0.842 0.12, 0.272 -0.12, 0.282

BMI matched controls. On the other hand, CFD is more prevalent in PCOS group and its correlation to the biochemical cardiovascular risk factors,

antibody microarray (Full Moon Biosystems). Proteins were biotinylated and conjugated to the antibody array slide in six replicates. Slides were standardized using control spots on each slide and normalized to GAPDH to determine relative expression of all phosphorylated and non-phosphorylated JAK-STAT pathway proteins. Results: PN significantly reduced phosphorylated JAK-1 compared to Chow (169.5 ± 15.7 vs 121.1 ± 10.2, p=0.02) with no differences in non-phosphorylated JAK-1 between the groups (104.5 ± 8.2 vs 89.1 ± 7.9, p=0.20). PN significantly reduced STAT-6 (Tyr641) compared to Chow (117.4 ± 16.3 vs 92.8 ± 8.3, p=0.03) with no change in non-phosphorylated STAT-6 (108.2 ± 10.8 vs 85.4 ± 8.3, p=0.13). PN significantly decreased both phosphorylated STAT-6 (Thr645) compared to Chow (162.4 ± 18.2 vs 105.6 ± 10.2, p=0.02) and non-phosphorylated STAT-6 (316.5 ± 41.2 vs 193.2 ± 17.5, p=0.02). Conclusions: PN significantly decreases the JAK-STAT pathway by reduc-ing levels of phosphorylated JAK-1 and STAT-6. Reduction in the JAK-STAT pathway is consistent with our observations of decreased production of pIgR , the major IgA transport protein, during PN.

S71 - Treatment of diminished bone mineral density with intravenous pamidronate in patients receiving chronic home parenteral nutrition: a comparison of 30 mg and 60 mg per monthJohn Siepler, Pharm.D.; Reid Nishikawa, Pharm.D.; Tom Diamantidis, Pharm.D.; Rod Okamoto, RPhNutrishare, Elk Grove, CA.

Introduction: Patients receiving home TPN (HPN) may develop BMD requiring treatment. Due to poor absorption in patients with short bowel syndrome, intravenous pamidronate(IVP) is used for treatment. Various doses are used, but the dose generally 30mg-60mg a month. Success is monitored by bone densitometry studies(DEXA). The aim of this study was to compare improvement in DEXA in patients receiving either 30mg or 60mg per month of IVP. Methods: Patients requiring HPN for SBS on IVP were included. An initial DEXA(T score: spine (S) and left femoral neck (FN)) was performed. DEXA was repeated every two years while on IVP. The mean of the T scores were evaluated to determine if there was a significant improvement at each time period from baseline. In addition the number of patients who had an improvement from osteoporosis(OPOR)


to osteopenia(OPEN) or OPEN to normal was recorded. Patients were divided into two groups. One group received 30mg of IVP monthly, and the other received 60mg of IVP monthly. Statistics were done using a t test and Chi Squared with p<0.05 significant. Results: Results were avail-able for 33 patients. The mean age was 54.1±14.7 years. There was a predominance of females(73%) and mean time on HPN was 20±6.6 years. Mean time on IVP was 6.5±29 years(range: 2.1 -21.1years). The patients received a mean of 6.3±1 bag of HPN per week and mean calcium content of HPN was 18.33±4.8mEq per day. None of these data were significantly different in either group. Mean % improvement of T scores from baseline can be seen in Table 1. Improvement in Spine T Scores were significantly better in the 60mg than the 30mg group at all time periods and at year two only in the LFN. The number of patients who improved a class of BMD in the 30mg group was 3(23%) and was 13(65%) in the 60mg group (p=0.02). Conclusions: HPN patients may develop osteoporosis and require treatment with IVP. Data documenting effectiveness of IVP in these patients are limited. We demonstrate an improvement in DEXA in HPN patients on IVP. Improvement in DEXA while on IVP is not associ-ated with age, gender, underlying disease, IVP dose, Calcium dose, or frequency of HPN use. Further investigation is required in this area to establish a role of intravenous bisphosphonate therapy in patients on HPN.

Capillary Column (30m×0.25mm× 0.25μm, Supelco, USA) on a Shimadzu GC2010 system. Peaks were identified by comparing with the individual reference standard. Sterols (Cholesterol, Desmosterol, Brassicasterol, Lanosterol, Ergosterol, Campsterol, Stigmasterol, β-Sitosterol, β-Sitostanol, and Lathosterol) and squalene were analyzed using both the internal standard and external standard curve approach and quantified using standard linear equation parameters. Results: Total sterol contents were as follows: Liposyn® III=662 mg/L, Intralipid®=713 mg/L, Lipofun-din® MCT=498 mg/L, ClinOleic®=384 mg/L, and SMOFlipid®=657 mg/L. The content of cholesterol was: Liposyn® III=64 mg/L, Intralipid®=274 mg/L, Lipofundin® MCT=219 mg/L, ClinOleic®=110 mg/L, and SMOFli-pid®=450 mg/L. Squalene content of the lipid emulsions was: Liposyn® III=9 mg/L, Intralipid®=7 mg/L, Lipofundin® MCT=6 mg/L, Clin-Oleic®=387 mg/L, and SMOFlipid®=52 mg/L. Conclusions: PLEs con-tained variable amounts and types of phytosterols and different amounts of squalene. ClinOleic®, an 80% olive and 20% soy lipid, had the lowest levels of sterols (including cholesterol) and highest level of squalene amongst the lipid emulsions. Squalene is a triterpine that has anti-inflammatory and anti-neoplastic properties. Further studies are required to determine the types and quantities of phytosterols that may cause tissue toxicity following intravenous administration.

S73 - Frequency of Lipid Administration and Risk for Infection in Trauma Patients Receiving Parenteral NutritionMeghan Jeffres, Pharm.D., BCPS1; Mark Decerbo, Pharm.D., BCPS, BCNSP1; Jingyang Fan, Pharm.D., BCPS2

1College of Pharmacy, University of Southern Nevada, Henderson, NV; 2College of Pharmacy, Southern Illinois University Edwardsville, Edwardsville, IL.

Introduction: Parenteral lipids are widely used as a source of essential fatty acids and nonprotein calories in patients requiring parenteral nutri-tion (PN). However, receipt of intravenous lipid emulsion has been associ-ated with altered immune function and an increased number of infectious complications. A previous study in trauma patients revealed adverse patient outcomes associated with the use of lipid-containing parenteral nutrition formulations, including a delay in recovery and increased susceptibility to infection. The objective of this study was to determine the rate of infectious complications and whether cumulative amount of infused intravenous lipid, either administered three times weekly (TIW) or daily, was associated with a higher rate of infectious complications. Methods: Over a three-year period, adult patients admitted to the trauma intensive-care unit at a 450-bed, urban, tertiary-care teaching hospital and initiated on parenteral nutrition therapy with lipids administered either daily or TIW were retrospectively identified. Patients receiving varying schedules of lipid administration, PN treatment course <5 days, and those with infection(s) or antimicrobial use at baseline were excluded. Results: Forty-six patients were included in the analysis, 30 in the daily lipid group, and 16 in the TIW cohort. Aside from the percentage of male patients (73.3% daily vs. 93.8% TIW; p<0.05), there were no differences in the baseline characteristics between patient groups. Infection rates between groups were not statistically significant. Seven (23.3%) patients in the daily group vs. 7 (43.8%) patients in the TIW group (p>0.05), developed either bacteremia, fungemia, pneumonia, or urinary tract infection. The average post-lipid initiation length of stay prior to development of infec-tion was 6 days in the daily lipid group and 18 days in the TIW group. A secondary analysis comparing infected patients (n=14) and uninfected patients (n=32) identified length of stay (59.7 vs. 34.5 days), duration of parenteral nutrition therapy (28.1 vs. 7.3 days), total lipid dose (1836 vs. 516 g), number of lipid doses (41 vs. 7), and duration of propofol therapy (8.5 vs. 3.3 days) as independent predictors of infection. Baseline char-acteristics including Glascow Coma Score, Injury Severity Score and APACHE II scores were similar between groups. Multiple logistic regres-sion analysis identified length of stay, days of propofol therapy, and cumu-lative lipid dose as independent risk factors for infection. Conclusions:

Percent improvement in DEXA by IVP dose and year of treatment

Year of DEXA 2 4 6

Spine30mg 0.7±0.6 0.3±0.6 3±0.460mg 14±0.3* 20±0.19* 21±0.2*

Left Femoral Neck30mg -5±0.3 5±0.2 8±0.360mg 2.7±0.6* 6±0.9 4±0.16

*p<0.05

S72 - Analysis of Phytosterols in Commercially Available Parenteral Lipid EmulsionsGary P. Zaloga, MD1; Zhidong Xu, PhD2; Thomas M. Pavlina, MS1; Kevin A. Harvey, BS2; Guy Dutot, PharmD3; Mary Hise, PhD, RD1; Rafat A. Siddiqui, PhD2

1Baxter Healthcare Corporation, , Deerfield, IL; 2Cellular Biochemistry, Methodist Research Institute, Indianapolis, IN; 3Baxter SAS, , Maurepas, France.

Introduction: The parenteral lipid emulsions (PLEs) are oil-in-water suspensions which are made from vegetable and/or fish oils. Although triglycerides and phospholipids are the major components of PLEs, these emulsions also contain sterol compounds. Phytosterols (PSts), or plant sterols, occur naturally in plant oils whereas cholesterol is the major sterol in animal oils. During oral consumption, the PSts are poorly absorbed from the gastrointestinal tract and do not exert toxic effects on tissues. However, if significant amounts of PSts are administered intravenously, they are taken up by the liver and other tissues and may exert toxic effects upon these organs. In fact, some of the toxic effects from high dose soy based lipid emulsions are believed to result from their PSts contents. Thus, it is important to know the levels of various steroid compounds present in current lipid emulsions. The objective of this analysis was to determine the types and amounts of sterols and squalene (a steroid pre-cursor) in parenteral lipid emulsions. Methods: An aliquot (200 μL) from a freshly opened bag/bottle of lipid emulsion [Liposyn® III (soy lipid), Intralipid® (soy lipid), Lipofundin® MCT (MCT/LCT lipid), ClinOleic® (olive/soy lipid), and SMOFlipid® (soy/MCT/olive/fish lipid)] was mixed with 20 μL 5α-cholestanol as an internal standard, and sterols were extracted in hexane. Sterol analysis was performed using a SACTM-5


In a population of adult hospitalized trauma patients receiving parenteral nutrition, provision of lipid emulsion on a TIW schedule did not decrease the rate of infectious complications when compared to lipids administered daily. However, in the cohort of patients developing an infection, length of stay and cumulative lipid dose from both parenteral nutrition and propofol was found to predict infection risk. Further studies quantifying the relationship of lipid dose to infection should be conducted.

S74 - Economic Evaluation of Parenteral Nutrition Therapies among Hospitalized Patients: Premixed Multichamber Bag System vs. CompoundingFrank Xiaoqing Liu, PhD1; Marc Botteman, MSc2; Katie Mercaldi, MPH3; Mary Hise, PhD1; Adel Gehchan, MD4; Robin Turpin, PhD1,5

1Baxter Healthcare Corporation, Deerfield, IL; 2Pharmerit International, Bethesda, MD; 3United BioSource Corporation, Lexington, MA; 4Baxter Corporation, Mississauga, ON, Canada; 5Public Policy Department, Thomas Jefferson Hospital, Philadelphia, PA.

Introduction: We compared overall expenditures and patient survival between hospitalized patients who received parenteral nutrition (PN) either through a premixed multichamber bag (MCB) system or a compounded bag from the perspective of the hospital. Methods: A decision analytic model comparing costs and survival of patients receiving either MCB or compounded PN was developed using the Premier Perspective™ database, a large US inpatient claims database, the largest of its kind in the US. Using this database, patients who received MCB (n=4,669) or compounded PN (n=64,315) between January 1, 2005 and December 31st, 2007 were included in the analysis. Rates of blood steam infections (BSI), non-BSI infections, probability of any ICU use, and survival rates were estimated using multiple logistic regression. Resource use (ICU and non-ICU length of stays) and associated costs were estimated using multiple ordinary least square regression. All regression models were adjusted for possible con-founding factors, including patients’ admission type, age, gender, surgical status, comorbidities, prior PN use, and duration of PN therapy, as well as hospital bed size, type, and region. These estimated figures were then used to populate the decision tree model. Results: The covariate-adjusted rates of infections were 52.49% and 54.69% for MCB and compounded PN, respectively. The covariate-adjusted rates of study defined BSI were 19.07% and 25.44%, respectively. Both differences were statistically sig-nificant at 95% confidence interval. The estimated total hospitalization costs for patients who received MCB PN was $51,198 (95% CI: $44,231, $58,798), $3,560 (95% CI: $1,222, $6,054) less than patients receiving compounding PN ($54,197; 95% CI: $47,596, $62,698). Model derived survival rates were 87.69% and 84.27% for MCB and compounding PN, respectively. One-way sensitivity analysis shows that the difference in costs and health outcomes are robust to the parameter changes. Conclusions: PN through premixed MCB system was associated with lower infections, including BSI, lower total hospitalization costs, and higher survival rate among hospitalized patients compared to the compounded PN.

TOPIC: Pediatrics

S75 - Parenteral Nutrition Admixtures For Pediatric Patients Compounded With Highly Refined Fish Oil-based Emulsion: Assessment of Physicochemical StabilityM Luisa Forchielli, MD1; Massimo Masi, MD1; Alessandra Stancari, RPh2; Silvia Maselli, RPh2; Anna Maria Guarguaglini, RPh2; Irma Mignini, RPh2; Cristina Puggioli, RPh2; Isabella Preite, PhD3; Alessandra Bonoli, Prof3; Germana Bersani, RPh2

1Pediatrics, med school bologna, Bologna, Italy; 2Pharmacy Service, Med School Bologna, Bologna, Italy; 3Civil Environmental and Materials Engineering, Bologna University, Bologna, Italy.

Introduction: Fish oil-based emulsion (FO) is increasingly used in pedi-atric patients receiving parenteral nutrition (PN). However, its unique use in children on long-term PN is nutritionally debatable as some patients are better off with a mixture of long-chain (LCT) or long-chain+medium-chain (LCT+MCT) triglycerides along with FO. Lipid emulsions are safely infused when particle diameter ranges between 0.4-1.0 micron (like chy-lomicra) according to the European Guidelines. No data exist on FO stability when added to other PN components typically present in pediatric formulations such as other lipids or micronutrients. Our goal is to evaluate the stability of a highly refined FO-emulsion in PN admixtures containing LCT or LCT+MCT triglycerides and different calcium content. Methods: Stability studies were carried out on olive LCT+FO, LCT+MCT+FO emulsion and pure FO alone, compounded respectively with calcium added at 6 and 9 mmol/L. The analysis was performed immediately at time 0 (t=0) and 24, 48, 72, 96 (t=96) hours after compounding. Particle diameter was determined by Light Scattering-Reverse Fourier Optics Technique. Every sample was stored at 4° C and triple tested. Statistical significance was verified by f-test. Results: In all the admixtures physi-cochemical stability did not change between t=0 and t=96 and particle diameter was in the range of 0.4 -1.0 micron provided calcium concentra-tion did not exceed 4.5 mmol/L. When calcium exceeded that level, 12% of particle diameters were larger than 1.0 micron with the 2% over 5.0 micron immediately after compounding. In particular, admixtures com-pounded with olive oil LCT+FO emulsion showed lower particle diameters compared to admixtures with olive oil LCT alone (data from previous study), probably due to a different steric encumbrance of oleic acid and omega-3. No changes occurred in the LCT+MCT admixtures with or without FO. Conclusions: PN admixtures containing FO-emulsion alone or in combination with olive LCT and LCT+MCT emulsion appear to be stable and can be safely infused in pediatric patients, when calcium con-centration is maintained below 4.5 mmol/L. If calcium level exceeds 4.5 mmol/L, as often required in premature patients, it is advisable to infuse FO emulsion alone through a second intravenous line.

S76 - Targeted indirect calorimetry in critically ill children: A pilot studyUrsula G. Kyle, MS, RD/LD, FADA1,2; Jorge A. Coss-Bu, MD1,2; Ana L. Arriaza, BS2; Monica I. Esposito, BS2

1Pediatrics, Baylor College of Medicine, Houston, TX; 2Intensive Care Medicine, Texas Children’s Hospital, Houston, TX.

Introduction: Critically ill children differ in their energy needs from healthy children in terms of underlying metabolism and growth, comor-bidities, preexisting energy reserve and response to critical illness. The purpose of this prospective pilot chart review was to determine how many pediatric ICU patients would be candidates for indirect calorimetry (IC), based on current ASPEN recommendations. Methods: This prospective review collected admission diagnosis, mechanical ventilation, medications, vital signs, age, height, weight, nutrition support (TPN/EN and IV fluids) for 7 days, Length of ICU/hospital stay. Patients were considered to be candidates for IC if they were classified as at high risk for metabolic alterations per ASPEN guidelines. Patients were also classified by diag-nostic categories (neuro/seizure; oncology; respiratory; sepsis/septic shock/infection and miscellaneous diagnoses which included cardiac, endocrine, gastrointestinal/hepatic, renal and miscellaneous). Results: Subjects (n = 150 (M/F 56/44%)), were 6.7±5.6 (SD) yrs old, and had a PRISM score of 4.9±6.1 and PICU LOS 3.9±5.3 days. IC, as determined by ASPEN guidelines, was indicated in 72.0% (108/150) of subjects during the first seven days of PICU stay. There were no significant differences for IC indication between gender (M/F 76 vs 67%, Chi2 p = 0.20) and age groups (<2 yrs 74 %, 2-12 yrs 65%, and >12 yrs 81%, Chi2 p = 0.20). Indications for IC were as follows: hypermetabolism 26.2% (48); not meeting nutrition goals (for 5 days) 13.7% (25); obesity 13.1% (24); overweight and under-weight 9.8% (18 each), oncology 9.3% (17), mechanical ventilation for >7 days 8.7% (16); neurotrauma 3.3% (6) and others 6.1% (11). A total


of 31 % of subjects met 2 or more indications for IC. There was a signifi-cant association between diagnostic categories and 2 or more indications for IC. Patients with neuro/seizure diagnoses - OR 7.0 (95% CI 1.8-26.1); oncology - OR 5.8 (95% CI 0.9-36.0); respiratory - OR 8.8 (95% CI 2.3-34.7) and sepsis/septic shock/infection - OR 9.3 (95% CI 2.1-42.0) were more likely to have 2 or more indications for IC compared to patients with miscellaneous diagnoses. Conclusions: This pilot study confirms that a significant proportion of children admitted to the pediatric intensive care unit are candidates for indirect calorimetry. Indirect calorimetry is a useful tool to determine energy needs in critically ill children with potentially altered metabolic needs due to disease, co-morbidities and energy reserves. If indirect calorimetry is to be implemented, pediatric hospitals may have to evaluate what resources they have available to perform indirect calorimetry.

S77 - Is There Survival Indicator With Nutritional Status With Hematopoietic Stem Cell Transplantation In Children? -One Aspect of Albumin and Lymphocyte -Teruyoshi Amagai, MD,PhD1; Dai-ichiro Hasegawa, MD,PhD2; Maki Wakita, RD1

1Food Science and Nutrition, Mukogawa Women’s University, Nishinomiya, Japan; 2Hematology and Oncology, Mukogawa Women’s University, Kobe, Japan.

Introduction: Hematopoietic Stem Cell Transplantation (HSCT) after a large dose of chemotherapy give a great stress to children with hematological disorders or solid malignancies and partly result in poor outcome,such as death and major complications. Aim: To examine any nutritional indicators to prospect outcome with children with HSCT. Methods: Methods: Subjects

was included children with disorders or solid malignancies admitted for medical therapy with HSCT to Kobe Children’s Hospital between 2003 and 2009.Chidlren within 6 months after HSCT were excluded. Methods-(1) Subjects were divided into three groups by living status at the time of 6 months after HSCT -survival(Sx), transplant-related death defining by death within 28 days after HSCT(TAD),and death by underlying disorders(DUD) group. (2) Three parameters were analyzed in Sx, DAT, and DUD groups -1)anthropometry:height, weight, height for age(H/A), weight for height (W/H), and weight for age (W/A), 2)laboratory data:serum albumin(Alb:mg/dL), peripheral total lymphocyte count (TLC:/cmm), prognostic nutritional index(PNI) calculated by 10*Alb+0.05TLC, and CRP(mg/dL).3)nutritional intake:energy (kcal/d, kcal/kg/d, %RDA), protein (g/d, g/kg/d, %RDA) and % energy with enteral route(%EN). All 2) and 3) parameters were taken at 7 times: before chemotherapy(T1), before HSCT after chemotherapy (T2), 1 week (T3),and 2weeks (T4),3 weeks(T5), 4 weeks (T6) after HSCT, and discharge from hospital (T7). Results: Statistically significances were identi-fied in (1) Height, higher at T2 in Sx than in TAD (120.8 +/- 51.1 vs 87.0 +/- 34.4cm,p=0.044). (2) Weights, heavier at T7 in Sx than in TAD (22.26 +/- 10.85 vs 7.95 +/- 4.20,p=0.013). (3) Alb , higher at T2 in Sx than TAD (8.8 +/- 0.4 vs 3.6 +/- 0.6, p=0.029). (4) TLC, larger at T2 in DUD than TAD (112.5 +/- 335.7 vs 18.0 +/- 15.7, p=0.040). (5) CRP, higher at T1 in TAD than DUD ( 0.02 +/- 0.13 vs 0.21 +/- 3.06, p=0.040). (6) Daily energy (kcal/d) at T1,higher in Sx than DUD (648 +/- 362.9 vs 372.4 +/- 225.9kcal/d,p=0.028) (7) Daily protein (g/d) intake at T1,higher in Sx than DUD (21.8 +/- 12.6 vs 8.8+/- 8.1gd,p=0.002). However energy and protein intake expressed per kg were not significantly different. Conclusions: Among results taken from our study with outcome indicators to prospect survival or death before or after HSCT, Alb and TLC before HSCT (at T2) might be helpful to prospect children’s life outcome and correction before HSCT in Sx might improve survival rate with pediatric HSCT therapy.

Outcome indicators among three groups before HSCT in children

T1 T2 p

Height(cm) SX/TAD/DUD (SD)

119.45 +/-52.8/ 87.00+/-34.4/ 96.65 +/-75.3

120.80 +/-51.1/ 87.00 +/-34.4/ 101.70 +/-77.1

p=0.044 Sx vs TAD (at T2)

Weight(kg) SX/TAD/DUD (SD)

22.25 +/-23.9/ 11.90 +/-9.8/ 15.83 +/-26.7

20.70 +/-17.94/ 11.30 +/-11.6/ 10.03 +/-9.2

n.s.

Alb(mg/dL) SX/TAD/DUD (SD)

4.2+/-0.6/ 4.2 +/-0.4/ 3.9 +/-0.6

3.8 +/-0.4/ 3.6 +/-0.6/ 3.7 /- 0.4

p=0.029 Sx vs TAD (at T2)

TLC(/cmm) SX/TAD/DUD (SD)

752.4 +/-1011.5/ 1008.0 +/-546.7/ 671.5 +/-844.4

25.0 +/-74.3/ 18.0 +/-15.7/ 112.5 +/-335.7

p=0.040 Sx vs TAD(at T2)

CRP(mg/dL) SX/TAD/DUD (SD)

0.03 +/-0.19/ 0.02 +/-0.13/ 0.21 +/-3.06

0.11 +/-0.50/ 0.03+/-0.67/ 0.72 +/-1.48

p=0.040 TAD vs DUD (at T1)

Energy Intake (kcal/day) SX/TAD/DUD (SD)

648.1+/-362.9/ 488.9+/-379.1/ 372.4+/-225.9

486.8 (424.1)/ 540.9 (440.4)/ 410.6 (531.5)

p=0.028 Sx vs DUD (at T1)

Energy(kcal/kg/day) SX/TAD/DUD (SD)

27.6 +/-27.1/ 43.9 +/-57.6/ 27.2 +/-41.2

23.3 +/-29.3/ 37.0 +/-37.1/ 29.6 +/-35.7

n.s.

Protein Intake (g/day) SX/TAD/DUD (SD)

21.8+/-12.6/ 17.0+/-13.1/ 8.8+/-8.1

3.7 +/-13.1/ 9.8 +/-23.4/ 7.9 +/-22.8

p=0.002 Sx vs DUD (at T1)

Sx:surviaval,TAD:ransplant-related death defining by death within 28 days after HSCT, DUD:death by underlying disorders.n.s.:not significantly different.

S78 - What are the Best Fat Removal Methods in Making Low Fat Milk for Infants with Chylothorax?Michelle Drewniak1; Tanis R. Fenton1,2; Andrew W. Lyon3

1Nutrition Services, Alberta Children’s Hospital, Calgary, AB, Canada; 2Community Health Science, University of Calgary, Calgary, AB, Canada; 3Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, AB, Canada.

Introduction: An accumulation of chyle can occur in the pleural, thoracic, or peritoneal space from congenital or acquired chylothorax. As part of

treatment, infants are placed on formulas without long chain triglycerides to reduce the flow and accumulation of chyle. Human milk, the gold standard for feeding infants for its immune protective qualities, is contra-indicated for use in chylothorax because of its long chain fatty acid content. In order for these infants to benefit from breastmilk, the fat needs to be removed. Two case studies report no reaccumulation of chyle with the use of low-fat breastmilk. As far as we are aware, the most effective method to remove the fat from breastmilk, after the fat is separated, is not known. The objective of this study was to determine whether removing either the low fat milk by syringe or the floating fat layer with a spoon is the superior method in removing the fat from breastmilk. Methods: To remove the fat


among 24 samples of breastmilk, two methods were compared to remove either the low fat milk (syringe method) or the fat (spoon method). First, a centrifuge was used to separate breastmilk into two layers: a floating fat layer and a lower low fat milk portion. The milk was refrigerated. For the syringe method, the lower low fat milk portion was extracted with a syringe; for the spoon method, the floating fat layer was removed with a spoon. Triglycerides were measured in triplicate from each sample. Results: The fat content in the milk before and after spoon and syringe removal methods is reported in the Table. Comparing the difference, the syringe method was a slightly, but not significantly superior method of fat removal (p = 0.19). Conclusions: Since the success of providing low fat human milk to infants with chylothorax depends on satisfactory preparation of low fat milk, effective methods of fat separation and fat removal are needed. This study has determined that both methods of fat removal, syringe versus spoon, were equally effective. Further study is needed to determine the best method of fat separation, prior to fat removal.

bowel length, in our SBS subjects. These findings raise the question as to whether SCL is associated to bowel length or intestinal adaptation. Further studies are warranted investigating longitudinal measurements of SCL as a dynamic marker for intestinal adaptation.

TOPIC: Pharmaconutrition

S80 - Glutamine Treatment Increases Nuclear Factor (Erythroid-Derived 2)-Like 2 and Heme Oxygenase 1 Expression and Nuclear Localization In Intestinal Epithelial CellsChristine Hamiel, B.S.; Alyssa R. Kallweit, B.S.; Lauren Zager, B.S; Alexandra Sufit, B.S.; Paul Wischmeyer, M.D.Anesthesiology, University of Colorado Denver, Aurora, CO.

Introduction: Glutamine (GLN) treatment can decrease mortality, length of stay, and infectious complications in critically ill patients. In cells, GLN protects from lethal heat stress (HS) and oxidant injury via heat shock proteins (HSPs). GLN is known to increase intracellular levels of multiple HSPs during HS, however GLN’s effects on the antioxidant response ele-ment (ARE) are not as well defined. Literature shows GLN can enhance HSP32 (heme oxygenase 1 (HO1)) during oxidant stress in the intestine, however the mechanism is currently unknown. Furthermore, no literature exists about the effect of GLN treatment on nuclear factor (erythroid-derived 2)-like 2 (NRF2), levels and cellular localization in intestinal epi-thelial cells (IEC). The purpose of this study was to determine GLN’s effect on HO1 and NRF2 expression and nuclear translocation in control, HS and oxidant injured intestinal epithelial cells. Methods: Cells were treated for 15 min with either 0mM (CT) or 10mM GLN, subjected to non-lethal injury (HS-43° for 45 min or 800uM H2O2 for 30 min), and allowed to recover (either 5 min for nuclear translocation experiments, or 3 hours for protein expression experiments). HSP25, HSP70, HO-1 and NRF2 expression levels and/or cellular localization were determined by western blot. Messenger RNA levels were also analyzed for HSP25 and HO1. Results: GLN treatment increased HO1 expression in CT, HS and oxidant injured cells (p<0.05 vs. CT groups). Cells treated with GLN also showed an increase in nuclear HO-1 content in all treatment groups (p<0.05). Total NRF2 protein levels increased more than 3 fold with GLN treatment in non-injured cells (p=0.003 vs. CT cells). H2O2 injury alone increased nuclear NRF2 however HS decreased levels (p<0.05 vs. CT cells). Treatment with GLN showed a trend of increasing nuclear NRF2 in both injuries. Interestingly, GLN increased HSP25 and HSP70 expres-sion in cells subjected to HS but decreased expression in oxidant injured cells (p<0.05 vs. HS CT and H2O2 only). GLN treatment increased mRNA expression of HO1 in both HS and oxidant injury (p<0.05 vs. HS CT or H2O2 only). GLN only increased HSP25 mRNA in HS injury (p<0.05 vs HS CT). Conclusions: GLN induces differential HSP25 and HSP70 expression based on the model of injury. However, GLN increases HO1 expression and nuclear translocation in CT, HS and oxidant injured cells. GLN increases total NRF2 levels in non-stressed cells. These are the first data showing GLN can enhance nuclear translocation of HO1 and upregu-late it’s transcription factor, NRF2, in intestinal cells. HO1 and NRF2 may play an integral role in GLN mediated cellular protection in oxidant injury.

TOPIC: Prebiotics

Encore abstract: Presented at the 25th Annual Meeting of Japanese Society for Parenteral and Enteral Nutrition, 2010. Reprint withheld at request of author.

S81 - Effects of an enteral nutrition containing prebiotics on influenza vaccination in the elderlyHiroyasu Akatsu, MD, PhD1; Shinya Nagafuchi, PhD2; Rina Kurihara, MD, PhD1; Kenji Okuda, MD, PhD1; Satoshi Takasugi, PhD2; Taketo Yamaji, PhD2; Masao Takami, PhD2; Takayuki Yamamoto, MD, PhD1; Mitsuo Maruyama, PhD3

Pre and Post Human Milk Fat Content (g/dl) by Spoon and Syringe Removal Methods.

n Mean SD

95% Confidence

Interval

Spoon Pre fat removal 12 4.8 0.7 4.4 5.2 Post fat removal 12 1.0 0.7 0.6 1.4 Difference 12 3.8 0.7 3.4 4.2

Syringe Pre fat removal 12 4.8 0.7 4.4 5.2 Post fat removal 12 0.6 0.2 0.5 0.7 Difference 12 4.2 0.5 3.9 4.5

Encore abstract: Presented at North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition, 2010.

S79 - Degree of Parenteral Nutrition Support Correlates with Serum Citrulline Levels in Short Bowel SyndromeMuhammad A. Khan, MD MPH1; Mar Miserachs, MD2; Brittany Hofmeister, RD1; Colleen Nespor, CNS1; Ricardo Castillo, MD1; John A. Kerner, MD1

1Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University Medical Center, Palo Alto, CA; 2Pediatric Gastroenterology, Hepatology, and Nutrition, Hospital Universitari Vall d’Hebron, Barcelona, Spain.

Introduction: Several intestinal markers, including length of residual bowel, presence of an ileocecal valve, and age at the time of resection, are useful tools to assess the likelihood of intestinal adaptation in patients with short bowel syndrome (SBS). Recently, serum citrulline, an amino acid produced by the intestinal mucosa, has been proposed as a marker of functional intestine. Serum citrulline levels (SCL) have been shown to correlate with residual bowel length in SBS, supporting the potential utility of SCL in a clinical setting. Successful intestinal adaptation is manifested by decreasing requirements for parenteral nutrition (PN). We therefore investigated whether SCL correlated with the degree of nutri-tional support provided by PN in our patients with SBS. Methods: Serum citrulline was measured in 19 subjects with short bowel syndrome; 10 were female and 17 utilized PN at the time of measurement. Subjects ranged from 7m to 21y, with bowel lengths of 5 to 150 cm, and percentage of PN providing 0-100% of caloric intake. SCL was compared to PN intake as well as bowel length. Comparisons were made using linear regression analysis. Results: Of the 19 subjects, SCL decreased with increased PN intake (R=0.69). Of the 17 subjects with known residual bowel length, SCL correlated with bowel length (R=0.73). Conclusions: Our findings support a correlation between SCL and degree of PN support, as well as


1Choju Medical Institute, Fukushimura Hospital, Toyohashi, Japan; 2Meiji Dairies Corporation, Odawara, Japan; 3Department of Mechanism of Aging, Research Insttitute, National Center for Geriatrics and Gerontology, Obu, Japan.

TOPIC: Quality Improvement

S82 - Implementation of Good Nutritional Practice: A One-year Intervention Study in a Danish University HospitalHenrik H. Rasmussen, Aarhus University1; Tina Beermann, Copenhagen University1; Karen Lindorff-Larsen, Aarhus University2; Marie Nerup Mortensen, Aarhus University1; Mette Holst, Aalborg University1

1Centre for Nutrition and Bowel Disease, Aalborg University Hospital, Aalborg, Denmark; 2Department of Surgical Gastroenterology, Aalborg University Hospital, Aalborg, Denmark.

Introduction: Malnutrition is extremely prevalent in hospitalized patients, associated with high rates of morbidity and mortality. Imple-mentation of good nutritional practice (GNP) is mandatory for targeted treatment of malnourished patients; that is: screening, plan, monitoring and follow-up. However, despite introduction of national and interna-tional guidelines for treating patients at nutritional risk these patients are not diagnosed and treated accordingly. Objectives: Were to improve GNP by a multi-modal strategic intervention according to the Danish Health Quality Programme which includes nutrition standards (www .IKAS.dk). Hypothesis: GNP can be improved by introducing a multi-modal strategic approach. Methods: Baseline measurements followed by a 12 months intervention period and follow-up measurements. All hospitalized patients (> 3 days of admittance) at a randomly selected day were included before and after the intervention period. The setting was a university hospital with 990 beds and all specialities. Baseline measurements (and follow-up measurements): Included record audit for demographics, screening (NRS 2002), nutrition plan, monitoring (energy- and protein intake by 24-hour recall interviews). Each depart-ment had their own results from the baseline measurement presented, together with the overall hospital results. Intervention period: Based upon the results from the baseline measurements, the nutrition team in each department (physician, nurse, dietician and kitchen staff) made action plans for intervention, supervised by an expert team consisting of a physician, nurse and dietician (nutritionist). Generally the following interventions were made: 1. Education for all clinical staff on behalf of local and common results targeted GNP. 2. Local investigations of bar-riers towards GNP. 3. Standard nutrition plans for eight diagnoses. 4. Improved hospital food. 5. Education of kitchen staff. 6. Improved environments in the dining rooms. Statistics: Mann-Whitney and Kruskal-Wallis test was used for ordinal data, and Pearson Chi square test for nominative data. P values <0.05 were considered significant. Results: Overall 545 patients participated (287 before and 258 after intervention period) from 26 departments. There were no significant differences in the two patient groups regarding sex, age and BMI before and after the intervention period. Weight loss < 3 months was found in 20% vs. 26% (ns). Screening improved from 56% to 77% (p<0.001), nutrition plans (including prescription of diet and requirements) from 21% to 56% (p<0.0001), monitoring (registration of food intake) from 29% to 58% (p<0.0001). In 24-hour nutrition intake recall interviews, improvement in energy intake (> 75% of their requirements) was found (52% vs. 68%, p<0.007), as well as protein intake (33% vs. 52%, p<0.001). Furthermore, patients with an intake of less than half of their requirements, were decreased with moreover 50%. Conclusions: A multi-modal strategic intervention across specialities in a university hospital can improve good nutritional practice, both regarding the process and the result, which ultimately increased nutritional intake in patients at nutritional risk.

TOPIC: Surgery

S83 - Even preoperative immunonutrition is able to reduce infectious complication rate and stress-induced immunosupression in patients undergoing pancreaticoduodenectomyToshiaki Aida, T.A.; Katsunori Furukawa, K.F.; Fumio Kimura, F.K.; Hiroaki Shimizu, H.S.; Hiroyuki Yoshidome, H.Y.; Masayuki Ohtsuka, M.O.; Atsushi Kato, A.K.; Hideyuki Yoshitomi, H.Y.; Dan Takeuchi, D.T.; Tsukasa Takayashiki, T.T.; Kohsuke Suda, K.S.; Shigetsugu Takano, S.T.; Satoshi Kuboki, S.K.; Masaru Miyazaki, M.M.Department of General Surgery, Chiba University Graduate School of Medicine, Chiba, Japan.

Introduction: Despite of recent advances in surgical techniques and peri-operative management, pancreaticoduodenectomy is still associated with a high morbidity rate. Several clinical studies have demonstrated that peri-operative immunonutrition reduces postoperative complications and improves surgical outcomes in gastrointestinal tract surgeries. We also reported effects of perioperative immunonutrition on cell-mediated immu-nity, Th1/Th2 differentiation and infectious complication rate after pan-creaticoduodenectomy (Suzuki D, et al. Surgery 2010; 148:573-81). It was demonstrated that perioperative immunonutrition reduced stress-induced immunosuppression after a major stressful surgery and that the modulation of Th1/Th2 differentiation and Th17 response might play important roles in this immunologic effect. The present study was designed to determine whether even preoperative immunonutrition is able to influence stress response, cell-mediated immunity and infectious complication rate after pancreaticoduodenectomy. Methods: This is a prospective, randomized clinical trial in our institution. Twenty-one patients who underwent pan-creaticoduodenectomy were divided into two groups. Ten patients in the preoperative group received oral supplementation enriched with arginine, ω-3 fatty acids, and RNA (1000 kcal/day) for five days before surgery in addition to a half-amount of regular food. Eleven patients in the control group received no artificial nutrition and were allowed to consume regular food before surgery. All patients received early postoperative enteral infusion based on a standard formula. Postoperative full nutritional goal was intended to provide 25 kcal/kg/day. Assessed parameters were concanavalin A (Con A)- or phytohemagglutinin (PHA)-stimulated lymphocyte proliferation, natural killer cell activity, plasma IL-6, C-reactive protein, fatty acids com-position and the rate of infectious complications. Results: In the preoperative group, the rate of infectious complications was significantly reduced (10.0%) compared with that in the control group (63.6%) (P<0.05). Con A-stimulated lymphocyte proliferation was significantly higher in the preoperative group (110.3 ± 14.4) than in the control group (67.4 ± 13.7) on postoperative day (POD) 7 (P<0.05). PHA-stimulated lymphocyte proliferation was also sig-nificantly higher in the preoperative group (135.9±32.8) than in the control group (63.2 ± 15.5) on POD 7 (P<0.05). There were not significant differ-ences between the two groups in natural killer cell activity. In plasma IL-6 and CRP, there were not significant differences between the two groups. Eicosapentaenoic acid and eicosapentaenoic acid/arachidonic acid ratios in the preoperative group were significantly higher than in the control group on POD -1, 1, and 3 (P<0.05). Conclusions: Even preoperative immuno-nutrition could reduce infectious complication rate and stress-induced immunosuppression after pancreaticoduodenectomy.

S84 - Effects of Preoperative Infusion of Glucose and Amino Acids on Blood Glucose KineticsTakashi Fukuda, MD1; Kazuhiko Fukatsu, MD, PhD2; Etsushi Ogaws, MD3; Takashi Mitsui, MD1; Yuhei Saito, BS3; Hiroshi Yasuhara, MD, PhD3; Yasuyuki Seto, MD, PhD1

1gastrointestinal surgery, The University of Tokyo, Tokyo, Japan; 2Surgical center, The University of Tokyo, Tokyo, Japan; 3surgery, The University of Teikyo, Tokyo, Japan.


Introduction: Surgical stress causes insulin resistance and stimulates protein metabolism. Enteral or intravenous carbohydrate treatment before elective surgery has been demonstrated to reduce the stress response and improve insulin sensitivity. Provision of amino acids limits net whole body protein loss. However, it is unclear whether addition of amino acids to intravenous carbohydrate solution, as well as intravenous carbohydrate treatment alone, before surgery would improve glucose metabolism. We examined the effects of preoperative intravenous solutions on the kinetics of blood glucose level after laparotomy in mice. Methods: Thirty six mice were randomized to receive saline (Ns) (n=12), 7.5% glucose (Glu) (n=11) or 7.5% glucose with 3% amino acids (Glu+AAs) (n=13). From 14 hours before laparotomy, mice were not allowed to receive an oral diet. During the first 12 hours of the period, mice were given intravenous infusion of Ns, Glu or Glu+AAs at 0.4 ml/hr through a central venous catheter. Then, all mice received normal saline at 0.4 ml/hr. Under general anesthesia, mice underwent major laparotomy and the abdominal wall was closed after 45 min. From 30 min after closure, all mice were infused 5% glucose solution containing electrolytes at 0.4 ml/hr. Blood glucose levels were measured just before (Pre) laparotomy, just after (0 hr) and at 1, 3, 5 and 7 hr after abdominal wall closure. Results: Blood glucose reached the highest levels at 3hr after closure in each group. The change in blood glucose level during the measurement period was marked in the Ns group, as compared with the Glu and Glu+AAs groups (Figure, p<0.01 repeated measures ANOVA). The trend in blood glucose levels was similar in the Glu and Glu+AAs groups. Conclusions: Preoperative intravenous infusion of carbohydrate and amino acid mixture stabilized the change in blood glucose level after laparotomy, as did carbohydrate infusion, although the Glu+AAs group received more total calories than the Glu group. A clinical benefit of infusion of a carbohydrate and amino acid mixture before surgery may exist in terms of both glucose and protein metabolism.

perioperative management. Among the proposed strategies of reducing postoperative morbidity, immunonutrition plays an important role in peri-operative management. Although it has been demonstrated that periopera-tive immunonutrition reduces the incidence of postoperative complications and length of hospital stay in gastrointestinal tract surgeries, it is poorly understood whether immunonutrition can perform these effects in patients undergoing hepatectomy. Recently, we have reported effects of periopera-tive immunonutrition on cell-mediated immunity, Th1/Th2 differentiation and infectious complication rate after pancreaticoduodenectomy (Suzuki D, et al. Surgery 2010; 148:573-81). Effects of immunonutrition on stress responses, cell-mediated immunity and infectious complication rate in patients undergoing hepatectomy were investigated in this study. Methods: Sixteen patients who underwent hemihepatectomy with resection of extra-hepatic duct were divided into two groups. Eight patients received oral supplementation enriched with arginine, ω-3 fatty acids, and RNA (1000 kcal/day) for five days before surgery in addition to a half-amount of regular food (group A). Eight patients received no artificial nutrition and were allowed to consume regular food before surgery (group B). All patients received total parenteral nutrition postoperatively. Postoperative full nutri-tional goal was intended to provide 25 kcal/kg/day. Assessed parameters were concanavalin A (Con A)- or phytohemagglutinin (PHA)-stimulated lymphocyte proliferation, natural killer cell activity, plasma IL-6, C-reactive protein, fatty acids composition and the rate of infectious complications. Results: Although the rate of infectious complications in group A (50.0%) was reduced compared with that in the control group (87.5%), there were no statistically significant differences between the two groups. Con A-stimulated lymphocyte proliferation was significantly higher in group A (140- ± 26) than in group B (53 ± 11) on postoperative day (POD) 3 (P < 0.05). PHA-stimulated lymphocyte proliferation was also significantly higher in group A (129 ± 37) than in group B (44 ± 14) on POD 3 (P < 0.05). In plasma IL-6 and CRP, there were not significant differences between the two groups. EPA and EPA/AA ratios in group A were significantly higher than in group B on POD -1, 1, 3, 7 and 14 (P < 0.05). Conclusions: These results indicate that immunonutrition may be able to reduce infectious complication rate and stress-induced immunosuppression in patients underwent hepatectomy with resection of extrahepatic duct.

S86 - How Do Japanese Surgeons View Nutritional Therapy and Manage Gastroenterological Surgery Patients? A Questionnaire-based StudyKazuhiko Fukatsu, MD1,3; Tsuneo Iiai, MD2,3; Katsuyoshi Hatakeyama, MD2,3

1Surgical Center, The University of Tokyo, Tokyo, Japan; 2Surgery, Niigata University, Niigata, Japan; 3Perioperative Nutritional Therapy Research Group, Niigata University, Niigata, Japan.

Introduction: Nutritional therapy (NT) is now of great interest to Japanese clinicians. The number of facilities with a nutritional support team (NST) is increasing, and the trend in NT appears to be changing in Japan. How-ever, the actual situation of NT in Japan is unclear. This study gathered information about how Japanese surgeons recognize the importance of NT and manage gastroenterological surgery patients by means of a question-naire. Methods: In 2009, a questionnaire (52 questions) was circulated to surgical departments (n=956) authorized by the Japanese Society of Gastroenterological Surgery. Directors of the departments were asked about NT of gastroenterological surgery patients. Results: Ninety-nine directors completed the questionnaire. The average number of gastroen-terological operations performed under general anesthesia was 515/year/department. An NST existed in 94% of the facilities. Opinions on NT: NT was considered to be important by all directors (100%). 62 to 71% were familiar with ASPEN, ESPEN or JSPEN guidelines. 95% expected NT to decrease postoperative complications, 81% to improve nutritional status, and 44% to reduce the duration of hospital stay. 87% paid attention to total calories given, 72% to the nutritional route, 51% to the amount of protein given, and 39% to the composition of the diet. Most directors recognized

S85 - Effects of immunonutrition on cell-mediated immunity and infectious complication rate in patients undergoing hepatectomyKatsunori Furukawa, kf; Toshiaki Aida, ta; Fumio Kimura, fk; Hiroaki Shimizu, hs; Hiroyuki Yoshidome, hy; Masayuki Ohtsuka, mo; Atsushi Kato, ak; Hideyuki Yoshitomi, hy; Dan Takeuchi, dt; Tsukasa Takayashiki, tt; Kohsuke Suda, ks; Shigetsugu Takano, st; Satoshi Kuboki, sk; Masaru Miyazaki, mmDepartment of General Surgery, Chiba University, Chiba, Japan.

Introduction: It has been reported that extended hepatectomy, which is one of the most severely stressful surgeries, is still associated with a high morbidity rate despite of recent advances in surgical techniques and


enteral nutrition (EN) as the preferred NT; 96% expected EN to maintain gut function, 90%: prevention of postoperative infectious complications, 85%: reduction of cost, and 81%: prevention of metabolic complications. 69% of the directors knew more than 4 EN diets, and 88% understood the use of EN diets in different clinical situations. However, only 58% had experience of attending meetings on NT. Clinical Practice: When the EN tube was inserted via the nasal cavity, the tip was kept in the stomach (68%) or in the jejunum (20%). Bolus administration was carried out through a nasogastric tube (77%), while continuous administration was performed through a nasojejunal tube (60%). A central vein catheter for total parenteral nutrition (TPN) was inserted via the right subclavian vein (56%). Multivitamins, trace elements, and lipid emulsion were given every day during TPN by 89%, 55%, and 14% of surgeons. Only 4% of the direc-tors had experience of preoperative oral carbohydrate loading, but 32% were willing to try this practice. Conclusions: Most directors of surgical departments in Japanese hospitals recognized the importance of NT for gastroenterological surgery patients and were performing reasonable nutri-tional practice. However, there were some practical differences from Western countries.

S87 - Nutritional Therapy for Esophageal Surgery Patients in Japan. Results of a Questionnaire from 100 Japanese Surgical UnitsKazuhiko Fukatsu, MD1,3; Tsuneo Iiai, MD2,3; Katsuyoshi Hatakeyama, MD2,3

1Surgical Center, The University of Tokyo, Tokyo, Japan; 2Surgery, Niigata University, Niigata, Japan; 3Perioperative Nutritional Therapy Research Group, Niigata University, Niigata, Japan.

Introduction: More attention is now being paid to nutritional therapy (NT) for surgical patients in Japan. Because patients undergoing esophageal surgery may have severe nutritional risk, well planned NT is essential for early recovery and prevention of postoperative complications. However, no report has surveyed the national trend in NT for esophageal surgery patients in Japan. We examined the trend by means of a questionnaire. Methods: In 2009, a questionnaire (35 questions) was circulated to surgical depart-ments (n=956) authorized by the Japanese Society of Gastroenterological Surgery. Chiefs of upper gastrointestinal tract surgery were asked about NT for esophageal surgery patients. Results: One hundred surgeons com-pleted the questionnaire. The average number of esophageal operations performed was 13.3/year/department. Nutritional Assessment: Before admis-sion to hospital, 74% of the surgeons assessed the nutritional status of patients, based on plasma albumin level (87%), body weight (74%), and body weight change (66%). 49% of the surgeons arranged for patients to receive nutritional guidance. Upon hospitalization, 78% assessed the nutri-tional status, based on plasma albumin level (86%), SGA (73%) and body weight (71%). 75% of the surgeons delayed the operation and 64% changed the surgical procedure according to the nutritional status. Nutritional Treatment: Preoperative NT was conducted in patients with nutritional risk by 87% of the surgeons. The duration of preoperative NT was 7 to 14 days (65%). Patients were allowed to eat until the evening before surgery (54%). Postoperative NT consisted of only enteral nutrition (EN) (8%), only peripheral parenteral nutrition (PPN) containing amino acids (21%), only total parenteral nutrition (TPN) (20%) and a combination of EN and PN (35%). When TPN was given, lipid emulsion was given every day (21%), several times a week (30%) or once a week (11%). EN was started on POD 1 to 2 (48%). The timing of EN initiation was decided according to the day after operation (57%), auscultation of bowel sounds (47%) and confirmation of first flatus (35%). When EN was started, the diet first given was glucose solution (37%), standard complex enteral diet (23%), semi-elemental diet (17%) or elemental diet (16%). An oral diet was started on POD 7 (37%) or POD 4 (15%). Conclusions: Most chief surgeons of upper gastrointestinal surgery in Japan appeared to manage esophageal surgery patients with attention to nutritional status. However, postoperative NT varied among surgeons.

SUBJECT: Trauma

S88 - Trauma Patients Increased Caloric and Protein Requirements Are Not MetCharles E. Wade, PhD1,2; Rosemary Kozar, MD, PhD2; Carmel Dyer, MD3; Eileen Bulger, MD4; Marina Mourtzakis, PhD6; Daren K. Heyland, MD5

1Center for Translational Injury Research (CeTIR), University of Texas Health Science Center Houston, Houston, TX; 2Department of Surgery, University of Texas Health Science Center Houston, Houston, TX; 3Medicine, University of Texas Health Science Center Houston, Houston, TX; 4Trauma Surgery, Harborview Medical Center, Seattle, WA; 5Medicine, Queen’s University at Kingston, Kingston, ON, Canada; 6Kinesiology, University of Waterloo, Waterloo, ON, Canada.

Introduction: Metabolically trauma patients represent a unique population. Following injury there is a pronounced hypermetabolic response which can be augmented by infection. This hypermetabolic state requires increased intakes of energy and protein in the critically injured trauma patient. We proposed to determine if the increased energy and protein requirements of trauma patients were being met, and contrast them with the critically ill non-trauma patients. In addition we examined the association of energy and protein administration on outcomes. Methods: From an international data-base involving 396 ICU’s and 8838 critically ill adult patients mechanically ventilated within 48 hrs that remained in ICU for >72 hrs, we identified patients admitted with trauma as their primary diagnosis and compared their nutritional practices and clinical outcomes with those of patients admitted with other (non-trauma) diagnoses. Descriptive data are presented as mean ± SD. P-values were calculated by using mixed model adjusting for ICU and year of data collection for continuous outcomes and Rao-Scott Chi-Squared method clustering by ICU for categorical outcomes. Results: In the study population there were 900 (10.7%) patients admitted for trauma. Trauma patients were younger, predominately male, and had a greater requirement for surgery and enteral feeding than non-trauma patients (Table 1). Trauma patients had a lower BMI, with significant differences in distribution across BMI groupings (Table 1). In spite of a lower BMI trauma patients had more calories (6.3%) and protein (18.2%) prescribed (Table 2). Though more were prescribed to trauma patients they received similar amounts of calories and protein as non-trauma patients (Table 2). Thus, percent of prescribed calories and protein met were reduced in trauma patients (Table 2). Trauma patients had a higher survival rate compared to non-trauma patients (85% vs. 71%, respectively; p<0.0001), but no significant differences were noted in length of mechanical ventilation, ICU stay or hospital stay between groups. Conclu-sions: As expected trauma patients were prescribed more calories and protein than non-trauma patients, but had greater deficits in meeting calorie and protein requirements. Significant deficits were noted in both patient popula-tions, identifying an area for possible improvement. Therefore, development and implementation of guidelines in the ICU to assure compliance with dietary prescriptions could improve outcomes in both patient populations.

Demographics and Outcomes

Variable Non-Trauma Trauma P value

Age (years) 61±16.5 44±19.4 <0.0001 Percent Male (%) 58 78 <0.0001 Percent Requiring Surgery (%) 33 68 <0.0001 Percent Requiring EN Feeding (%) 70 79 <0.0001 BMI 27.4±7.9 26.9±6.4 <0.0001 BMI <18.5 (%) 5.1 2.8 <0.003 BMI 18.5 - <25(%) 39.5 41.7 0.19 BMI 25 - <30 (%) 29.0 34.7 P<0.001 BMI 30 - <35(%) 14.0 12.2 0.17 BMI ≥35 (%) 12.4 8.6 P<0.002


Author Index: Scientific Poster Presentation

Nutritional Parameters

Parameter Non-Trauma Trauma P value

Prescribed energy (kcal/kg/day) 23.8±5.7 25.3±5.2 <0.0001Prescribed protein (g/kg/day) 1.1±0.3 1.3±0.3 <0.0001Received calories (kcal/kg/day) 13.9±7.6 14.2±7.1 0.11Received protein (g/kg/day) 0.63±0.38 0.66±0.38 0.20Adequacy of calories (%) 58.7±28.3 56.4±25.9 <0.0001Adequacy of protein (%) 54.7±29.2 51.9±26.6 <0.0001

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Journal of Parenteral and Enteral Nutrition Volume 35 Number 1 … · 2016. 8. 24. · 2 Journal of Parenteral and Enteral Nutrition / Vol. 35, No. 1, January 2011 fasting of 8h (control