Increasing plasma glutamine in postoperative patients fed an arginine-rich immune-enhancing diet--a pharmacokinetic randomized controlled study.

OBJECTIVE: Immune-enhancing diets (IEDs) rich in arginine (ARG) reduce morbi-mortality in trauma and surgical patients. Among the pharmaconutrients inducing these effects, ARG may be involved by generating active metabolites such as glutamine (GLN). However, the ability of an ARG-enriched diet to normalize GLN plasma levels in intensive care unit (ICU) patients has never been documented. To analyze plasma GLN and related amino acid (AA) kinetics in response to an ARG-enriched IED in ICU surgical patients. DESIGN: This prospective, randomized, single-blind, comparative study was performed on 22 patients randomized to receive total enteral nutrition for 7 days with either an ARG-enriched IED or a standard formula (rendered isonitrogenous to the IED, S group, n = 11), providing 30 kcal/kg/day and 0.3 g N/kg/day. MEASUREMENTS: Plasma AA concentrations were measured on day 5 after a 3-hour washout period (basal values = T0) and after 30, 60, 90, 120, 180, and 360 minutes of enteral nutrition. The primary end point was the variation in plasma GLN from T0 to T90. RESULTS: Only the IED-fed patients showed an increase in plasma levels of GLN (differences [T90 - T0]: +40 +/- 6 vs. -35 +/- 18 micromol/L, mean +/- sem, p < 0.05, two-way analysis of variance), ARG (+35 +/- 5 vs.+1 +/- 4 micromol/L, p < 0.05), ornithine (+23 +/- 6 vs. -2 +/- 2 micromol/L, p < 0.05), and proline (+36 +/- 10 vs. -6 +/- 11 micromol/L, p < 0.05). CONCLUSION: To our knowledge, this is the first reported pharmacokinetic study on an IED even though these products have been on the market for 20 years. Our main result is that administering an ARG-enriched IED causes a significant increase in plasma GLN probably from de novo GLN synthesis from ARG. This suggests that the ARG present in IED can serve to supply GLN to ICU patients, who are usually depleted in this conditionally essential AA during injury.

[Standards, Options and Recommendations 2005 for a good practice in enteral nutrition in oncology (summary report.)]. / Recommandations pour la pratique clinique: Standards, Options et Recommandations 2005. Bonnes pratiques pour la prise en charge diététique en cancérologie: la nutrition entérale (rapport abrégé). Validation du rapport original: avril 2005.

CONTEXT: The "Standards, Options and Recommendations" (SOR) project, which started in 1993, is a collaboration between the French Federation of Cancer Centers (FNCLCC), the 20 French Regional Cancer Centers, and specialists from French public universities, general hospitals and private clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and the outcome of cancer patients. OBJECTIVE: To develop good practice guidelines for a good practice of enteral nutrition in oncology, in collaboration with three French learned societies involved in this area. METHOD: The methodology is based on a literature review and critical appraisal by a multidisciplinary group of experts who define the CPGs according to the definitions of the Standards, Options and Recommendations project. Once the guideline has been defined, the document is submitted for review by independent reviewers. RESULTS: The good practices suggested in the document approach seven topics: indications and counter-indications, conditions of the installation of the enteral nutrition, monitoring, prevention of complications, education of the patient, specificities of enteral nutrition in children and at home. In the setting of enteral nutrition, feeding tubes, type of insertion, enteral nutrition products, material and techniques of administration are described as well as the criteria permitting their selection.

Semi-elemental formula or polymeric formula: is there a better choice for enteral nutrition in acute pancreatitis? Randomized comparative study.

BACKGROUND: Jejunal nutrition is recommended during acute pancreatitis. The use of semi-elemental formulas presents several theoretical advantages over polymeric formulas, but their clinical value has been poorly documented. Our aim was to evaluate in patients with acute pancreatitis the effect of enteral nutrition by a semi-elemental formula compared with a polymeric formula. METHODS: A randomized prospective pilot study, stratified according to severity, was performed in 30 consecutive patients with acute pancreatitis requiring jejunal nutrition. The semi-elemental group received 35 kcal/kg/d of Peptamen (n = 15), and the polymeric group received the same quantity of Sondalis-Iso (n = 15). Tolerance was evaluated after 7 days of enteral nutrition (D7) on visual analog scale (VAS), stool frequency, and 24-hour steatorrhea/creatorrhea. Outcome was evaluated by weight loss, length of hospital stay, and infection rate. RESULTS: Results were calculated as mean +/- SEM, t-test, or chi2. Patients of the 2 groups were comparable in terms of age, gender, and severity. Tolerance was good in both groups (semi-elemental vs polymeric: VAS, 7.4 +/- 0.6 vs 7.1 +/- 0.6, not significant (NS); number of stools per 24 hours, 1.7 +/- 0.4 vs 1.8 +/- 0.4, NS). Steatorrhea and creatorrhea were lower than normal in both groups. In semi-elemental group, the length of hospital stay was shorter (23 +/- 2 vs 27 +/- 1, p = .006) and weight loss was less marked (1 +/- 1 vs 2 +/- 0, p = .01). One patient in semi-elemental group and 3 patients in polymeric group developed an infection (NS). CONCLUSIONS: Semi-elemental and polymeric nutrition are very well tolerated in patients with acute pancreatitis. Nutrition with a semi-elemental formula supports the hypothesis of a more favorable clinical course than nutrition with a polymeric formula, but this conclusion needs to be established in larger adequately powered clinical trials.

Colonic Crohn's disease in children does not respond well to treatment with enteral nutrition if the ileum is not involved.

Data supporting a response to treatment with exclusive enteral nutrition in pediatric colonic Crohn's disease are few. We examined clinical and biochemical responses of ileal, colonic, and ileocolonic Crohn's disease and assessed the endoscopic and histological colonic mucosal response in the colonic and ileocolonic groups. We prospectively enrolled 65 children (age: 8-17 years) with acute intestinal Crohn's disease (Pediatric Crohn's Disease Activity Index [PCDAI] >20). After ileocolonoscopy, gastroscopy, and a barium meal and follow-through, they were distributed into three groups (ileal, n = 12, ileocolonic, n = 39; and colonic, n = 14). All patients received exclusive polymeric feed as treatment, with a repeat endoscopy at completion of treatment. At enrollment the ileal group had significantly less severe disease (P = 0.05) compared to the colonic and ileocolonic groups. However, the colonic disease group showed the least fall in PCDAI scores at completion of treatment with enteral nutrition (P = 0.03), with the lowest remission rate (50%, vs 82.1% in the ileocolonic and 91.7% in the ileal group [chi2 test, P = 0.021]). Endoscopic and histologic colonic mucosal assessment showed a post-treatment improvement in the ileocolonic (P < or = 0.01) but not in the colonic disease group (P = ns). Children with disease in the colon respond better to enteral nutrition if the ileum is also involved. This may be due to different underlying inflammatory mechanisms. Detailed pretreatment assessment in studies of Crohn's disease according to disease distribution with appropriate individualized tailoring of treatment may be important in this regard.

Ornithine alpha-ketoglutarate metabolism in the healthy rat in the postabsorptive state.

To gain further insight into the ability of ornithine alpha-ketoglutarate (OKG) to generate key metabolites, the aim of this work was to study the short-term metabolism, that is, 1 hour after administration, of OKG in plasma and tissues. Particular attention was paid to keto acids (alpha-ketoglutarate and branched-chain keto acids). Young (3 weeks old) male Wistar rats in the postabsorptive state received either 1.5 g/kg of monohydrated OKG (OKG group, n = 8) diluted in distilled water or an equivalent volume of saline solution at 0.9% (control group, n = 8) by gavage and were killed 1 hour later. Plasma, liver, jejunal and ileal mucosa, and the extensor digitorum longus muscle were removed to analyze amino and keto acid contents. Major metabolites detected after OKG ingestion (ornithine [ORN], alpha-ketoglutarate, proline and glutamate; OKG vs control, P < .05) and the absence of increased arginine (and even a decrease in jejunum and muscle) and citrulline levels suggested that ORN was mainly metabolized by the ORN aminotransferase pathway. In addition, significantly decreased plasma branched-chain keto acids and increased hepatic branched-chain amino acids (OKG vs control, P < .05) were observed upon OKG ingestion. Finally, glutamine accumulation restricted to the intestine, as evidenced in this short-term study, suggests that the effects of OKG on glutamine pools in other tissues in various pathological states after several days of treatment, as observed in previous studies, may be related to a long-term induction of glutamine synthetase.

Improvement of weight and fat-free mass with oral nutritional supplementation in patients with Alzheimer's disease at risk of malnutrition: a prospective randomized study.

OBJECTIVES: To study the effects of oral nutritional supplements (OS) on body weight, body composition, nutritional status, and cognition in elderly patients with Alzheimer's disease (AD). DESIGN: Prospective, randomized, controlled study. SETTING: Geriatric wards and day care centers in the Toulouse area, France. PARTICIPANTS: Ninety-one subjects with AD aged 65 and older at risk of undernutrition as evaluated using the Mini Nutritional Assessment. INTERVENTION: After randomization, 46 patients (intervention group) received 3-month OS. The other 45 patients (control group) received usual care. MEASUREMENTS: Weight, body composition (evaluated using dual-energy x-ray absorptiometry), cognitive function, activities of daily living, eating behavior, and dietary intakes were evaluated at the beginning of the study and at 3 months and 6 months. Supplement compliance was recorded each day. RESULTS: Between baseline and 3 months, energy and protein intakes significantly improved in the intervention group, resulting in a significant increase in weight and fat-free mass, but no significant changes were found for dependence, cognitive function, or biological markers. The nutritional benefit was maintained in the intervention group after discontinuation of OS at 3 months. CONCLUSION: Three-month daily OS significantly improves body weight. It is practicable and effective, and the patients accepted it well. The improvement that was observed even in the control group showed that caregiver education is an important factor in maintaining the nutritional status of patients with AD. Moreover, regular courses of OS may help to maintain the increase in fat-free mass and improve the nutritional status of these patients.

Prevention of malnutrition in older people during and after hospitalisation: results from a randomised controlled clinical trial.

OBJECTIVE: to prevent the occurrence of weight loss during hospitalisation and following discharge by daily oral supplementation. DESIGN: in a prospective, randomised, controlled study of 80 patients aged 75 or more, and at risk of undernutrition based on their initial Mini Nutritional Assessment score, patients were randomised into a control group or one receiving oral supplementation. The intervention was a prescription of 200 ml sweet or salty sip feed twice daily (500 kcal, 21 g protein per day) throughout hospitalisation and convalescence. Nutritional status was assessed at baseline and after 2 months using Mini Nutritional Assessment and body weight record. RESULTS: compliance with oral supplementation was good and daily extra energy intake was 407+/-184 kcal. On day 60, significant weight loss from upon admission was observed in the control group (-1.23+/-2.5 kg; P=0.01), but not in the supplemented group (0.28+/-3.8 kg; NS). At the end of the study, Mini Nutritional Assessment scores were higher in the supplemented group than in the control group (23.5+/-3.9 versus 20.8+/-3.6; P<0.01). CONCLUSION: use of daily oral supplementation during and after hospitalisation maintains body weight and increases Mini Nutritional Assessment score in patients at risk of undernutrition.