Prevention of recurrent hepatitis B virus infection after liver transplantation: hepatitis B immunoglobulin, antiviral drugs, or both? Systematic review and meta-analysis.

OBJECTIVES: To evaluate antiviral prophylaxis against hepatitis B virus (HBV) following liver transplantation. METHODS: Systematic review and meta-analysis. Clinical trials and comparative cohort studies comparing the use of hepatitis B immunoglobulin (HBIg), antivirals, or both following liver transplantation for HBV infection were included. The primary outcome was reappearance of hepatitis B surface antigen (HBsAg). Other outcomes included all-cause and HBV-related mortality, HB-related active liver disease, and reappearance of HBV DNA after transplantation. Relative risks (RR) with 95% confidence intervals (CIs) are reported. RESULTS: Twenty studies (22 comparisons) were included. Ten studies compared HBIg to combination treatment, 9 compared antivirals to combination treatment, and 3 compared lamivudine (LAM) to HBIg. Combination treatment reduced HBsAg reappearance (RR 0.28; 95% CI 0.12-0.66), and was superior to HBIg alone in all other outcome measures. Combination treatment was significantly better than antivirals in preventing reappearance of HBsAg (RR 0.31; 95% CI 0.22-0.44), even when low-dose HBIg was given. No significant difference was found between HBIg and LAM monotherapy for all measured outcomes. Major limitations with regard to comparability of the study groups in non-randomized trials were revealed. CONCLUSIONS: Combination treatment with HBIg and LAM reduced HBV recurrence following liver transplantation, compared with HBIg or LAM alone, and reduced mortality compared with HBIg alone.

Visual acuity and blood lipids in term infants fed human milk or formulae.

This multicenter, parallel group study determined plasma phospholipid and red blood cell (RBC) phosphatidylcholine and phosphatidylethanolamine fatty acids, plasma cholesterol, apo A-1 and B, growth and visual acuity (using the acuity card procedure) in term infants fed from birth to 90 d of age with formula containing palm-olein, high oleic sunflower, coconut and soy oil (22.2% 16:0, 36.2% 18:1, 18% 18:2n-6, 1.9% 18:3n-3) (n = 59) or coconut and soy oil (10.3% 16:0 18:6% 18:1, 34.2% 18:2n-6, 4.7% 18:3n-3) (n = 57) or breast-fed (n = 56) with no formula supplementation. Different centers in North America were included to overcome potential bias due to differences in n-6 or n-3 fatty acids at birth or in breast-fed infants that might occur in a single-site study. Plasma and RBC phospholipid docosahexaenoic acid (DHA, 22:6n-3) and arachidonic acid (AA, 20:4n-6), cholesterol and apo B were significantly lower in the formula- than breast-fed infants. There were no differences in looking acuity or growth among the breast-fed and formula-fed infants. No significant relations were found between DHA and looking acuity, or AA and growth within or among any of the infant groups. This study provides no evidence to suggest the formula provided inadequate n-6 or n-3 fatty acids for growth and looking acuity for the first 3 mon after birth.

Effect of age on the intestinal absorption of vitamin D3-palmitate and nonesterified vitamin D2 in the term human infant.

This study was undertaken to investigate the utility of vitamin D3-palmitate as a nutritional supplement and thus define the intestinal absorption profile of vitamin D2 and vitamin D3 liberated after its cleavage from vitamin D3-palmitate in the human infant at various postnatal ages. The subjects for study consisted of 48 normal infants that were simultaneously administered 0.07 and 0.08 micromol/kg BW vitamin D as vitamin D3-palmitate and nonesterified vitamin D2 respectively, by orogastric tube. Blood samples were obtained before and 6, 12, and 24 h postadministration and analyzed simultaneously for vitamins D2 and D3. For data analysis, the infants were divided into two groups based on postnatal age: group 1, 1 day of age; and group 2, more than 10 days of age. Data were analyzed using the integrated peak area under the absorption curve for each subject. All subjects demonstrated the ability to absorb vitamin D after oral administration, although postnatal age as well as vitamin form had a profound effect on the absorption of vitamin D2 and vitamin D3 liberated from vitamin D3-palmitate. Nonesterified vitamin D2 is well absorbed both in very young and older infants, although absorption efficiency increases with age, perhaps due to increased bile acid secretion. Liberation of vitamin D3 from vitamin D3-palmitate was shown to increase, perhaps due to gastrointestinal tract maturation, beyond 10 days of age, probably coinciding with the secretion of intestinal esterases. Our data indicate that both forms of the orally administered vitamin approach equivalency in their abilities to elevate circulating vitamin D levels in the human infant at a postnatal age of approximately 89 days. Thus, vitamin D3-palmitate would appear not to be dietarily equivalent to free vitamin D as a nutritional source of vitamin D in the human neonate.

The importance of dietary protein in healing pressure ulcers.

OBJECTIVE: To determine the effect of dietary protein on healing of pressure ulcers in malnourished patients. DESIGN: Nutritional intervention trial with the non-randomized assignment of patients by pressure ulcer stage and bed type. SETTING: Long-term care facility. PATIENTS: Twenty-eight malnourished patients (age = 72 +/- 18 years, mean +/- SD) with a total of 33 truncal pressure ulcers. Nine patients had stage II ulcers, eight had stage III ulcers, and 16 had stage IV ulcers. METHODS: Patients received liquid nutritional formulas as tubefeedings or meal supplements containing either 24% protein (61 g protein/L; n = 15) or 14% protein (37 g protein/L; n = 13) for 8 weeks. RESULTS: There was a significant decrease in total truncal pressure ulcer surface area of the 15 patients in the 24% protein group (-4.2 +/- 7.1 cm2, P < 0.02), but not in the 13 patients in the 14% protein group (-2.1 +/- 11.5 cm2, P = NS). The change in total ulcer area correlated with both dietary protein intake per kg body weight (rs = -0.50, P < 0.01) and caloric intake per kg body weight (rs = -0.41, P < 0.03). The decrease in stage IV ulcer area in eight patients in the 24% protein group (-7.6 +/- 5.8 cm2, P < 0.02) was significantly greater (P < 0.05) than in eight patients in the 14% protein group (-3.2 +/- 16.4, P = NS). In these 16 patients, the decrease in ulcer size also correlated with dietary protein intake per kg body weight (rs = -0.63, P < 0.01). CONCLUSION: High protein diets may improve the healing of pressure ulcers in malnourished nursing home patients.

Modulation of infant formula fat profile alters the low-density lipoprotein/high-density lipoprotein ratio and plasma fatty acid distribution relative to those with breast-feeding.

The effect of breast-feeding was compared with that of two fat-modified milk formulas in 45 infants (15 per group) studied by assessing body weight gain for 4 months and plasma lipids, lipoprotein profiles, fatty acid profiles of plasma and red blood cells, and plasma tocopherol status 3 months after birth. A saturated fat formula with coconut oil/soybean oil (COCO/SOY) had a fatty acid content and polyunsaturated/saturated ratio (P/S, 0.55) comparable with that of human milk fat (P/S, 0.39) and had the same fat energy content (50% kcal). The second formula, with corn oil/soybean oil (CORN/SOY), was highly unsaturated (P/S, 4.6), with only 35% kcal from fat. Energy intake and body weight gain were similar for all groups. Plasma total cholesterol, triglyceride, and phospholipid levels were significantly lower (greater than 20% on average) in infants fed the CORN/SOY formula than in infants fed either the COCO/SOY formula or human milk. Infants fed the CORN/SOY formula also had lower (25% to 35%) plasma low-density lipoprotein cholesterol and apolipoprotein B levels and low-density lipoprotein/high-density lipoprotein and apolipoprotein B/apolipoprotein A-I ratios. Plasma, red blood cell, and cholesteryl ester fatty acids from infants fed COCO/SOY contained less 18:1 and more 18:2; cholesterol esters in plasma from breast-fed infants had the highest 20:4n-6 levels. Plasma tocopherol levels were higher in infants consuming formulas. The presence of cholesterol in human milk appeared to expand the low-density lipoprotein pool and exert an "unfavorable" increase in the low-density lipoprotein/high-density lipoprotein ratio. Thus modulation of infant lipoproteins by changing dietary fat and cholesterol is feasible and in keeping with the known response in adults.

Iron absorption from infant foods.

To determine the bioavailability of iron from iron-fortified infant foods, we have determined erythrocyte incorporation of the stable isotope, 58Fe, after feeding the following foods extrinsically labeled with 58Fe: 1) rice cereal with apples and bananas ("cereal-fruit product"), 2) Mead Johnson Enriched Baby Food (MJEBF), a vitamin, mineral, and protein-enriched rice cereal, 3) vegetables and beef ("vegetable-beef product"), 4) grape-juice, and 5) MJEBF. Foods 1-4 were fortified with ferrous sulfate, and food 5 was fortified with ferrous fumarate. Blood was obtained at ages 140, 168, and 196 d of age, and the test meal was fed under standardized conditions at 154 d of age. Erythrocyte incorporation of the 58Fe label was determined from the increase in the mass isotope ratio, 58Fe/57Fe, from the baseline value (at 140 d of age) to the follow-up values. The mass isotope ratio was determined by inductively coupled mass spectrometry. Geometric mean total iron incorporation into erythrocytes from the test meal of MJEBF fortified with ferrous sulfate (food 2) was 0.05 mg, and from the vegetable-beef product test meal (food 3) was 0.08 mg. The low value for MJEBF is presumably explained by the low level of iron fortification. The low value for the vegetable-beef product may reflect the presence of inhibitors of iron absorption. Geometric mean erythrocyte incorporations of iron from the test meals with foods 1, 4 and 5 were 0.15, 0.14, and 0.18 mg, respectively. These erythrocyte incorporation values are 20 to 26% of the estimated 0.7 mg requirement for absorbed iron, and therefore seem nutritionally important.

The effect of the hydrolytic state of dietary protein on post-irradiation morbidity and mucosal cell regeneration.

Diets containing hydrolyzed casein have been observed to enhance post-irradiation intestinal mucosal recovery. The intake and the composition of such diets were not carefully controlled. This study attempted to do so. Male specific pathogen-free Sprague-Dawley rats were randomized to receive either an enzymatically hydrolyzed casein semi-purified diet (EHC), a whole casein semi-purified diet (WC), or powdered lab chow (C). All diets were isonitrogenous, and the WC and C rats were pair-fed to the ad libitum fed EHC rats. Seven days after initiation of feeding, the rats were abdominally irradiated with a single 9.0 Gy dose of 137Cs gamma rays. The rats were continued on the diets for another 5 days. Intestinal mucosa from transverse segments at the duodenum, jejunum, proximal ileum, and distal ileum were measured for incorporation of (3H methyl) Thymidine 1 hour after interperitoneal injection. Incorporation reached a maximum by day 4 post-irradiation regardless of diet or segment. Incorporation in the duodenum was enhanced by the EHC diet compared to the C diet, while the incorporation in the jejunum was initially suppressed by the EHC diet compared to the WC diet. In the jejunum, the number of mitoses per crypt of 25 anti-mesenteric crypts post-irradiation was increased by the EHC diet. Prior to irradiation, all groups gained similar amounts of weight. After irradiation, the C rats lost weight, while the EHC and WC rats remained the same or gained weight. Guaiac tests for occult blood were negative prior to irradiation, but positive for all rats on days 1-5 postirradiation. When calorie and protein intakes were controlled, different areas of the small intestine responded differently to EHC.

Effect of diets high in carbohydrate, soy oil, medium-chain triglycerides or tripelargonin on blood and liver lipid and glucose intermediates in meal-eating rats.

Medium-chain odd carbon fats have been reported to be ketogenic as have medium-chain triglycerides (MCT). Such an odd carbon fat, tripelargonin, was compared to MCT for its effect on ketogenic and glucogenic intermediates when fed as a part of a complete diet to meal-eating rats. Isonitrogenous diets containing, as 68% of the calories, soy oil (SO), MCT, tripelargonin (C9TG) were fed 2 hours twice a day. After 4 weeks, the C9TG rats during meals had blood and liver beta-hydroxybutyrate levels approximately 300 and 125%, respectively, of the fasting levels and similar to the prandial SO-fed levels. These levels were significantly less than the 1,000 and 500% elevations observed in the MCT-fed rats. Prandial blood glucose and liver glycogen levels were similar in the C9TG and SO-fed rats; whereas, these intermediates appeared to remain at or drop below the fasting levels in the MCT-fed animals. Levels of plasma non-esterified fatty acids and liver glucose-6-phosphate in the MCT and C9TG were similar and different from the SO-fed values. The results point to the uniqueness of C9TG when compared to even-numbered triglycerides under these dietary conditions.