Compliance of energy-dense, small volume oral nutritional supplements in the daily clinical practice on a geriatric ward--an observational study.

INTRODUCTION: Compliance is important in optimizing the clinical effectiveness of oral nutritional supplements (ONS). Small volume, energy-dense ONS (ED-ONS; ≥ 2 kcal/ml) have been shown to improve compliance in clinical trial settings. However, data from clinical practice is still lacking. The aim of the present study was to evaluate the effect of ED-ONS on the compliance in an observational set-up to obtain data from daily clinical practice on a geriatric ward. METHODS: Geriatric inpatients, undernourished or at risk of undernutrition received two servings of either ED-ONS (125 ml, 2.4 kcal/ml: Nutridrink Compact Energy, Nutricia) or a standard ONS (S-ONS; 200 ml, 1.5 kcal/ml: Nutridrink) as part of their daily routine care. Patients were allocated to a group according to availability of beds and placement on the ward. Compliance (kcal/day and % of prescribed volume) was assessed by weighing returned bottles. Data were analyzed via Mixed Model for Repeated Measures. RESULTS: Forty-seven patients received ED-ONS, and 61 patients received S-ONS. Compliance was significantly higher with ED-ONS in geriatric inpatients compared to S-ONS ( 378 ± 14.0 kcal/day vs. 337 ± 13.6 kcal/day (mean ± SEM), p = 0.039, 63.0 ± 2.34% vs. 56.2 ± 2.26%, p = 0.039). Moreover, a trend (p=0.078) was observed towards an increasing difference in compliance over time. CONCLUSION: This study shows that compliance to ED-ONS is significantly better than to S-ONS in daily clinical practice. Although small, the difference in compliance seems to increase over time, suggesting clinical relevance with longer treatment.

A review on the extensive skin benefits of mineral oil.

This review was initially prepared in 2011 before Professor Johann Wiechers tragically passed away. It has been updated and is being published in his memory. It discusses the importance of mineral oil and its benefits to skin. Its source, structure, properties and efficacy are discussed. Mineral oil has been shown to improve skin softness and barrier function better than some other emollients using the gas-bearing dynamometer and standard water vapour transmission testing as well as in vivo studies showing its effects on suppressing transepidermal water loss (TEWL). It has also been subjected to the rigour of the newer in vivo confocal microscopic measurements now used for testing the performance of moisturizers by following the swelling characteristics of the stratum corneum and been found favourable compared with many vegetable oils. Its introduction as a cosmetic oil was in the late 1800s, and still today, it is used as one of the main components of moisturizers, a true testament to its cost to efficacy window. Naturally, it has physical effects on the stratum corneum, but it is expected that these will translate into biological effects simply through its mechanism of hydrating and occluding the stratum corneum from which many benefits are derived.

A review of the effects of moisturizers on the appearance of scars and striae.

Scars are well known to have a stratum corneum (SC) that is malfunctional. Increases in transepidermal water loss and decreases in SC capacitance and conductance have been reported. Occlusion therapy is a well-known route to improving the signs and symptoms of scarring. Until recently that has been assumed to be totally pressure related. However, studies have demonstrated that the direct effects of hydration on keratinocytes and fibroblasts contribute to the reduction in hypertrophic scarring. Now it is well known that occlusion can regulate epidermal cytokine and growth factor production; changes in profibrotic and anti-fibrotic factors have been established. As a result, it is to be expected that moisturizers may improve the signs and symptoms of scars. As striae have been suggested to be anatomically similar to scars and as it is well established that paracrine signalling occurs in skin, it is expected that striae have similar SC issues. While one cannot exclude the effects of some of the ingredients used in the products, several studies are reported in this review that demonstrates that moisturization is a key component to reducing the clinical signs and symptoms of scars and striae. This is a good example of how knowledge of corneobiology leads to corneotherapies for these skin condition problems. The review is being written in memory of Professor Johann Wiechers who, before he died tragically in November 2011, performed two of the reported studies together with colleagues.

A review of the effects of moisturisers on the appearance of scars and striae.

Scars are well known to have a stratum corneum that is malfunctional. Increases in transepidermal water loss and decreases in stratum corneum capacitance and conductance have been reported. Occlusion therapy is a well-known route to improving the signs and symptoms of scarring. Until recently that has been assumed to be totally pressure related. However, studies have demonstrated that the direct effects of hydration on keratinocytes and fibroblasts contribute to the reduction in hypertrophic scarring. Now it is well known that occlusion can regulate epidermal cytokine and growth factor production; changes in profibrotic and antifibrotic factors have been established. As a result it is to be expected that moisturisers may improve the signs and symptoms of scars. As striae have been suggested to be anatomically similar to scars and since it is well established that paracrine signalling occurs in skin it is expected that striae have similar stratum corneum issues. While one cannot exclude the effects of some of the ingredients used in the products, several studies are reported in this review which demonstrates that moisturisation is a key component to reducing the clinical signs and symptoms of scars and striae. This is a good example of how knowledge of corneobiology leads to corneotherapies for these skin condition problems. The paper is being written in memory of Professor Johann Wiechers who, before he died tragically in November 2011, performed two of the reported studies together with colleagues. © 2012 Society of Cosmetic Scientists and the Société Française de Cosmétologie.

Effect of intravenous iron supplementation on erythropoiesis in erythropoietin-treated premature infants.

OBJECTIVE: To test the efficacy and safety of combining intravenous iron in amounts approximating the in utero iron accretion rate and the postnatal iron loss with erythropoietin (EPO) in very low birth weight (VLBW) infants. METHODS: A prospective, controlled, randomized, unmasked trial lasting 21 days was performed in 29 clinically stable VLBW infants <31 weeks' gestation and <1300 g birth weight not treated with red blood cell transfusions during the study period. Mean (+/- standard error of the mean) age at study entry was 23 +/- 2.9 days. After a 3-day run-in baseline period in which all participants received oral supplements of 9 mg/kg/day of iron polymaltose complex (IPC), participants were randomized to receive 18 days of treatment with: 1) oral IPC alone (oral iron group); 2) 300 U of recombinant human EPO (r-HuEPO) kg/day and daily oral IPC (EPO + oral iron group); 3) 2 mg/kg/day of intravenous iron sucrose, r-HuEPO, and oral iron (intravenous iron + EPO group). To assess efficacy of the 3 treatments, serial blood samples were analyzed for hemoglobin (Hb), hematocrit (Hct), reticulocyte count, red blood cell indices and plasma levels of transferrin, transferrin receptor (TfR), ferritin, and iron. Oxidant injury was assessed before and after treatment by plasma and urine levels of malondialdehyde (MDA) and o-tyrosine. RESULTS: At the end of treatment, Hb, Hct, reticulocyte count, and plasma TfR were markedly higher in both of the EPO-treated groups, compared with the oral iron group. At study exit a trend toward increasing Hb and Hct levels and significantly higher reticulocyte counts were observed in the intravenous iron + EPO group, compared with the EPO + oral iron group. During treatment, plasma ferritin levels increased significantly in the intravenous iron + EPO group and decreased significantly in the other 2 groups. By the end of treatment, ferritin levels were significantly higher in the intravenous iron + EPO group compared with the other 2 groups. Although plasma and urine MDA or o-tyrosine did not differ among the 3 groups, plasma MDA was significantly greater in the subgroup of intravenous iron + EPO participants sampled at the end of the 2-hour parenteral iron infusion, compared with values observed immediately before and after parenteral iron-dosing. CONCLUSIONS: In stable VLBW infants receiving EPO treatment, parenteral supplementation with 2 mg/kg/day of iron sucrose results in a small, but significant, augmentation of erythropoiesis beyond that of r-HuEPO and enteral iron alone. However, to reduce the potential adverse effects of parenteral iron/kg/day on increasing plasma ferritin levels and on causing oxidative injury, we suggest that the parenteral iron dose used should be reduced and/or the time of infusion extended to maintain a serum iron concentration below the total iron-binding capacity.

Postmortem diffusion of autoradiographic blood flow tracers.

The heterogeneity of blood flow in the brain under normo- and pathophysiological conditions, as well as during functional activation, has stimulated an interest in the use of autoradiography as a technique for the measurement of local cerebral blood flow. [14C]iodoantipyrine is the most prevalent tracer for the autoradiographic measurement of local cerebral blood flow since it is inert, nonvolatile, and is readily diffusible through the blood-brain barrier. The ability to diffuse freely in cerebral tissue, however, can lead to significant errors if the time duration between when the animal is sacrificed and when the tissue is frozen becomes appreciable, leading to significant postmortem diffusion of the tracer. Using an in vitro technique, the bulk diffusion coefficient for [14C]iodoantipyrine was measured in brain tissue (2.1 x 10(-6) cm(2)/s). Cerebral blood flow was measured with [14C]iodoantipyrine in anesthetized rats. At the end of the radiotracer infusion, the brain was freeze-captured using a device consisting of two rapidly spinning stainless steel blades that were pneumatically driven through the head, freezing the tissue several hundred milliseconds following sacrifice. Autoradiograms from these brains exhibit considerable heterogeneity in blood flow. Computer simulations of the effect of tracer diffusion on these autoradiograms show significant degradation of the images highlighting the importance of very rapid postmortem freezing.

Disturbances in biotin metabolism in children undergoing long-term anticonvulsant therapy.

BACKGROUND: In subjects undergoing long-term therapy with carbamazepine and/or phenytoin, reduced plasma concentrations of biotin have been reported. However, the diagnostic value of plasma biotin is unclear, in part because of the presence of significant plasma concentrations of biotin metabolites. Pathologic organic aciduria has also been reported with long-term anticonvulsant therapy, suggesting biotin deficiency, but no mechanism leading to deficiency has yet been determined. METHODS: In the current study, we sought to determine whether biotin catabolism was accelerated in children receiving long-term treatment with certain anticonvulsants and to assess biotin status as judged by urinary excretion of biotin and 3-hydroxyisovaleric acid, an organic acid that is an indicator of deficiency of a biotin-dependent enzyme. Seven children treated with carbamazepine and/or phenytoin and six treated with phenobarbital provided untimed urine samples. Sixteen healthy children receiving no anticonvulsants served as controls. Biotin and biotin metabolites were determined by high-performance liquid chromatography/avidin-binding assay. Urinary excretion of 3-hydroxyisovaleric acid was determined using gas chromatography/mass spectrometry. RESULTS: Bisnorbiotin excretion was increased significantly in the carbamazepine/phenytoin group and in the phenobarbital group. Biotin sulfoxide excretion was significantly increased in the carbamazepine/phenytoin group but not in the phenobarbital group. 3-Hydroxyisovaleric acid excretion was increased significantly in the carbamazepine/phenytoin group. However, only one child (carbamazepine/phenytoin group) had a decreased urinary excretion of biotin. CONCLUSION: These data provide evidence that long-term administration of some anticonvulsants can accelerate biotin catabolism, but the indicators of biotin status conflict.

Erythrocyte incorporation and absorption of 58Fe in premature infants treated with erythropoietin.

We hypothesized that treatment of very low birth weight premature infants with r-HuEPO would increase erythrocyte incorporation and gastrointestinal absorption of iron. Infants with birth weights < or = 1.25 kg and gestational ages < 31 wk were randomized to receive 6 wk of 500 U of r-HuEPO/kg/wk (epo group, n = 7) or placebo (placebo group, n = 7). All infants received daily enteral supplementation with 6 mg of elemental iron per kg. An enteral test dose of a stable iron isotope, 58Fe, was administered after the 1st ("early dosing") and 4th ("late dosing") wk of treatment. Mean (+/-SD) erythrocyte incorporation of the dose of 58Fe administered determined 2 wk after early dosing was significantly greater in the epo group compared with the placebo group (4.4% +/- 1.6 versus 2.0 +/- 1.4%, p = 0.013). In contrast, after late 58Fe dosing, there was no difference between groups in incorporation (3.8 +/- 1.6% versus 5.5 +/- 2.7%). Within the epo group, percentage erythrocyte incorporation of 58Fe did not differ between early and late dosing, whereas in the placebo group it increased 3-fold (p < 0.01). Percentage absorption of 58Fe was not different between the epo and placebo groups after both early dosing (30 +/- 22% versus 34 +/- 8%) and late dosing (32 +/- 9% versus 31 +/- 6%). Absorption of nonlabeled elemental iron and 58Fe were significantly correlated with one another. The percentage of the absorbed 58Fe dose incorporated into Hb was not different between groups. We conclude that, although erythropoietin treatment stimulates erythrocyte iron incorporation in premature infants, it has no effect on iron absorption at the r-HuEPO dose studied.

Renal adaptation to dietary carnitine in humans.

Carnitine homeostasis in humans is maintained by dietary carnitine intake, a modest rate of endogenous carnitine synthesis, and efficient conservation of carnitine by the kidney. To assess the effect of dietary carnitine on the efficiency of carnitine reabsorption in humans, rates of carnitine excretion and reabsorption, indexed to the glomerular filtration rate, were determined over a range of plasma free and total carnitine concentrations in 12 strict vegetarians before and after dietary carnitine supplementation (0.248 mmol/d). This amount of dietary carnitine supplementation did not significantly increase plasma carnitine concentration and did not alter the glomerular filtration rate. At normal physiological plasma carnitine concentrations, the rate of carnitine excretion was increased and the rate of carnitine reabsorption was decreased by carnitine supplementation. We conclude that the kidney adapts to carnitine intake by reducing the efficiency of carnitine reabsorption.

Nutritional management of infants with bronchopulmonary dysplasia.

The nutritional needs of the child with bronchopulmonary dysplasia (BPD) vary significantly from those of a healthy child. To address the many special aspects of the nutritional care of the child with BPD, a nutrition management protocol was established at the University of Iowa Hospitals and Clinics. This protocol discusses caloric requirements; selection of enteral feedings; electrolyte, vitamin, and mineral supplements; growth, oral feeding advancement, and monitoring of nutritional status. Although many of the guidelines are supported by research, some are based on clinical practice. Many questions remain to be answered about the optimal nutrition therapy for these infants. One goal of this protocol is to stimulate discussion and research that will lead to a better understanding of the nutritional requirements of the BPD population.

Effect of hylan on cartilage and chondrocyte cultures.

The protective role of hylan, a hyaluronan [hyaluronic acid (HA)] derivative, was studied in explanted bovine cartilage and isolated chondrocytes. Cartilage and chondrocytes were exposed to degradative enzymes (lysate from activated polymorphonuclear leukocytes), oxygen-derived free radicals (ODFR), conditioned media from mononuclear cells (MCCM), and interleukin-1 (IL-1), in the presence and absence of hylan. The effect of HA was also studied. In cartilage explants susceptibility to pertubation was evaluated in terms of 35S release and proteoglycan depletion and was compared to control cultures; high viscosity hylan was found to reduce 35S release in cartilage explants caused by degradative enzymes, ODFR, MCCM, and IL-1. The hylan effect was reversible and viscosity-dependent. In chondrocyte cultures, high viscosity hylan was effective in reducing cell injury caused by degradative enzymes and ODFR. The data suggest that the glycosaminoglycan hylan, as well as native HA, may mediate exposure to and/or response to stimuli associated with initiation of degenerative processes in cartilage tissues.

Effect of a lactase preparation on lactose content and osmolality of preterm and term infant formulas.

Lactose intolerance due to lactase deficiency often follows acute gastroenteritis. In such situations, a lactose-free formula may be indicated for preterm infants. Therefore, the effect of addition of lactase on the lactose content and osmolality of preterm and term infant formulas was studied. Lactose content of formulas at room temperature was decreased by approximately 50% 1 hour after addition of lactase. Concentration of lactose was reduced by 70% or more after 2 hours in all formulas. Because of the higher initial lactose concentration in term formulas, it took 24 hours to reach the same absolute lactose concentration (10 g/kg formula) found in preterm formulas after 2 hours. There was a moderate increase in osmolality in preterm formulas. The increase was greater in term formulas because of the greater initial concentration of lactose. The addition of lactase appears to be a suitable method for reduction of lactose content of preterm and term formulas, although the increase in osmolality of term formulas may preclude their clinical use.

Biotin nutritional status of vegans, lactoovovegetarians, and nonvegetarians.

Urinary excretion of biotin (total avidin-binding substances) was measured in adults and children who were adhering to one of the following self-selected diets: strict vegetarian (vegan), lactoovovegetarian, or mixed (containing meat and dairy products as well as plant-derived foods). In a subset of subjects, plasma biotin concentrations were also measured. In adults the biotin excretion rate was significantly greater in the vegan group than in either the lactoovovegetarian or the mixed-diet groups; the latter were not significantly different from one another. In children the biotin excretion rates in both the vegan group and the lactoovovegetarin group were significantly greater than in the mixed-diet group. A similar trend (vegan greater than lactoovovegetarian greater than mixed) was detected in the plasma concentrations of biotin of adults and children but differences were not generally statistically significant. These observations provide evidence that the biotin nutritional status of vegans is not impaired.

Carnitine status of lactoovovegetarians and strict vegetarian adults and children.

Because carnitine is contained primarily in meats and dairy products, vegetarian diets provide a model for assessing the impact of prolonged low carnitine intake on carnitine status. Plasma carnitine concentrations and urinary carnitine excretion were measured in adults and children consuming a strict vegetarian, lactoovovegetarian, or mixed diet. In adults plasma carnitine concentration and urinary carnitine excretion of strict vegetarians and lactoovovegetarians were significantly lower than those in the mixed-diet group but were not different from each other. In children significant differences were found between all three diet groups for both plasma carnitine concentration and urinary carnitine excretion. The differences in plasma carnitine concentrations were greater in children than in adults, possibly reflecting the effects of growth and tissue deposition. Small differences between diet groups in adults do not suggest a nutritionally significant difference in carnitine status. Whether vegetarian children are at greater risk for overt deficiency is not answered.

Ileal stricture as a late complication of Henoch-Schonlein purpura.

Although Henoch-Schonlein purpura is known for its acute vasculitic manifestations, chronic residual problems, other than nephritis, are uncommon. A case report of late ileal stricture following Henoch-Schonlein purpura is presented, noting associated findings suggestive of a primary enteropathy which delayed timely surgical management.