A randomized clinical trial of ciprofloxacin and metronidazole to treat acute pouchitis.

Metronidazole is effective for the treatment of acute pouchitis after ileal pouch-anal anastomosis, but it has not been directly compared with other antibiotics. This randomized clinical trial was designed to compare the effectiveness and side effects of ciprofloxacin and metronidazole for treating acute pouchitis. Acute pouchitis was defined as a score of 7 or higher on the 18-point Pouchitis Disease Activity Index (PDAI) and symptom duration of 4 weeks or less. Sixteen patients were randomized to a 2-week course of ciprofloxacin 1,000 mg/d (n = 7) or metronidazole 20 mg/kg/d (n = 9). Clinical symptoms, endoscopic findings, and histologic features were assessed before and after therapy. Both ciprofloxacin and metronidazole produced a significant reduction in the total PDAI score as well as in the symptom, endoscopy, and histology subscores. Ciprofloxacin lowered the PDAI score from 10.1+/-2.3 to 3.3+/-1.7 (p = 0.0001), whereas metronidazole reduced the PDAI score from 9.7+/-2.3 to 5.8+/-1.7 (p = 0.0002). There was a significantly greater reduction in the ciprofloxacin group than in the metronidazole group in terms of the total PDAI (6.9+/-1.2 versus 3.8+/-1.7; p = 0.002), symptom score (2.4+/-0.9 versus 1.3+/-0.9; p = 0.03), and endoscopic score (3.6+/-1.3 versus 1.9+/-1.5; p = 0.03). None of patients in the ciprofloxacin group experienced adverse effects, whereas three patients in the metronidazole group (33%) developed vomiting, dysgeusia, or transient peripheral neuropathy. Both ciprofloxacin and metronidazole are effective in treating acute pouchitis with significant reduction of the PDAI scores. Ciprofloxacin produces a greater reduction in the PDAI and a greater improvement in symptom and endoscopy scores, and is better tolerated than metronidazole. Ciprofloxacin should be considered as one of the first-line therapies for acute pouchitis.

Recent developments in home total parenteral nutrition.

Home parenteral nutrition (HPN) support has been an advancing therapy in the past 30 years. Patients who previously had no options to sustain their lives are now able to live at home, maintain employment, and continue with most daily activities. Although this therapy has been innovative and successful, it requires great financial and professional resources. The expense of HPN makes most patients dependent on third-party payment, and the complications can result in frequent hospitalizations and may be life-threatening. For these reasons, extensive training of the patient and caregivers is necessary. Thorough and time-consuming monitoring by a multidisciplinary team of professionals is also essential. Home care and supply companies offer services that make the process of home TPN easier for the patient and the healthcare team. Advances in the area of home nutrition support are expected to continue as the demand for this therapy rises.

Foscarnet-induced electrolyte abnormalities in a bone marrow transplant patient receiving parenteral nutrition.

Cytomegalovirus (CMV) is a serious complication of immunosuppressed patients receiving bone marrow transplantation. Foscarnet, a pyrophosphate analog, has been used in the treatment of CMV infections. Renal impairment and electrolyte abnormalities are potential adverse reactions associated with the use of foscarnet. We report a case of significant electrolyte changes after initiation of foscarnet in a bone marrow transplant patient receiving parenteral nutrition.

Tunneled right atrial catheter infection presenting as renal failure.

We report two cases of progressive renal failure secondary to membranoproliferative glomerulonephritis associated with subclinical septicemia from a tunneled right atrial catheter used for home parenteral nutrition administration. Although the occurrence of line infection and septicemia is a common complication of central venous catheters, a review of the literature reveals only one case report of renal failure secondary to an infected implanted central venous device. Both patients presented with azotemia and had biopsy-proven membranoproliferative glomerulonephritis, accompanied by leukocytoclastic vasculitis. In both cases, removal of the right atrial catheter and prolonged antibiotic therapy was effective in resolving the ongoing infection and resulted in marked improvement in renal function. A high index of suspicion for catheter sepsis should be maintained in patients with tunneled right atrial catheters presenting with subacute renal failure.

Nutrition in the elderly.

The elderly represent the fastest growing segment of the American population. Nutrition has a significant influence on the development and progression of certain diseases. This article reviews the pathophysiology of aging and its effect on nutritional status and the incidence, pathogenesis, and impact of malnutrition in the elderly. The authors provide nutritional recommendations in health and disease.

Nutritional management of patients with feeding-induced pain: acute pancreatitis.

A 36-year-old women with severe acute pancreatitis induced by familial hyperlipidemia is presented. Ranson's score, APACHE-II score, assessment of organ function, and a computed tomography scan are used to diagnose the severity of pancreatitis. Withholding oral alimentation, parenteral analgesia, fluid resuscitation, and antibiotics all serve important roles in management of this disease. Protein-calorie malnutrition can easily develop as a result of no oral intake and hypercatabolism. Tube feeding into the jejunum using a partially hydrolyzed formula has been reported in modest to severe pancreatitis. If tube feeding is not tolerated or a feeding tube cannot be properly positioned, parenteral nutrition may be necessary to maintain bowel rest. Parenteral nutrition administered to patients with pancreatitis is associated with catheter-related infection, hyperglycemia, and hypertriglyceridemia. These complications can be managed through careful design of parenteral solutions and close monitoring.

The effect of folic acid supplementation on the risk for cancer or dysplasia in ulcerative colitis.

BACKGROUND & AIMS: Two case-control studies have shown that folate may protect against neoplasia in ulcerative colitis. This historical cohort study was performed to better define this association. METHODS: The records of 98 patients with ulcerative colitis who had disease proximal to the splenic flexure for at least 8 years were reviewed. Documented folate use of at least 6 months was deemed a positive exposure. RESULTS: Of the patients, 29.6% developed neoplasia and 40.2% took folate supplements. The adjusted relative risk (RR) of neoplasia for patients taking folate was 0.72 (95% confidence interval [CI], 0.28-1.83). The dose of folate varied with the risk of neoplasia (RR, 0.54 for 1.0 mg folate; RR, 0.76 for 0.4 mg folate in a multivitamin compared with patients taking no folate). Folate use also varied with the degree of dysplasia (RR for cancer, 0.45; RR for high-grade dysplasia, 0.52; RR for low-grade dysplasia, 0.75 compared with patients with no dysplasia) (P = 0.08). CONCLUSIONS: Although not statistically significant, the RR for folate supplementation on the risk of neoplasia is < 1 and shows a dose-response effect, consistent with previous studies. Daily folate supplementation may protect against the development of neoplasia in ulcerative colitis.

Use of old and new oral 5-aminosalicylic acid formulations in inflammatory bowel disease.

Although sulfasalazine, a 5-aminosalicylic acid (5-ASA) agent, is still the anti-inflammatory agent of choice for ulcerative colitis and Crohn's disease, newer formulations, which release drug to specific regions of the colon for maximal efficacy, also can be appropriate first-line agents. This article reviews recent clinical studies of therapy with older and newer 5-ASA formulations.

Lymphatic absorption of enterally fed structured triacylglycerol vs physical mix in a canine model.

The lymphatic absorption of a structured triacylglycerol vs an equivalent physical mixture of the constituent medium-chain triacylglycerol and fish oils was studied. Each of four canines served as its own control in a crossover feeding design with the investigators unaware of diet contents. Lymphatic absorption of n-3 and medium-chain fatty acids peaked within 4-8 h of feeding either diet. The lymph contained more 10:0 fatty acids than 8:0 despite an overall ratio of 10:0 to 8:0 of 0.3 for the diets. The mass of medium-chain fatty acids absorbed in the lymph at measured time points was 2.6 +/- 0.5-fold higher (mean +/- SE of 12 determinations) for the structured triacylglycerol compared with the physical mix. Molecular species analyses revealed that the medium-chain fatty acids in lymph were present as mixed triacylglycerols. The unique molecular structure of these mixed triacylglycerols and the fatty acids at the 2-position may account for the improved absorption.

Long-term silastic catheters and chest pain.

There are multiple reports in the literature of vascular erosion in the innominate vein or superior vena cava from the use of temporary central venous catheters. Catheter malposition is likely to precede the development of superior vena cava perforations, a catastrophic complication of central venous catheters. Catheter malposition after initial adequate placement is a very unusual long-term complication and delayed recognition of this complication may have disastrous consequences. Should the catheter change position so the tip is angled toward the sidewall, the repetitive movement of the catheter tip that occurs with respiratory excursion and the cardiac cycle may lead to endothelial injury and eventual erosion of the vein. These problems are thought to be alleviated in the patient receiving long-term intravenous therapy by using a soft Silastic catheter, which may not cause as much damage to the endothelium of the vein. We report three patients with left-sided long-term indwelling Silastic catheters that had changed position over time who presented with chest pain upon infusion of their total parenteral nutrition solutions. In each case, chest x-ray revealed that the tip of the catheter had migrated and was directed against the sidewall of the superior vena cava. In each case, catheter removal and replacement with a new catheter into the right side (subclavian and jugular systems) led to prompt relief of the patient's symptoms.

Esophageal obstruction after ingestion of a fiber-containing diet pill.

Foreign bodies of the esophagus in adults may be the result of a food bolus that becomes lodged proximal to a structural abnormality of the distal esophagus. A case of peptic stricture of the esophagus in a patient who presented with acute dysphagia after ingesting an over-the-counter diet pill composed of guar gum is discussed. It is recommended that anorectics composed of dietary fiber should not be used in patients with a history of esophageal stricture.

Parenteral infusion of long- and medium-chain triglycerides and reticuloendothelial system function in man.

Previous study demonstrated that patients who received total parenteral nutrition (TPN) with standard intermittent infusion of long chain triglyceride (LCT) at 0.13 g kg-1hr-1 over 10 hr for each of three days showed a significant decline in 99Tc-sulfur colloid (TSC) clearance rate by the reticuloendothelial system (RES). The present studies evaluated eight patients who received the same total lipid dose of LCT infused continuously as in a three-in-one admixture, and another nine patients receiving the same amount of fat as a medium chain triglyceride (MCT)/LCT (75%/25%) emulsion intermittently over 10 hr at 0.13 g kg-1hr-1 for three consecutive days. Patients were given continuous total parenteral nutrition (TPN) comprised of protein, 1.5 g kg-1day-1, and dextrose, 4.5 g kg-1day-1. RES function was examined by measuring the clearance rates of intravenously injected TSC while receiving TPN containing only protein and dextrose, and again after three days of fat infusion. Mean (+/- SEM) clearance rate constants before and after continuous LCT infusion were 0.38 +/- 0.09 and 0.41 +/- 0.08 min-1, respectively, while those before and after intermittent MCT/LCT infusion were 0.50 +/- 0.18 and 0.73 +/- 0.24 min-1, respectively. In contrast to intermittent LCT infusion, the administration of continuous LCT or an intermittent MCT/LCT mixture does not impair TSC clearance by the RES. These findings suggest that condensing the daily period of LCT infusion at standard dosage may exceed the rate of metabolic utilization, resulting in increased fat removal and diminished TSC uptake by the RES.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of long-chain triglyceride emulsions on reticuloendothelial system function in humans.

Parenteral administration of long-chain triglyceride emulsions has been shown to have deleterious effects on reticuloendothelial system function in animal models. It is unknown whether this interference occurs in humans with clinically relevant doses of intravenous fat. Two studies were done. Eighteen patients were prospectively enrolled for study. Patients received full feeding by continuous total parenteral nutrition (amino acids 1.5 g/kg/day and dextrose 4.5 g/kg/day) with 33.1 kcal/kg/day. Forty-three % of the nonprotein calories were provided as soybean oil emulsion (Travamulsion 20%) and was administered intravenously over 10 hr (0.130 g/kg/hr). Reticuloendothelial system function was determined by measuring the change in the clearance rate of intravenously injected 99mTc-sulfur colloid (TSC) in each patient. In study 1 (n = 10), one day of lipid (10 hr) was infused, with the clearance of 99mTc-sulfur colloid measured before the lipid was infused and then during the last hour of the 10-hr infusion. In study 2 (n = 8), the clearance rates were measured before the lipid emulsion was begun, and then during the last hour of the infusion on the 3rd day. Clearance rates for TSC after 10 hr of lipid infusion in study 1 did not differ (0.27 +/- 1/min to 0.26 +/- 0.1/min, p greater than 0.10). However, after 3 days of lipid infusion (10 hr/day), a statistically significant reduction in TSC was seen (0.46 +/- 0.08/min-0.27 +/- 0.03/min, p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)