The tight calorie control study (TICACOS): a prospective, randomized, controlled pilot study of nutritional support in critically ill patients.

PURPOSE: To determine whether nutritional support guided by repeated measurements of resting energy requirements improves the outcome of critically ill patients. METHODS: This was a prospective, randomized, single-center, pilot clinical trial conducted in an adult general intensive care (ICU) unit. The study population comprised mechanically ventilated patients (n = 130) expected to stay in ICU more than 3 days. Patients were randomized to receive enteral nutrition (EN) with an energy target determined either (1) by repeated indirect calorimetry measurements (study group, n = 56), or (2) according to 25 kcal/kg/day (control group, n = 56). EN was supplemented with parenteral nutrition when required. RESULTS: The primary outcome was hospital mortality. Measured pre-study resting energy expenditure (REE) was similar in both groups (1,976 ± 468 vs. 1,838 ± 468 kcal, p = 0.6). Patients in the study group had a higher mean energy (2,086 ± 460 vs. 1,480 ± 356 kcal/day, p = 0.01) and protein intake (76 ± 16 vs. 53 ± 16 g/day, p = 0.01). There was a trend towards an improved hospital mortality in the intention to treat group (21/65 patients, 32.3% vs. 31/65 patients, 47.7%, p = 0.058) whereas length of ventilation (16.1 ± 14.7 vs. 10.5 ± 8.3 days, p = 0.03) and ICU stay (17.2 ± 14.6 vs. 11.7 ± 8.4, p = 0.04) were increased. CONCLUSIONS: In this single-center pilot study a bundle comprising actively supervised nutritional intervention and providing near target energy requirements based on repeated energy measurements was achievable in a general ICU and may be associated with lower hospital mortality.

Effects of polyunsaturated fatty acid consumption in diabetic nephropathy.

The complex metabolic, vascular and inflammatory perturbations that characterize diabetes mellitus often lead to progressive albuminuria, renal injury and dysfunction (diabetic nephropathy [DN]), and diabetes is the leading cause of end-stage renal disease in the US and Europe. Diet has an important role in cardiometabolic disorders and its potential influence on DN is of interest. Fatty acids are a major source of energy, but in excess, fatty acids (particularly saturated fatty acids) can induce lipotoxicity. Omega-3 polyunsaturated fatty acids (PUFAs) confer protection against cardiovascular disease-the major cause of death in patients with DN-by virtue of their antihyperlipidemic, antihypertensive, anti-inflammatory and other properties. Omega-6 PUFAs are also cardioprotective. However, a significant proportion of adults consume insufficient quantities of these essential nutrients. This Review describes the role of omega-3 and omega-6 PUFAs in nutrition and metabolism, with a focus on experimental, epidemiologic and clinical studies that have investigated their renoprotective effect in patients with diabetes. Results from a number of studies suggest, but do not firmly establish, that long-chain omega-3 PUFAs (found in fish oil) reduce albuminuria in the setting of DN. Intake of omega-6 fatty acids is associated with reduced albuminuria in experimental settings and in epidemiologic studies of DN. Although PUFAs do not seem to attenuate glomerular dysfunction, insufficient evidence exists to rule out such an effect. We feel that further research is needed into the potential of PUFA consumption and supplementation in DN.

Anti-inflammatory properties of omega-3 fatty acids in critical illness: novel mechanisms and an integrative perspective.

INTRODUCTION: Fish oil-based nutrition is protective in severe critical care conditions. Regulation of the activity of transcription factor NF-kappaB is an important therapeutic effect of the major omega-3 fatty acids in fish oil, eicosapentaenoic and docosahexaenoic acid (EPA and DHA). METHODS AND RESULTS: Using the articles obtained by a Pubmed research, this article reviews three aspects of NF-kappaB/inflammatory inhibition by fish oil. (1) Inhibition of the NF-kappaB pathway at several subsequent steps: extracellular, free omega-3 inhibits the activation of the Toll-like receptor 4 by endotoxin and free saturated fatty acids. In addition, EPA/DHA blocks the signaling cascade between Toll-like/cytokine receptors and the activator of NF-kappaB, IKK. Oxidized omega-3 also interferes with the initiation of transcription by NF-kappaB. (2) The altered profile of lipid mediators generated during inflammation, with production of the newly identified, DHA-derived inflammation-resolving mediator classes (in addition to the formation of less pro-inflammatory eicosanoids from EPA). Resolvin D1 and Protectin D1 are potent, endogenous, DHA-derived lipid mediators that attenuate neutrophil migration and tissue injury in peritonitis and ischemia-reperfusion injury. Their production is increased in the later stages of an inflammatory response, at which time they enhance the removal of neutrophils. (3) Modulation of vagal tone with potential anti-inflammatory effects: vagal fibers innervating the viscera down-regulate inflammation by activating nicotinic receptors upon infiltrating and resident macrophages. Stimulation of the efferent vagus is therapeutic in experimental septic shock. Fish oil supplementation increases vagal tone following myocardial infarction and in experimental human endotoxinemia. CONCLUSION: It remains to be shown whether these pleiotropic actions of EPA/DHA contribute to fish oil's therapeutic effect in sepsis.

Eating habits and quality of life of patients receiving home parenteral nutrition in Israel.

BACKGROUND & AIMS: Using the database of an infusion provider, we assessed the quality of life and the eating behavior of patients receiving long-term home parenteral nutrition (HPN). METHODS: Fifty-one patients were recruited during a 2-month period and anthropometric measurements, etiology of the disease and length of therapy were noted. A questionnaire including seven questions evaluating four functions was completed by a student by phone interview. The FAACT (Functional Assessment of Anorexia/Cachexia Therapy questionnaire) defined the response from grade 0 (no acceptance) to grade 4 (full acceptance) and evaluated physical, social/familial, emotional and functional well-being. Results are expressed as mean+/-S.D. or median (range) and correlation calculated using the Pearson's correlation test. RESULTS: Fifty patients responded to the questionnaire. Median length on HPN was 27.5 months (range 5-180 months). More than 56% were aged between 17 and 59 years, 62% suffered from an intestinal disease and less than 10% from cancer. Ten percent were receiving HPN for >10 years. Physical activity was scored 1.77+/-1.11, social activity 3.18+/-0.96, emotional status 1.88+/-1.17 and oral intake 1.95+/-0.95. Physical activity was lower in females. Physical activity was highly related to emotional and social status (r=0.61, p<0.0001 and r=0.73, p<0.0001, respectively). Social status was negatively related to emotional level (r=-0.43, p<0.002) while emotional status influenced oral intake (r=0.45, p<0.004). Age or length of therapy did not influence these factors. CONCLUSIONS: Patients on HPN have a low physical activity and an impaired quality of life despite a good social performance. Their emotional status is impaired and their oral intake strongly altered. These alterations are not related to time on therapy or age, but the highest the physical activity, the better the emotional and social status. We should encourage these patients to increase their physical activity when possible.

A diet enriched in eicosapentanoic acid, gamma-linolenic acid and antioxidants in the prevention of new pressure ulcer formation in critically ill patients with acute lung injury: A randomized, prospective, controlled study.

BACKGROUND & AIMS: Pressure ulcers are a significant burden in the ICU. Many factors have found to be associated with pressure ulcers including malnutrition. While it has been recognized that high protein diets decrease the incidence of pressure ulcers, the role of lipids as well as vitamins and antioxidants remains unclear. The aim of this study was to evaluate the preventive and healing effects of an enteral diet enriched in eicosapentanoic acid (EPA) and gamma-linolenic acid (GLA) and vitamins (vitamins A, C and E) on pressure ulcers. METHODS: One hundred patients with acute lung injury were included in a larger study evaluating the effects of lipids and vitamins on respiratory function. A secondary end point, occurrence and healing of pressure ulcers was included. A diet enriched in lipids (EPA, GLA) and vitamins (vitamins A, C and E) was compared with a diet similar in macronutrient composition. The occurrence and healing of pressure ulcers was evaluated according to the National Pressure Ulcer Panel. Nutritional assessment included calorie intake, resting energy expenditure, levels of serum prealbumin, albumin, vitamins A and E, zinc and copper. C-reactive protein and procalcitonin were also measured. RESULTS: Patient's age, severity of disease and gender distribution were similar in the two groups. The study group had a higher body mass index. At baseline, the pressure ulcer score was similar in the two groups A significantly lower rate of occurrence of new pressure ulcers was observed in the study group compared to the control group (p<0.05). No difference was observed in the healing of existing pressure ulcers in the study as opposed to the control group. There was no significant difference in the nutritional parameters between the two groups. CONCLUSIONS: A diet enriched with EPA, GLA and vitamins A, C and E is associated with a significantly lower occurrence of new pressure ulcers in critically ill patients with acute lung injury.

WITHDRAWN: A diet enriched in eicosapentanoic acid, gamma-linolenic acid and antioxidants in the prevention of new pressure ulcer formation in critically ill patients with lung injury: A randomized, prospective, controlled study.

The Publisher regrets that this article is an accidental duplication of an article that has already been published in Clin. Nutr., doi:10.1016/j.clnu.2007.06.015. The duplicate article has therefore been withdrawn.