Incorporation of conjugated linoleic acid isomers into porcine erythrocytes.

PURPOSE: The aim of the current study was to determine the incorporation of cis (c) 9, trans (t) 11-conjugated linoleic acid (CLA) and t10, c12-CLA into porcine erythrocytes-both isomers were supplemented in equal proportions. METHODS: The study group consisted of 16 piglets randomly assigned into experimental and control group. For the period of 5 weeks, the piglets from the experimental group were receiving a 1.2% CLA supplement while the controls were supplemented with the same amount of sunflower oil. For the remaining 7 weeks, the piglets were fed without a supplement. Blood samples to evaluate incorporation of CLA into erythrocyte membranes were taken from all animals on weekly basis. RESULTS: Compared to t10, c12-CLA isomer, proportion of c9, t11-CLA isomer in the membrane of erythrocytes was higher for the whole time of the study period. After 4 weeks of feeding, it approaches the plateau. The peak value for both isomers was measured at the end of week 5, with a value of 3.24 g c9, t11-CLA/100 g of fatty acids and a 1.09 g t10, c12-CLA/100 g of fatty acids (p < 0.0001). After cessation of supplementation, the proportion of both isomers gradually decreased to be almost completely washed out-in 7 weeks. CONCLUSIONS: During supplementation with equivalent amounts of CLA isomers, their proportion in membranes of porcine erythrocytes increases with time, with higher proportion of c9, t11-CLA. CLA isomers probably differently incorporate into different cell membranes at different species which could explain its various biological functions.

Oral glutamine supplementation during preoperative radiochemotherapy in patients with rectal cancer: a randomised double blinded, placebo controlled pilot study.

BACKGROUND & AIMS: Enteral glutamine may have protective effects on gut function and reduce metabolic stress in patients receiving radiochemotherapy. The aim of our study was to evaluate its influence in patients with rectal cancer undergoing preoperative radiochemotherapy. METHODS: We performed a randomized double blind, placebo controlled pilot study in 33 patients. 30 g of glutamine, average dose 0.41 g/kg (SD = 0.07) g/kg/day was administered orally in three doses per day for five weeks during preoperative radiochemotherapy of rectal cancer. 30 g of maltodextrin was given as placebo. Body weight was measured and NRS 2002 screening was performed before and after treatment. Bowel function was evaluated by stool consistency and frequency. Plasma levels of inflammatory parameters and hormones were measured. RESULTS: There was no difference between groups in frequency and severity of diarrhoea during radiochemotherapy (p = 0.5 and p = 0.39 respectively), insulin levels significantly increased in both groups, IL-6 only in glutamine group. CONCLUSION: Results of this small pilot study in rectal cancer patients receiving preoperative radiochemotherapy, showed that ingestion of larger quantities of glutamine given more often as previously reported did not diminish the incidence and severity of diarrhoea and did not affect inflammatory and metabolic activity compared to the placebo treatment with maltodextrin.

Is replacement of albumin in major abdominal surgery useful?

STUDY OBJECTIVE: To evaluate retrospectively serum albumin concentrations as well as morbidity and mortality of abdominal surgical patients who--if hypoalbuminemic--did not receive human albumin solutions versus those who did receive such solutions. DESIGN: Retrospective observational study. SETTING: Academic community hospital. MEASUREMENTS: The records of 76 consecutive patients who had undergone elective abdominal surgery were reviewed. Preoperative and postoperative serum albumin concentrations up to the seventh day after surgery were recorded. Morbidity and mortality were followed until the time of discharge from the hospital. RESULTS: 38 patients who received albumin replacement if they were hypoalbuminemic versus 38 patients who did not receive albumin replacement showed no significant difference in cumulative (P < 0.52) or individual postoperative complications (infections P < 0.35, cardiovascular complications P < 1.0, organ failure P < 0.67, thromboembolic incidents P < 0.26), and mortality (P < 0.47). CONCLUSIONS: Postoperative serum albumin concentration had no correlation with postoperative morbidity. There is no justification for perioperative albumin replacement in abdominal cancer surgical patients.

Preoperative synbiotic bowel conditioning for elective colorectal surgery.

BACKGROUND: Preoperative bowel cleaning for elective colorectal surgery is a routine procedure. Synbiotics (probiotics plus prebiotics) are known for their beneficial effects on gut immune function and maintenance of the gut barrier. The main purpose of this study was to replace preoperative mechanical bowel cleaning with synbiotics and to assess the systemic inflammatory response and clinical outcome in patients undergoing colorectal surgery. PATIENTS AND METHODS: A prospective double-blind randomized placebo-controlled trial was conducted in 68 patients. The first group of 20 patients received synbiotics, the second group of 28 patients prebiotics and heat-deactivated probiotics, and the third (control) group of 20 patients mechanical bowel cleaning prior to the operation. RESULTS: Significantly higher values of interleukin 6 (IL-6) were detected 72 h after the operation in the synbiotic group (P = 0.025), as well as an increase of fibrinogen at 24 h postoperatively (P = 0.030). No statistical differences were found in leukocytes count, C-reactive protein or the lymphocyte/granulocyte ratio. There were no differences in postoperative complications between the groups. Mean hospital stay was 9.2 days in the prebiotic group, 9.5 days in the control group, and 10.95 days in the synbiotic group. CONCLUSIONS: Preoperative administration of prebiotics in elective colorectal surgery appears to have the same protective effect in preventing a postoperative inflammatory response as mechanical bowel cleaning. Further prospective studies are needed to verify the effects of synbiotics.

Prevalence and factors of intensive care unit conflicts: the conflicus study.

RATIONALE: Many sources of conflict exist in intensive care units (ICUs). Few studies recorded the prevalence, characteristics, and risk factors for conflicts in ICUs. OBJECTIVES: To record the prevalence, characteristics, and risk factors for conflicts in ICUs. METHODS: One-day cross-sectional survey of ICU clinicians. Data on perceived conflicts in the week before the survey day were obtained from 7,498 ICU staff members (323 ICUs in 24 countries). MEASUREMENTS AND MAIN RESULTS: Conflicts were perceived by 5,268 (71.6%) respondents. Nurse-physician conflicts were the most common (32.6%), followed by conflicts among nurses (27.3%) and staff-relative conflicts (26.6%). The most common conflict-causing behaviors were personal animosity, mistrust, and communication gaps. During end-of-life care, the main sources of perceived conflict were lack of psychological support, absence of staff meetings, and problems with the decision-making process. Conflicts perceived as severe were reported by 3,974 (53%) respondents. Job strain was significantly associated with perceiving conflicts and with greater severity of perceived conflicts. Multivariate analysis identified 15 factors associated with perceived conflicts, of which 6 were potential targets for future intervention: staff working more than 40 h/wk, more than 15 ICU beds, caring for dying patients or providing pre- and postmortem care within the last week, symptom control not ensured jointly by physicians and nurses, and no routine unit-level meetings. CONCLUSIONS: Over 70% of ICU workers reported perceived conflicts, which were often considered severe and were significantly associated with job strain. Workload, inadequate communication, and end-of-life care emerged as important potential targets for improvement.

Influence of conjugated linoleic acid on the porcine immune response and morbidity: a randomized controlled trial.

BACKGROUND: Conjugated linoleic acid (CLA) has diverse influences on the immune response in different experimental models. In the present study we investigated the effect of CLA feeding on inflammatory and immune responses in a piglet model. We studied the duration of this effect and possible detrimental effects of CLA feeding. After 12 weeks of CLA and control supplementation and washout, animals were sacrificed and parenchymal organs were histologically examined. RESULTS: In activated peripheral mononuclear cells interferon-gamma was significantly (p = 0.008) lower in the CLA group by the end of the feeding period. This effect disappeared as soon as supplementation was stopped. No differences were found in the tumour necrosis factor-alpha, interleukin-10 production, serum immunoglobulin-G levels and fat infiltration of the liver, except that fat storage cell infiltration was significantly (p < 0.04) higher in the CLA-fed group. The effect of time for interferon-gamma, interleukin-10 and immunoglobulin-G levels was statistically significant. CONCLUSION: At the end of the feeding period the interferon-gamma response was depressed. However, the maturation of the piglet immune system in our young pig model probably outweighs the impact of CLA feeding on the immune response, even though liver fat storage cell infiltration, which plays an important role in liver regeneration, increased during CLA feeding of the piglets.

Synbiotics, prebiotics, glutamine, or peptide in early enteral nutrition: a randomized study in trauma patients.

BACKGROUND: Since the hepatosplanchnic region plays a central role in development of multiple-organ failure and infections in critically ill trauma patients, this study focuses on the influence of glutamine, peptide, and synbiotics on intestinal permeability and clinical outcome. METHODS: One hundred thirteen multiple injured patients were prospectively randomized into 4 groups: group A, glutamine; B, fermentable fiber; C, peptide diet; and D, standard enteral formula with fibers combined with Synbiotic 2000 (Synbiotic 2000 Forte; Medifarm, Sweden), a formula containing live lactobacilli and specific bioactive fibers. Intestinal permeability was evaluated by measuring lactulose-mannitol excretion ratio on days 2, 4, and 7. RESULTS: No differences in days of mechanical ventilation, intensive care unit stay, or multiple-organ failure scores were found between the patient groups. A total of 51 infections, including 38 pneumonia, were observed, with only 5 infections and 4 pneumonias in group D, which was significantly less than combined infections (p = .003) and pneumonias (p = .03) in groups A, B, and C. Intestinal permeability decreased only in group D, from 0.148 (0.056-0.240) on day 4 to 0.061 (0.040-0.099) on day 7; (p < .05). In group A, the lactulose-mannitol excretion ratio increased significantly (p < .02) from 0.050 (0.013-0.116) on day 2 to 0.159 (0.088-0.311) on day 7. The total gastric retention volume in 7 days was 1150 (785-2395) mL in group D, which was significantly more than the 410 (382-1062) mL in group A (p < .02), and 620 (337-1190) mL in group C (p < .03). CONCLUSIONS: Patients supplemented with synbiotics did better than the others, with lower intestinal permeability and fewer infections.

Intestinal permeability and cytokine inflammatory response in multiply injured patients.

In experimental settings, the increased intestinal permeability (IP) following severe trauma is associated with increased serum concentrations of cytokines. Multiply injured patients are susceptible to the development of multiple organ failure (MOF). The aim of this study was to determine if altered IP after trauma was associated with upregulation of cytokines and if cytokines and IP influenced the development of MOF. In 30 multiply injured patients, IP was measured on days 2 and 4 after injury using the lactulose-mannitol (L-M) test, and the levels of tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), and IL-8 were determined simultaneously. The L-M ratio increased significantly from 0.049 (0.017-0.133) on day 2 to 0.150 (0.059-0.339) on day 4 (p < 0.02) On day 4, a significant correlation was also found between the L-M ratio and IL-6 (r = 0.43, p < 0.03). The IL-6 level on days 2 and 4 was significantly (p < 0.01 and p < 0.03, respectively) higher in MOF patients than in those without MOF, as was the TNF-alpha level on day 4 significantly higher (p < 0.04) in MOF patients. IP increases following multiple trauma, and on day 4 it correlates with the IL-6 level. However, in patients who develop MOF only cytokines are invariably increased, with IL-6 alone being significantly increased on both measurements in these patients.

Is early enteral nutrition a risk factor for gastric intolerance and pneumonia?

BACKGROUND: Early enteral nutrition (EN) after injury reduces septic complications, but upper digestive intolerance (UDI) occurring immediately post-trauma is a risk factor for pneumonia. Our study aimed to determine whether early intragastric feeding may lead to gastric intolerance and subsequent pneumonia in ventilated multiply injured patients. METHODS: This prospective study involved two groups of patients randomized either to immediate intragastric EN, or to delayed intragastric EN started later than 24 h after admission. UDI was diagnosed when gastric residual volume, measured with a 50-ml syringe after stopping the feeding for 2 h, exceeded 200 ml at least at two consecutive measurements, and/or when vomiting occurred. RESULTS: Out of 52 patients, 27 were included in the early EN group, and 25 in the delayed-EN group. On day 4, the early EN group received a greater amount of feeding because of intolerance problems occurring in the delayed-EN group (1175 +/- 485 ml vs. 803 +/- 545 ml). Twenty-five subjects--33% of the early EN patients and 64% of the delayed-EN patients--met the criteria for pneumonia (P = 0.050). On average, patients with pneumonia were older, more severely injured, and therefore required more ventilator days and a longer stay in the intensive care unit than patients without pneumonia. CONCLUSIONS: If properly administered, early enteral nutrition can decrease the incidence of upper intestinal intolerance and nosocomial pneumonia in patients with multiple injuries.

Assessment of acid-base status and plasma lactate concentrations in arterial, mixed venous, and portal blood from dogs during experimental hepatic blood inflow occlusion.

OBJECTIVE: To determine the effects of extended experimental hepatic blood flow occlusion (ie, portal triad clamping [PTC]) in dogs by measuring acid-base status and plasma lactate concentrations in arterial, mixed venous, and portal blood and evaluating the relationship between metabolic and concurrent hemodynamic changes. ANIMALS: 6 healthy Beagles. PROCEDURE: During anesthesia with isoflurane, cardiac output and arterial blood pressure were measured. Arterial, mixed venous, and portal blood samples were collected simultaneously for blood gas analyses and plasma lactate measurements before PTC and at 8-minute intervals thereafter. RESULTS: PTC resulted in severe hemodynamic and metabolic alterations. Eight minutes after PTC, significant decreases in cardiac index from a baseline value of 3.40 +/- 0.27 to 1.54 +/- 0.26 L/min/m2 and in mean arterial blood pressure from a baseline value of 74 +/- 6 to 43 +/- 6 mm Hg were recorded. After PTC, results indicative of lactic acidosis were found in portal blood at 16 minutes, in mixed venous at 32 minutes, and in arterial blood at 48 minutes. Significant differences in measured variables were also found between arterial and portal blood samples, between mixed venous and portal blood samples, and between arterial and mixed venous blood samples after PTC, compared with differences at baseline. CONCLUSIONS AND CLINICAL RELEVANCE: Analysis of mixed venous blood is preferable to analysis of arterial blood in the assessment of metabolic derangement. In a clinical setting, occluded portal blood is released to the systemic circulation, and the degree of reperfusion injury may depend on the metabolic status of pooled portal blood.