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Nutrition support for bone marrow
transplant patients (Cochrane Review).
Reference: Cochrane Database Syst Rev
2002;(2):CD002920
BACKGROUND: Bone marrow transplantation involves the
administration of toxic chemotherapy and infusion of
marrow cells. After treatment, patients can develop a
poor appetite, mucositis and gastrointestinal failure,
leading to malnutrition. To prevent this, parenteral
nutrition (PN) support is the first choice but is
associated with an increased risk of infection. Enteral
nutrition (EN) is an alternative, as is the addition of
substrates e.g. glutamine to enteral and parenteral
solutions. However, the relative effectiveness of these
treatments is not clear. OBJECTIVES: To determine the
efficacy of EN or PN support for patients receiving a
bone marrow transplant. SEARCH STRATEGY: Trials were
identified by searching the Cochrane Library (Issue 4,
2000 ), MEDLINE (1966-2000), EMBASE (1988-2000) and
CINAHL (1982-2000 ). Reference lists of identified trials
and conference proceedings were searched for relevant
reports. Date of the most recent search: 2000. SELECTION
CRITERIA: RCTs that compared one form of nutrition
support with another, or control, for bone marrow
transplant patients were included. DATA COLLECTION AND
ANALYSIS: Thirty five reports were identified, 11 were
excluded. Two reviewers extracted data from 24 studies;
16 were allocated to four interventions: oral glutamine
versus placebo; PN and glutamine versus standard PN; PN
versus IV hydration; PN versus EN. Eight studies were
other interventions. Data were collected on participants'
characteristics; adverse effects; neutropaenia; % change
in body weight; graft versus host disease; and survival.
Trialists were contacted for unreported data. MAIN
RESULTS: Two studies (82 subjects) found that glutamine
mouthwash reduced days of neutropaenia (6.82 days, 95% CI
(1.67-11.98) p=0.009) compared with placebo. Three
studies (103 subjects) showed that patients receiving PN
with glutamine had a reduced hospital stay, 6.62 d (95%
CI 3.47, 9.77, P=0.00004) compared with patients
receiving standard PN. Two studies (73 subjects)
indicated that patients receiving PN plus glutamine had a
reduced incidence of positive blood cultures (OR 0.23,
95% CI 0.08-0.65, p=0.006) compared to those receiving
standard PN. One study, (25 subjects) showed patients
receiving PN had a higher incidence of line infections
(odds ratio 21.23, 95% CI 4.15,108.73, P=0.0002) compared
to those receiving standard IV fluids. There were no
evaluable data to compare PN with EN. REVIEWER'S
CONCLUSIONS: Lack of evaluable data means that the
relative effectiveness of EN versus PN cannot be
evaluated. Further studies and missing data from
completed trials need to be retrieved. Studies comparing
PN with glutamine versus standard PN suggest that
patients leave hospital earlier, and experience a reduced
incidence of positive blood cultures, than those
receiving standard PN. Patients with gastrointestinal
failure should consider PN with the addition of glutamine
if enteral feeding is not possible.
Measured versus estimated energy
expenditure in mechanically ventilated critically iII
patients.
Clin Nutr 2002;21(2):165-72.
Accurate determination of energy expenditure is essential
in patients receiving nutritional support to meet
metabolic needs. The purpose of this study was to assess
and compare the energy expenditure as measured by
indirect calorimetry (MEE) and estimated by 5 equations
in the mechanically ventilated critically ill patients.
Forty-six patients were divided into either enteral
nutrition (EN) (n=l2), total parenteral nutrition (TPN)
(n=16) or combined (EN plus TPN) (n=l8) groups. Patients'
energy expenditure was measured by indirect calorimetry
on two occasions. Anthropometric and biochemical
measurements, energy expenditure and medical status
(APACHE II score) were also assessed in the intensive
care unit (ICU) of Taichung Veteran General hospital. No
significant difference was found in the MEE among the 3
groups. The type of nutritional support did not affect
MEE. Energy expenditure calculated by using Harris-
Benedict, Kleiber and Liu equations times the estimated
stress factor did not significantly different than the
values of MEE in all groups. There were significant
correlations (P<0.01) between MEE and patients' sex
(r=-0.499), age (r=-0.402), height (r=0.533), knee height
(r=0.431), current body weight (r=0.379), usual body
weight (r=0.407), ideal body weight (r=0.466) and urinary
urea nitrogen (r=0.383) in the pooled group. Results
demonstrated that energy expenditure could be estimated
in most critically ill patients by using Harris-Benedict,
Kleiber and Liu equations if the estimated stress factor
is in the reasonable value.
Enteral feeding in patients with major burn
injury: the use of nasojejunal feeding after the failure of
nasogastric feeding.
Reference: Burns 2002;28(4):386-90.
Patients with major burn injury have increased protein and energy
requirements and early feeding is an established part of their
management. The optimal method of feeding is unknown. Nasogastric
feeding is often unsuccessful and total parenteral nutrition has a
number of potential disadvantages. Post pyloric feeding is an
alternative means of providing enteral nutrition. We report our
experience of enteral feeding of patients with significant burn
injury. Nasogastric feeding was successful in only 7 of 17
patients (41%). The commonest reason that nasogastric feeding
failed was gastric stasis. All patients who failed nasogastric
feeding were commenced on nasojejunal feeding and a further two
patients were fed by this route initially. Ten of these 12
patients (83%) were successfully fed nasojejunally. No major
adverse events attributable to nasojejunal feeding were
identified, a nasojejunal tube was successfully placed in all but
1 patient and the tubes were well tolerated. We conclude that
nasojejunal tube feeding should be considered in all patients with
significant burn injury who cannot tolerate nasogastric tube
feeding-
Glycemic index: overview of implications in
health and disease
Reference: Am J Clin Nutr 2002;76(1):266S-273S.
The glycemic index concept is an extension of the fiber
hypothesis, suggesting that fiber consumption reduces the
rate of nutrient influx from the gut. The glycemic index
has particular relevance to those chronic Western diseases
associated with central obesity and insulin resistance.
Early studies showed that starchy carbohydrate foods have
very different effects on postprandial blood glucose and
insulin responses in healthy and diabetic subjects, depending
on the rate of digestion. A range of factors associated with
food consumption was later shown to alter the rate of glucose
absorption and subsequent glycemia and insulinemia. At this
stage, systematic documentation of the differences that exist
among carbohydrate foods was considered essential. The resulting
glycemic index classification of foods provided a numeric
physiologic classification of relevant carbohydrate foods
in the prevention and treatment of diseases such as
diabetes. Since then, low-glycemic-index diets have been
shown to lower urinary C-peptide excretion in healthy
subjects, improve glycemic control in diabetic subjects,
and reduce serum lipids in hyperlipidemic subjects. Furthermore,
consumption of low-glycemicindex diets has been associated with
higher HDL-cholesterol concentrations and, in large cohort
studies, with decreased risk of developing diabetes and
cardiovascular disease. Case-control studies have also
shown positive associations between dietary glycemic index
and the risk of colon and breast cancers. Despite
inconsistencies in the data, sufficient, positive findings
have emerged to suggest that the dietary glycemic index is
of potential importance in the treatment and prevention of
chronic diseases
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Nutrition support for bone marrow transplant
patients (Cochrane Review).