This article is an open access article distributed under the terms and conditions of the Creative... more This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY
Nutritional support is an integral part of the treatment of the critically ill patient. Enteral f... more Nutritional support is an integral part of the treatment of the critically ill patient. Enteral feeding is viewed as the first line of feeding of the intensive care unit (ICU) patient and has many benefits in maintaining the functionality of the intestine. When we consider the nutritional support of the ICU patient, we first define the calorie-protein target, and then then determine the route of feeding, timing for starting the feeding, and the most appropriate formula. Usually enteral feeding is started in the early stages of ICU hospitalization, after 24-48 h, in order to maintain the gut barrier functionality and support the immune system response. The patient population in the ICU is very heterogenic and the appropriate formula should be chosen with care. A right formula could positively affect clinical outcomes. Many available formulas, including formulas enriched with specific pharmaconutrients such as arginine, glutamine, fish oil, and antioxidants have proven to be beneficial. In this chapter, we will discuss the known properties and the different approaches of various formulas according to clinical conditions and will also estimate the possible complications of enteral feeding.
Malnutrition is common in hip fracture elderly patients. There is no gold standard for screening ... more Malnutrition is common in hip fracture elderly patients. There is no gold standard for screening nutritional risk. We compared the adequacy of 3 screening tools, their association to nutritional measurements and their ability to predict outcome. The Mini Nutrition Assessment Short Form (MNA-SF), the Malnutrition Universal Screening Tool (MUST) and the Nutrition Risk Screening 2002 (NRS-2002) were prospectively determined. Length of stay (LOS), complications, 6 months readmission and up-to 36 months mortality were recorded. 215 operated patients were included: 154 (71.6%) were women; mean age was 83.5 ± 6.09 years (66-104). According to the MNA-SF, 95 patients were well-nourished, 95 were at risk of malnutrition and 25 were malnourished. Based on the MUST, 171 patients were at a low risk of malnutrition, 31 at a medium risk, 13 at a high risk. According to the NRS-2002, 134 patients were at a low risk of malnutrition, 70 at a medium risk, 11 at a high risk. A significant relationship between the nutritional groups of the 3 scores (p < 0.001) was found. In all screening tools, body mass index, weight loss and food intake prior to admission were found to be related to the patients' nutritional status (p < 0.001). No differences in LOS and complications were found between the patients' nutritional status of each screening tool; only the MNA-SF predicted that well-nourished patients would have less readmissions during a 6 month follow-up (p = 0.024). During a 36 month follow-up, 79 patients died. According to the MNA-SF, mortality was lower in the well-nourished patients vs. the malnourished (p = 0.001) and at risk of malnutrition patients (p = 0.01). A less significant association was found between the NRS-2002 patients' nutritional status and mortality (p = 0.048). The MUST did not reveal this relationship. All screening tools were adequate in assessing malnutrition parameters in hip fracture operated elderly patients, however, only the MNA-SF could also predict readmissions and mortality.
The Israel Medical Association journal : IMAJ, 2003
The beneficial effect of 3-hydroxy-3-methylglutyaryl co-enzyme A reductase inhibitors on cardiova... more The beneficial effect of 3-hydroxy-3-methylglutyaryl co-enzyme A reductase inhibitors on cardiovascular risk reduction has been clearly established. Concerns have been raised that lowering blood cholesterol by other hypolipidemic drugs or by a non-pharmacologic approach may have deleterious effects on psychopathologic parameters. Garlic is one of the most commonly used herbal remedies and is considered to have hypocholesterolemic as well as other cardioprotective properties. Its effect on psychopathologic parameters has never been reported. To evaluate the effect of garlic on lipid parameters and depression, impulsivity, hostility and temperament in patients with primary type 2 hyperlipidemia. In a 16 week prospective double-blind placebo-controlled study, 33 patients with primary hypercholesterolemia and no evidence of cardiovascular disease were randomly assigned to receive either garlic or placebo. Garlic in the form of alliin 22.4 mg/day was given to 13 patients, and placebo to ...
n-3 Fatty acids are recognised as influencing both wound healing and immunity. We assessed the im... more n-3 Fatty acids are recognised as influencing both wound healing and immunity. We assessed the impact of a fish oil-and micronutrientenriched formula (study formula) on the healing of pressure ulcers and on immune function in critically ill patients in an intensive care unit. A total of forty patients with pressure ulcers and receiving nutritional support were enrolled (intervention group, n 20, received study formula; and a control group, n 20, received an isoenergetic formula). Total and differential leucocyte count and percentage of adhesion molecule positive granulocyte and lymphocyte cells (CD11a, CD11b, CD18 and CD49b) were measured on days 0, 7 and 14. Percentage of positive lymphocytes for CD54, CD49b, CD49d and CD8 were also measured on days 0, 7 and 14. The state of pressure ulcers was assessed by using the pressure ulcer scale for healing tool score on days 7, 14 and 28 of treatment. No between-group differences in patient demographics, anthropometry or diagnostic class were observed. Patients who received the study formula showed significant increases in the percentage of positive CD18 and CD11a lymphocytes and of CD49b granulocytes as compared to controls (P,0·05). While the severity of pressure ulcers was not significantly different between the two groups on admission, severity increased significantly over time for the control group (P,0·05), but not for the study group. The present study suggests that a fish oil-and micronutrient-enriched formula may prevent worsening of pressure ulcers and that this effect may be mediated by an effect on adhesion molecule expression.
e-SPEN, the European e-Journal of Clinical Nutrition and Metabolism, 2009
The Israel Ministry of Health was willing to update the National Recommendations for Parenteral N... more The Israel Ministry of Health was willing to update the National Recommendations for Parenteral Nutrition administration and asked the Israel Society for Clinical Nutrition to write these guidelines. A group of experts in the field met and reviewed the literature before been separate in small working groups in purpose to write the recommendations of the society. These recommendations were proposed after large agreement between the participants since the group believed that consensus was required. These guidelines are proposed to Clinical Nutrition. Ó
Rationale: Insulin resistance (IR) after major surgery is associated with postoperative morbidity... more Rationale: Insulin resistance (IR) after major surgery is associated with postoperative morbidity. Preoperative oral nutritional supplements (ONS) can reduce postoperative infectious complications, but their effect on postoperative glucose metabolism (GM) is unknown. Effects were studied of an ONS, containing carbohydrates, antioxidants and glutamine, on postoperative GM. Methods: A double blind randomized controlled pilot study in rectal cancer patients. ONS (A) or placebo (B) was given 15, 11 and 4 hrs before surgery. Patients were studied before and one day after surgery in the basal state and during a two-step hyperinsulinemic euglycemic clamp using a stable isotope. Basal endogenous glucose production (EGP), insulin-mediated suppression of EGP and plasma free fatty acids (FFA) (hepatic and adipose tissue insulin sensitivity (IS) respectively) and peripheral (Rd) IS were measured.
Critical Care II 115 (weight gain, caloric and protein intake). The level of significance was set... more Critical Care II 115 (weight gain, caloric and protein intake). The level of significance was set at p < 0.05. Results: There was no significant difference on weight gain, caloric and protein intake among the groups (p > 0.05). Blood, MLN, liver, spleen and lungs of sham (100.00; 226.02; 115.38; 201.34; 50.00 cpm/g) and Arg group (29.63; 290.32; 285.4; 320.00; 67.16 cpm/g) showed significantly lower uptake of 99m Tc-E.coli than IO (427.15; 2,285.70; 846.33; 1,488.90; 1,557.90) and Arg / groups (541.48; 2,937.50; 770.79; 795.45; 1,078.60) (p < 0.05). Arg / and IO groups showed similar levels of counts (p > 0.05). Arg / group had higher levels of bacterial translocation than Arg group (p > 0.05). Conclusion: Arginine was able to decrease BT in wild animals. However iNOS / mice although receiving arginine presented increased of BT. These results show the importance of nitric oxide during stressful situations and its relation with the arginine pathway.
Rationale: In critically ill patients, feeding is determined by health professionals. Hormones re... more Rationale: In critically ill patients, feeding is determined by health professionals. Hormones regulating appetite like ghrelin (G), leptin (L) and adiponectin (A) have been poorly studied when intake was defined. The aim of the TICACOS study was to compare the outcome of patients receiving tight calorie control according to resting energy expenditure measured by indirect calorimetry to energy administered according to predictive formulas. Methods: Blood samples were taken from the 130 included patients on the 1st and 7th/discharge day of the study. G, L and A paired determination was obtained in 92, 71 and 43 patients respectively. Serum L and A were determined using ELISA kits for L and A and RIA kits for G. Statistical analysis was performed using ANOVA with repeated measures. Correlation with energy balance and outcome results was performed using Pearson correlation. Results: Serum G levels were stable from day 1 to 7 (730.5±705.5 pg/ml, 703.6±568.5 pg/ml) comparing an increase in the control group (692.9±567.4 pg/ml, 798.4±557.5 pg/ml) (p < 0.08). L levels in the study group increased significantly from day 1 to 7 (18,009±21,093 pg/ml, 29,806±41,629 pg/ml p < 0.05) comparing the control (21,341±43,221 pg/ml, 22,957±32,638 pg/ml). A levels increased significantly (p < 0.04) from days 1 to 7 in both groups, there were no significant differences between A levels in days 1 to 7 between the study group (7,912±6,462 pg/ml, 9,895±6,044 pg/ml) and the control (9,725±9,114 pg/ml, 12,259±8,587 pg/ml). There were no significant correlations between the cumulative energy balance and the A, G or L levels.
This article is an open access article distributed under the terms and conditions of the Creative... more This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY
Nutritional support is an integral part of the treatment of the critically ill patient. Enteral f... more Nutritional support is an integral part of the treatment of the critically ill patient. Enteral feeding is viewed as the first line of feeding of the intensive care unit (ICU) patient and has many benefits in maintaining the functionality of the intestine. When we consider the nutritional support of the ICU patient, we first define the calorie-protein target, and then then determine the route of feeding, timing for starting the feeding, and the most appropriate formula. Usually enteral feeding is started in the early stages of ICU hospitalization, after 24-48 h, in order to maintain the gut barrier functionality and support the immune system response. The patient population in the ICU is very heterogenic and the appropriate formula should be chosen with care. A right formula could positively affect clinical outcomes. Many available formulas, including formulas enriched with specific pharmaconutrients such as arginine, glutamine, fish oil, and antioxidants have proven to be beneficial. In this chapter, we will discuss the known properties and the different approaches of various formulas according to clinical conditions and will also estimate the possible complications of enteral feeding.
Malnutrition is common in hip fracture elderly patients. There is no gold standard for screening ... more Malnutrition is common in hip fracture elderly patients. There is no gold standard for screening nutritional risk. We compared the adequacy of 3 screening tools, their association to nutritional measurements and their ability to predict outcome. The Mini Nutrition Assessment Short Form (MNA-SF), the Malnutrition Universal Screening Tool (MUST) and the Nutrition Risk Screening 2002 (NRS-2002) were prospectively determined. Length of stay (LOS), complications, 6 months readmission and up-to 36 months mortality were recorded. 215 operated patients were included: 154 (71.6%) were women; mean age was 83.5 ± 6.09 years (66-104). According to the MNA-SF, 95 patients were well-nourished, 95 were at risk of malnutrition and 25 were malnourished. Based on the MUST, 171 patients were at a low risk of malnutrition, 31 at a medium risk, 13 at a high risk. According to the NRS-2002, 134 patients were at a low risk of malnutrition, 70 at a medium risk, 11 at a high risk. A significant relationship between the nutritional groups of the 3 scores (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001) was found. In all screening tools, body mass index, weight loss and food intake prior to admission were found to be related to the patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; nutritional status (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). No differences in LOS and complications were found between the patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; nutritional status of each screening tool; only the MNA-SF predicted that well-nourished patients would have less readmissions during a 6 month follow-up (p = 0.024). During a 36 month follow-up, 79 patients died. According to the MNA-SF, mortality was lower in the well-nourished patients vs. the malnourished (p = 0.001) and at risk of malnutrition patients (p = 0.01). A less significant association was found between the NRS-2002 patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; nutritional status and mortality (p = 0.048). The MUST did not reveal this relationship. All screening tools were adequate in assessing malnutrition parameters in hip fracture operated elderly patients, however, only the MNA-SF could also predict readmissions and mortality.
The Israel Medical Association journal : IMAJ, 2003
The beneficial effect of 3-hydroxy-3-methylglutyaryl co-enzyme A reductase inhibitors on cardiova... more The beneficial effect of 3-hydroxy-3-methylglutyaryl co-enzyme A reductase inhibitors on cardiovascular risk reduction has been clearly established. Concerns have been raised that lowering blood cholesterol by other hypolipidemic drugs or by a non-pharmacologic approach may have deleterious effects on psychopathologic parameters. Garlic is one of the most commonly used herbal remedies and is considered to have hypocholesterolemic as well as other cardioprotective properties. Its effect on psychopathologic parameters has never been reported. To evaluate the effect of garlic on lipid parameters and depression, impulsivity, hostility and temperament in patients with primary type 2 hyperlipidemia. In a 16 week prospective double-blind placebo-controlled study, 33 patients with primary hypercholesterolemia and no evidence of cardiovascular disease were randomly assigned to receive either garlic or placebo. Garlic in the form of alliin 22.4 mg/day was given to 13 patients, and placebo to ...
n-3 Fatty acids are recognised as influencing both wound healing and immunity. We assessed the im... more n-3 Fatty acids are recognised as influencing both wound healing and immunity. We assessed the impact of a fish oil-and micronutrientenriched formula (study formula) on the healing of pressure ulcers and on immune function in critically ill patients in an intensive care unit. A total of forty patients with pressure ulcers and receiving nutritional support were enrolled (intervention group, n 20, received study formula; and a control group, n 20, received an isoenergetic formula). Total and differential leucocyte count and percentage of adhesion molecule positive granulocyte and lymphocyte cells (CD11a, CD11b, CD18 and CD49b) were measured on days 0, 7 and 14. Percentage of positive lymphocytes for CD54, CD49b, CD49d and CD8 were also measured on days 0, 7 and 14. The state of pressure ulcers was assessed by using the pressure ulcer scale for healing tool score on days 7, 14 and 28 of treatment. No between-group differences in patient demographics, anthropometry or diagnostic class were observed. Patients who received the study formula showed significant increases in the percentage of positive CD18 and CD11a lymphocytes and of CD49b granulocytes as compared to controls (P,0·05). While the severity of pressure ulcers was not significantly different between the two groups on admission, severity increased significantly over time for the control group (P,0·05), but not for the study group. The present study suggests that a fish oil-and micronutrient-enriched formula may prevent worsening of pressure ulcers and that this effect may be mediated by an effect on adhesion molecule expression.
e-SPEN, the European e-Journal of Clinical Nutrition and Metabolism, 2009
The Israel Ministry of Health was willing to update the National Recommendations for Parenteral N... more The Israel Ministry of Health was willing to update the National Recommendations for Parenteral Nutrition administration and asked the Israel Society for Clinical Nutrition to write these guidelines. A group of experts in the field met and reviewed the literature before been separate in small working groups in purpose to write the recommendations of the society. These recommendations were proposed after large agreement between the participants since the group believed that consensus was required. These guidelines are proposed to Clinical Nutrition. Ó
Rationale: Insulin resistance (IR) after major surgery is associated with postoperative morbidity... more Rationale: Insulin resistance (IR) after major surgery is associated with postoperative morbidity. Preoperative oral nutritional supplements (ONS) can reduce postoperative infectious complications, but their effect on postoperative glucose metabolism (GM) is unknown. Effects were studied of an ONS, containing carbohydrates, antioxidants and glutamine, on postoperative GM. Methods: A double blind randomized controlled pilot study in rectal cancer patients. ONS (A) or placebo (B) was given 15, 11 and 4 hrs before surgery. Patients were studied before and one day after surgery in the basal state and during a two-step hyperinsulinemic euglycemic clamp using a stable isotope. Basal endogenous glucose production (EGP), insulin-mediated suppression of EGP and plasma free fatty acids (FFA) (hepatic and adipose tissue insulin sensitivity (IS) respectively) and peripheral (Rd) IS were measured.
Critical Care II 115 (weight gain, caloric and protein intake). The level of significance was set... more Critical Care II 115 (weight gain, caloric and protein intake). The level of significance was set at p < 0.05. Results: There was no significant difference on weight gain, caloric and protein intake among the groups (p > 0.05). Blood, MLN, liver, spleen and lungs of sham (100.00; 226.02; 115.38; 201.34; 50.00 cpm/g) and Arg group (29.63; 290.32; 285.4; 320.00; 67.16 cpm/g) showed significantly lower uptake of 99m Tc-E.coli than IO (427.15; 2,285.70; 846.33; 1,488.90; 1,557.90) and Arg / groups (541.48; 2,937.50; 770.79; 795.45; 1,078.60) (p < 0.05). Arg / and IO groups showed similar levels of counts (p > 0.05). Arg / group had higher levels of bacterial translocation than Arg group (p > 0.05). Conclusion: Arginine was able to decrease BT in wild animals. However iNOS / mice although receiving arginine presented increased of BT. These results show the importance of nitric oxide during stressful situations and its relation with the arginine pathway.
Rationale: In critically ill patients, feeding is determined by health professionals. Hormones re... more Rationale: In critically ill patients, feeding is determined by health professionals. Hormones regulating appetite like ghrelin (G), leptin (L) and adiponectin (A) have been poorly studied when intake was defined. The aim of the TICACOS study was to compare the outcome of patients receiving tight calorie control according to resting energy expenditure measured by indirect calorimetry to energy administered according to predictive formulas. Methods: Blood samples were taken from the 130 included patients on the 1st and 7th/discharge day of the study. G, L and A paired determination was obtained in 92, 71 and 43 patients respectively. Serum L and A were determined using ELISA kits for L and A and RIA kits for G. Statistical analysis was performed using ANOVA with repeated measures. Correlation with energy balance and outcome results was performed using Pearson correlation. Results: Serum G levels were stable from day 1 to 7 (730.5±705.5 pg/ml, 703.6±568.5 pg/ml) comparing an increase in the control group (692.9±567.4 pg/ml, 798.4±557.5 pg/ml) (p < 0.08). L levels in the study group increased significantly from day 1 to 7 (18,009±21,093 pg/ml, 29,806±41,629 pg/ml p < 0.05) comparing the control (21,341±43,221 pg/ml, 22,957±32,638 pg/ml). A levels increased significantly (p < 0.04) from days 1 to 7 in both groups, there were no significant differences between A levels in days 1 to 7 between the study group (7,912±6,462 pg/ml, 9,895±6,044 pg/ml) and the control (9,725±9,114 pg/ml, 12,259±8,587 pg/ml). There were no significant correlations between the cumulative energy balance and the A, G or L levels.
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