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The use of probiotics (live viable microbial organisms) in the treatment of specific diseases has evolved into an extremely valuable option yet to be optimally used in clinical medicine. Probiotics have been shown to have immunomodulating properties and enhance the mucosal barrier. This review will briefly discuss the use of probiotics in inflammatory bowel disease, pancreatitis, liver transplantation, and various uses in diarrhea. When using probiotics, one must be cautious of the sometime overzealous claims that are commonly made when dealing with medical foods. As we begin to appreciate the degree of complexity that our indigenous microbial population has on health, it is only then that we can begin to understand the importance in disease. In the arena of probiotics, numerous fundamental questions remain unanswered.

This article represents the views of an international group of surgeons on the need for pre-operative optimisation of patient's nutritional status prior to elective surgery as a means of reducing post-operative infective complications.

Objective The benefits of enteral nutrition when compared with parenteral nutrition are well established. However, provision of enteral nutrition may not occur for several reasons, including lack of optimal feeding access. Gastric feeding is easier to initiate, but many hospitalized patients are intolerant to gastric feeding, although they can tolerate small bowel feeding. Many institutions rely on costly methods for placing small bowel feeding tubes. Our goal was to evaluate the effectiveness of a hospital-developed protocol for bedside-blind placement of postpyloric feeding tubes. Methods The Surgical Nutrition Service established a protocol for bedside placement of small bowel feeding tubes. The protocol uses a 10- or 12-French, 110-cm stylet containing the feeding tube; 10 mg of intravenous metoclopramide; gradual tube advancement followed by air injection and auscultation; and an abdominal radiograph for tube position confirmation. In a prospective manner, consults received by the surgical nutrition dietitian for feeding tube placements were followed consecutively for a 10-mo period. The registered dietitian recorded the number of radiograph examinations, the final tube position, and the time it took to achieve tube placement. Results Because all consults were included, feeding tube placements occurred in surgical and medical patients in the intensive care unit and on the ward. Of the 135 tube placements performed, 129 (95%) were successfully placed postpylorically, with 84% (114 of 135) placed at or beyond D3. Average time for tube placement was 28 min (10 to 90 min). One radiograph was required for 92% of the placements; eight of 135 (6%) required two radiographs. No acute complications were associated with the tube placements. Conclusions Hospitalized patients can receive timely enteral feeding with a cost-effective feeding tube placement protocol. The protocol is easy to implement and can be taught to appropriate medical team members through proper training and certification.

Purpose of review Recognition that the gastrointestinal tract is a key element of the immune system has led to a greater interest in understanding its role as a central figure in host defenses. Biologic systems that are perturbed by any destabilizing stimulus are known to respond by adaptive strategies in an attempt to maintain or return to global homeostasis. In critically ill patients, the gut has previously been described as a promoter of progression to sepsis and multi-organ failure. However, with better understanding of gastrointestinal tract mucosal immunity, we are now provided with a new arsenal to combat nosocomial infection and significantly impact return to health. Recent findings In this review we focus on five key topics in the rapidly expanding landscape of knowledge on the gastrointestinal tract in the critical care setting. These include a discussion of probiotic therapy, now the new frontier of immuno-nutrition, the concept of ischemia/reperfusion injury and changes in gut permeability, anti-oxidant and micronutrient therapy, blood glucose regulation, and enhancement of gut motility, all in the intensive care setting. Summary Ongoing research in nutritional support in both normal and pathologic gastrointestinal function and response to injury has opened the door to several new opportunities for enhancing rapid recovery in critical care.

Published guidelines for surgical antibiotic prophylaxis recommend that an appropriately selected and administered antibiotic should be repeated in a timely manner in lengthy procedures. To assess concordance with published guidelines we reviewed the prophylactic antibiotic usage in procedures lasting more than 4 hours at a 500-bed university hospital. The records of 300 procedures longer than 4 hours in duration from the gastrointestinal, neurosurgery, and vascular surgery services were retrospectively reviewed. Analysis was confined to the usage of antibiotics in a prophylactic setting. Using a liberal interpretation of the American College of Surgeons, Centers for Disease Control and Prevention, Surgical Infection Society, and Medical Letter Guidelines each case was evaluated for the appropriateness of the antibiotic selection, the interval between the first dose and the skin incision, and the timeliness of repeat dosing. Twenty-five patients (8.3%) did not receive any antibiotic coverage at all. One hundred ninety cases (63.3%) received the correct antibiotic, but only 96 (32%) received it in a timely manner before surgery. Nine patients (3%) in 300 cases received repeat doses at the correct time for the entire duration of the surgery in complete compliance with the published guidelines. We conclude that antibiotic prophylaxis of lengthy procedures is rarely in accordance with published guidelines.

Background Medical students have historically perceived a lack of training in clinical nutrition. Rapid advances in medical science have compelled significant changes in medical education pedagogy. It is unclear what effect this has had on student's perceptions. Objective To assess interns' perception of clinical nutrition education during medical school. Design A cross-sectional survey of medical, surgical, and obstetric interns from 6 academic hospitals across the United States during the middle of their first year in November of 2010 (n = 289). Bivariate analysis and logistic regression was used to describe interns' perceptions and evaluate for factors that determined these perceptions. Results A total of 122 interns responded to the survey, for a response rate of 42%. These interns represented 72 different medical schools. Only 29% of interns reported they had been sufficiently trained in nutrition. On average, interns who reported being prepared reported a mean of 4 ± 3.4 weeks of training during medical school, while unprepared interns reported a mean of 2 ± 2.6 weeks of training (P = .02). Interns with prior graduate training in nutrition (n = 18) almost exclusively reported that medical school training was insufficient (94%, P = .02). After adjusting for age, gender, internship, undergraduate training, and being a foreign graduate, only the number of weeks of training remained significantly associated with perceived preparation (P = .03). Conclusion Most interns in medicine, surgery, and obstetrics feel unprepared to handle cases requiring knowledge of clinical nutrition. Interns feel that medical school is not adequately preparing them for the needs of clinical practice.

Nutrients have traditionally been viewed as a means to provide basic energy for cellular homeostasis and amino acids for protein synthesis in all humans. Young, healthy men and women in the military today are presumed to be well nourished and mentally and physically fit to perform their duties in austere environments. Exposure to high-intensity projectiles, blast injuries, and other wounds of war, however, is an everyday occurrence during deployment that potentially challenges all homeostatic mechanisms. After sustaining such devastating injuries, critically ill, surgical, and trauma patients are in a constant dynamic state between the systemic inflammatory response syndrome (and compensatory anti-inflammatory response syndrome. Compelling evidence supports both immune and metabolic response modulation by specific nutrients, including omega-3 fatty acids, primarily eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA). The concept of providing nutrients as therapeutic rather than supportive agents to meet the basic cellular caloric and metabolic demands requires a major paradigm shift. Although the exact route and dose of these metabolically active lipids has yet to be determined, data from large clinical studies of cellular ex-vivo experiments in patients support the liberal use of eicosapentaenoic acid and docosahexaenoic acid in the setting of trauma, surgery, and intensive care.

Obesity is a leading cause of preventable death in the USA. The American Medical Association recently recognized obesity as meeting the definition of a chronic disease. This declaration had the intention of improving screening and long-term treatment and is historically similar to the designation of tobacco and alcohol dependence as a chronic disease. Nevertheless, it has ignited a nationwide debate in both academia and public opinion. The current article reviews the implications of treating obesity as a chronic disease, comparing the similarities in pathophysiology of obesity and other addictions, and discusses the pros and cons of this designation as it pertains to health care workers and patients.

Nutrition plays an integral part in the care of all patients, especially those who are critically ill or severely malnourished.1 In patients unable to maintain adequate volitional intake, enteral access achieved through a variety of techniques becomes essential. For short-term nutrition supplementation, nasoenteric tubes (such as nasogastric, nasoduodenal, and nasojejunal) are used. These enteral access devices are readily used but may be difficult to keep in the proper position. Regardless of the location of the tube tip or level of infusion within the gastrointestinal tract, securing the nasoenteric tube is important. Tube dislodgement may lead to delays in enteral nutrition (EN), increased risk for aspiration or malposition of the tube at the time of replacement, and added cost (time spent replacing tubes, the new feeding tube itself, radiographic confirmation studies). Traditionally, nasoenteric tubes have been kept in place by taping the tube to the face, nose, and forehead of the patient. Such practice, however, may be relatively ineffective, with a displacement rate as high as 62%.2,3 The adhesive tape itself may cause discomfort to the patient or nasal necrosis, lead to skin tears, cause cutaneous sensitivity reactions to the tape, or may interfere with endotracheal tubes, facial wounds, or other monitoring devices. In 1980, Armstrong et al4 described a technique for securing nasoenteral feeding tubes by using a nasal bridle, whereby some type of anchor (extra feeding tube, umbilical tape, or red rubber tube) is placed around the vomer bone or nasal septum. The bridle is placed by a variety of methods, including via nares or mouth, with the end result being an anchor through 1 naris, around the nasal septum, and exiting the other naris. Both ends of the bridle are secured together to the nasoenteric tube near the nares. The advantage of the nasal bridle is that no taping is required. Anecdotally, the patients who are able to voice concerns do not seem to complain of increased discomfort with the bridle. With no tape on the nose, forehead, or cheeks, the nasal bridle is less likely to interfere with wounds, burns, orotracheal tubes, or oral airway devices.5–9 Many different types of anchors have been used with varying degrees of success.2,10–21 In 2009, Gunn et al18 described a new technique for a nasal bridle using a commercial magnetic retrieval system attached to 1/8-inch umbilical tape to place and secure the nasoenteric tube (Applied Medical Technology, Brecksville, OH). Given a limited number of small studies and a variety of techniques described,2,3,18–21 this meta-analysis was performed to examine the overall effectiveness of nasal bridles vs the traditional alternative of no bridle, using tape alone for securing nasoenteric tubes.

Endoscopic insertion of enteral feeding tubes is a major advance in the delivery of nutrition therapy. Since the first report of percutaneous endoscopic gastrostomy (PEG) in 1980 (Gauderer et al. J Pediatr Surg. 15:872–5, 1980), insertion techniques and equipment have been refined and improved. Despite this progress, deep jejunal enteral access remains a difficult procedure, and many endoscopists do not have experience with the techniques of nasojejunal (NJ) placement, percutaneous endoscopic gastrojejunostomy (PEGJ), or direct percutaneous endoscopic jejunostomy (DPEJ) (Shike and Latkany, Gastrointest Endosc Clin N Am. 8:569–80, 1998). The difference between an exasperating experience and a rewarding procedure lies in mastering the “tips and tricks” that make insertion easy. While the basic techniques are described elsewhere (McClave and Chang 2011), we review several universal basic principles to enhance deep jejunal access, which should promote a more efficient and successful procedure.

Probiotics are living microorganisms which have demonstrated many benefits in prevention, mitigation, and treatment of various disease states in critically ill populations. These diseases include antibiotic-associated diarrhea, Clostridium difficile diarrhea, ventilator-associated pneumonia, clearance of vancomycin-resistant enterococci from the GI tract, pancreatitis, liver transplant, major abdominal surgery, and trauma. However, their use has been severely limited due to a variety of factors including a general naivete within the physician community, lack of regulation, and safety concerns. This article focuses on uses for probiotics in prevention and treatment, addresses current concerns regarding their use as well as proposing a protocol for safe use of probiotics in the critically ill patient.

Short bowel syndrome (SBS) is a manifestation of massive resection of the intestines resulting in severe fluid, electrolyte, and vitamin/mineral deficiencies. Diet and parenteral nutrition play a large role in the management of SBS; however, pharmacologic options are becoming more readily available. These pharmacologic agents focus on reducing secretions and stimulating intestinal adaptation. The choice of medication is highly dependent on the patient's symptoms, remaining anatomy, and risk versus benefit profile for each agent. This article focuses on common and novel pharmacologic medications used in SBS, including expert advice on their indications and use.

Nutrition education for physicians in the United States is limited in scope, quality, and duration due to a variety of factors. As new data and quality improvement initiatives highlight the importance of nutrition and a generation of nutrition experts retire, there is a need for new physician educators and leaders in clinical nutrition. Traditional nutrition fellowships and increased didactic lecture time in school and postgraduate training are not feasible strategies to develop the next generation of physician nutrition specialists in the current environment. One strategy is the development of short immersion courses for advanced trainees and junior attendings. The most promising courses include a combination of close mentorship and adult learning techniques such as lectures, clinical experiences, literature review, curricular development, research and writing, multidisciplinary interactions, and extensive group discussion. These courses also allow the opportunity for advanced discourse, development of long-term collaborative relationships, and continued longitudinal career development for alumni after the course ends. Despite these curricular developments, ultimately the field of nutrition will not mature until the American Board of Medical Specialties recognizes nutrition medicine with specialty board certification.

Enteral access is a cornerstone in the provision of nutrition support. Early and adequate enteral support has consistently demonstrated improved patient outcomes throughout a wide range of illness. In patients unable to tolerate oral intake, multiple options of delivery are available to the clinician. Access requires a multidisciplinary effort that involves nurses, dietitians, and physicians to be successful. These techniques and procedures are not without morbidity and even mortality. A comprehensive understanding of the appropriate management of these tubes and their inherent complications should be garnered by all those involved with nutrition support teams. This tutorial reviews available options for enteral access in addition to commonly encountered complications and their management.

Solitary fibrous tumor (SFT) of the peritoneum is an unusual spindle-cell neoplasm. SFT was originally described in the pleura; however it is now diagnosed in multiple extrathoracic sites. Most believe that the tumor is of mesenchymal origin and should be classified as a variant of fibroma. SFT of the pleura and peritoneum have also been called fibrous mesothelioma, and the cell of origin is felt to be a pluripotential submesothelial mesenchymal cell. Primary tumors arising in hernia sacs are rare, and we report on two patients with hernia SFT. The first is a 67-year-old man who had a diffusely thickened distal left inguinal hernia sac. Within the sac was copious myxoid material mimicking pseudomyxoma peritonei. Herniorrhaphy and orchiectomy were performed. The second is a 44-year-old woman with a midepigastric mass attached to a ventral hernia. Wide local excision was performed. Both tumors demonstrated plump spindle cells, one with myxoid background and the other with keloidal collagen. Calretinin immunostaining was positive in both tumors, whereas CD34 was negative. This suggests tumor origin from a submesothial pluripotential cell that maintains potential for mesothelial differentiation. Surgical excision is the treatment of choice with the degree of resectability being a powerful predictor of outcome.

Optimization of metabolic state prior to major surgery leads to improved surgical outcomes. Nutrition screening protocols should be implemented in the preoperative evaluation, possibly as part of a bundle. Strategies to minimize hyperglycemia and insulin resistance by aggressive preoperative nutrition and carbohydrate loading may promote maintenance of a perioperative anabolic state, improving healing, reducing complications, and shortening the time to recovery of bowel function and hospital discharge. Short courses of preoperative immune-modulating formulas, using combinations of arginine, ω-3 fatty acids, and other nutrients, have been associated with improved surgical outcomes. These immune-modulating nutrients are key elements of metabolic pathways that promote attenuation of the metabolic response to stress and improve both wound healing and immune function. Patients with severe malnutrition and gastrointestinal dysfunction may benefit from preoperative parenteral nutrition. Continuation of feeding through the intraoperative period for severely stressed hypermetabolic patients undergoing nongastrointestinal surgery is another strategy to optimize metabolic state and reduce prolonged nutrition deficits. In this paper, we review the importance of preoperative nutrition and strategies for effective preoperative nutrition optimization.

To date, two different transporters that are capable of transporting α-(methylamino)isobutyric acid, the specific substrate for amino acid transport system A, have been cloned. These two transporters are known as ATA1 and ATA2. We have cloned a third transporter that is able to transport the system A-specific substrate. This new transporter, cloned from rat skeletal muscle and designated rATA3, consists of 547 amino acids and has a high degree of homology to rat ATA1 (47% identity) and rat ATA2 (57% identity). rATA3 mRNA is present only in the liver and skeletal muscle. When expressed in Xenopus laevis oocytes, rATA3 mediates the transport of α-[ 14 C](methylamino)isobutyric acid and [ 3 H]alanine. With the two-microelectrode voltage clamp technique, we have shown that exposure of rATA3-expressing oocytes to neutral, short-chain aliphatic amino acids induces inward currents. The amino acid-induced current is Na + -dependent and pH-dependent. Analysis of the currents with alanine as the substrate has shown that the K 0.5 for alanine (i.e., concentration of the amino acid yielding half-maximal current) is 4.2±0.1 mM and that the Na + :alanine stoichiometry is 1:1.

The amino acid glutamine has become one of the most intensively studied nutrients in the field of nutrition and metabolic support. A variety of studies in cell culture systems, animal models of gut mucosal atrophy, injury/repair and adaptation and a limited number of clinical trials demonstrate trophic and cytoprotective effects of glutamine in small bowel and colonic mucosal cells. Although the routine clinical use of glutamine-enriched parenteral and enteral nutrient solutions remains controversial, available data demonstrate both the safety and metabolic and clinical efficacy of glutamine treatment in selected patient groups. Basic investigations are elucidating underlying mechanisms of glutamine action in intestinal cells. These will inform preclinical and clinical investigations designed to determine glutamine efficacy in selected gastrointestinal disorders. Emerging clinical trials will further define the utility of adjunctive glutamine supplementation as a component of specialized nutrition support in gastrointestinal disease.

Objective: To investigate whether intraperitoneal gallstones increase the risk of pelvic adhesions in a rabbit model. Design: Prospective, randomized, blinded, sham and human antigen controlled trial. Setting: An academic research environment. Subject(s): Twelve New Zealand white rabbits. Intervention(s): Twelve rabbits were divided into three groups of four each; a sham operation group, a gallstone and bile group (study group), and a human serum albumin and bile group (antigenic control). Three weeks after the operation individual subjects were randomized, with groups concealed to observers, and a necropsy was performed on each rabbit. Main Outcome Measurement(s): Necropsy was performed on each rabbit, and the adhesions were scored for extent, type, tenacity, inflammation, and gallstone involvement. Result(s): There was a statistically and biologically significant increase in gallstone involvement in adhesions, especially pelvic adhesions, in the study group. Conclusion(s): This study, along with an increasing number of case reports, suggests that gallstones inadvertently left in the peritoneal cavity may increase the morbidity of laparoscopic cholecystectomy. In females of reproductive age these gallstones may induce pelvic adhesions that may interfere with fertility or be associated with pelvic pain.

Microorganisms living throughout the body comprise the human "microbiota" and play an important role in health and disease. Recent research suggests that alterations in the skin microbiota may underlie chronic wound pathology. Probiotics are bacteria or yeast that confer a health benefit on the host and may have a role in preventing and treating nonhealing wounds by modulating host-microbe interactions.The English literature on skin microbiota, chronic wounds, biofilms, and probiotics is reviewed.Recent evidence indicates that disruption of microbial communities and bacteria-host interactions may contribute to impaired wound healing. Preclinical and human studies highlight the potential of probiotics to prevent or treat various infectious, immune-mediated, and inflammatory diseases.Advances in molecular sequencing and microbiology have shed light on the importance of the human microbiota in development, health, and disease. Probiotics represent a novel approach to altering the microbial environment with beneficial bacteria. Ongoing challenges include the need for better understanding of therapeutic mechanisms, improved regulation of manufacturing practices, and validation in controlled human trials. Current evidence suggests that probiotic-based therapies have considerable potential to exploit host-microbe relationships and improve clinical outcomes.

Recent advances in nutrition therapy of the patient undergoing elective surgery have focused on greater utilization of the gut, feeding closer to the time of surgery, avoiding extensive bowel preparations or use of nasogastric tubes and drains, and measures to promote and maintain intestinal motility. Failure to have protocols in place for delivery of enteral nutrition (EN) through the perioperative period should not lead to inappropriate use of parenteral nutrition (PN) as a default therapy, because in many circumstances, standard therapy with no specialized nutrition support may be associated with better outcome. In cases where EN is not feasible and the patient shows evidence of malnutrition, surgery should be delayed 7-10 days to provide perioperative PN. For patients requiring urgent surgery where EN is not feasible, the initiation of PN postoperatively should be delayed 5-7 days. Whether alternative sources for lipid emulsion and availability of parenteral immune-modulating agents in the future can improve the risk/benefit ratio of PN and expand its use through the perioperative period awaits further study.

The expanding understanding of the biochemical and physiologic role of micronutrients, commonly referred to as vitamins and minerals, is driving the identification of their consequences in both deficiency and toxicity. Neural tissue is quite sensitive to physiologic changes, and as such, micronutrient deficiencies can have significant and profound effects on the functioning of both the central and peripheral nervous systems. Understanding which micronutrients can affect the nervous system can aid physician identification of these neurological symptoms and signs, leading to diagnostic testing and appropriate therapy.

There has been a virtual explosion in the number of bariatric procedures done in the USA and globally in the past 5 years. It is anticipated that more than 200,000 bariatric procedures will be done in the USA in 2012. Bariatric procedures carried out today are generally safe, in most cases effective, and commonly cost-effective in the total health care cost of this population [1]. This chapter reviews the short- and long-term complications of bariatric procedure.

The field of surgical and critical care nutrition has evolved beyond the basic provision of macronutrients to sustain metabolism into a discipline that treats and modifies disease states with immunonutrients and timely provision of macronutrients to modulate deranged physiology. Evidence-based, multidisciplinary, and protocol-driven nutritional interventions have proven effective in improving outcomes in surgical and critically ill patients. A mastery or at least understanding of the principles of nutrition therapy are in integral part of the practice of anesthesia, surgery, and critical care medicine.

Probiotics, when considered in clinical practice, have traditionally been used for prophylaxis; however, there is growing data suggesting treatment benefits in numerous disease states. In this review, we focus on probiotics as treatment for and prevention of several acute and chronic infectious processes including Helicobacter pylori, Clostridium difficile, necrotizing enterocolitis, ventilator-associated pneumonia, vancomycin-resistant enterococci, and nonalcoholic fatty liver disease. It is inaccurate to generalize findings observed in a single probiotic species to all probiotics. This reasoning is due to the variability of colonizing abilities of native intestinal floras, probiotic or otherwise, secondary to different combinations, doses, and duration of treatments. Given these limitations, multiple animal and human studies have shown anti-inflammatory and selective antimicrobial effects of specific probiotics. Some studies suggest a role for probiotics as supplemental treatment, in combination with antibiotics, for the aforementioned disease processes. It is apparent from this review that the efficacy of probiotics is widely variable and multifaceted. More focused clinical and basic science research is necessary to better understand the treatment potential of various probiotics.

This report compiles the conclusions and recommendations for nutrition therapy of the obese, critically ill patient derived by the group of experts participating in this workshop on obesity in critical care nutrition. The recommendations are based on consensus opinions of the group after review of the current literature. Obesity clearly adds to the complexity of nutrition therapy in the intensive care unit (ICU). Obesity alters the incidence and severity of comorbidities, tolerance of the prescribed regimen, and ultimately patient outcome through the course of hospitalization. Although the basic principles of critical care nutrition apply to the obese ICU patient, a high-protein, hypocaloric regimen should be provided to reduce the fat mass, improve insulin sensitivity, and preserve lean body mass. The ideal enteral formula should have a low nonprotein calorie to nitrogen ratio and have a variety of pharmaconutrient agents added to modulate immune responses and reduce inflammation.

As care of the critically ill patient grows more complex, so does the breadth of knowledge required of the intensivist to deliver quality service. Nutrition is one area of many where the complexity of care has grown and the opportunity for improving patient outcomes has become evident. The use of mnemonics has proven successful in compartmentalizing information that must be considered in complex decision-making processes. The authors propose one such mnemonic, "CAN WE FEED?" to assist in the development and initiation of early enteral nutrition therapy in the intensive care unit (ICU). Critical illness severity (C), age (A), and nutrition risk screening (N) are considered when performing a baseline evaluation of the critically ill patient upon presentation to the ICU. Wait for resuscitation (W) is a key component in the care of most critically ill patients and is an important consideration prior to the initiation of feeding. Energy requirements (E) are determined using conventional weight-based equations, indirect calorimetry, or combinations of both techniques. The more practical aspects of support that follow include formula selection (F), enteral access (E), efficacy (E), and the determination of tolerance (D). With careful consideration of these components through the use of the mnemonic "CAN WE FEED?" the intensivist can successfully implement a nutrition plan, and the clinical nutritionist can appreciate where nutrition therapy appropriately intervenes in the initial resuscitation and management of the critically ill patient.

Albumin has been the focus of literally thousands of articles since its first use in the clinical setting during World War II. Despite being at the centre of several clinical controversies, many questions still remain regarding the use and abuse of albumin. The major physiologic functions include maintaining colloid osmotic pressure, binding and transport of metabolically active molecules, serving as an antioxidant, use as a surrogate marker of nutritional status and predictor of outcome in elective surgical populations, having an anti-thrombotic influence on platelets, aiding in acid–base balance and having a protective influence on capillary membrane integrity. Albumin will continue to be widely used in clinical medicine despite many of the drawbacks. It now appears the benefits in the use of albumin in most cases outweigh the risks. The clinical implications of hypoalbuminaemia as an indicator of surgical or intensive care unit (ICU) outcome or nutritional status is clearly disease- and organ specific. The use of albumin as a volume expander appears to have limited, if any, benefit over crystalloid. The "secondary" benefits of albumin in specific surgical and intensive-care conditions, such as sepsis and organ dysfunction, are numerous and are well supported in the current literature.

Suitable and timely early enteral nutrition is paramount to providing optimal patient care for the critically ill. Lipids serve many essential roles throughout the human body, and are important components of most enteral formulations. This paper reviews lipid structure, function, and optimal utility for this macronutrient in enteral feeds. The use of omega-3 fatty acids has become common in critical care formulations, and their clinical efficacy is outlined separately. Available evidence is reviewed, and future directions are discussed.

Bariatric operations are increasingly being used to induce weight loss and ameliorate or cure most of the morbidities that accompany obesity. These procedures not only produce substantial weight loss (>50% body weight), but they cure or ameliorate the comorbidities (diabetes type 2, hypertension, sleep apnea, hyperlipidemia) in the vast majority of patients. These procedures can usually be performed laparoscopically with a mortality of less than 0.5% and a hospital stay of 1 to 3 days. Presently they are the only effective treatment for weight loss in the extremely obese patient (body mass index ≥ 35).

Americans spent 2.4 trillion dollars on health care in 2008. The massive size of this expenditure has led to perpetual efforts to improve health care quality while attempting to reduce overall cost. A recent development in reimbursement strategies is the “pay-for-performance” model. Retrospective reports showed variable success for this model for the treatment of acute myocardial infarction, pneumonia, and congestive heart failure. As the model gains popularity, there is pressure to apply pay for performance to an increasing number of diseases and treatment settings. In this article, we evaluate the appropriateness of the pay-for-performance model with regard to nutritional support in the hospitalized patient.

Background Acellular human dermal matrix (AHDM) has mechanical properties suitable for complex abdominal wall reconstructions and physiologic properties that allow more resistance to infection in contaminated fields. The purpose of this study was to determine which patient and technical factors lead to optimal surgical outcomes. Methods A retrospective review was conducted of 144 abdominal wall reconstructions using AHDM over a 33-month period. Data were recorded and analyzed. Results Fifty-three percent were women. The average age was 55 years, with an average body mass index of 35 kg/m 2 . Thirty percent were smokers at the time of repair, and 24% had diabetes. Forty-three percent of the operative fields had some degree of contamination. The indication for operation in half the patients was to reconstruct a previously failed hernia repair. The recurrence rate was 27.1%. The significant factors that affected the recurrence rate were female gender ( P = .02), reconstructing a failed prior repair ( P = .025), and high body mass index ( P = .004). An underlay mesh placement trended to a lower recurrence rate ( P = .053). Average follow-up time was 23 weeks (range, 0–100 weeks). Conclusions Three patient factors contributed significantly to the recurrence rate in this study: gender, above-normal body mass index, and repairing a recurrent hernia. Placing the matrix as an underlay appears to decrease recurrence rates. Long-term follow-up is needed to further determine the durability of hernia repairs with AHDM. AHDM offers a viable option with acceptable morbidity in complex abdominal wall reconstructions in high-risk patient populations.

Major trauma induces metabolic alterations that contribute to the systemic immune suppression in severely injured patients and increase the risk of infection and posttraumatic organ failure. Nutrition modulation of cellular processes has evolved into a high-priority therapy, backed by substantial scientific evidence. The appropriate selection, timing, and dose of nutrients required for metabolic resuscitation must be individualized and goal directed. Ideally, the nutritional interventions for warfighters will be developed strategically based on the extent of injuries and underlying deficiencies and will be designed to provide the nutrients necessary to balance hypermetabolic processes, heal wounds, and promote optimal recovery.

Spontaneous infection with Clostridium septicum (C. septicum) is rare, but when isolated it is commonly associated with malignancy. We report a case of a 47-year-old man with infected pancreatic necrosis involving greater than 80% of the pancreas, transmural gastric necrosis, and liquefaction necrosis of the spleen. Initial cultures revealed C. septicum infection. He was managed with prompt aggressive surgical debridement, resection, appropriate broad spectrum antibiotics, and early enteral nutrition.

Arginine is a nonessential amino acid in the normal physiological state that becomes conditionally essential during periods of hypermetabolic stress. Recent literature supports the hypothesis that arginine plays an important role in the intermediary metabolism of the critically ill patient. Current critical care literature is conflicting on arginine use in the clinical setting, with some proposing it as a panacea, whereas others report it as poison. Multiple individual reports and at least 5 major meta-analyses using combinations of immune-modulating nutrients have reported mostly beneficial results, but few have evaluated the effects of arginine when given as a single supplemental nutrient. This review attempts to objectively analyze the literature and evaluate the potential role of arginine in the critical care setting.

Expression of Breast Cancer Resistance Protein (BCRP/ABCG2) in tumor cells is associated with resistance to multiple chemotherapeutic agents. BCRP also protects against phototoxicity by mediating the efflux of protoporphyrins from cells. However, chemotherapy and photodynamic therapy are effective treatment options for cancer. Furthermore, protoporphyrins are essential, in the form of heme, for the synthesis of nitric oxide, over-production of which is associated with cancer. This raises the question as to whether the expression of this transporter is altered in cancer. To address this question, we investigated the expression of BCRP in colorectal cancer and cervical cancer. Paired normal and cancer tissues from colectomy specimens were used for the analysis of BCRP mRNA by RT-PCR and Northern blot. BCRP was analyzed by immunohistochemistry/immunofluorescence. Similar studies were also done with specimens of normal cervix and cancer cervix. A commercial dot blot was probed to quantify the expression of BCRP in paired normal and cancer cDNA samples from 154 patients with tumors in 19 different tissues. BCRP mRNA was present in normal colorectal tissue and showed a 6-fold decrease in cancer. BCRP was abundant in the normal colon and showed a decrease in colon cancer. The down-regulation of BCRP mRNA and protein was also evident in cervical cancer. There was also a decrease in BCRP mRNA in cancer in 12 of the 19 different tissues collected from 154 patients. These data show that cancer-associated down-regulation of BCRP is likely to be a common phenomenon in several tissues. Decreased expression of BCRP may have a role in tumorigenesis by allowing accumulation of genotoxins and over-production of nitric oxide.