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CLINICAL NUTRITION WEEK 2012 ALL ABSTRACTS Table of Contents: Session Page

number Premier Paper Session – Oral 1 Critical Care Paper Session – Oral 5 Enteral Nutrition Paper Session – Oral 10 GI / Hepatic Paper Session – Oral 15 Malnutrition / Nutrition Assessment Paper Session - Oral 20 Parenteral Nutrition Paper Session – Oral 26 Pediatric / Neonatal Paper Session – Oral 32 Abstracts presented in educational symposia – Oral 38 Poster Abstracts 1-46 Parenteral Nutrition 44 Poster Abstracts 47-69 Critical Care, Trauma, Infection, Surgery, Inflammation, Transplant

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Poster Abstracts 70-90 Enteral Nutrition 104 Poster Abstracts 91-119 Malnutrition/Nutrition Assessment

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Poster Abstracts 120-145 Pediatric/Neonate 142 Poster Abstracts 146-167 GI/Hepatic 165 Premier Paper Session - Harry M. Vars Research Award Candidates

Vars Research Award Candidate, Abstract of Distinction 274231 - Intestinal Adaptation is Stimulated by Partial Enteral Nutrition Supplemented with the Prebiotic Short Chain Fructooligosaccharide in a Neonatal Intestinal Failure Piglet Model Jennifer Barnes, BS. 1; Kelly Tappenden, PhD, RD. 1 1University of Illinois, Urbana,IL Background: Butyrate, a short chain fatty acid (SCFA), has been shown to stimulate intestinal adaptation when added to parenteral nutrition (PN) following small bowel resection. However, due to its putrid and volatile properties, butyrate is not available in current PN formulations. Prebiotics are non-digestible food ingredients that promote activity of health stimulating intestinal bacteria, are fermented into SCFA, and may be a clinically feasible strategy to administer butyrate. This study investigated the effect of short chain fructooligosaccharide (scFOS) supplemented partial enteral nutrition (EN), with and without a probiotic, in neonatal piglets following partial enterectomy. We hypothesized that prebiotic consumption would stimulate intestinal adaptation, but may require concomitant provision of a probiotic. Methods: Neonatal piglets (48hrs old, n=87) underwent placement of a jugular catheter, an 80% jejunoileal resection and were then randomized to one of four treatment groups: 1) control (20% standard EN/80% standard PN); 2) control plus prebiotic (10 g/L scFOS); 3) control plus probiotic (1 x 109 CFU Lactobacillus rhamnosus GG (LGG)), or; 4) control plus synbiotic (scFOS + LGG). Animals received infusions for various times following surgery to examine acute (24h, n=6/group) and chronic (3d, n=6/group; 7d, n=9-10/group) adaptations. Dependent variables included cellular composition, crypt-villus architecture, epithelial proliferation and nutrient transport, measured in modified Using chambers. Results were analyzed as a randomized complete block design, treatments were separated using the least significant difference test and considered significant at p≤0.05. Results: Prebiotic treatment, regardless of day, resulted in increased ileal mucosa weight compared to all other treatments (mg/cm ileum, p=0.02), whereas the synbiotic treatment resulted in increased jejunal weight (g/kg piglet, p=0.03). Within piglets receiving treatment for 7 days, the prebiotic increased cellular protein abundance in the jejunum compared to the control and probiotic (μg protein/μg DNA, p=0.02). Prebiotic supplementation also resulted in greater ileal protein per length compared to control (mg protein/cm ileum, p=0.05). Ileal villus height increased in the synbiotic group (μm, p=0.01), regardless of day, specifically due to an increase in epithelial proliferation (PCNA cells/crypt, p=0.003). In the 7d prebiotic group, peptide transport was upregulated in the

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jejunum [∆ μA/cm2 (10 mM glycylsarcosine), p=0.03]; whereas glutamine transport was increased in both the jejunum and colon [∆ μA/cm2 (10 mM glutamine), p=0.001 and 0.003, respectively]. Conclusions: Prebiotic and/or synbiotic supplementation resulted in an expansion of the functional surface area throughout the residual intestine by increasing epithelial cell proliferation and villus length, resulting in increased mucosal mass in the ileum. Individual cells expressed more protein and the absorptive capacity of glutamine and peptides was enhanced. Structural remodeling of the mucosa preceded increases in nutrient absorption. As such, prebiotic therapy may require protracted consumption for maximum benefit. The parallel effects of the prebiotic and synbiotic treatments, in conjunction with the probiotics lack of efficacy, indicate that adaptations are due to scFOS, with no further impact provided by LGG administration. Identification of a synergistic prebiotic and probiotic combination may enhance the promising results obtained with prebiotic treatment alone, but awaits further study.

Vars Research Award Candidate, Abstract of Distinction 273941 - Glutamine Prevents Apoptosis in Intestinal Epithelial Cells during Heat Stress and Oxidative Injury Models Alyssa Kalweit, BA.1; Diana Stutzman, BS.1; Christine Baird, BS.1; Paul Wischmeyer, MD.1

1 University of Colorado Anschutz Medical Campus. Aurora, Co. Introduction: Glutamine (GLN) treatment can decrease mortality, length of hospital stay and infectious complication in critically ill patients. Our laboratory has shown GLN mediated cellular protection involves different mechanisms specific to type of injury. During heat stress (HS) injury, GLN enhances heat shock proteins (HSPs) 25, 32 and 70 which are protective. During oxidant injury, GLN only enhances HSP32. However, GLN’s effect on cleaved caspase 3, a key mediator for apoptosis, during these specific injuries remains to be elucidated. The purpose of this study was to determine if GLN is protecting by decreasing apoptotic mediators during both models of injury. Methods: IEC-18 cells were treated for 15 min with 0mM GLN (CT) or 8mM GLN, and subjugated to either lethal injury for cell survival (HS of 44 degrees for 50 min or 4mM H2O2 for 30 min), or non-lethal injury for protein expression (HS of 43 degrees for 45 min or 600uM H2O2 for 30 min). Survival was determined via MTS assays after 24hrs. All injured groups were normalized to non-injured controls to account for differences in cell proliferation and growth. HSP25, HSP32, HSP70 and Cleaved Caspase-3 protein levels were evaluated via western blotting after a 3hr recovery. Results: MTS assays showed GLN increased survival 4-5 fold during lethal HS and oxidant injury (p<0.01 vs HS CT or H2O2). Western Blot showed an increase in all three HSPs in GLN treated groups (p<0.03 vs HS CTs). In oxidant injured cells, GLN more than doubled HSP32 (p<0.001 vs. H2O2 only). Cleaved caspase-3 decreased in GLN treated groups in both HS and oxidant injury (p<0.0002 and p<0.02 respectively, vs. non-GLN treated CTs). Conclusions: GLN protects intestinal cells from both heat and oxidant injury. HSP25, 32, and 70 levels were significantly increased by GLN during HS. In the oxidant injury model, only HSP32 protein levels were affected by GLN. In both HS and oxidant injured cells GLN lowered the expression of cleaved CASP3, a key activator in programmed cell death, thereby preventing apoptosis.

Vars Research Award Candidate, Abstract of Distinction 273654 - Perioperative immunonutrition in surgical cancer patients Stanislaw Klek, MD, PHD.1; Piotr Szybinski, MD, PhD.1; Kinga Szczepanek, MD.1

1Stanley Dudrick's Memorial Hospital, Skawina, Poland Introduction: The immunomodulating nutrition was designed to improve the outcome of surgery. Recently, my authors questioned its real clinical value. The aim of our studies was to evaluate the impact of enteral immunonutrition on treatment results. Methods: Between January 2003 and December 2009, 488 patients (192 F, 296 M, m. age 61) undergoing resection for pancreatic or gastric cancer were randomized in double-blind manner to receive either postoperative immunomodulating enteral diet (IMEN) or standard oligopeptide diet (SEN). Outcome measures of the intend-to-treat analysis were: number and type of complications, length of hospitalization, mortality, and vital organ function. Results: In malnourished patients median postoperative hospital stay was 17.1 days in SEN and 13.1 days in IMEN group (p = 0.006). Infectious complications were observed in 60 patients (39.2%) in SEN and 43 (28.3%) in IMEN group (p = 0.04). Differences were also observed in overall morbidity (47.1 vs 33.5%, p = 0.01) and mortality (5.9 vs 1.3%, p = 0.03). In well-nourished median postoperative hospital stay was 12.4 days (SD 5.9) in SEN and 12.9 days (SD 8.0) in IMEN group (p=0.42). Complications were observed in 21 patients (23.1%) in SEN and 23

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(25.2%) in IMEN group (p>0.05). Four (4.4%) patients in SEN group and 4 (4.4%) in IMEN had surgical complications (p>0.05). In both groups, vital organ function and treatment tolerance did not differ. Conclusions: The study proved that postoperative immunomodulating enteral nutrition should be the treatment of choice in malnourished surgical cancer patients, while its use in well-nourished patients should be carefully considered.

Vars Research Award Candidate, Abstract of Distinction 272847 - Insulin resistance induced by continuous parenteral or enteral nutrition is associated with impaired insulin signaling and GLP-1 secretion in neonatal pigs. Barbara Stoll, PhD.1; Liwei Cui, Research Assistant1; Jens J Holst, MD, PhD.2; Douglas Burrin, PhD.1 1USDA-ARS Children's Nutrition Research Center, Dept Pediatrics, Baylor College of Medicine, Houston, TX; 2Panum Institute, Department of Medical Physiology, University of Copenhagen, Copenhagen, Denmark Introduction: We previously showed that continuous administration of an elemental diet, parenterally or enterally, results in hepatic insulin resistance and steatosis in neonatal pigs (CNW abstract 2009). Our current aim was to test whether continuous compared to intermittent nutrient administration impacts insulin signaling and incretin response in neonatal pigs. Methods: Neonatal pigs (3-d-old, n=56), implanted with catheters in the jugular vein, carotid artery, and stomach were fed enterally via gastric catheter or parenterally via jugular vein catheter for 14 d with one of 4 feeding modalities as follows: 1) enteral feeding of a milk-based formula every 4 h (FORM); 2) enteral feeding of a complete elemental diet (ED) (amino acid, glucose, lipid) every 4 h (intermittent enteral nutrition, IEN); 3) enteral feeding of ED continuously (continuous enteral nutrition, CEN); 4) parenteral feeding of ED continuously (total parenteral nutrition, TPN). Subgroups of pigs (n=4-8/group) underwent intravenous glucose tolerance tests (IVGTT) on d 7 and 14. At the end of the study period, subgroups of pigs (n=5-8/group), were infused with D-[13 C6] glucose and submitted to hyperinsulinemic-euglycemic clamps (CLAMP). Following the clamp, pigs were euthanized, and tissues were collected for further analysis. Results: GLP-1 secretion during feeding was highest in FORM and lowest in TPN pigs (Fig 1). Insulin secretion during IVGTT on d 7 and 14 was significantly higher in CEN and TPN than FORM. Glucose infusion rates during CLAMP were not different between TPN and CEN, whereas IEN and FORM were significantly higher than TPN or CEN. The endogenous glucose production rate (EGP) was higher in FORM that all other treatments, and not different from Zero during CLAMP. Phosphorylation of the insulin receptor (pIR) in liver (Fig 2) and muscle under insulin-stimulated conditions (post-clamp) was decreased in IEN, CEN, and TPN compared to FORM (Fig). Liver mass was highest in TPN and liver triglyceride content was higher in CEN and TPN than FORM and IEN. GLP-2 secretion during feeding was higher in all enteral groups compared to TPN and final ileal mass was different between all treatments, with FORM, IEN, CEN, TPN from greatest to smallest. Conclusions: We conclude that intermittent nutrient administration, given either in elemental or polymeric form, maximized insulin sensitivity compared to continuous feeding. Moreover, insulin resistance induced by continuous parenteral or enteral administration of an elemental nutrient solution is closely linked to reduced GLP-1 secretion and tissue insulin signaling. Interestingly, enteral elemental nutrients, given continuously or intermittently, were associated with marked steatosis, but this was not strictly linked to insulin sensitivity. Thus, it appears that the pattern (continuous vs intermittent) has a greater impact than the route (enteral vs parenteral) of nutrient administration on insulin sensitivity. It remains to be seen whether feeding FORM continuously or TPN intermittently decreases or increases insulin sensitivity, respectively.

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Mean ± SEM. abcd different from TPN, CEN, IEN, FORM, respectively, P<0.05.

Mean ± SEM. abcd different from TPN, CEN, IEN, FORM, respectively, P<0.05.

Vars Research Award Candidate, Abstract of Distinction 274380 - A Randomized Controlled Pilot Trial of Glutamine in Patients Undergoing Cardiac Surgery: Oral Glutamine Reduces Myocardial Injury and Peri-Operative Complications Lindsay Weitzel, PhD.1; Alexandra Sufit, BA.1; Christine Baird, BS.1; Kelly Queensland, BA. 1; Ira Dauber, MD. 2; Olav Rooyackers, MD.3; Paul Wischmeyer, MD.1

1 University of Colorado Anschutz Medical Campus. Aurora, Co; 2. South Denver Cardiology Associates, Littleton, Co; 3Karolinska University Hospital, Stockholm, Sweden. Objective: Glutamine (GLN) has been shown to protect against in vitro and in vivo myocardial injury. In humans, peri-operative ischemia/reperfusion (I/R) injury during cardiac surgery is associated with higher morbidity and mortality. The objective of this pilot trial was to determine if pre-operative GLN attenuates myocardial injury in cardiac surgery patients. Methods: Patients undergoing elective cardiac surgery, requiring cardiopulmonary bypass, were enrolled in a randomized, double-blind pilot trial to receive 25g twice of oral Alanyl-glutamine (GLN) (n=7) or maltodextran (CONT) (n=7) daily for 3 days pre-operatively. Serum troponin (TROP I) and creatine kinase (CK-MB) were measured at multiple peri-operative time-points. Clinical outcomes were also recorded and compared. Results: GLN therapy significantly decreased TROP I levels at 24, 48, and 72 hours post-operatively (all p <0.05) versus CONT. GLN also reduced CK-MB at 24 and 48 hours (p < 0.05, p < 0.001) versus CONT. GLN also significantly reduced pooled clinical complications versus CONT (p=0.03).

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Conclusion: This pilot study showed that high dose oral GLN therapy prior to cardiac surgery was feasible. GLN therapy reduced myocardial injury and clinical complications in this randomized, blinded trial of 14 patients. This data indicates that a larger trial of pre-operative GLN therapy in patients undergoing cardiac surgery is warranted. Clinical Nutrition Week 2012: Nutrition & Metabolism Paper Sessions & Oral Presentations in Educational Symposia CRITICAL CARE – SURGERY PAPER SESSION

Abstract of Distinction 271615 - Underfeeding and protein catabolism lead to hospital-acquired infections in subarachnoid hemorrhage patients Neeraj Badjatia1, Aimee Monahan1, Amanda Carpenter1, Laura Friedman2, Jacqueline Zimmerman2, J. Michael Schmidt1, Jan Claassen1, Kiwon Lee1, E. Sander Connolly1, Stephan A. Mayer1, Wahida Karmally2, David Seres1 1Columbia University College of Physicians and Surgeons, New York, NY; 2Bionutrition Research Core, Irving Institute for Clinical and Translational Research, Columbia University, New York, NY.

Objective: To understand whether caloric intake and protein metabolism impacted the development of hospital acquired infections (HAI) after aneurysmal subarachnoid hemorrhage (SAH). Methods: Prospective serial assessments of resting energy expenditure (REE) and urine urea nitrogen (UUN, g/day) over 4 preset time periods during the first 14 post bleed days (PBD) in addition to daily caloric intake measurements in all SAH patients admitted between May 2008 – June 2011. Patients were excluded from study if they arrived >72 hours after ictus, had care withdrawn 3. Multivariate linear regression models were utilized to identify factors associated with the 14 day mean nitrogen balance. Factors associated with the time to initial HAI were entered into a backward Wald Cox proportional hazards model. Predictors of poor clinical outcome were identified by multivariate logistic regression. Results: There were 180 patients that met criteria during the study period. The mean age was 56 +/- 15 years old, 36%(n=65) women, mean body mass index (BMI) 28 +/- 6 kg/m2, median Hunt Hess score 3 (2,4), and median modified Fisher score of 3 (2,4). Over the first 14 days post hemorrhage, the mean REE was 1675 +/- 551 calories/day, total caloric intake was 850 +/- 450 calories /day (11.5 +/- 7 calories/kg/day), with a mean nitrogen balance of -4.9 +/- 5.3 grams/day. There were 45 SAH patients that developed 56 infections on mean PBD 9 +/- 3. The most common HAIs were pneumonia (n = 22, 39%) and urinary tract infection (n=14, 25%). The mean 14 day nitrogen balance was associated with mean caloric intake (β = 0.29, P <0.001), craniotomy for aneurysm clipping (β = - 2.2, P = 0.01), and modified Fisher score (β = -0.91, P = 0.02). Older age (HR: 1.03, 95% CI: 1.003, 1.05, P = 0.027), higher Hunt Hess score(HR: 1.63, 95% CI: 1.25, 2.13, P < 0.001), lower mean caloric intake (HR for every 450 calories/day: 0.41, 95% CI: 0.17,0.98 , P<0.001), more negative nitrogen balance (HR for every gram/day: 0.92 , 95% CI: 0.87, 0.97, P = 0.004) and higher BMI (HR: 1.05, 95% CI: 1.01, 1.1, P = 0.043) predicted time to HAI. Older age (OR: 1.05, 95% CI: 1.02,1.08, P = 0.001), HAI (OR: 2.63, 95% CI: 1.03,6.71 , P =0.04), and Hunt Hess score (OR: 2.46, 95% CI: 1.71, 3.55, P<0.001) were predictive of poor outcome at 3 months, after adjusting for female sex and modified Fisher score. Conclusions: Severity of underfeeding and protein catabolism predicts the development of HAI in the first two weeks after SAH. Prospective studies comparing different levels of matching nitrogen balance are required to know whether the negative nitrogen balance, and/or underfeeding, is causal or simply a marker for risk.

274329 - Performance of Predictive Equations in Ventilated Surgery Patients Jill Cherry-Bukowiec1, Allan Andrews1, Jennifer Wooley2, Melissa Pleva1, Heidi Reichert1, Kurt Sieloff1, Pauline Park1, Lena Napolitano1 1University of Michigan, Ann Arbor, MI; 2University of Michigan Hospital Patient Food and Nutrition Services, Ann Arbor, MI.

Introduction: Measuring resting energy expenditure (REE) by indirect calorimetry (IC) is considered the clinical gold standard for determining goal caloric requirements in hospitalized patients. If IC is unavailable, several different weight-based predictive equations are commonly used to estimate REE as they are readily available and low-cost, but most were originally developed in healthy subjects. In mixed medical–surgical adult ICU patients, calculated measurements have often been found to be inaccurate; however, little data is available regarding the

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accuracy of predictive equations in unmixed surgical ICU patient populations. Critically ill surgical patients requiring mechanical ventilation often have altered body composition secondary to resuscitation efforts in addition to variable metabolic demands dictated by their disease course. Evaluation of the accuracy predictive equations surgical ICU patients would be valuable to help guide clinician nutrition recommendations. We hypothesized that predictive equations would be inaccurate in predicting measured REE (mREE) by IC. Methods : Prospectively collected data were examined retrospectively for all adult mechanically ventilated surgical patients admitted to a single institution surgical ICU who had a valid IC measurement and the required data to predict REE using the following22 predictive equations The study cohort included patients who had a valid IC measurement and the required data to predict REE using the following equations: Harris-Benedict, 20, 25, and 30 Kcal/Kg/Day, World Health Organization, Ireton-Jones 1992 and 1997, Mifflin-St. Jeor, Liu, Penn State 1998, 2003a, and 2003b Shofield, Swinamer, Savard/Faisy, Roza, Fusco, and Kleiber. The accuracy and validity of each predictive equation was assessed by direct comparison with the measured REE by IC using the Delta Trac II. The data was evaluated collectively (Table 1) and stratified by age, gender and BMI class. The equations used to determine body mass are listed in Table 2. Results: A total of 537 surgical ICU patient studies were identified for evaluation. The equations with the best overall performance were the Penn State 2003a, Swinamer, and Penn State 2003b equations. Even these equations, predicted the mREE within +/- 10% (defined as accurate) less than 40% of the time and within +/- 15 % less than 57% of the time. Some equations performed better in certain age, gender and BMI classes, while others performed more poorly. Equation tendencies to over or under-estimate mREE often varied with age, gender, and BMI class. Conclusion: Estimating daily caloric requirements using predictive equations in critically ill surgical patients is often inaccurate. Some equations, including ACCP and ESPEN guidelines, performed particularly poorly in this cohort. Therefore, IC should be performed whenever possible in ventilated surgical ICU patients.

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Abstract of Distinction 271568 - Pre-Operative Carbohydrate Loading Improves Post-Operative Food Intake in Rats Joanna Luttikhold1, Annemarie Oosting1, Paul van Leeuwen2, Klaske van Norren1, Hetty Bouritius1 1Nutricia Advanced Medical Nutrition, Danone Research - Centre for Specialised Nutrition, Wageningen, The Netherlands; 2VU University Medical Center, Amsterdam

Background: The “Enhanced Recovery of patients After Surgery” (ERAS) program is based on a multi target approach, intended to attenuate a patient’s metabolic stress response to surgery, improve clinical outcomes, and enabling a faster recovery. This approach, also known as “fast track” rehabilitation in colorectal surgery, is based on a combination of evidence based principles, designed to optimise patients care peri-operatively and accelerate recovery times. The ERAS program recommends pre-operative carbohydrate loading 2 hours prior to surgery, and re-establishment of oral feeding as early as possible after surgery. The aim of this study was to investigate whether a pre-operative carbohydrate drink improves spontaneous post-operative food intake. An intestinal ischemia reperfusion (IR) model in rats was used to investigate our hypothesis. Methods: Male Wistar rats were divided into 3 groups. A fasted sham-operated group (Sham-group, n=16) was subjected to 16 hours of fasting and sham laparotomy. The second group (IR-fasted-group, n=18), was also fasted for 16 hours followed by laparotomy and 70 minutes of intestinal ischemia (a 100% occlusion of the superior mesenteric artery). The third group was subjected to laparotomy and intestinal ischemia, but was given 35 ml of a clear carbohydrate drink (12.6% carbohydrates, Nutricia preOp, Nutricia Zoetermeer) pre-operatively (IR-carb-group, n=14). All animals had ad libitum access to water. After surgery, animals were allowed to recover for 24h with ad libitum access to food. Spontaneous food intake was measured every hour after surgery for 24 hours. Results: In the first 24h post-operatively, rats in the IR-carb-group had a significantly higher food intake (p<0.05) compared to the rats in the IR-fasted-group (5.69±2.47 versus 3.28±2.01 g/24h) (figure 1). Also, rats in the IR-carb-group started eating significantly earlier (p<0.01) than the IR-fasted-group (4.14±1.10 versus 7.28±2.95h) (figure 2). Moreover, the mean starting time of eating of the IR-carb-group was equal to the time the Sham-group started eating. Conclusions: Pre-operative carbohydrate loading improved food intake in the first 24h post-operative. The animals started eating earlier, but also ate more the first 24 hours than the fasted group. Moreover, after pre-operative carbohydrate loading rats started eating at the same time as the rats who were subjected to a sham laparotomy. There is an important role of carbohydrate loading in allowing early post operative food intake, as recommended in the ERAS guidelines. These findings suggest that pre-operative carbohydrate loading facilitates other nutritional key aspects of post-operative care.

Figure 1. Ad libitum cumulative food intake after intestinal ischemia and reperfusion compared to sham laparotomy. Results are presented as mean ± SEM.

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Figure 2. Start of food intake after intestinal ischemia and reperfustion compared to sham laparotomy. IR carb versus Sham p=0.6 and IR carb versus IR fasted p=0.001. 274624 - Computed tomography fails to validate Subjective Global Assessment measures of malnutrition in critically ill patients Patricia Sheean1, Sarah Peterson2, Sally Freels1, Sandra Gomez1, Karen Troy1, Joy Sclamberg2, Ankur Patel2, Omar Lateef2, Carol Braunschweig1 1University of Illinois at Chicago, Chicago, IL; 2Rush University Medical Center, Chicago, IL.

Introduction: Subjective Global Assessment (SGA) utilizes data concerning weight loss, gastrointestinal symptoms, functional capacity and physical appearance to classify nutritional status. We previously reported that SGA can be conducted reliably in critically ill patients, yet we did not validate these findings with a “gold standard” nutritional status measure to confirm the ability of SGA to detect lower levels of lean body mass (LBM) - a fundamental presumption made for patients classified as “malnourished.” Computed tomography (CT) scans completed for diagnostic purposes have been used to precisely assess body composition in a variety of other patient populations. The purpose of this cross-sectional investigation was to validate SGA using CT, since this has not been previously reported. We hypothesized that critically ill individuals classified as “malnourished” (ie, moderate or severe malnutrition) would have lower levels of LBM than those classified as “normal” nourished. Methods: The medical records of patients admitted to the medical or surgical intensive care unit (ICU) at a tertiary care hospital over a 15 month period were reviewed for individuals who: 1) had a nutrition assessment completed by an ICU registered dietitian trained and experienced in using SGA; and 2) had undergone diagnostic abdominal, chest or pelvic CT scanning within 7 days of SGA evaluation. Demographic data, admission body mass index (BMI), APACHE II scores, and hospital length of stay (LOS) were collected for patients meeting eligibility criteria. Muscle mass was quantified by a trained individual using appropriate software to obtain the volume of muscle (cm2) at the third lumbar vertebrae (L3). This technique incorporates quantification of the rectus abdominis, transverse abdominus, internal and external obliques, latissimus dorsi, erector spinae and quadratus lumborum muscles and has previously been shown to correlate with whole body lean mass. Descriptive statistics and T-tests were conducted to assess differences across nutrition status strata. Results: Twenty-one individuals had evaluable data. The majority were male (62%), white (48%), 58 + 17 years of age and overweight (BMI 28.3 + 5.1 kg/m2) with APACHE II scores of 25.8 and a hospital LOS of 40 + 25 days. When dichotomized, 10 patients were classified as “normally nourished” and 11 were ranked as “malnourished” (11 ranked as “moderate”; 0 ranked as “severe”) at ICU admission. No significant differences were observed in muscle volume at the L3 region for patients initially classified as “normally nourished” vs. “malnourished” (14,520 + 4657 vs. 13,227 + 4215 cm2, respectively, p=.67),; adjustment for BMI was not significant (p=.28). Conclusions: While this sample is small and does not reflect changes over time, these data do suggest SGA cannot differentiate levels of LBM in individuals deemed “malnourished” or “normal nourished” at ICU admission. Further studies are needed to identify and/or refine a “gold standard” nutrition status classification that can accurately discriminate lower levels of LBM in a larger cohort of critically ill patients.

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Abstract of Distinction 273875 - Use of parenteral nutrition in critically ill cardiovascular patients is related to higher mortality Peter Weijs1, Albertus Beishuizen1 1VU University Medical Center, Amsterdam, The Netherlands

Rationale: In previous studies (Strack van Schijndel et al. 2009; Weijs et al. 2011) we showed that adequate protein and energy intake relates to decreased 28 day mortality in ICU patients. Use of parenteral nutrition (PN) in critically ill patients is highly debated and associated with disruption of the intestinal mucosa, hyperglycemia and increased risk for nosocomial infection. The EPaNIC trial showed no advantage of early supplemental use of PN, day 1 versus day 8 (Casaer et al. NEJM 2011). A recent Supplemental PN RCT from Switzerland showed beneficial effects of supplemental PN from day 4 (Lancet 2011, in press). One of the main differences was the number of cardiovascular patients, 60% in the EPaNIC trial and only very few patients in the Swiss RCT. In a large cohort of critically ill patients with detailed monitoring of adequate protein and energy intake and who were all fed according our energy-protein targeted algorithm, we looked at diagnosis-specific effects of use of PN on outcome parameters. Methods: From a cohort of 2226 ICU patients diagnostic categories such as sepsis, respiratory insufficiency, post surgical, and cardiovascular failure, were analysed for outcome effects of PN use (any amount used during total period of mechanical ventilation). Effect was analysed by Cox regression analysis on ICU mortality with adjustment for common confounders such as sex, age, BMI, hyperglycemic index, APACHE II, and protein and/or energy target reached (yes/no). Hazard ratios (HR) with 95% confidence interval (CI) are presented for cardiovascular and non-cardiovascular patients. Results: The table shows higher ICU mortality in critically ill cardiovascular patients with PN compared to those without PN. This in contrast to other all other diagnoses. EN use within cardiovascular group was similar, with a mean of 0.5 liter PN in PN+ group. Therefore the PN+ received more adequate amounts of nutrition. However, there was no difference in energy or protein targets achieved between survivors and died patients in the PN+ group. This observations were similar for the non-cardiovascular group. Conclusion: The use of parenteral nutrition is associated with adverse effects on outcome in critically ill cardiovascular patients. This should be confirmed by a randomized trial. Reference(s): Strack van Schijndel RJ, et al. Crit Care. 2009;13(4):R132. Weijs PJM, et al. JPEN. 2011 (in press).

274162 - Glutamine Activates Heat shock transcription Factor-1 (HSF1) Gene Transcription Hongyu Xue1, Dobromir Slavov1, Paul Wischmeyer2 1University of Colorado, Aurora, CO; 2University of Colorado Anschutz Medical Campus, Aurora, CO

Introduction: Glutamine (GLN) is a key “pharmacologically-acting nutrient? Recent studies by our group show bolus GLN in pharmacologic doses can safely enhance heat shock protein (HSP) expression in experimental models of inflammatory and infectious injury. Induction of HSPs is an important innate mechanism to protect cells against stress/injury and thus appears to be vital for GLN’s protection against injury. However, the mechanisms by which GLN enhances HSP expression remain unclear. Heat shock transcription factor-1 (HSF1) is the master regulator for heat shock gene expression. In this study, we are aimed to explore GLN’s effects on HSF1’s expression and activity. Methods: Non-stressed or stress-challenged (hyperthermia or cytokine injury) YAMC colonic epithelial cells were exposed to GLN at 0, 0.5 or 2mM. HSF1’s expression (Western blot and RT-PCR), global phosphorylation (Western blot), nuclear translocation (Western blot and immunofluorescent staining), trimerization (native gel electrophoresis) and DNA binding (electromobility shift assay) were determined. HSF1 gene promoter-driven luciferase (luc) activity assay was performed. HSF1 expression was knocked down via siRNA to explore the role of enhanced HSF1 expression in GLN’s modulation of HSPs. Deletion analysis of HSF1 gene promoter region was conducted to identify the key cis-element(s) involved in GLN-induced HSF1 transcription activation, Results: GLN upregulated HSF1’s transactivation activity by increasing its spontaneous and stress-induced trimerization, nuclear translocation and DNA binding in non-stressed and stress-challenged cells. Further, GLN increased HSF1

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expression in both non-stressed and stressed cells. Immunofluorescent staining against HSF1 confirms that GLN increased HSF1 total cellular expression and nuclear localization. Knocking down HSF1 expression abrogated GLN’s upregulation of HSP expression suggesting GLN-mediated upregulation of HSP is dependent on GLN’s induction of HSF1 expression. Analysis of HSF1 mRNA expression kinetics suggests GLN transcriptionally activates HSF-1 expression. Deletion constructs of HSF1 promoter down to p331/luc didn’t have significant effect on GLN inducibility; whereas deletion construct p200/luc lost this response, suggesting the key cis-positive element responsible for GLN response is present in the HSF1 promoter between bp -331 to -200. Further, within this 132 bp region, deletion of the putative C/EBP binding site (-263/-254) resulted in decreased responsiveness to GLN, whereas deletion of the other putative site (-211/-202) for ATF/CREB binding didn’t have significant effects on GLN inducibility. This suggests that c/EBP site is essential to GLN-induced transcriptional activation of HSF1 gene. When we knocked down C/EBPβ expression by siRNA, HSF1 protein expression was markedly de-repressed when no GLN supplemented, suggesting that C/EBPβ is essential for repressed HSF1 expression associated with GLN deprivation. Conclusions: This study provides the First evidence showing that GLN is not only an activator of HSF1’s transactivation activity, but also increases HSF1 expression per se. GLN-mediated HSF1 induction is the direct mechanism underlying GLN’s upregulation of HSP. Further, we for the first time show that GLN activates HSF1 gene transcription. C/EBP binding site within the proximal promoter sequence of HSF1 could be the key cis-element responsible for GLN response and further, we identified C/EBPβ could be a potential sensor molecule linking GLN’s availability signaling to HSF1 transcriptional regulation.

ENTERAL NUTRITION PAPER SESSION 273652 - Which is More Effective to Prevent Enteral Nutrition-Related Complications, High- or Medium-Thickened Enteral Formula? - in Patients with Percutaneous Endoscopic Gastrostomy - Satomi Ichimaru1, Teruyoshi Amagai2, Yoshihiko Shiro1, Maki Wakita2 1Kobe City Hospital Organization Medical Center West Hospital, Kobe; 2Mukogawa Women’s University, Nishinomiya

Introduction: Nausea, vomiting, diarrhea are common complications occurring in patients receiving enteral nutrition (EN) via percutaneous endoscopic gastrostomy (PEG) tube. To prevent these complications, reducing the rate of infusion or providing a small bolus less than 100 ml per feeding are recommended. However, these methods increase caregivers' burden, risk for pressure ulcer, and decrease patients' rehabilitation time. Recently, an administration of thickened enteral formula (TEF), instead of liquid formula via PEG tube is becoming common practice in Japan expecting to prevent complications of gastroesophageal reflux, aspiration pneumonia, vomiting, diarrhea, and to improve patients' quality of life. TEFs are often made by combination of liquid formula and thickener (LT), or some ready-to-use (RTU) TEF products with various viscosities are available in the market. Although higher viscosity is thought to be more effective, an adequate viscosity remains to be studied. Aim: To study clinical effects of TEFs with different viscosities administered through PEG tube. Methods: (1) Measure the viscosities of LT (100 ml of CZ-Hi® and 4 g of thickener: Tsururinko for Milk and Liquid Diet® with 25 ml water) and RTU (PG-Soft EJ®) were evaluated by a rotational viscometer TV-22 (TOKI SANGYO Co. Ltd. Tokyo, Japan). (2) A retrospective chart review was conducted in patients who underwent PEG placement and were fed EN in a single municipal hospital between April, 2010 and March, 2011. Analyzed parameters were types of formula, enteral and parenteral nutritional intake (daily energy intake: kcal/day, kcal/kg/day, and daily protein intake: g/day, g/kg/day), EN-related complications, outcomes for two weeks after initiating EN via PEG tube. Statistical analysis was performed by using the Mann-Whitney's U test and differences at P<0.05 were considered to be statistically significant. Results: (1) The viscosities of RTU- and LT-TEF were 10,382±931 mPa・s, defined as high viscosity and 3,492±296 mPa・s, defined as medium viscosity in this study. (2) Fifty-three patients were recruited in the study. Three patients were excluded: one took oral nutrition more than 20kca/kg/day, one died after PEG, and one discharged on the next day of PEG. Twenty-one subjects were fed high-viscosity TEF, and sixteen were fed medium-viscosity TEF. Five subjects were fed TEFs made by other liquid formulas and eight were fed liquid formulas. (3) Fluid intake via PEG tube was less in patients with high-viscosity TEF in the first week (9.0 vs.15.0 ml/kg/day, P<.001) although no significant difference was observed in energy intake. (4) There was no significant difference in the amount of cough, sputa, or the number of cases of fever, diarrhea, constipation, vomiting and infection among two groups who were fed high- or medium-viscosity TEF in the first week (Table1), and the same results were observed in the second week. (5) There was no significant difference in length of hospital stay or

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mortality rate (Table2). Conclusions: High-viscosity formula does not appear to have advantages for preventing EN-related complications in comparison with medium-viscosity formula.

273985 - Ciprofloxacin dissolution inhibited by enteral nutrition Mark Klang1, Patrick Hu1, Yasmin Saafan1 1Memorial Sloan-Kettering Cancer Center, New York , NY.

Introduction: Ciprofloxacin interacts with enteral nutrition. The mechanism is not known. This study was undertaken to determine if diluting the tablet formulation would improve dissolution and avoid withholding nutrition when drug administration is needed. The tablet formulation was tested since the suspension formulation package insert advises against feeding tube administration. Methods: All phases of this study were conducted in triplicate. Ciprofloxacin 500 mg tablets were crushed and mixed with water to concentrations of 10, 12.5 and 25 mg/mL. Dialysis pouches were prepared which included 2.5 ml of the drug mixture and 2.5 ml of standard enteral nutrition formula (Isocal® 1.2). A control packet was prepared for each of the concentrations using water to replace nutrition. Each packet was placed in 100 mL simulated gastric solution (SGS) (pH 1.2) and incubated at 37ºC for one hour. A one mL sample was withdrawn. Sodium bicarbonate was added to each bottle in sufficient quantity to shift the pH value to 6.8. Bottles were placed back in incubator. After 48 hours a sample was withdrawn. Samples were analyzed by HPLC using a previously validated stability indicating assay. Six linear samples were prepared for validation and the fraction dissolved was calculated and reported as the mean. The fraction dissolved was compared between the bottles containing nutrition addition and those with water added only. Results The samples of the most diluted (10 mg/ml) resulted in ~75% of the dissolved dose in SGS as compared to no nutrition. There was overlap in the high (25mg/ml and 12.5 mg/ml) resulting in 65% dissolved as compared to control. Samples taken at the end of the study

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showed a dramatic difference in the concentration dissolved as the amount dropped to ~25% dissolved in low concentration as opposed to 20% in the medium and high concentrations when compared to no nutrition present. The difference in outcome between the two groups was statistically significant (P= 0.04, Student T for paired samples) Conclusion This study reconfirms that a significant interaction occurs between enteral nutrition and ciprofloxacin dissolution. This study demonstrates that diluting the drug with water does little to minimize the interaction between ciprofloxacin and nutrition formulas. This in-vitro analysis does not establish that the ciprofloxacin will not be absorbed, but will be less available, since it did not dissolve when combined with nutrition. A clinical study is needed to verify the results found in this evaluation.

273733 - Enteral Nutrition in Liver Disease: A Systematic Review of the Medical Literature Ronald Koretz1, Timothy Lipman2, Alison Avenell3 1Olive View-UCLA Medical Center, Sylmar, CA; 2Veterans Affairs Medical Center, Washington, DC; 3Health Services Research Unit, Aberdeen, MD.

Background: In 2007, a systematic review of the randomized clinical trials (RCTs) of enteral nutrition (EN) in patients with liver disease failed to show that this intervention improved morbidity, but did improve survival. The objective of this study was to update that review. Methods: RCTs comparing EN to no nutritional intervention in patients with liver disease were sought via computer searches of MEDLINE, EMBASE, Science Citation Index Expanded, Cochrane Hepato-Biliary Group (CHBG) Controlled Trials Register, and the Cochrane Central Register of Controlled Trials through August 2011. In addition, hand-searches of specific journals and Index Medicus, including abstracts of both the American and European nutrition support societies, Digestive Disease Week and the annual meetings of both the American and European liver societies were done. In order to qualify, the trial had to have been randomized (quasi-randomized trials excluded), include a control group that received no more nutrition than regular food and up to 5% dextrose intravenously, and report at least one clinical outcome (mortality, ascites, gastrointestinal bleeding, encephalopathy, postoperative complications, duration of hospitalization, or cost). The identified trials were separated into those containing medical or surgical patients. The estimated effect was expressed as the relative risk (RR) for dichotomous data or as a weighted mean difference (WMD) for continuous data; the 95% confidence interval (CI) was calculated (Revman 5.0, Cochrane Collaboration). Risk of bias was determined by CHBG criteria. Results: Nine RCTs were identified (7 medical, 2 surgical); all were at high risk of bias. The estimated effects are summarized in the table. No cost data were available. Conclusions: There were only a small number of RCTs available, and these were all at high risk of bias (which may produce an overestimation of the treatment effect). The previously observed difference in mortality is no longer present, suggesting that the previous observation was a type I error. In medical patients, EN had no apparent effect. In surgical patients, EN improved postoperative morbidity, but this conclusion rests on the results of a single RCT at high risk of bias. The data are not strong enough to recommend the use of EN in liver disease.

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273953 - Postprandial Glycaemic Response to a Specific and Hypercaloric Diabetes Enteral Formula. Alejandro Sanz1, Javier Perez-Nogueras2, Jose Luis Gascon3, Teodoro Corrales3, Diana Boj4, Isabel Melchor4, Guayente Verdes4, Ramon Albero4 1Miguel Servet Hospital, Zaragoza, Spain; 2Residencia Elias Martinez, Zaragoza,Spain; 3Residencia Romareda, Zaragoza, Spain; 4Miguel Servet Hospital, Zaragoza, Spain

There is a close association between postprandial hyperglycaemia and cardiovascular risk. A lower glycaemic response after administration of diabetes specific enteral formulas (DSEF) compared to standard products has been demonstrated. However, a new hyper caloric specific formula for diabetics has been recently developed. Furthermore, in the daily practice most of the patients use enteral formulas in combination with regular food. The aim of this study was to evaluate the effect of two DSEF on postprandial glucose alone and in combination with meals. Subjects: Thirty five patients with type 2 diabetes treated with sulfonilurea who need nutritional supplementation due to of protein malnutrition. Informed consent was obtained. Intervention: Patients randomly received 220cc of 1.0 Kcal /cc DSEF or other 1.5 Kcal /cc DSEF instead of breakfast and added to lunch on two separate days with 6 days in between. In this way we can see postprandial response alone and in combination with lunch. Serum glucose was determined before and 1hour after breakfast and lunch. Blood glucose levels typically peak approximately 1 hour after the start of a meal. Diabetes Associations recommends a blood sugar target lower than 180 mg/dl one hour after a meal. Percentage of patients with postprandial glucose lower than 180 mg/dl (lower 180) was calculated. Formula Composition (grams of proteins/carbohydrates/fats/fiber in 100ml): 1.0-DSEF: 4.7/10/3.4/1.18 and 1.5-DSEF: 7.5/12.95/7.5/1.7. Statistics: Repeated measures analysis for variance with Wilcoxon test and Chi square. Results: 1-After DSEF intake in substitution of breakfast, mean glucose increase was similar for both formulas. Lower than180 were in 94.4% for DSEF 1.0 and 77.7% for DSEF 1.5 (p: 0.054). 2-Glucose late response (pre-Lunch) was again similar in both formulas. 3-After lunch supplemented with DSEF glucose increase was lower with DSEF 1.5 without significance. Lower than180 were in 72.2% for DSEF 1.0 and 83.3% for DSEF 1.5. Conclusion: The new concentrated DSEF-1.5 formula show similar glucose response than norm caloric DSEF-1.0.

273653 - Percutaneous Endoscopic Gastrostomy with Gastropexy Greatly Reduces the risk of Peristomal Infection

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Naoko Tsuji1, Naoki Okumura1, Norio Yamamoto1, Takehisa Takaba1, Nozomu Matsumoto1, Masatoshi Kudo2 1Sakai Hospital Kinki University Faculty of Medicine, Sakai, Japan; 2Kiniki University Faculty of Medicine, Osaka-Sayama, Japan

Introduction: The most widely used technique of percutaneous endoscopic gastrostomy (PEG) is the pull method, and the fistula infections are common early complication because gastrostomy catheters pass through oropharyngeal bacterial flora. The Funada-style gastropexy kit has two parallel needles with a wire loop and suture thread, and was developed about 20 years ago in Japan. This kit allowed us to perform a dual gastropexy very easily. PEG with gastropexy has become a very popular technique in Japan. METHODS: The present study aims to assess the advantages and disadvantages of PEG with the gastropexy technique compared to the standard pull method. The study included 172 consecutive patients undergoing PEG in our hospital, and a comparative study was made between the gastropexy group (87 patients) and non-gastropexy group (94 patients). The gastropexy group consisted of 28 patients of pull PEG with gastropexy and 59 patients of direct puncture PEG with gastropexy. All patients had an abdominal CT scan before procedure. RESULTS: There were no statistical differences between groups with respect to the clinical background, i.e., gender and age distributions, basic illnesses, and albumin. The success rates in both groups were 99%. The rates of patients with erythema in the peristomal area (10% vs. 47%, P<0.01), exudates (2% vs. 15%, P<0.01), ulceration (0% vs. 2%) and focal peritonitis (0% vs.2%) were lower in the gastropexy group. The rate of minor bleeding from the peristomal area was higher in the gastropexy group (13% vs. 2%, P<0.01), but no patient required a blood transfusion. Overall procedure times were longer in the gastropexy group (14 min to 72 min, mean 31 min vs. 6 min to 77 min, mean 24 min, P<0.01). The 30-day mortality rates were 4% and 5%, respectively, and these deaths were not related to the gastrostomy procedure. The peristomal inflammation rates of pull PEG with gastropexy patients (erythema: 10%, exudates: 3.5%) was not statistically different from that of direct puncture PEG patients. CONCLUSION: PEG with gastropexy markedly reduces peristomal infection. Although minor bleeding and a longer procedure time were disadvantages, there were no severe complications. Even if we adopt pull PEG methods, the peristomal infection rates become equal to that of direct puncture methods by using gastropexy. PEG with Funada-style gastropexy seems to be a safe and feasible method for reducing early complications of PEG.

274174 - Identifying a Caloric Requirement in Critically Ill Children within 48 hours of Admission is Associated with Early Enteral Nutrition Martin Wakeham1, Melissa Christensen1, Jennifer Manzi1, Susan Connolly1, Evelyn Kuhn2, Matthew Scanlon1, Praveen Goday1, Theresa Mikhailov1 1Medical College of Wisconsin, Milwaukee, WI; 2Children's Hospital of Wisconsin, Milwaukee, WI

Hypothesis: Identifying a caloric requirement (CR) within 48 hours of admission to the pediatric critical care unit (PICU) is associated with early enteral nutrition (EN), which is defined as intake of 25% of the caloric requirement via the enteral route within 48 hours of admission. Aims: To determine whether identifying a CR within 48 hours of admission to the PICU is associated with early EN and higher total daily caloric intake during the first 4 days of admission. Methods: This was a sub-group analysis of patients being studied as part of a retrospective chart review nutrition project by 12 centers participating in this multicenter study through the PICU FOCUS Group of the National Association of Children’s Hospitals and Related Institutions. Five centers amended their local Institutional Review Board (IRB) approval to collect supplementary data. Information relating to demographics and Pediatric Intensive Care Unit (PICU) admission was acquired from the Virtual PICU Systems (VPS LLC) clinical database. Nutritional intake data (i.e., route, quantity, and content) and identified CR data (i.e., presence/absence and amount) was obtained by chart abstraction. Data were collected for a subset of patients, ages 1 month to 18 years who had a PICU length of stay greater than 96 hours from January 1, 2007 to December 31, 2008. Timing of patient data collection for each center depended on when IRB amendment approval was obtained relative to data collection for the larger nutrition project, but represented at least 43.8% of their total sample. Nutritional intake data were gathered on only the first 96 hours of PICU admission, and CR data were collected for the first 48 hours of PICU admission. All daily caloric intakes are reported as a percentage of the caloric requirement that was determined using the WHO equation and not from the CR identified by chart review. The difference of early EN among patients with and without a CR was analyzed using chi-square test. Caloric intake among patients with and without an identified CR was analyzed using Mann-Whitney tests (due to the skewed distribution of caloric intake). Results: We studied 1350 patients, of which 52.1% were male. The mean age was 4.9 (± 5.5) years. About half of the patients (n=645, 47.8%) had an identified CR entered in the chart within 48 hours of admission. Patients with an identified CR were more

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likely to receive early EN than those without an identified CR [31.8% vs. 19.6%, OR= 1.9 (95% confidence interval 1.5-2.5) (p< 0.0001)]. Patients with an identified CR had higher total daily caloric intake (enteral or enteral + parenteral) than those without an identified CR at hours 24, 48, 72 and 96 after PICU admission (p<0.001). Conclusions: Identifying a caloric requirement within 48 hours of admission to the PICU is associated with early EN and higher total daily caloric intake during each of the first four 24 hour intervals after PICU admission.

GI – HEPATIC PAPER SESSION

Abstract of Distinction 273738 - Non-digestible Carbohydrates in the Diet Modulate Toxicity of CPT-11\5Fluorouracil Chemotherapy in Rats Bearing Ward Colon Tumor Xiaoxi Lin1, Arazm Farhangfar1, Michael Gaenzle1, Michael Sawyer1, Catherine Field1, Bart Meijer2, Vickie Baracos3, Levinus Dieleman1 1University of Alberta, Edmonton, AB, Canada; 2Leiden University Medical Center, Leiden, the Netherlands; 3Cross Cancer Institute, Alberta Health Services, Edmonton, AB, Canada.

INTRODUCTION: It is suggested that selective fermentation of the non-digestible portion of plant foods (dietary fibre) by gastrointestinal microbiota may alter intestinal physiology and response to injury. Our aim was to assess effects of non-digestible carbohydrates (NDCHO) on the pathobiology of mucosal injury after CPT-11 chemotherapy. This toxicity is a primary limitation to treatment of colorectal cancer. Gut injury is attributed to the toxic and active CPT-11 metabolite (SN-38), which is thought to be generated by conversion of its inactive glucuronide by bacterial β-glucuronidase in the large intestine, leading to loss of intestinal barrier, inflammation, microflora alterations and impaired intestinal and systemic immunity. METHODS: Female Fisher rats bearing Ward colon tumor were treated with 2 cycles of CPT-11/5 fluorouracil (FU). Animals (n=6/diet) were fed 6 different AIN-76 based diets including 10% (w/w) fibre as cellulose, inulin, oligofructose (OligoF), 50:50 (w/w) inulin and oligoF (Synergy®), isomalto-oligosaccharide (IMO), type IV resistant starch (RS4); one further low fibre diet containing 2% (w/w) cellulose was included. Body weight and food intake were followed continuously, prior to killing 2 days after the 2nd chemotherapy cycle. Evaluations included immune cell phenotypes in mesenteric lymph nodes (MLN), as well as caecal digesta β-glucuronidase activity and CPT-11 metabolites, systemic and intestinal inflammatory markers, intestinal microbiota (qPCR) and microbial metabolites. RESULTS: Variations in NDCHO across the 7 diets corresponded to significant variation in clinical and biological indices of toxicity. Animals fed RS4 or Synergy® were least ill based on the following criteria: body weight, food intake, acute phase response (haptoglobin, alpha-1-acid glycoprotein), immune cell phenotype in MLN (levels of T (CD3+) and cytotoxic T (CD3+CD8+) lymphocytes, T cell inhibitory marker CD152, T cell activation marker CD71 and MHC II antigen presenting cells (OX6)). By these same criteria, animals fed IMO or 2% cellulose were the most ill, with animals fed inulin, 10% cellulose and OligoF showing intermediate values. Across all animals and diets (n=42), concentration of SN38 in jejeunal and caecal digesta was significantly correlated (p<0.05) with weight loss, decreased food intake as well as all of the inflammatory and immune indices cited above. With respect to the involvement of the microbiota, proportions of major species in caecal digesta (i.e Clostridium, Enterobacteriacae, Lactobacillus, Bifidobacteria) were largely invariant and these organisms showed no expression of virulence factors. Unexpectedly, animals with the least toxicity had higher β-−glucuronidase activity in the caecal digesta as well as increased levels of buyrate, acetate and propionate and up-regulation of butyrate transporter gene expression in colon tissue. CONCLUSIONS: In this controlled comparison of multiple NDCHOs in CPT-11-induced intestinal injury, RS4 and Synergy® mitigated toxicity compared with other fibres or a low (2%) fibre diet. The potential for clinical benefit of dietary fibres in human colorectal cancer patients treated with CPT-11 remains to be established. CPT-11 toxicity appears related primarily to SN38 levels, while bacterial β-−glucuronidase activity is not the main culprit as generally believed. An alternative explanation of the role of the microbiota in this form of chemotherapy-induced injury is the formation of metabolites beneficial to the mucosa, such as butyrate.

Abstract of Distinction 271548 - Symbiotic improves women chronic constipation. A prospective, double blind, controlled study. Luciana Logullo1, Maria de Lourdes Teixeira da Silva1, Amanda Figueiredo Bittencourt1, Glaucia Midori Shiroma1, Natalia Pelegrino Paulino1, Dan Waitzberg2 1GANEP, São Paulo, AL, Brazil; 2Hospital Santa Catarina, São Paulo, Brazil

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BACKGROUND / OBJECTIVES: Chronic constipation has high prevalence among adult women. Symbiotic can positively affect the composition and balance of human intestinal microbiota, thereby improving bowel function. These properties can be potentially useful for the treatment of chronic constipation. Our aim was to evaluate the effectiveness (applicability and tolerance) of a commercially available symbiotic (FOS + probiotics) for the treatment of chronic constipation in women. SUBJECTS / METHODS: Our study was a prospective, double-blind, randomized, placebo-controlled trial involving 100 volunteer women considered constipated according to Rome III criteria. Both groups (experimental (e) and control (c)) had one basal week (observational) followed by four weeks of treatment. The group (c) received placebo (maltodextrin) and the group (e) received symbiotic (FOS, Lactobacillus paracasei 10 8-9 UFC, Lactobacillus rhamnosus 108-9 UFC, Lactobacillus acidophilus 108-9 UFC and Bifidobacterium lactis 108-9 UFC), twice a day, with identical sachets (6g). Outcome clinical measurements included abdominal discomfort, bloating, stool consistency (Bristol scale) and bowel movements daily frequency, evaluated and graded by the patients through a recorded daily questionnaire and a weekly interview done by the researcher. RESULTS: There was an increased frequency of bowel movements and a statistically significant difference along the second week of treatment onwards in the symbiotic versus placebo group (frequency in second week: 0.64 +/- 0.28 vs 0.47+/- 0.20, p0.05). CONCLUSIONS: In chronic constipated women, the consumption of symbiotic for 30 consecutive days was effective to increase the number of bowel movements and stool format. The average of bowel movements over time increases in patients with symbiotic from the second week of their intake. Symbiotic over placebo favorably modifies the format and consistency of the stool from the third week of their intake without significant adverse effects.

274379 - Acute intake of saturated fat/polyunsaturated fat influences postprandial lipid and lipoprotein metabolism in children with nonalcoholic fatty liver disease (NAFLD). Diana Mager1, Carla Rodriguez-Dimitrescu1, Jason Yap1, Vera Mazurak1, Donna Vine1, Mary Jetha1, Geoff Ball1 1University of Alberta, Edmonton, AB, Canada.

Background: Postprandial hyperinsulinemia and insulin resistance (IR) are thought to be important mediators of nonalcoholic fatty liver disease (NAFLD). Little is known how acute intake of saturated/polyunsaturated fat (PUFA) may contribute to changes in postprandial lipid and lipoprotein expression in childhood NAFLD. We hypothesized that consumption of a high saturated/low PUFA meal would result in prolonged postprandial hyperinsulinemia and altered lipid and lipoprotein expression in childhood NAFLD. Methods: We prospectively studied 31 children (NAFLD, biopsy proven disease (n=11); age-gender matched obese (n=9) and lean controls (n=11)) following consumption of a high saturated/low PUFA meal (420 kcal, 47.9% fat, 28.4% saturated fat, 2.8% PUFA) similar in content to fast food meals consumed by children. Controls underwent screening blood work and/or abdominal ultrasound to rule out NAFLD. Blood for analysis of alanine aminotransferase (ALT), aspartate aminotransferase (AST), insulin, glucose, triglycerides (TG), total-HDL-and-LDL-cholesterol, adiponectin, non-esterified-fatty-acids (NEFA), inflammatory markers (TNF-α, IL-6, IL-10), apolipoproteins-B48 (Apo-B48), B100 (Apo-B100), C-III (Apo-CIII) and fatty acids (FA) composition of TG fractions was collected prior-to-and at 1, 3 and 6 hr post-meal consumption. Postprandial area-under-the curve (AUC) and incremental AUC (iAUC) were analyzed using the trapezoidal method. Results: Mean age and BMI-z (±SD) of participants was 13.1±2.6 yrs and 2.3±0.5 (NAFLD); 14.3±1.7 yrs and 2.3±0.5 (obese) and 13.6±2.6 yrs and 0.2±1.0 (lean), respectively (p>0.05). Children with NAFLD had significantly higher fasting levels of ALT (87±54/L; 17-175), AST (52±33.5U/L; 20-132) and Apo-C-III (20.6 ± 11.3 mg/dL; 9.5-42.9) compared to obese/lean controls (p<0.05). Obese children (NAFLD and controls) had lower fasting HDL-cholesterol than lean children (0.8 ± 0.2 vs 1.3 ± 0.2 mmol/L; p<0.05). AUC/iAUC for insulin was significantly higher in children with NAFLD (389±270/225± 207 mU/L(hrs)) vs obese (221 ± 112/113±73 mU/L(hrs))) and lean controls (87± 24/47 ±19.9 mU/L(hr)) (p<0.001). Children with NAFLD had significantly higher AUC for apoB-100 (3675 vs 1895 (ng/ml(hrs)), and TNF-α (13.0 vs 6.9 pg/ml(hrs)) than their lean counterparts (p<0.05); while iAUC for apoC-III was higher in NAFLD than the obese/lean controls (43 vs 15.6 vs 9.9 mg/dl(hrs) (p<0.05). Obese children (controls and NAFLD) had the highest concentrations of C16:0, C18:1 and C22:5ω3 and the lowest levels of C14:0 in TG fractions when compared to lean children (p<0.05) pre-and-post meal consumption. Conclusions: Children with NAFLD consuming a high saturated/low PUFA meal have prolonged postprandial hyperinsulinemia and altered lipid and lipoprotein expression when compared to healthy obese and lean controls. Treatment strategies aimed at modifying the postprandial metabolic environment may contribute to therapy in childhood NAFLD.

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273871 - Optimal fish-to-soybean oil ratio for restoring parenteral nutrition-induced atrophy of Peyer's patches in mice Midori Noguchi1, Kazuhiko Fukatsu2, Tomoyuki Moriya3, Satoshi Murakoshi1, Koichi Okamoto3, Hiromi Miyazaki1, Hiroshi Yasuhara2, Daizoh Saitoh1 1Division of Traumatology, National Defense Medical College Research Institute,Tokorozawa, Japan; 2Surgical Center, University of Tokyo, Tokyo, Japan; 3Department of Surgery, National Defense Medical College, Tokorozawa, Japan.

Parenteral nutrition (PN) induced-atrophy and dysfunction of gut associated lymphoid tissue (GALT), observed in humans and animal models, leads to increased susceptibility to infectious complications. Our previous study of PN containing either fish oil (FO: source of omega-3 PUFAs) or soybean oil (SO: source of omega-6 PUFAs) demonstrated no marked beneficial effects on GALT. Herein, we examined whether combinations of FO and SO exert preventive effects on PN-induced reductions of Peyer’s patch (PP), the inductive site of gut immunity, lymphocyte number. Male ICR mice (n=31) were randomized to chow (n=6), 100%FO-PN(n=5), 33%FO-PN(n=6), 8%FO-PN(n=9) and 0%FO-PN(n=5) groups and underwent jugular vein catheter insertion. The PN groups were given isocaloric and isonitrogenous nutritional support with 20% of total calories from fat emulsions. Fat emulsions consisted of various FO to SO ratios (100:0, 33:67, 8:92, 0:100). After 5 days of each feeding, PP lymphocytes were isolated, counted and analyzed with flowcytometry for determination of their phenotypes (alpha-betaTCR+, gamma-deltaTCR+, CD4+, CD8+ and B cells). Combinations of FO and SO, particularly the 33%FO-PN ratio, increased total lymphocyte and B cell numbers in PPs, as compared with the 100%FO- and 0%FO-PN ratios, in mice. PN containing both FO and SO, especially that with a 33:67 ratio, may be advantageous for preserving gut immunity in the absence of enteral nutrition.

Abstract of Distinction 274046 - Preoperative lack of enteral nutrition as a prognostic factor of relapse free survival after colon cancer surgery Koichi Okamoto1, Kazuhiko Fukatsu2, Youjiro Hashiguchi1, Hideki Ueno1, Eiji Shinto1, Yoshihisa Naito1, Tomoyuki Moriya1, Atushi Shikina1, Jyunji Yamamoto1, Kazuo Hase1 1Department of surgery, National Defense Medical College, Tokorozawa, Saitama, Japan; 2Surgical Center, University of Tokyo, Tokyo, Japan.

Background Reduction of gut associated lymphoid tissue (GALT) size and functions due to lack of enteral nutrition (EN) is considered to be an important mechanism underlying increased morbidity of infectious complications during parenteral nutrition (PN). Our previous study demonstrated preoperative PN to reduce T, IgA-producing and mature dendritic cell numbers in GALT of colon cancer patients, tripling the morbidity of infectious complications, as compared with oral feeding. Because impairment of acquired immunity is reportedly associated with poor long-term outcomes of cancer patients, preoperative lack of EN may also be a prognostic factor for survival after colon cancer surgery. Methods: 324 patients with Dukes B and C colon cancer (except T1 and T2) who underwent elective colectomy in our institute from 1997 to 2004 were studied retrospectively. Patients with complete bowel obstruction were excluded. The EN(-) group (n=98) was fed PN without EN for 4 to 50 days before surgery, while the EN(+) group (n=226) received oral feeding with or without supplementary PN. We examined whether preoperative lack of EN could be a prognostic factor for relapse-free survival (RFS) after colon cancer surgery. Results: Among Dukes B patients, EN(-) was associated with worse RFS than the EN(+). Likewise, among Dukes C patients, RFS was worse with EN(-) than with EN(+). The prognostic significance of preoperative lack of EN was investigated together with 7 other possible prognostic factors by univariate analysis. Preoperative lack of EN, age, tumor depth, nodal metastasis and bowel obstruction were identified as significant prognostic factors. On multivariate analysis,

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preoperative lack of EN age, tumor depth and node metastasis remained independent prognostic factors. Conclusion: Lack of EN before colon cancer surgery was associated with decreased RFS and was an independent prognostic factor. Use of the gut before cancer surgery may be advisable not only for the prevention of infectious complications but also for better long-term survival.

Abstract of Distinction

273852 - Teduglutide Enhances Nutrient Absorption in Adult Subjects With Short Bowel Syndrome and Maintains Nutritional Balance Despite Significant Reductions in Parenteral Support Marion Winkler1, Ken Fujioka2, Nader N Youssef3, Ken Storch4, Susanne Wolf5, Kelly Tappenden6, Palle B Jeppesen7 1Rhode Island Hospital, Providence, RI; 2Scripps Clinic Del Mar, San Diego, CA; 3NPS Pharmaceuticals, Bedminster, NJ; 4Storch Medical Nutrition Center, Florham Park, NJ; 5Nycomed GmbH, Konstanz, Germany; 6University of Illinois, Urbana, IL; 7Rigshospitalet, Copenhagen, Denmark.

Background: Patients with short bowel syndrome (SBS) often have inadequate absorptive capacity to support their oral requirements for fluids, calories, macronutrients, trace elements, vitamins, and minerals. They often require parenteral support (PS) to avoid alterations of their nutritional status, such as dehydration, adipose depletion, weight loss, loss of lean body mass, signs of specific deficiencies with inadequate maintenance of their nutritional status including negative effects on bone mineralization. Meaningful PS reduction is desirable if nutritional balance is maintained, since a potential for decreasing co-morbidities exists and quality of life may be enhanced. Teduglutide has recently been developed for the treatment of adult SBS and has been shown to have a significant targeted effect on the absorptive capacity of and the integrity of the intestinal epithelium. Aim: To demonstrate continued nutritional balance despite significant reductions in parenteral support volume with teduglutide treatment. Methods: Surrogate endpoints for maintenance of nutritional status and important markers of intestinal absorption were examined across three completed teduglutide studies, including 127 teduglutide-treated subjects and 59 placebo-treated subjects comprised of studies ALX-0600-92001, CL0600-004, and CL0600-020. Measures explored included teduglutide effect on oral intake, fecal and urine output and GI fluid absorption, citrulline levels, small bowel histology, and specific laboratory tests including liver function tests. Results: In the ALX-0600-92001 study, teduglutide treatment of adult subjects with SBS increased mean GI fluid absorption (507 g/day), with mean increases in absorption of fat (10.0 g/d), nitrogen (2 g/d), sodium (0.5 g/d), potassium (0.5 g/d), and calories (200 kcal/d) (p<0.05). Corresponding clinically meaningful decreases in fecal/stomal output was demonstrated for GI fluids (-886.7 g/d), fat (-11.5 g/d), nitrogen (-1.7 g/d), sodium (-0.6 g/d), potassium (-0.4 g/d) and calories (-258.5 kcal/d). In the CL0600-004 study, plasma citrulline levels increased by 16.7 mmol/L compared to baseline (p<0.05). In the CL0600-004 study, teduglutide increased villus height and crypt depth, leading to an increased absorptive

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surface area. A significant improvement vs baseline was also seen in mean levels ALT (-12.1 UI/L) and AST (-5.4 UI/L). In the CL0600-004 and -020 studies, significant reductions in parenteral support volume were demonstrated and in the CL0600-020 study, even an increased number of infusion free days/week were observed. Conclusions: Teduglutide treatment effectively increases the capacity of the intestine to absorb fluids, calories, macronutrients, vitamins, and trace elements through expansion of the intestinal absorptive surface, maintaining nutritional homeostasis in the setting of significant PS reductions and thereby conserves nutritional status. Additionally, diarrhea, the predominant symptom of SBS, which has the most impact on fluid balance, is improved as a consequence of increased absorption of fluids and nutrients. A trend toward significant improvement in liver enzymes in relation to teduglutide treatment (bilirubin p<=0.01 and ALT p<=0.01) supports hypotheses that either teduglutide treatment improved integrity of intestinal mucosa (barrier function), or decreased exposure to parenteral constituents which may be the mechanism for this benefit seen in patients treated with teduglutide.

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Bilirubin and gamma-glutamyl transferase, Study CL0600-020

Hepatic transaminases, Study CL0600-020

MALNUTRITION – NUTRITION ASSESSMENT PAPER SESSION 274147 - Subjective satiety improves early after gastric bypass surgery Lauren Beckman1, Shalamar Sibley2, Carrie Earthman1 1University of Minnesota, Saint Paul, MN; 2University of Minnesota, Minneapolis, MN

INTRODUCTION Subjective satiety, or the absence of hunger during the inter-meal period, has been reported to increase after gastric bypass (GB), secondary to the reduced stomach capacity imparted by the surgery. Limited data exist on the longitudinal satiety changes in both the early (2 to 6 weeks), and later post-GB period (≥ 1 year). Protein has been suggested to be the most satiating of the three macronutrients, but it is not known if subjective satiety is macronutrient specific in this population. The objective of this analysis was to evaluate short- and long-term subjective satiety changes after GB and to assess the macronutrient effect. METHODS Subjective satiety was assessed in 20 extremely obese women (BMI: 48±1 kg/m2; age: 48±2 years (mean±SE)) before GB (V1) and

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approximately two weeks (V2), six weeks (V3), six months (V4), and one year (V5) postoperatively. Half of the subjects consumed a protein-containing beverage (20 g protein, 0g fat, 2 g carbohydrate, 90 kcals; PRO-BEV) while the rest of the subjects consumed an equicaloric fat-containing beverage (0 g protein, 9 g fat, 3 g carbohydrate; FAT-BEV). Subjective satiety was measured before (Time 0) and at several time points after consumption of the beverage for 150 minutes with a generalized labeled magnitude scale. Beverage groups were compared and longitudinal changes were analyzed using mixed-effects linear models with a random effect to model the correlation of repeated measurements within each subject. RESULTS Post-GB changes in subjective satiety scores from V1 were similar between beverage groups. Because no significant differences between treatment groups were found, data were analyzed together. After controlling for Time 0 scores, subjective satiety increased from V1 to V2 (30, 45, 60, 75, 90, 120, and 150 minutes; P<0.05), V1 to V3 (45, 60, 75, 90, and 120 minutes; P<0.05), V1 to V4 (75, 90, 120, and 150 minutes; p<0.05), and V1 to V5 (only at 75 minutes; P<0.05). CONCLUSIONS Subjective satiety increased at nearly all sampling time points early after GB (V2 and V3), before substantial weight loss occurred, but was generally not maintained 1-year post-operatively. While the early change was expected due to the highly reduced stomach capacity after surgery, we did not anticipate subjective satiety at V5 to be similar to V1. Weight maintenance and/or regain tends to occur 1-2 years post-GB. Might it be possible that a return to pre-GB satiety levels is a factor contributing to the reduced weight loss trajectory? Clearly more research is needed to ascertain this relationship. In addition, we did not find an acute macronutrient effect on subjective satiety. Insufficient dosage of either protein or fat might play a role. In summary, this study was unique in that we measured the satiety response after an acute dose of either protein or fat in both the early and later post-operative period. Future large-scale studies that investigate the effect of higher doses of the macronutrients on subjective satiety in post-GB patients are warranted given the potential clinical importance that this information could have for optimal diet management after GB.

274035 - A Systematic Literature Review of Nutrition Assessment in Head and Neck Cancer: What About Lean Tissue Wasting? Leah Gramlich1, Lisa Martin1, Cathy Alberda2, Adam Henley3, Tanadech Dechaphunkul4, Karin Olson3, Vickie Baracos4 1Alberta Health Services, Edmonton, AB, Canada; 2Royal Alexandra Hospital, Edmonton, AB, Canada; 3University of Alberta, Edmonton, AB, Canada; 4Cross cancer institute, Edmonton, Alberta, Canada;

Background: Patients with head & neck cancers are exposed to an intensive number, type, and combination of therapies (surgery, radiation, chemotherapy) magnifying risk for the development of severe malnutrition. An increasingly wide spectrum of initial body weight, as well as varied nutritional risk, ranging from negligible to severe malnutrition requiring non-volitional, enteral nutritional support is seen in this population. While weight loss and dietary intake continue to be important requirements for nutritional assessment, there is increased recognition of the importance of the assessment of lean body mass and skeletal muscle mass in patients with cancer. Severe muscle depletion has been clearly associated with poor prognosis in these patients. Methods: This study is part of a larger systematic review of nutritional therapy in head & neck cancer patients from 01/2005-11/2010. Searches were conducted in the electronic databases CINAHL, Embase, PsycInfo, Cochrane, and MEDLINE. Excluded studies included case reports, cancer prevention and population risk. Studies included were in English and the nutritional assessment included one or more of the following domains: depletion of reserves (weight loss, body weight, body composition), limitations to intake (food intake, nutrition impact symptoms), catabolic drive (inflammation, hypermetabolism), functional/psychological effects of malnutrition (QOL, distress, functional status), or other clinically relevant outcomes affected by malnutrition (complications, length of hospital stay, survival, employment). Here, we report on the consideration given to body composition assessment in this literature. Results: 743 studies were identified, after reviewing titles and abstracts 245 full text articles were selected for full review. Weight loss was recorded in only 88/245 studies(36%) and this was of especially large magnitude during concurrent chemotherapy and radiation (i.e 10-20 kg). Only 10/245 studies (4%) evaluated body composition as an outcome, with six of these emanating from just two research groups. Methods used were bioelectrical impedance (n=7), anthropometry (triceps skinfold thickness,mid-upper arm muscle circumference; n=6) and dual-energy x-ray absorptiometry, DXA (n=1). No study was available to test the reliability of bioimpedance with DXA, even though studies in patients with other cancers have shown very poor agreement between these approaches. The treatment setting in which body composition was evaluated was variable. One study evaluated body composition of treatment-naïve patients as a component of nutritional status. Two studies focused on the composition of large weight losses during chemoirradiation. The effect of enteral feeding on body composition during radiation (n=1), chemoirradiation

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(n=3), and post-operatively (n=3) were studied. Sample sizes were generally small but with a wide variation (n=7 to n=1077) and the cancer site and stage of the populations was often heterogeneous. Conclusion: There is a clear gap in the recognition that body composition is an important component of nutritional assessment in head & neck cancer. In only a single instance (0.4% of studies) was a method with high specificity for lean and fat tissue and high precision used. The prevalence, implications and nutritional modulation of lean tissue and skeletal muscle wasting remain essentially unknown in a group of cancer patients at extremely high risk for the development of malnutrition.

273703 - Hypocaloric Parenteral Nurition in Obese Patients--Comparision with Resting Energy Expenditure Kelly Kinnare1, Diane Sowa1, Sarah Peterson1 1Rush University Medical Center, Chicago, IL Background: There is strong evidence to support the use of a hypocaloric high-protein parenteral nutrition (PN) regimen in the obese hospitalized patient. Complete wound healing and positive nitrogen balance has been observed with the use of hypocaloric PN using 2 grams per kilogram of ideal body weight (IBW). Determining the energy needs of the obese patient is difficult due to varying metabolically active tissue. The nutrition support practitioner has the difficult task of providing adequate amounts of calories and protein to minimize metabolic complications while preserving lean body mass in a time of critical illness where there is an altered state of substrate utilization. The exact calorie level based on a person’s degree of obesity has yet to be determined and measurement of resting energy expenditure (REE) with indirect calorimetry (IC) remains the gold standard. Objectives: The objective of this study was to compare measured REE using IC to hypocaloric and normocaloric PN calculations in obese patients requiring PN for nutrition support. Methods: This study was part of a larger study in which obese (BMI 30.0-39.9) patients admitted to Rush University Medical Center who were ordered to receive PN for nutrition support were randomized to receive hypocaloric or normocaloric PN. Subjects in the hypocaloric group with Class I obesity (BMI 30-34.9) were provided 20 kilocalories (kcal)/kilogram (kg) of their baseline actual body weight (ABW), whereas subjects with Class II obesity (BMI 35-39.9) were provided 15 kcal/kg of ABW. Subjects randomized to the normocaloric group for both BMI categories were provided 30 kcal/kg of the baseline adjusted body weight (Table 1). Measured REE was conducted using IC within 72 hours of PN initiation. Paired t-tests were used to determine the difference between feeding prescriptions. Results: Mean REE for the entire group was 1656.9 kcal/day. Mean REE (1656.9 kcal/day) and hypocaloric energy prescription (1750.2 kcal/day) were not significantly different (p=0.18). Mean REE (1656.9 kcal/day) and normocaloric energy prescription (2145.5 kcal/day) differed by 488.6 kcal/day (p<0.001). Upon dividing by BMI category, REE and hypocaloric prescription were significantly different (p=0.004), overpredicting calories in the BMI Class I group (Table 2). Mean REE came within 150 kcals of the hypocaloric group for the entire sample, regardless of age, gender, whether they had surgery, or received morphine. Conclusions: Hypocaloric parenteral nutrition calculations were not significantly different when compared with measured REE. Using a hypocaloric calculation when IC is not available appears to be a viable option and is able to come within 100 calories of REE. Thus, the term hypocaloric should not be used. Using normal calculations may result in significantly more calories than REE measurements suggest is needed. More research is needed to examine changes in body composition, metabolic complications and weight loss between various feeding calculations. Indirect calorimetry remains the gold standard to assess energy requirements when available.

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Abstract of Distinction 274280 – Malnutrition Prevalence in Elders with Cancer Gemma Hernandez1, Pilar Matia1, Lucio Cabrerizo1, Angelica Larrad1, Pilar Soria1, Aranzazu Manzano2, Maria Juliana Gonzalez2, Antonio Casado2, Eduardo Diaz-Rubio2, Miguel Angel Rubio1 1Department of Endocrinology and Nutrition. Clinico San Carlos Hospital, Madrid, Spain; 2Oncology Department.Clinico San Carlos Hospital, Madrid,Spain;

OBJECTIVES: To describe prevalence of malnutrition in elderly patients (≥65) with cancer, and to compare it with that of younger subjects under the same circumstances. METHODS: Random sample of outpatients from an oncology ward of a public tertiary Spanish hospital. Malnutrition tool: Patient-Generated Subjective Global Assessment. Statistics: Chi-square test and binary logistic regression (grouping malnutrition risk and malnutrition diagnosis versus well-nourished as dependent variable). RESULTS: 1608 patients were included: 741 (46.1%) over 64 years old (range 65-90; mean –SD-: 73.1 -9.5-; 268 subjects over 75; 45.7% women). Under 65: mean age (SD): 51.3 (9.5); 61.5% women. Moderate and severe malnutrition prevalence was (≥65/<65): 62.8%/44.5% (p<0.001). There were differences in (≥65/<65): less than usual food intake (55.1/44.9%), normal with no limitations activities and function (33.2%/66.8%), global fat deficit (57.1%/42.9%), global muscle deficit (56.0%/44.0%), and existing edema (58.3%/41.7%) –p<0.001 for all comparisons. Symptoms related to poor intake were different (≥65/<65): no appetite (50.9%/33.3%), pain (37.8%/31.3%), feel full quickly (32.0%/22.4%), depression (29.0%/23.0%), dental problems (18.6%/7.8%), and bothered smells (5.3%/13.9%) -p<0.001 for all comparisons. Other symptoms were similar (≥65/<65): constipation (20.7%/20.4%), funny taste (20.4%/20.9%), diarrhea (13.9%/11.0%), having no taste (10.1%/10.3%), nausea (9.7%/12.7%), problems with swallowing (7.0%/8.0%), and vomiting (6.9%/8.9%). Age (≥65/<65) –OR 2.099; 95%CI 1.718-2.565-, gender (men/women) –OR 2.080; 95%CI 1.704-2.539-, tumor site (head and neck, upper gastrointestinal tract, pancreas, ovary, and lung/colon, breast, and other) -OR 2.568; 95%CI 2.076-3.146-, chemotherapy treatment (yes/no) -OR 1.256; 95%CI 1.000-1.576-, tumor stage -OR 2.729; 95%CI 2.036-3.659-, and diabetes mellitus (DM) diagnosis –OR 2.009 ; 95%CI 1.718-2.565- were associated with undernutrition. After adjustment by gender, tumor site, chemotherapy treatment, tumor stage, and DM diagnosis the association between age and malnutrition was: OR 1.751; 95%CI 1.407-2.179. CONCLUSIONS: Malnutrition prevalence was over 60% in the aged studied sample, higher than observed in the younger population. Some signs and symptoms were more frequent in the elderly. Undernutrition was associated with age, but this association was attenuated after adjustment by tumor site, chemotherapy treatment, tumor stage, DM diagnosis, and gender.

Abstract of Distinction 274189 - The Effects of Human Immunodeficiency Virus and Antiretroviral Therapy on Resting Energy Expenditure in Adult HIV-Infected Women Alison Mittelsteadt1, Corrilynn Hileman2, Kelly Payne3, Stephanie Harris1, Barbara Gripshover4, Grace McComsey5 1Case Western Reserve University, Cleveland, OH; 2MetroHealth Medical Center, Cleveland, OH; 3Greenbrier Nursing Home, Parma Heights, OH; 4John T Carey Special Immunology Unit, University Hospitals Case Medical Center, Cleveland, OH; 5Case Western Reserve University School of Medicine, Cleveland, OH

Background: Several studies reported increased resting energy expenditure (REE) in human immunodeficiency virus (HIV). However, limited data exist on REE in HIV-infected women and the effect of antiretroviral therapy (ART) on REE in this population. The studies that focused on women with HIV involved a small sample size or included mostly women with wasting, a diagnosis that is now uncommon in the current era of potent ART. The purpose of this study was to compare REE in healthy controls to adult HIV-infected women in three groups: naïve to ART, on ART with virologic suppression, and on ART with an HIV-1 RNA level > 5000 copies/mL. Methods: Body composition was determined via bioelectrical impedance analysis (BIA) and resting energy expenditure was measured in a thermo-neutral environment by indirect calorimetry after a four hour fast from food, drink and nicotine. Waist circumference and hip circumference were measured in triplicate. Weight, height, and temperature were also measured. Distributionally appropriate two sample tests were used for between-group analyses and ANCOVA was used for confounding adjustment. Results: Eighty-seven subjects were enrolled. There was no difference (P=0.6525) in mean REE between naïve (n=25, REE 1465±342) and undetectable subjects (n=25, REE 1507±362) even after adjustment for body composition differences, current or nadir CD4 count or duration of HIV infection. However, the HIV-infected subjects (n=62, REE 1456±359) had a 13% higher absolute REE (p=0.0342 log-transformed) compared to controls (n=25, REE 1284±240) and the difference became greater when adjusted for body composition (p=0.0006 log-transformed). In addition, log-transformed mean REE was significantly higher in

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ART-naïve subjects when compared to the controls (p=0.0413) and in the undetectable group compared to controls (p=0.0119). Again, the differences were greater when adjusted for body composition differences (p=0.0080 and p=0.0003, respectively). When comparing subjects with detectable (n=12) and undetectable (n=37) HIV-1 RNA levels, there was no difference in REE (1421±358 vs. 1507±362, p=0.3047). HIV-1 RNA levels were not correlated to log-transformed REE (n=12, r= -0.33721). However, CD4 count was weakly correlated with log-transformed REE in HIV-infected subjects (n=61, p=0.0390, r= 0.27). There was no difference in adjusted or unadjusted REE between subjects on ART (n=37), regardless of HIV-RNA level, compared to ART-naïve (1450±374 vs. 1465±342, p=0.8076). However, log-transformed REE, adjusted for body composition differences, was significantly higher in subjects on ART compared to controls (1450±374 vs. 1284±240, p=0.0008). Conclusion: REE is elevated in ART-naïve HIV-infected women and continues to be elevated when on effective ART regardless of virologic suppression, suggesting an effect of HIV infection and not antiretroviral therapy. This should be considered during nutrition assessment and counseling of HIV-infected adult women.

272168 - Mid Upper Arm Circumference and Body Mass Index as Indices of Nutritional Risk Lee-Boo Tan1, Stephanie Fook-Chong1 1Singapore General Hospital, Singapore, Malasia  Introduction: Undernutrition in hospital patients is often unrecognized and there is a need for a simple means of assessment to facilitate targeted nutritional intervention. Body mass index (BMI) has been emphasized as one of the objective anthropometric parameters and used to assess the nutritional status of patients. However it is not always possible to measure weight or height in the acutely ill because patients may not be able to stand or leave their bed. Therefore, Mid Upper Arm Circumference (MUAC) emerges as a useful measure of nutritional status which is applicable in most of the patients. This study aims to investigate the use of MUAC and BMI as nutritional risk indices when compare to the gold standard, Subjective Global Assessment (SGA). Methods: Patients above 21 years old and referred to dietitians for nutritional support were consecutively recruited from Sep 09 to Sep 10. Patients who were critically ill, pregnant or with fluid overload were excluded. SGA was used to assess and classify patient’s nutritional status into three categories: Grade A (well-nourished), Grade B (moderate) and Grade C (severely malnourished). MUAC ≥ 23.5cm and BMI ≥ 18.5 kg/m2 were used as a normal cut off as well-nourished and not at nutritional risk. Differences in body weight, percentage weight loss, MUAC, BMI, and length of stay among the three SGA grades were assessed by one-way ANOVA. The association between MUAC and BMI was determined by Pearson correlation. Chi-square test was used to find out the association between MUAC, BMI and SGA. Agreement between the MUAC and BMI cut offs against three grades of SGA was analyzed using the kappa statistics. Statistically significant is considered at p<0.05. Results: A total of 561 patients (302 women, 259 men) were recruited with mean age of 69.8 ± 15.7 years, BMI 20.2 ± 4.4. Sixty two percent of patients required oral nutritional supplements, 32% on tube feedings and 6% needed parenteral nutrition. Of the total patients assessed, 108 (19%) were classified as Grade A, 333 (60%) Grade B and 120 (21%) Grade C. The study showed significant differences in body weight, percentage weight loss, MUAC, BMI, and length of stay across the three SGA grades. There was a significant correlation between MUAC and BMI (R= 0.74, p <0.001). The gender subgroup analysis revealed similar correlation (R=0.74 for men and R=0.77 for women). Majority (80%) patients rated grade A had MUAC ≥ 23.5cm and BMI ≥ 18.5kg/m2. On the other hand, 68% patients rated grade C had MUAC ≤ 23.5cm and BMI ≤ 18.5kg/m 2 (Figure 1). A relatively high level of agreement was found between the normal MUAC, BMI cut offs in well-nourished (k=0.54, p<0.001); and low MUAC, BMI in severely malnourished patients (k=0.58, p<0.001). Conclusions: The study showed that MUAC correlates closely with BMI. These two parameters revealed substantial concordance with SGA in classifying well-nourished and severely malnourished patients. Both MUAC and BMI are simple measures and should be used as a routine assessment of nutritional status.

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Figure 1: The relation between MUAC (dashed line represents cutoff at 23.5) and BMI (cutoff 18.5) and according to SGA grades.

PARENTERAL NUTRITION PAPER SESSION

274226 - Improving Patient Safety By Simplifying Initiation of Parenteral Nutrition: A safer Way To Start Suzanne Benjamin1, Thomas Hayward1, Bee Yen Poh2 1Indiana University Health-University Hospital, Indianapolis, IN; 2Singapore General Hospital, Singapore 169608

Introduction: Parenteral nutrition (PN) is one of the most complex intravenous admixtures to prescribe and prepare in today's medication use system. The ordering practitioner must have a thorough understanding of nutrition support therapy. To facilitate ordering and improve safety, standard ordering forms are used at most institutions that are reviewed by pharmacists prior to preparing the admixture. While trusting the health care practitioner with the use of standard ordering forms and the pharmacist to review and catch any errors has been a long standing clinical practice, there are numerous avenues in which errors can enter into this system. Through the use of a continuous quality improvement process, we found that a review based system can still lead to problems when orders arrive late and time pressure or work hour limitations prevent a complete evaluation. Additionally, having a firm stop-gap hold until a complete review can be performed can lead to delays of delivering nutrition support to patients, thereby converting an error of commission to an error of omission. It has been the goal of our nutrition support team to work on reducing system errors in the prescribing of parenteral nutrition. We hypothesized that by redesigning the order process to include a commercially compounded PN, standardized to ideal body weight ranges and renal function, a further reduction in errors would occur. This redesign would provide firm safeguards to inexperienced practitioners,

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yet minimize impact on practitioners with an expertise in PN. The redesigned order process still allows for immediate customized start of PN; however, the compounding pharmacist must first confirm that the prescription is compatible with an electronic note written by the nutrition support team member, with a mandatory stop if not congruent. All other newly initiated customized PN orders (without a corresponding nutrition note) will be replaced with a commercially compounded PN, if patient identifier information, height, weight and creatinine clearance are available in the electronic chart. This commercially compounded PN will infuse at a pre-determined (weight-based)rate, and provide a fixed, conservative amount of protein and calories (1.0 - 1.2g protein/kg/day, and 15-18 kcal/kg/day). This conservative provision of calories is also designed to offset potential issues for a patient at risk for refeeding syndrome. Patients receiving commercially compounded PN are converted to a customized prescription if clinically indicated within the first few days of therapy. Methods: A retrospective review comparing a month in November 2009 utilizing the "old" review based system versus November 2010 using the redesigned ordering system was compared. Chi square testing was used to compare the results. Results: See Table #1 Conclusions: By introducing mandatory safeguards in a PN prescribing system, a reduction in error rates was seen, even in a well established nutrition support team model. The multidisciplinary team convened to oversee this prescribing improvement initiative, proactively addressed key stakeholders throughout the revision process, and overcame barriers by maintaining a focus on improving a patient safety.

273591 - Hospital Readmissions for Catheter Related Blood Stream Infection and Use of Ethanol Lock Therapy: Comparison of Patients Receiving Parenteral Nutrition in the Home versus a Skilled Nursing Facility Mandy Corrigan,1, Cassandra Pogatschnik1, Denise Konrad2, Donald Kirby, MD1 1Cleveland Clinic, Cleveland , OH; 2Job seeking, PA.

Introduction: Regardless of where patients reside receiving parenteral nutrition (PN), either at home or a skilled nursing facility (SNF), catheter related blood stream infection (CRBSI) is a common and life threatening infectious complication. Ethanol has recently emerged as a catheter locking solution in the home PN setting for prevention of CRBSI; however, it has potential to also benefit patients receiving PN in a SNF. Ethanol lock (ETL) is inexpensive, has no potential for resistance, and has been shown to be safe and efficacious in preventing CRBSI. Standard practice at our institution is to initiate ETL either as prophylaxis or after initial CRBSI in home PN patients with silicone catheters by administering 3mL of 70% ethanol after cycled PN or intravenous fluids (IVF). Our aim was to evaluate the number of hospital readmissions and length of stay (LOS) for CRBSI between patients receiving PN at home (with or without ETL) versus at a SNF. Methods: After obtaining IRB approval, a retrospective chart review was completed for all patients sent home with PN or IVF followed by the Cleveland Clinic (CC) Nutrition Support Team and patients sent a SNF with PN from 1/2010 to 3/2011. Data collection included reason for PN or IVF, primary diagnosis, vascular access device and number of lumens, LOS for CRBSI hospital admission(s), name of hospital, causative organism(s), presence or absence of ETL therapy, and compliance with ETL (if known). Hospital readmissions for SNF patients only included CC Hospitals whereas home PN patient’s hospital readmissions were

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both within CC and non-CC hospitals due to availability of data in patients followed by our service at home. Results: There were 38 patients in the SNF group with 56 readmissions for CRBSI and 93 patients in the home PN group with 106 readmissions for CRBSI. There was no evidence to suggest a significant association between location of PN delivery (home vs. snf) and number of readmissions for CRBSI, but a trend towards significance was seen (p=0.056). SNF patients had a significantly longer LOS for CRBSI hospital admissions compared to patients receiving PN at home with or without ETL (p <0.001, 16 days vs. 8 days vs. 8 days). There was no LOS difference for CRBSI between home patients with or without ETL. Home PN patients not receiving ETL were more likely to have a CRBSI from Staphyloccous sp. (48% vs. 27%, p=0.015) whereas SNF PN patients not receiving ETL were more likely to have a CRBSI from Enterococcus sp. (16% vs. 3%, p=0.004). There was no evidence that number of lumens or location of PN delivery was associated with polymicrobial CRBSI. There were no readmissions for CRBSI in 81% of home PN patients after starting ETL. The only significant difference in patient characteristics was more inflammatory bowel disease in the home patients not receiving ETL vs. SNF patients. Conclusion: The causative CRBSI organisms are different between the home and SNF populations and SNF PN patients had a longer LOS for CRBSI admissions, which could be due to underlying complexity of their medical conditions. A main limitation of this study is that many of the patients discharged from CC to a SNF with PN may never have been readmitted to a CC hospital for future care or CRBSI, but rather a local hospital near the SNF. The true readmissions for CRBSI in SNF PN patients may be underreported. Future research with ETL may consider ETL in the SNF PN population and observing the effect on LOS, CRBSI readmission rates, and causative CRBSI organisms. ETL shows promise, as 81% of home PN patients on ETL did not have future CRBSI admissions. Future studies with ETL in the SNF population are needed to evaluate for a decrease in CRBSI admissions or LOS as seen in home patients

273725 - Parenteral Nutrition in Liver Disease: A Systematic Review of the Medical Literature Ronald Koretz1, Timothy Lipman2, Alison Avenell3 1Olive View-UCLA Medical Center, Sylmar, CA; 2Veterans Affairs Medical Center, Washington, DC; 3Health Services Research Unit, Aberdeen, MD

Background: In 2001, a systematic review of the randomized clinical trials (RCTs) of parenteral nutrition (PN) in patients with liver disease failed to show that this intervention was beneficial. The objective of this study was to update that review. Methods: RCTs comparing PN to no nutritional intervention in patients with liver disease were sought via computer searches of MEDLINE, EMBASE, Science Citation Index Expanded, Cochrane Hepato-Biliary Group (CHBG) Controlled Trials Register, and the Cochrane Central Register of Controlled Trials through August 2011. In addition, hand-searches of specific journals and Index Medicus, including abstracts of both the American and European nutrition support societies, Digestive Disease Week and the annual meetings of both the American and European liver societies were done. In order to qualify, the trial had to have been randomized (quasi-randomized trials excluded), include a control group that received no more nutrition than regular food and up to 5% dextrose intravenously, and report at least one clinical outcome (mortality, ascites, gastrointestinal bleeding, encephalopathy, postoperative complications, duration of hospitalization, or cost). The identified trials were separated into those including medical or surgical patients. The estimated effect was expressed as the relative risk (RR) for dichotomous data or as a weighted mean difference (WMD) for continuous data; the 95% confidence interval (CI) was calculated (Revman 5.0, Cochrane Collaboration). Risk of bias was determined by CHBG criteria. Results: Ten RCTs were identified (5 medical, 5 surgical); all were at high risk of bias. The estimated effects calculated from the meta-analyses are summarized in the table. No cost data were available. Conclusions: There were only a small number of RCTs available, and these were all at high risk of bias (which may produce an overestimation of the treatment effect). In medical patients, PN improved nitrogen balance and serum bilirubin, but these changes in surrogate outcomes did not translate into improvement in morbidity or mortality. In surgical patients, PN improved postoperative morbidity; this conclusion rested on the results of a single RCT at high risk of bias. The data are not strong enough to recommend the use of PN in liver disease.

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274218 - Process Improvement Strategies for Successful Reduction of Inappropriate Parenteral Nutrition Prescribing Amanda Naranjo1, Ashley Mullins1, Stephani Parish1 1Baylor All Saints Medical Center, Fort Worth, TX.

Background: Enteral nutrition (EN) over parenteral nutrition (PN) has been established as the preferred means of nutrition support for benefits including decreased cost and less incidence of complications. Inappropriately prescribed PN (IPPN) is well documented to be a national challenge contributing to increased cost risks to patients. Insufficient understanding of and adherence to evidence-based guidelines (EBG) has been cited in literature as a compounding factor. EBG for prescribing PN have been established by the American Society for Parenteral and Enteral Nutrition (ASPEN) and the Society of Critical Care Medicine (SCCM). In 2009, a six month retrospective review was conducted at Baylor All Saints Medical Center in Fort Worth, TX. Review of all inpatients prescribed PN revealed 55% was IPPN when compared to EBG. A root cause analysis was conducted identifying untimely notification and consultation of the registered dietitian (RD) prior to PN initiation, inadequate understanding of EBG and insufficient collaboration between disciplines as primary factors. Methods: A quality improvement plan was implemented to reduce IPPN over 12 months. The plan included requiring all RD’s managing PN to become Certified Nutrition Support Clinicians (CNSC), notification via pager from the pharmacist to RD for all PN orders, physician education to consult RDs on all PN cases, timely RD communication with MDs regarding IPPN, RD and pharmacist daily rounds for PN management, and quarterly educational sessions on EBG for all disciplines. To quantify the change in IPPN after these interventions, the CNSC documented all PN orders and identified indications for PN. A PN order was classified as IPPN in the absence of any diagnosis not considered as a contraindication for EN per ASPEN guidelines (Table1). Results: Table 2 The average percent of IPPN orders per month was reduced to 35% from the baseline average of 55% resulting in a 40% reduction of IPPN. Avoidable bags of PN were defined as the number of inappropriately administered bags of PN which was reduced from 103 bags per month to 43 bags per month, a reduction of 58%. Timeframe for notification of all PN orders was decreased by up to 24 hours with direct paging from the receiving pharmacist, which allowed for more timely intervention to the prescribing physician. Physicians were receptive to an alternative nutrition plan of care 52% of the time with IPPN orders. Conclusions: Despite perceived barriers to reducing IPPN including time constraints related to increased interdisciplinary communication, inconsistent adherence to EBG and an absence of a formalized nutrition support team, a significant reduction in IPPN was achieved. RDs obtaining CNSC credentials and establishing effective and efficient communication across disciplines were key practices in achieving this outcome. A timely reaction by the CNSC prior to the initiation of IPPN was most effective in preventing further invasive procures such as central line placement as well as reduced risk of infection.

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274607 - Catheter Salvage in Home Parenteral Nutrition Patients Following Catheter Related Bloodstream Infection: 5-year Analysis. Marianne Opilla1, Tom Diamantidis1, Rod Okamoto1, Reid Nishikawa1 1Nutrishare, Inc., Elk Grove, CA

Introduction: Maintenance of a long term central venous access device (CVAD) is a priority in home parenteral nutrition (HPN). Loss of vascular access sites occurs when multiple CVADs are removed due to complications. The most frequently reported complication in patients receiving HPN is catheter related bloodstream infection (CRBSI). The Center for Disease Control (CDC) recommends that CVADs be removed with severe sepsis, positive blood cultures 72 hours after initiation of appropriate antibiotic therapy, and fungal infections. Often, CVADs are prematurely removed in situations where they could have been salvaged. The aim of this study was to evaluate successful CVAD salvage by infection group following CRBSI in an HPN population. Methods: CRBSI data were collected for a 5 year period on all patients from one HPN provider. Patient demographics were collected including age, sex, and HPN diagnosis. CVADs included tunneled catheters, implanted ports, and peripherally inserted central

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catheters (PICCs). CRBSI was diagnosed by symptoms such as fever, chills, and positive blood cultures. All infected patients were treated using appropriate antibiotic therapy. A CRBSI with the same organism occurring within 30 days was counted as the same incident. Infections were divided into gram positive, gram negative, fungal, and multi-organism. CVADs were considered salvaged if still in place without additional infection after 90 days. Results: 98 patients developed 266 infections during the 5 year period. These patients had an average age of 43 yrs (1-81 yrs) and were 61% female. The most common HPN diagnosis was short bowel syndrome (63%), followed by motility disorder (34%), radiation enteritis (2%), and scleroderma (1%). Devices were primarily tunneled (80%) followed by implanted ports (11%) and PICCs (9%). 151 Gram positive infections resulted in 45% salvage; 54 gram negative infections resulted in 50% salvage; 39 fungal infections resulted in 5% salvage; and 22 multi-organism infections resulted in 23% salvage. Conclusion: In this cohort, device salvage was accomplished following 38% of diagnosed and treated CRBSIs. Gram positive and negative infections resulted in the highest incidence of successful salvage. In the fungal infections, salvage was rarely attempted as it is well documented that there is a very high failure rate. It is unknown if some removed devices could have remained in place, as many were removed immediately upon infection diagnosis without salvage attempt. Careful evaluation of the patient’s clinical and vascular condition should be considered prior to removing long term CVADs used for administration of lifetime HPN.

Abstract of Distinction 272674 - Evaluation of efficacy and safety of premixed parenteral nutrition (PN) vs. customized parenteral nutrition in a large teaching hospital: an observational study Teresa Pounds1, Khalid Iqbal1, Israel Orija1, Jessica Chimielewski2, Susiana Eng3 1Atlanta Medical Center, Atlanta, GA; 2Cartersville Medical Center, Cartersville, GA; 3Mercer University College of Pharmacy, Atlanta, GA

Background: In the last two decades, there has been a significant degree of controversy regarding the use of premixed parenteral solutions in the United States. Individualized PN is necessary because critically ill patients require daily manipulations of macro and micronutrients secondary to stress and disease state. European experience suggests that 70-85 percent of patients receiving PN can be managed with premixed PN. Premix solutions have advantages that include ease of preparation, reduced risk for microbial contamination, reduced risks for instability, and lower costs. Objectives: The specific hypothesis for the proposed research is that premixed PN solutions are equally safe, effective, and less costly than customized PN solutions in managing hospitalized patients’ nutritional needs. Safety goals were measured by Adverse Drug Reaction reports. Efficacy was measured by positive trend in electrolyte, prealbumin, and glucose levels. Cost justifications of the components associated with premixed PN versus customized PN are additives, labor, supplies, wastes, and quality. Costs were determined by the difference between premixed double chamber bags vs. customized PN. Methods: This was a randomized observational sequential study of 100 patients requiring central PN. Fifty subjects were consecutively observed under the current customized PN format and fifty subjects were observed with a premixed double chamber PN solution containing protein, carbohydrate, and electrolytes; vitamins and trace elements. All subjects that needed additional lipid infusion had lipids co-infused through a y-site. A randomization chart was used to place each patient in a study group after consent was obtained. Each subject enrolled in the study was followed until the PN was either discontinued, patient was transferred from the facility, or the patient expired. Due to the nature of the study, blinding was not possible since the clinician prescribing the PN needed be aware of the formulations they were ordering. Results: Results of the study revealed that premixed PN solutions were equally safe, effective, and less costly than customized PN solutions. Patients receiving premixed PN were noted to have improved metabolic status, experienced less ADRs, and had positive trend in prealbumin levels. Cost analysis of the various components associated with premixed PN and customized PN revealed an annual cost savings of $41,900 associated with premixed PN. Conclusions: Premixed PN were equally safe, effective, and less costly than customized PN solutions in managing nutritional needs for hospitalized patients.

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PEDIATRIC / NEONATAL PAPER SESSION

Abstract of Distinction 274395 - Correlation of Metabolic State with Length of Stay and the Risk of Overfeeding in Chronically Ill Children in the PICU Katelyn Ariagno1, Lori Bechard1, Nilesh Mehta2 1Children's Hospital Boston, Boston, MA; 2Children’s Hospital Boston, Boston, MA

Introduction: Establishing the optimal nutrition prescription in critically ill patients in the pediatric intensive care unit (PICU) remains a challenge. Indirect Calorimetry (IC) is an effective tool to determine energy needs of high-risk patients, especially those with an extended PICU stay. The energy needs of chronically ill patients in the PICU are particularly challenging due to their variable metabolic state. We hypothesized that energy expenditure is correlated with length of stay (LOS) in the PICU. Methods: We conducted a prospective cohort study of all critically ill children with LOS up to 60 days who were selected for resting energy expenditure (REE) measurements using IC. For each patient, we recorded actual daily energy intake (EI), estimated metabolic state by the physician, estimated energy expenditure (EEE) using age appropriate energy equations (Schofield and WHO), and measured energy expenditure (MEE) using IC. Subjects were classified as hypermetabolic (MEE:EEE >110%), normal (MEE:EEE 90-110%), or hypometabolic (MEE:EEE 110%), underfed (EI:MEE <90%) or appropriately fed (EI:MEE = 90-100%). Results: 40 IC measurements were obtained during steady state in 39 patients with PICU LOS <60 days. The

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median (range) age was 7.8 (0.07-32) years and the median (range) weight was 19.65 (3.4-100) kg. Physician-estimated metabolic state was inaccurate in 30 (77%) cases. Metabolic state was characterized as hypometabolic in 24 (60%) and hypermetabolic in 9 (22.5%) patients. Based on MEE, measured by IC, the energy prescription was modified in 19 (47.5%) cases, with a reduction in daily energy requirements in almost all of these patients. PEE was significantly negatively correlated (r = -0.382, p = 0.015) with LOS in these patients. (See figure). Conclusions: MEE revealed a predominance of hypometabolism in critically ill children in our study. The majority of children in this cohort was at risk of overfeeding and required a reduction of the prescribed daily energy goal. Overfeeding places a significant carbon dioxide burden and may prolong or increase ventilator needs during critical illness. Our results reiterate the importance of the role of IC in optimizing nutrition prescriptions for critically ill children. If IC is unavailable, it may be prudent to adjust energy goals in patients with a greater LOS.

Percent Predicted Energy of Critically Ill Children in relation to Length of Stay in the PICU

Abstract of Distinction 273962 - A Premature Infant's Gestational Age is a Predictor for the Risk of Hypertriglyceridemia During First Week of Life Douglas Drenckpohl1, Huaping Wang2, Kamlesh Macwan3 1Children's Hospital of Illinois, Peoria, IL; 2University of Illinois College of Medicine at Peoria , Peoria , IL; 3University of Illinois College of Medicine at Peoria, Peoria , IL

Background: Historically clinicians have been cautious with the initiation and advancement of intravenous fat emulsions (IVFE) because of the perceived risk for hypertriglyceridemia and potential risk for theoretical adverse outcomes, such as kernicterus and pulmonary complications. Previous research has shown very low birth weight infants are able to tolerate the initiation of IVFE at 2 grams (gm)/kilogram (kg)/day (d) on the first day of parenteral nutrition (PN) without complications. Unfortunately, the true definition of hypertriglyceridemia is arbitrarily defined. Some centers define hypertriglyceridemia as serum triglycerides >201 mg/dl, while other centers define it as serum triglycerides >250 mg/dl. Hypothesis: Our primary outcome is to show that a premature infant’s gestational age at birth can be a predictor for identifying who is at greater risk for developing hypertriglyceridemia >201 milligrams (mg)/deciliter (dl). The secondary outcome is to compare theserum triglycerides at >250 gm/dl between the two groups. Methods: The data was combined from two randomized controlled trials examining the lipid tolerance of appropriate for gestational age (AGA) infants with birthweights between 500-1500 gm. In both trials infants in the experimental group were started at 2mg/kg/d of IVFE on the first day of PN and IVFE was advanced by 0.5 gm/kg/d, until reaching a goal of 3 gm/kg/d. Infants in the control group were started at 0.5 gm/kg/d of IVFE on the first day of PN and IVFE were advanced by 0.5 gm/kg/d, until a goal of 3 gm/kg/d was reached. For this analysis infants were stratified into two groups based on gestational age (GA) at birth, 23 to 25 weeks, and infants 26 to 32 weeks. The statistical analysis used was Chi Square for the categorical variables and the Spearman Rho test was used to determine the correlation between variables. Results: One hundred nineteen AGA

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premature infants were analyzed. Sixty-five percent of the premature infants (Table 1) with GA between 23-25 weeks developed hypertriglyceridemia (>201 mg/dl), while only 10% of the infants with GA between 26-32 weeks developed hypertriglyceridemia (>201 mg/dl), which was significant (p250 mg/dl, 35% of the infants with GA between 23 to 25 weeks had serum triglycerides >250 mg/dl, while only 8% of the infants with GA between 26-32 weeks had serum triglycerides >250 mg/dl, which was significant (p=0.001). A premature infant’s lowering gestational age at birth significantly correlated with their increased risk for developing hypertriglyceridemia during the first week of life (Table 2). The correlation of an increased risk for hypertriglyceridemia remained significant from the first day until the seventh day of life (Day 1 p=0.002; Day 2-7 p<0.0001). Conclusions: Premature infants with GA between 26 and 32 weeks are able to tolerate higher infusions of IVFE initially and have IVFE advanced, with minimal risk for hypertriglyceridemia. Premature infants with GA between 23 and 25 weeks at birth are at a higher risk for developing hypertriglyceridemia during the first 7 days of PN. Premature infants <25 weeks may benefit from having IVFE be advanced more cautiously, during the first 7 days of PN.

Abstract of Distinction 272163 - Human milk oligosaccharides (HMO) influence intestinal maturation in vitro Hannah Holscher1, Steven Davis2, Kelly Tappenden1 1University of Illinois, Urbana, IL; 2Abbott Nutrition, Columbus, OH

Introduction: Although exclusive breast feeding is recommended for infants until 6 months of age, by one month of age nearly 40% of infants are receiving infant formula as their sole source of nutrition. Formula-fed infants are at increased risk of morbidity and mortality compared to their breast fed counterparts. As such, research is needed to identify infant formula ingredients that impart some of the benefits of breast feeding onto formula-fed infants. Human milk oligosaccharides (HMO) are abundant in breast milk (> 15 g/L) and associated with decreased disease risk and enhanced intestinal maturation in vitro. This study aimed to assess the induction of ‘epithelial differentiation’ by three individual HMO, 2’-fucosyllactose (2’FL), lacto-N-neotetraose (LNnT), and 6’-sialyllactose

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(6’SL), using an in vitro epithelial model of the crypt-villus axis. Methods: Pre-confluent HT-29, pre-confluent Caco-2Bbe, and post-confluent Caco-2Bbe cells were used to model the epithelium at various stages along the crypt-villus axis and assess HMO effect on epithelial cell kinetics, differentiation and function. Cells were randomized to treatments with one of three HMO at the following levels for 72 hrs of incubation: a) LNnT at 0, 20, 200 or 2000 mg/L or substrate control (0 mg /L plus lactose + N-acetyllactosamine); b) 2’FL at 0, 20, 200 or 2000 mg/L or substrate control (0 mg/L plus lactose + fucose); c) 6’SL at 0, 40, 400, 4000 mg/L or substrate control (0 mg/L plus lactose + sialic acid). Dependent variables used to assess effect of HMO were proliferation via MTS assays, differentiation via alkaline phosphatase (AP) activity, cell cycle analysis via flow cytometry, apoptosis via caspase-3 activity, digestive function via sucrase and lactase activity, and absorption and barrier function via modified Ussing chambers. Treatment effects were assessed within individual HMO groups by one-way ANOVA and paired-comparisons. Statistical significance was set at p<0.05. Results: Proliferation of pre-confluent HT-29 cells was reduced (p<0.05) when incubated with 200 and 2000 LNnT, 2000 mg/L 2’FL and 400 and 4000 6’SL. Reduced proliferation correlated with cell cycle arrest primarily in the G2/M phase as demonstrated in pre-confluent HT-29 cells treated with 200 (p=0.027) and 2000 (p=0.0033) of LNnT or 2000 2’FL (p=0.021). Interestingly, treatment with 4000 6’SL resulted in S phase arrest (p<0.001), whereas 400 6’SL tended (p=0.058) to occur in the G2/M phase. AP activity increased 31% (p=0.030) in pre-confluent HT-29 cells treated with 2000 2’FL and 33% (p=0.071) in post-confluent CaCo-2Bbe cells treated with 2000 2’FL. Sucrase activity was increased 54% (p=0.036) in post-confluent CaCo-2Bbe cells compared to control. Transepithelial resistance increased 21% (p=0.0021) in post-confluent Caco-2Bbe cells with 200 LNnT, and by 12% (p=0.059) with 2000 LNnT, compared to control. Conclusions: In summary, HMO inhibited proliferation in transformed small intestinal cell lines with associated cell cycle arrest, primarily within the G2/M phase. More importantly, inhibition of cellular proliferation within our model of the crypt-villus axis was associated with enhanced epithelial differentiation. Well differentiated villus enterocytes, modeled by post-confluent CaCo-2Bbe cells, had greater digestive and barrier function, as an effect of treatment with physiologically relevant doses of 2’FL and LNnT, respectively. Although further study is needed, the addition of HMO to infant formula may promote maturation of the small intestine and provide benefit to preterm infants.

Abstract of Distinction 273872 - Protein and Energy Intake in Critically Ill Children: An Observational Study Hannah Slattery1, Melinda White2, Robyn Littlewood2, Susan Ash1, Lynne Daniels1, Scott Blundell2 1QUT, Brisbane,Australia; 2Queensland Health, Brisbane, Australia

Background: The provision of optimal nutritional support is an essential component in clinical practice in the paediatric intensive care unit (PICU). Predictive equations used to determine energy requirements are often unreliable; therefore, this population is prone to under and overfeeding. Inadequate intake of nutrients during critical illness can amplify any pre-existing nutritional deficiencies thus impacting clinical outcomes, lengthening the duration of hospital admission as well as negatively impacting growth, while overfeeding can lead to ventilation and liver difficulties. The aim of this study was to observe feeding practices in the PICU in order to determine if patients are meeting their predicted requirements. Methods: This was a prospective, observational, cross-sectional study. Nutrition therapy was observed over a 2 month period for patients admitted to the PICU, Royal Children’s Hospital, Brisbane, Australia, for greater than 24 hours. Nutrition therapy was determined by the PICU dietitians, following ASPEN, 2009 guidelines. Patients’ estimated energy requirements were calculated using the Schofield weight-only equation and adding a physical activity level (PAL). The total number of calories (kcal/kg/day) and protein (g protein/kg/day) were calculated from the individual components consumed by the patients from intake records. The type and route of feeding was noted for each patient; age (months), sex (M/F), length of stay, ventilation status and number of days ventilated, principle diagnosis and underlying causes were also collected. Bland-Altman analysis was used to determine the difference between predicted and actual requirements. Patients’ admission weight was used for baseline data and discharge weight was collected post PICU discharge. Results: Patients (n=40) received 45.8 ± 24.6 kcal/kg/day. The majority of patients (75%) received enteral nutrition therapy. On average, patients were meeting 75% of estimated requirements for their calculated basal metabolic rate (BMR), 67% of their BMR with a PAL of 1.2 (while ventilated) and 65% of BMR with a PAL of 1.3 (non-ventilated). Requirements were based on published equations and the PAL was altered as required. Mean protein intake was 1.05 ± 0.78 g protein/kg/day which was lower than the recommended 1.5-3g protein/kg/day. The mean age of the patients was 54 ± 54 months, the mean weight was 16 ± 10.5 kg, this study included 29 males and 11 females, mean length of stay was 7 ± 7.8 days. Respiratory illness was the largest cause of admission, with 35% (n=14) of patients admitted for this reason.

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82.5% (n=33) of patients required ventilation during their PICU stay, with the average number of ventilated days being 4.3 ± 5.6 days (or 61.4% of admission time). 15% (n=6) of patients did not require nutrition support, of these; mean energy intake was 46.8 ± 46.6 kcal/kg/day. On average, patients were meeting 59% of their predicted protein requirement. 57% percent (n=16/28) of patients lost weight during PICU admission, of these patients 43.75% (n=7) had lost greater than or equal to 5% body weight and 12.5% (n=2) had lost greater than or equal to 10% body weight. Conclusions: Current PICU practice is leading to the under-provision of energy and protein when compared to predicted requirements for critically ill children. There was no statistically significant difference found between admission and discharge weight. As predictive equations are based on requirements for healthy children and due to limitations with using weight as the sole anthropometric assessment, it is difficult to determine the prevalence of malnutrition is increased in PICU patients.

Abstract of Distinction 272501 - Peroxisome proliferator-activated receptor-alpha expression and activity are altered by omega-3 polyunsaturated long-chain fatty acids in a cholestatic liver disease model Emma Tillman1, Richard Helms1, Dennis Black1 1The University of Tennessee Health Science Center, Memphis, TN

Background: Parenteral nutrition (PN)-associated liver disease (PNALD) occurs in children receiving long-term PN. Studies have demonstrated improvement of PNALD with omega-3 long-chain polyunsaturated fatty acids (ω3PUFA) containing eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) that have anti-inflammatory and anti-apoptotic properties, and are ligands for the nuclear receptor transcription factor, peroxisome proliferator-activated receptor-alpha (PPARα). When bound to a ligand, PPARα forms a heterodimer with retinoid X receptor (RXR) that binds to the peroxisome proliferator response element (PPRE) in the promoter region of target genes and modulates transcription. Activation of PPARα inhibits NFκB activation, thereby repressing inflammation. Studies in cystic fibrosis transmembrane conductance regulator (CFTR) knockout mice with bile duct injury showed a defect in PPARα expression, which was reversed by DHA treatment (Pall H et al.J Pediatr Gastroenterol Nutr. 2006;42:275-81). The aim of this study was to determine if PPARα activity is altered with ω3PUFA treatment in a model of PNALD. Methods: Cultured HepG2 cells were treated with the lipophilic bile acid, chenodeoxycholic acid (CDCA) 200 μM ± ω3PUFA (EPA 5 μM + DHA 5 μM). Activation of PPARα was evaluated by isolation of nuclear protein after 4-hr treatment and assessing transcription factor activity via a non-radioactive, sensitive ELISA method for detecting PPARα DNA binding activity in nuclear extracts. Concentrations of PPARα and RXR mRNA were evaluated at 0.5 hours using quantitative real-time RT-PCR. Results: Treatment of HepG2 cells with ω3PUFA alone resulted in PPARα activity equal to that observed with recombinant PPARα. DNA binding of PPARα was decreased by 70% in the presence of CDCA (p < 0.001). Treatment with CDCA and ω3PUFA resulted in less reduction of PPARα activity as compared to treatment with CDCA alone, but activity was not restored to the control level. Treatment with CDCA alone resulted in a 67% reduction in PPARα mRNA levels as accessed by RT-PCR, as compared to cells treated with a vehicle control. Treatment with CDCA and ω3PUFA resulted in restoration of PPARα mRNA concentrations to control levels. There was no statistical difference in RXR mRNA concentrations. Conclusion: Activity and expression of PPARα were reduced by treatment with a lipophilic bile acid and increased in the presence of ω3PUFA. These results are similar to studies in CFTR knockout mice with liver disease and suggest that PPARα activation may be a promising mechanism by which ω3PUFA attenuate bile acid-induced hepatocellular injury that occurs in cholestasis, such as that seen in PNALD.

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Means of data from various treatment conditions with different letters above the bars are significantly different from each other at p < 0.05 by ANOVA. Those sharing the same letter or no letter are not significantly different from each other.

Abstract of Distinction 273716 - The relationship between mid-upper arm circumference to occipitofrontal circumference ratio and standard anthropometric measurements in pediatrics Sarah Vermilyea1, Pamela Rothpletz-Puglia2, James Scott Parrott3, Julie Slicker1, Khalil El-Chammas4, Mutaz Sultan4, Martin Wakeham4, Riva Touger-Decker3, Praveen Goday4 1Children's Hospital of Wisconsin, Milwaukee, W; 2François-Xavier Bagnoud Center University of Medicine and Dentistry of New Jersey (UMDNJ), Newark, NJ; 3University of Medicine & Dentistry of New Jersey , Newark, NJ; 4Medical College of Wisconsin, Milwaukee, WI

Objective: Anthropometric measurements are critical components of pediatric nutrition assessment. However, accurate weight and height measurements can be difficult to obtain for critically ill children. A calculation using mid-upper arm circumference (MAC) and occipitofrontal circumference (OFC) that reflects body proportionality has been shown to detect protein calorie malnutrition (PCM) when weight or height measurements are not available. This MAC/OFC ratio has been shown to differentiate between adequately and inadequately nourished ambulatory children aged three to 48 months, and has historically been used in developing countries when weight and height measuring devices were not available. The purpose of this study was to explore the relationship between the MAC/OFC ratio and standard anthropometric measures (weight-for-age, length-for-age, weight-for-length, and BMI-for-age z-scores), among children aged three months corrected age to four years admitted to the pediatric intensive care unit (PICU). Design: This was a retrospective secondary analysis of data collected between March and August 2010, for another study which used a consecutive sample of children aged one month corrected age to five years admitted to the cardiac, surgical, or medical PICU. This retrospective study includes data from children aged three months corrected age to four years (48 months) because the use of the MAC/OFC ratio is limited to this age. Statistical Analysis: Descriptive statistics were used to report demographic characteristics and anthropometric measurements. Pearson’s product moment correlation coefficient statistic was used to test the relationships between the MAC/OFC ratio and weight-for-age, length-for-age, weight-for-length (for children ≤ 3 years), and BMI-for-age z-scores (for children aged 3-4 years), and the agreement between the MAC/OFC ratio categories and weight-for-length or BMI-for-age categories was tested using a kappa statistic. Sensitivity and specificity analysis were used to describe misclassifications by the MAC/OFC ratio. Underweight was defined as a weight-for-length or BMI-for-age z-score less than – 1.65 SD and MAC/OFC classification of PCM was defined as less than or equal to 0.31. Results: 108 patients were identified with a mean age of 19.30 (SD = 13.02) months. Of participants aged three to 36 months (n = 88), 27.27% were underweight, while 13.33% of children aged 36-48 months (n = 15) were underweight. The mean MAC/OFC ratio was 0.33 (SD = 0.03); 26.85% had protein calorie malnutrition according to MAC/OFC ratio

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classification. There was a strong, significant correlation between the MAC/OFC ratio and weight-for-length z-scores (r = 0.720, p <0.0010). The MAC/OFC ratio accurately classified 85.23% of participants in this age group. Because there were only 15 children in the 36-48 month age group, the relationship between the MAC/OFC ratio and BMI-for-age was not analyzed. There was a moderate, significant correlation between the MAC/OFC ratio and weight-for-age z-score (r = 0.491, p <0.001). Conclusion: This study of standard anthropometric measurements and the MAC/OFC ratio provided preliminary data supporting a relationship between weight-for-length z-scores and the MAC/OFC ratio in critically ill children aged three months corrected age to 36 months, as well as between weight-for-age z-scores and the MAC/OFC ratio in critically ill children aged three months corrected age to 48 months. Further research is needed to test this relationship.

ORAL ABSTRACTS PRESENTIONS IN EDUCATIONAL SYMPOSIA 273699 - BIVA: A Novel Method for Nutritional Assessment in Children with Cancer Katherine Allen1, Zhiguo Zhao2, Frank Fan2, Yu Shyr2, John Pietsch1 1Vanderbilt Children's Hospital, Nashville, TN; 2Vanderbilt University Medical Center, Nashville, TN.

Background: Nutritional status in children treated for cancer correlates with outcome. Early identification of decline should allow for timely nutritional support intervention and improved outcomes. Current methods for nutritional assessment (NA) consist of anthropomorphic measurements. They do not detect malnutrition early. This study aims to ascertain if Bioelectric Impedance Vector Analysis (BIVA) can be used as a NA tool and to examine how it compares to conventional NA methods. Methods: BIA measures impedance, which is a combination of resistance (R), a measure of the restriction of flow of an electrical current, and reactance (Xc), a measure of the resistivity of a current as it travels. Changes in R are due to changes in tissue hydration and changes in Xc are due to changes in the number of intact cell membranes present. BIA was measured in 49 patients and plotted as a BIVA graph (Xc/H vs R/H). A review of participant’s clinical course was conducted including weight, height, and BMI calculations. Binary logistical regression and linear mixed effects models were used to analyze association between BMI &BIVA. Results: A significant association was found between a BIVA score of 8 (indicating severe cachexia) and a BMI of less than 5% (p=0.003). No association was found between a BIVA score of 4 (indicating obesity) and a BMI percentile of greater than 95% (p= 0.52). A correlation between the clinical course of the patient and changes in the BIVA measurements was also noted. Conclusion: BIVA measurements appear to be a useful NA tool in pediatric cancer patients. Initial findings suggest that BIVA is able to identify the type of weight being gained or lost, and it can identify patient that are cachectic. The next step is to prospectively determine if nutritional support based on BIVA results in improved outcomes.

Bioelectrical Impedance Vaector Analysis. The vector's position on graph is used to describe body composition (right graph) or changes to body composition over time (left graph)

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274599 - Comparison of Use of Piggyback Electrolytes for Patients Receiving Premixed versus Individualized Parenteral Nutrition Solutions Caitlin Curtis1, David Hager1, Lauralei Schuster2, Kenneth Kudsk4 1University of Wisconsin Hospital and Clinics, Madison , WI; 2University of Wisconsin-Madison, Madison, WI; 3University of Wisconsin-Madison College of Medicine and Public Health, Madison, WI.

INTRODUCTION: Prescribers now have available mixing of parenteral nutrition (PN) solution by individualized prescription using an automated compounding device, or use of premixed dextrose/ amino acids solution prepared by the manufacturer. Our institution used only individualized prescriptions until a recent amino acid shortage forced a temporary switch to premixed solutions. The premixed solutions contain lower concentrations of electrolytes than is typically used in individualized prescriptions. OBJECTIVES: 1) To quantify the use of piggyback electrolytes necessary in adults patients cared for by the Nutrition Support Team in a tertiary referral hospital who received premixed versus individualized prescriptions of PN. 3) To quantify any cost differences of piggyback electrolyte administration between the two types of formulas. METHODS: We compared the use of piggyback electrolytes ordered by anyone with prescriptive authority and administered to patients on the Nutrition Support Service during consecutive periods when patients received individualized prescriptions versus premixed PN. Piggyback electrolytes quantified included: potassium 10 meq, potassium 20meq, magnesium 2g, magnesium 4g, phosphate potassium 7.5 mmol, phosphate potassium 15mmol, phosphate sodium 7.5 mmol, phosphate sodium 15mmol bags. RESULTS: We compared 31 days of individualized prescription PNs (457 PN ordered) with 35 days of premixed PN (490 PNs ordered). There was no statistical difference in the number of PNs administered per day during each period (14.7+/- 3.9 vs 14.0 +/- 2.6, individualized vs premixed, respectively). Significantly more total piggyback electrolytes provided per day of PN in the premixed PN period compared to the individualized prescription PNs period (13.8+/- 6.9 vs 7.03+/- 3.8, p<0.0001). These included significantly more administration of potassium chloride 20meq bags/day (6.4+/-4.7 vs 2.4+/-2.1, p<0.0001), more potassium phosphate 7.5 mmol bags/day (0.5+/-1.2 vs 0.03+/-0.18, p <0.035), and more sodium phosphate 15mmol bags/day (2.2+/- 1.9 vs 1.4+/- 2, p<.0.028) used in the premixed PN period than with individualized prescription PNs. By using the pre-mixed PN, using the means above, approximate extra cost per 30 days for piggyback electrolytes is $5,698.72 for potassium chloride 20meq, $624.49 for phosphate potassium 7.5 mmol, and $1056.48 for phosphate sodium 15 mmol. At our institution, pre-mixed PN and individualized PN are equivalent in cost per bag, therefore costs for piggyback electrolytes are important. CONCLUSIONS: Using premixed PNs in a hospitalized population of patients in a tertiary referral hospital results in a significantly greater need for supplemental electrolytes administration and increased cost.

273878 - Refeeding After TPN Leads to a Pro-Inflammatory State within the Intestinal Mucosa Yongjia Feng1, Daniel Teitelbaum1 1University of Michigan, Ann Arbor, MI

Background: Total Parenteral nutrition (TPN) leads to a decline in epithelial cell (EC) proliferation, increase in EC apoptosis and loss of epithelial barrier function (EBF). TPN also leads to profound increases in pro-inflammatory cytokines, including TNF-alpha and IL-6.On a clinical level, patients frequently move from a state of TPN to enteral feeding. The consequences of acutely feeding a gastrointestinal tract which was nutrient deprived has not been well studied. We hypothesized that re-feeding would lead to a rapid reversal in many of these adverse gastrointestinal changes. Methods: C57BL/6J male mice received enteral nutrition (Control) or TPN for 7 days. A third group consisted of mice given TPN for 7 days followed by cessation of TPN and given chow for 24 hours(Refeeding group). BrdU (50mg/kg) was given 2 hours before sacrifice, and small intestine was then harvested. Chemokine, cytokine and regulatory genes were measured with real-time PCR, EC proliferation was measured with PCNA and BrdU staining, and apoptosis via TUNEL staining. Transepithelial resistance (TER) was measured to assess EBF. Finally, to determine changes in intestinal stem cell lineages, Lgr5 transgenic mice (stem cell marker) were examined. Results: TPN significantly lost PCNA+ and BrdU+ ECs (Table and Figure). Refeeding led to a rapid increase in EC proliferation (80% of controls). TUNEL+ ECs significantly increased in TPN mice (1% vs 10% control vs TPN). Unlike proliferation, this high apoptosis index did not reverse in the refeeding group. Lgr5 mRNA decreased 5.8-fold in TPN mice vs. controls, refeeding did not affect this change. There were 20% crypts with LGR5+ cells in the controls, and these markedly decreased in the TPN group, and failed to change in the refeeding group(Table). In order to examine downstream consequences of these stem cell changes, several factors were examined. This showed a loss of several regulatory factors with TPN (Table) and partial return with refeeding. EGFR and its ligands EGF, epiregulin, and TGF-alpha were down-regulated with TPN, and all recovered with

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refeeding. Pro-inflammatory cytokines TNF-alpha and IL-6 increased 2-fold with TPN vs. controls. Surprisingly, TNF-alpha expression in refeeding mice rose even higher (4-fold vs. controls), and IL-6 expression remained similar to the TPN group. Toll-like receptor 4 (TLR4) expression increased with TPN, and rose much more (>2-fold the TPN group) with refeeding. This trend was also seen with the chemokine monocyte chemoattractant protein-1 (MCP1/CCL2)(Table). The T-regulatory cytokines IL-10 and TGF-beta decreased in TPN group, and TGF-beta expression was recovered in refeeding group, refeeding did not significantly affect loss of IL-10 expression after TPN. TER decreased 50% in TPN mice (Table); and refeeding led to a partial recovery. Examination of tight junction markers showed loss of these markers with TPN administration. Refeeding, however, led to a striking shift, with a marked increase in ZO-1 and Occludin above controls (both pro-EBF), but a marked increase in Claudin-2, the pore-forming (loss of EBF). Conclusions: Reintroduction of enteral feeding reversed the decline in EC proliferation, possibly via EGF signaling and stimulation of the Wnt pathway. However, refeeding led to a marked stimulation of several inflammatory factors. This pro-inflammatory state may well counter some of the beneficial effects of introducing enteral feeding. While potentially longer periods of refeeding may prevent these adverse changes; the results suggest that the simple process of refeeding a TPN patient may be far more complex than previously perceived.

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Caption Figure 1: Refeeding recovered TPN associated loss of EC proliferation, not affect increased EC apoptosis

273408 - Early Enteral Nutrition is associated with significantly lower mortality in critically ill children Praveen Goday1, Melissa Christensen1, Jennifer Manzi1, Susan Connolly1, Evelyn Kuhn2, Martin Wakeham1, Theresa Mikhailov1 1Medical College of Wisconsin, Milwaukee, WI; 2Children's Hospital of Wisconsin, Milwaukee, WI

Hypothesis: Early enteral nutrition (EN), which is defined as delivery of 25% of goal calories via the enteral route within the first 48 hours of admission, is associated with a lower mortality rate, shorter medical length of stay (LOS) in the pediatric intensive care unit (PICU) and shorter duration of mechanical ventilation (MV). Aims: To determine whether early EN is associated with a lower mortality rate, shorter medical LOS in the PICU, a shorter duration of MV in critically ill children. Methods: This was a retrospective chart review of patients from 12 centers participating in this multicenter study through the PICU FOCUS Group of the National Association of Children’s Hospitals and Related Institutions. All participating centers obtained approval from their local Institutional Review Board. Information relating to demographics and PICU admission was acquired from the Virtual PICU Systems (VPSLLC)

clinical database. We obtained weight, sex, PIM-2 score, medical LOS, duration of MV and mortality data. Data regarding MV were collected only by 9 centers. Nutritional intake data including route, quantity, and content was obtained by chart abstraction. Data was collected for all patients aged 1 month to 18 years who had a PICU LOS greater than 96 hours from January 1, 2007 to December 31, 2008. Nutritional intake data was gathered on only the first 4 days of PICU admission. Goal calories were determined using the WHO equation. The association of early EN with medical LOS and duration of MV was analyzed using Mann-Whitney tests (due to their skewed distributions) and regression analysis. Mortality was compared between the groups using chi-square tests and logistic regression analysis. Results: We identified 5105 patients of which 53.8% were male and mean age was 5.3 years. The overall mortality was 5.3%. MV data was analyzed for the 2174 mechanically ventilated patients from

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the 9 centers. Of all the patients, 27% achieved early EN. Those who received early EN were less likely to die than those who did not, even after adjustment for PIM-2 score and center [OR=0.50 (0.34-0.72), p<0.001]. The unadjusted medical LOS for those who received early EN (median 8.0, mean 12.5 ± 15.6 days) was significantly longer than medical LOS for those who did not receive early EN (median 7.7, mean 12.5 ± 16.5 days) (p=0.037). When adjusted for PIM-2 score and center, the difference in medial LOS was no longer statistically significant (p=0.092). The unadjusted duration of MV for those who received early EN (median 6.3, mean 10.9 ± 18.7 days) was significantly longer than duration of MV for those who did not receive early EN (median 5.5, mean 9.9 ± 16.7 days) (p=0.003). When adjusted for PIM-2 score and center, the duration of MV for those who received early EN was longer than for those who did not (p=0.002). Trends for medical LOS and duration of MV were similar when deaths were excluded. Conclusions: Early EN, defined as 25% of goal calories delivered by 48 hours after PICU admission, is strongly associated with lower mortality rate even after adjustment for risk of mortality. The LOS tends to be longer in those patients who received early EN; however, the difference is not statistically significant. Early EN is associated with a longer duration of MV.

274271 - Survival in Chemotherapy Patients: Questioning the Obesity Paradox defined by Body Mass Index Maria Cristina Gonzalez1, Carla Pastore1, Silvana Orlandi2 1Universidade Católica de Pelotas, Pelotas, Brazil; 2Universidade Federal de Pelotas, Pelotas, Brazil BACKGROUND: Changes in body composition are prevalent in cancer patients and a low fat-free mass (FFM) compartment has been considered as a risk factor for chemotherapy patients. Otherwise, obesity, accessed as Body Mass Index (BMI), is considered a protective factor for survival in several diseases. The purpose of this study was to investigate the role of FFM or obesity, defined as a high fat mass index (FMI) or BMI, in the survival of cancer patients receiving chemotherapy. METHODS: A longitudinal study was conducted in 175 patients before the first chemotherapy course. Bioelectrical impedance analysis was used to assess body composition and FFM index (FFMI = FFM (kg)/height2) and FMI (FMI = FM (kg)/ height2) were estimated. Low FFMI and high FMI were defined according to Kyle, 2005. Values of FFMI < 17.5 kg/m2 or < 15.1 kg/m2 were considered low FFMI and FMI ≥ 5.2 kg/m2 or 8.2 kg/m2 were considered high FMI, for men and women, respectively. The time of survival was monitored during 3 years after the first assessment. The Kaplan-Meier method was used to calculated survival and the multivariate Cox regression was used to evaluate the independent prognostic effect of the BMI, FFMI and FMI after adjustment for other variables. RESULTS: Most of the patients were female (65.7%) with mean age of 56.9 ± 12.8 years old and 78.2% were in tumor stage II or III. The most prevalent cancers were breast, head or neck, gastrointestinal and liver. According to BMI, 60% of the patients were overweighed or obese and only 3.4% had BMI <18.5 kg/m2. Survival time for patients with BMI ≥ 25 kg/m2 was significantly higher compared to normal and low BMI groups (0.52 X 2.04 X 2.64 X 2.61 years, respectively), with a HR = 0.07 for both groups with BMI ≥ 25 kg/m2 (p< 0.001). When analyzed according to FFMI, patients with low FFMI had a significantly smaller survival time compared to normal FFMI (0.47 X 2.6 years, respectively), with a HR = 7.3 (CI: 4.2 – 12.8; p < 0.001). When obesity was defined as high FMI, patients with a higher FMI also had a higher survival time when compared to normal FMI patients (2.6 X 1.93 years, respectively) with a HR = 0.47 (CI: 0.29 – 0.77; p = 0.002). At the end of study, the groups with the smallest percentages of survival were BMI < 18.5 kg/m2 (no one survivor) and low FFMI (9.5% of survivors). After a multivariate Cox regression controlling for confounding variables including BMI, patients with lower FFMI still showed a significantly higher risk for mortality (HR = 5.19 CI: 2.58 – 10.43; p < 0.001). CONCLUSIONS: FFMI seems to be a significant risk factor for survival in this group of chemotherapy patients, independently of BMI, age or tumor staging. Body composition should become part of all cancer patients’ assessment to identify these higher risk patients. Other studies may show if an improvement in FFMI can change the survival of these patients.

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273904 - Implementation of an Intestinal Rehabilitation Approach in the Home Setting Deborah Pfister1, Maria Karimbakas1, Karen Ackerman1 1ThriveRx, Cincinnati, OH Introduction: The Intestinal Rehabilitation (IR) concept was initiated by Wilmore and Byrne at the Nutritional Restart Center (NRC), where they implemented a multidisciplinary approach to the management of short bowel syndrome. This program demonstrated that diet and medication modification significantly impacted outcome for the short bowel patient and was instrumental in reducing Parenteral Nutrition (PN) requirements. The NRC model incorporated intensive patient education with an on-going two year follow-up period to encourage compliance to the dietary principles. Outcomes from this program documented: 25% total PN weaning, 50% reduced PN needs and 25% without weaning potential. Since then, the IR model has been formalized and incorporated into care at medical centers nationwide, where a three-pronged approach is followed to include; Parenteral and Enteral nutrition management; intestinal rehabilitation through diet and medication management; and surgical intervention and/or transplantation. Description: Our home nutrition support program is focused on the care of complex gastrointestinal disorders including short bowel. In an effort to achieve the goals of IR in the home setting, we developed a web-based diet education program. Over a 12-month period, monthly modules were introduced to cover topics related to diet modification. The modules were available as a self-directed, web-based learning program coupled with a monthly webinar to allow didactic review of the material and encouraged individual questions for concept clarification. In conjunction with the modular program, each patient received one-on-one consultation with our clinical team including Dietitian, Nurse and Pharmacist. The following case study exemplifies our home IR program. Discussion: D.M. is a 41 year old male diagnosed with short bowel syndrome due to mesenteric ischemia, with 122 cm remaining. Prior to IR program registration, D.M. required 7 days per week of PN for 7 years, was at 93% of Ideal Body Weight (IBW) with monitored stool output of 26 times per day. As part of the IR program the following goals were established: to increase weight to IBW; to optimize oral food and fluid choices to reduce stool

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output; to decrease daily PN requirements; and to maximize micronutrient status. D.M. was taught to modify his oral intake to include high complex carbohydrate, low sugar, high protein and high essential fatty acid foods. This included implementation of small, frequent meals evenly spaced through the day, inclusion of Oral Rehydration Solutions and restriction of free fluids. Within 8 weeks, D.M.’s weight had increased 2.3 kg, stool output decreased 70%, lab indices reflected improved hydration status and PN was reduced from 7 to 5 days per week. Overall, D.M. reported improved quality of life related specifically to his reduced stool output and reduction in days on PN. Conclusion: Our experience is that a home-based IR program can successfully provide patient education, as an extension of a traditional IR program. Our goal is to further individualize our IR program and to measure clinical outcome relative to other published program results. CLINICAL NUTRITION WEEK 2012 POSTER ABSTRACTS PARENTERAL NUTRITION Encore Abstract. Presented at Pediatric Academic Societies and Asian Society for Pediatric Research Joint Meeting 2011. 1 - Evaluation of Ethanol Lock Therapy in Pediatric Patients on Long-Term Parenteral Nutrition Kevin Pieroni1, Colleen Nespor2, Marisa Ng2, William Berquist1, John Kerner1 1Stanford University School of Medicine / Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Palo Alto, CA;, 2Children's Home Pharmacy at Lucile Packcard Children's Hospital, Palo Alto, CA

Background: Pediatric home parenteral nutrition (PN) patients present a unique challenge with risks of catheter associated blood stream infections (CABSI), sometimes requiring subsequent catheter removal. These children use PN as their primary nutrition source via a central venous catheter (CVC). Recurrent infections can lead to catheter removal and potential loss of venous access in the future. Previous small studies have shown that ethanol lock therapy can potentially decrease CABSI. Objective: Demonstrate that weekly ethanol lock therapy decreases CABSI in long-term home PN patients and decreases catheter removals due to infections. Methods: Beginning August 2007, patients receiving PN with a history of multiple previous CABSI were started on ethanol lock therapy. One to 2 ml of 70% ethanol solution was instilled into the CVC for two hours weekly based on the patient's weight and catheter volume. The solution is then withdrawn, and the CVC is flushed with normal saline and heparin. Nursing staff or trained parents administered this protocol. Once followed by our home pharmacy, episodes of CABSI and catheter removal due to infection were documented in patients prior to and after ethanol lock therapy. Results: Thirteen patients were followed for an average of 537 days after ethanol lock therapy was initiated. Patients had short bowel syndrome secondary to gastroschisis, necrotizing enterocolitis, intestinal atresia, long segment Hirschsprung's disease, or previous surgical complication. These patients were found to average 14 CABSI per 1000 days prior to starting ethanol lock therapy and only 2.8 CABSI per 1000 days after ethanol lock therapy, p value <0.001. Prior to ethanol lock therapy the group averaged 1.5 catheter removals but only 0.3 after ethanol lock therapy; nine patients did not require any further catheter removals after ethanol lock therapy. Conclusions: Our group of patients showed an 80% reduction in CABSI and an 80% reduction in catheter removal due to infection after ethanol lock therapy. In our patient population, weekly ethanol lock therapy for 2 hours is an effective technique to reduce CABSI and catheter removal in long-term home PN patients. This significant decrease in infection and catheter removal can decrease mortality secondary to sepsis, worsening liver function, and loss of permanent vascular access sites.

2 - Successful Ethanol Lock Therapy Treatment of Fungal Central Venous Catheter Infections Kevin Pieroni1, Colleen Nespor2, Robert Poole2, John Kerner1, William Berquist1 1Stanford University School of Medicine / Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Palo Alto, CA; 2Children's Home Pharmacy at Lucile Packcard Children's Hospital, Palo Alto, CA

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Background: Pediatric home Parenteral Nutrition (PN) patients present a unique challenge with risks of catheter associated blood stream infections (CABSI), sometimes requiring subsequent catheter removal. These children use PN as their primary nutrition source via a central venous catheter (CVC). Recurrent infections can lead to line removal and potential loss of venous access in the future. Fungal infections have been particularly difficult to clear even with appropriate antifungal drugs. Failure to treat fungal CABSIs has historically led to the vast majority of CVCs being removed once a fungal CABSI was identified. A few case reports have shown that ethanol lock therapy (ELT) can help treat and clear CVCs that have fungal infections. Methods: Retrospective review of a series of pediatric patients with fungal CABSIs that were treated with ethanol lock therapy. Patients with a silicone CVC, followed by our Children's Home Pharmacy, that were admitted for fevers and found to have a positive fungal blood culture were started on ELT. Based on the size of the catheter, 1 to 2 ml of 70% ethanol was instilled in the CVC and allowed to dwell for 2 hours for 5 consecutive days. Patients were also treated with an antifungal drug infused through the CVC. The patients completed 5 days of ELT even if cultures became negative before the fifth day. The patients then finished their intravenous antifungal drug regimen either at home or in the hospital and began weekly ELT for maintenance, if not already on weekly prophylactic ELT. If the patient was clinically unstable or the blood cultures continued to be positive after 5 days then the line was removed. Results: Six patients with a CVC were treated with ELT for 7 episodes of fungal CABSI. They were found to have 1 case of Saccharomyces cerevisiae, 1 case of Candida parapsilosis, 3 cases of Candida glabrata, and 2 cases of Candida albicans. Of note, the patient that was culture positive with Saccharomyces cerevisiae was on a probiotic that contained the same strain. Five out of the 7 fungal CABSI episodes were successfully treated, i.e. blood cultures from the CVC became negative. The unsuccessfully treated episodes involved Candida parapsilosis and Candida glabrata, which lead to removal of both catheters. No CVC was removed due to clinical instability. The patient with Candida glabrata had an earlier fungal CABSI, also Candida glabrata, which was treated and cleared 30 days earlier. Initially patients were started on amphotericin B liposomal, voriconazole, or fluconazole but ultimately were switched to complete a course of micafungin or caspofungin after consultation with our infectious disease colleagues. Conclusion: Five of 7 fungal CABSIs were successfully treated with 5 days of consecutive ELT. It is still unclear as to the necessary dwell time and frequency of ELT, but our experience has shown that even 2 hours is sufficient to help eradicate fungus from a CVC. Echinocandin antifungal drugs also seem to be a particularly efficacious treatment option especially since some reports believe that this class of drugs has been shown to have activity against Candida biofilms. Due to the positive outcome of our ELT data, we now follow this protocol for fungal CABSIs that consists of ELT instilled in the CVC for 2 hours daily for 5 days along with the use of an echinocandin administered intravenously via the CVC.

Encore: Previously presented at NASPGHAN Oct. 2011 Conference. Predecessor abstract available at: http://www.naspghan.org/user-assets/Documents/pdf/Annual%20Meeting%202011/Speaker%20presentations/2011%20NASPGHAN%20abstracts_JPGN.pdf 3 - Pre-emptive restriction of Intralipids dose is not necessary for management of PNALD Timothy Sentongo1, Ellen Newton1, Dana Weinstein1, Melanie Purser1, Ranjana Gokhale1, Stefano Guandalini1 1University of Chicago, Chicago, IL

BACKGROUND: Recent association of Soy-based intravenous lipid emulsions with risk for Parenteral Nutrition Associated liver disease (PNALD) has prompted the practice of pre-emptive reduction in initial dose of Soy lipids or use of fish oil-based intralipids. This study demonstrates that liberal use of Soy-based intralipids with individualized dose adjustments at onset of cholestasis is effective for management and reversal of PNALD. METHODS: Review of Nutrition Support Practice in NICU infants during 7/09 to 6/10. 520 infants received PN therapy; 129 (25%) were randomly sampled. PN was initiated by day 2 of life (DOL) and advanced to goal of 150 mL/kg/d; 90 – 100 kcal/kg/d; Protein 3-4 g/kg/d and intralipids 3 g/kg/d by DOL 7 – 10. PN volume was reduced while advancing enteral feeds. At onset of PNALD (direct bili >1.5 mg/dL x >7 d) the lipid dose was gradually reduced by 0.5 – 1.0 g/kg/d/week to minimum of 1 g/kg/d x 3/week depending on severity of PNALD and maintenance of weight gain. Prevalence of PNALD, risk factors, time to onset and reversal of PNALD were examined. RESULTS: 129 infants (49% female), birth weight (median; range) 1557 g (425 – 4085 g), gestation age 31 weeks (23 – 41). The most frequent

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co-morbidity was severe pulmonary disease (76%) followed by cardiac 21% and gastrointestinal disorders (11%). The duration of PN was 16-d (1 – 322). 22 infants (16%) developed PNALD, with 33-days as the median duration of PN to onset of PNALD. The median duration of PN in infants that developed PNALD vs. no PNALD was 51 d, p <0.01. There was a significant association between resolution of PNALD and reduction of intralipids dose p = 0.026. Average weight gain was 12 g/d. Resolution of PNALD occurred in 100% of infants regardless of birth weight, degree of prematurity or presence of GI disease. CONCLUSION: Duration of PN therapy was the most consistent risk for onset of PNALD, while continual use of Soy based intralipids at a reduced dose was significantly associated with resolution of PNALD. Time to onset of PNALD was variable and thus did not support the practice of pre-emptive restriction of lipid dose.

Encore: previously presented at ESPEN 2011 conference. Published: Clinical Nutrition Supplements, 2011, Vol.6, No.1 page 179-180. Available at http://clinicalnutritionsupplements.com. 4- Central Venous Catheter Infection in Canadian Home Parenteral Nutrition Patients: A 5-Year Multicentre Retrospective Study Olivia Saqui1, Gail Fernandes1, Jayvee Guerrero1, Johane Allard1 1Toronto General Hospital, University Health Network, Toronto, ON. Canada 5 - Vitamin D status of patients receiving home parenteral nutrition Katja Kogovsek1, Nada Rotovnik Kozjek1, Laura Petrica1 1Oncology Institute Ljubljana, Ljubljana, Slovenia

Rationale Vitamin D has pleiotrophic effect in a variety of extraskeletal tissues that are important in health and in optimal treatment of chronic diseases. However, optimal serum concentrations of 25-hydroxyvitamin D [25(OH)D] have not been defined. For all endpoints, the most advantageous serum concentrations of 25(OH)D begin at 75 nmol/L (30 ng/mL), and the best are between 90 and 100 nmol/L (36-40 ng/mL) for healthy population. Recent evidence suggests that vitamin D intakes above current recommendations of 200 and 600 IU vitamin D/d for younger and older adults, respectively, may be associated with better health outcomes (1). In disease states, as in patients with underlying diseases which requires parenteral nutrients intake, we have no data about optimal serum 25(OH)D concentration. Recent study by Thomson group showed that patients on Home Parenteral Nutrition (HPN) are vitamin D deficient according to recent definitions (1,2). The purpose of study was to evaluate the 25(OH)D concentration in serum in our group of patients with HPN and correlate it to dry lean mass and phase angle. Methods In 17 patients with cyclic HPN seven times per week the serum concentration of 25(OH)D was measured. 3 of them were paliative cancer patients. All of them had daily supplementation of vitamin D 200 IE as a part of daily vitamin parenteral supplementation. None of them was taking any form of oral vitamin D supplementation. Body composition was measured with Bodystat 4000 bioimpedance machine. Results Serum 25(OH)D levels in this group of patients were in the range from 10 nmol/ l to 42,7 nmol/l, average value was 23,24 nmol/l. 5 of them had very low value, 10nmol/l. In this group 1 of them was paliative cancer patient, average dry lean mass was 9.0kg and average phase angle 4,1. In other 10 patients 2 of them were paliative cancer patients, average average dry lean mass was 9.0kg and average phase angle 4,1. Conclusion All of patients, regardless the underlying disease state, had the serum concentration of 25(OH)D below the lower recommended limit for healthy population. We did not find any correlation between 25(OH)D concentration and markers of body composition. Probably in both groups blood 25(OH)D levels were too low. Obviously their needs exceed their daily routine vitamin D supplementation. Literature 1. Bischoff-Ferrari HA, Giovannucci E, Willett WC, Dietrich T, Dawson-Hughes B. Estimation of optimal serum concentrations of 25-hydroxyvitamin D for multiple health outcomes.Am J Clin Nutr. 2006 Jul;84(1):18-28. Review. Erratum in: Am J Clin Nutr. 2006 Nov;84(5):1253. 2. Thomson P, Duerksen DR.Vitamin D deficiency in patients receiving home parenteral nutrition.JPEN J Parenter Enteral Nutr. 2011 Jul;35(4):499-504.

6 - Fish Oil-Based Lipid Emulsion in an Adult Patient with Intestinal Failure-Associated Liver Disease

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William Mittendorff1, Barbara Crouse2 1Scripps Coastal Medical Center, San Diego, CA; 2Coram Specialty Infusion Services, San Diego, CA

Intestinal failure-associated liver disease (IFALD) is a complication in the pediatric intestinal failure patient that often leads to the need for a combined liver-intestine transplant. Fortunately, the incidence of IFALD in adult parenteral nutrition (PN) patients is substantially lower than in PN-dependent infants and children. This case study presents the second reported adult PN-dependent patient in North America to receive fish oil-based IV lipid emulsion (FOLE). The patient is a 58-year-old Caucasian female with a complex medical history that began with a ruptured appendix at age six years. Subsequent repeated bowel obstructions and multiple bowel resections, resulted in short bowel syndrome and PN dependence since 2006 with only a gastric remnant, 50 cm of ileum (no iloececal valve) and rectosigmoid colon remaining. Her medical history is also notable for rheumatoid arthritis, duodenal and gastric ulcers, and recurring enterocutaneous fistulae. In 2005, the patient had an antrectomy and Bilroth II for a perforated gastric ulcer. In 2007, she had a cholecystectomy, which resolved cholestasis. The patient experienced several episodes of confirmed catheter related bloodstream infections (CRBSI) in 2010, requiring multiple PICC line replacements. Ethanol lock therapy and use of luer access valve caps were instituted; she has been free of CRSBI since October 2010. Her liver enzymes had been moderately elevated since 2009. Home PN (HPN) was reduced in October 2010 to four days/week. By December 2011, her T. bili was greater than 7 mg/dl; liver biopsy on 12/16/10 demonstrated cholestatic injury. Her T. bili continued to progressively worsen, reaching greater than 14 mg/dl by March 2011. The patient was unable to maintain functional status, requiring assistance with ambulation and ADLs; her weight declined to 91.5 pounds (87% of UBW). Daily HPN was resumed in March 2011. An emergency Investigational New Drug (IND) protocol request was submitted to the FDA and approved five days later for use of FOLE infusion dosed at 0.45 gm/kg per day; soybean-based lipid emulsion, at 0.9 gm/kg, was discontinued. The patient’s T. bili peaked on 4/10/11 at 19.6 mg/dl. She experienced a GI bleed requiring blood transfusion just prior to beginning FOLE therapy. Four weeks after beginning FOLE therapy, she was admitted to the hospital with a second GI bleed, severe peripheral edema and ascites, and recent associated weight gain of 30 pounds. She was markedly icteric, with a bronze skin color. FOLE therapy was not provided during her hospital stay. At this time, her prognosis was grim and she was evaluated for combined liver-intestinal transplantation. After seven weeks of FOLE therapy, ascites and peripheral edema had resolved, and the patient was able to ambulate and perform ADLs independently. Following 22 weeks of FOLE therapy, her T. bili had declined to 1.2 mg/dL, her activity level had increased to include daily 30-minute walks, and liver-intestinal transplantation was no longer being pursued. Her weight had increased to 100 pounds (95% of UBW). The mechanism of action of FOLE infusion in ameliorating IFALD and cholestatic injury is not fully understood. Therapeutic response in reversing cholestasis was similar to that in other research protocols. In conclusion, use of FOLE may offer an alternative to liver transplantation for PN-dependent adult patients affected by severe IFALD.

7 - Using Customized Parenteral Nutrition to Manage Organic Acid Disorders: A Case Study Tanyia Abel1, Brenda Gray2 1Coram Specialty Infusion Services, Mendota Heights, MN, 2Coram Specialty Infusion Services, Tampa Bay, FL

Introduction: Our patient was born in August 2010 and diagnosed with 3-Methylcrotonyl-CoA Carboxylase (3MCC) deficiency, a rare organic acid disorder that prevented her from properly metabolizing leucine. Use of a custom-made parenteral nutrition (PN) formula allowed the patient to receive a reduced amount of leucine and still receive sufficient protein for growth and development. Description: The patient’s metabolic disorder and short bowel syndrome meant that she required parenteral nutrition (PN) with a reduced amount of leucine. To control her leucine intake, custom PN was begun in October 2010 when the patient was two months old. This custom PN restricted her diet to a specific amount of leucine while still providing 2–3 gm/kg of protein to maintain appropriate macronutrient management. In February 2011, at 6 months old, the patient was stable enough to go home from the hospital. She continued to receive the custom PN, which provided 98 mg/kg/day of leucine in its amino acid component. Discussion: With organic acid disorders, the enzymes needed for protein metabolism are either missing or do not function properly. In most patients, one or two specific amino acids are most affected. The inability to properly

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break down these components leads to a buildup of harmful substances in the blood, urine, and tissues, resulting in significant impact to health, growth, and learning. The goal of critical care management in patients like ours who require PN has historically been to minimize the amount of protein consumed, while meeting a patient’s calorie needs with lipids and glucose. Standard pediatric protein PN formulas have 140 mg of leucine in each gram of total protein administered. Therefore, restriction of the amount of leucine in PN formulations that provide the primary or sole source of nutrition results in a significantly limited overall protein provision ( 0.7gm/kg/day in this case). After the patient’s group of specialists conducted a careful analysis of her utilization versus accumulation of leucine, she was found to tolerate and require 98 mg/kg/day of leucine in her diet. Working with her physician, a custom PN formula was developed that met the patient’s specific leucine needs. In this formula, individual amino acid powders are used, resulting in provision of 3 gm/kg/day of protein and only 98 mg/kg/day of leucine. A standard, commercially available pediatric amino acid formula would have provided 420 mg/kg/day of leucine in order to provide 3 gm/kg/day of protein. The compounding process using powdered amino acids and other components of the PN formula follows strict procedures, requires strict adherence to regulations, and undergoes process validation with quality assurance for sterility of the PN. Although provision of PN in this manner requires specialized equipment, training, and testing, it allows for specific formulations that meet the nutritional needs for patients with metabolic disorders. Conclusion: Through the identification of the specific amino acid that the patient was unable to properly metabolize, a customized PN formula was compounded using individual amino acids powders. The formula restricted the specific amino acid that was not metabolized properly while providing adequate protein from other amino acids to promote growth and development.

8 - Fast Insulin Stability in Parenteral Nutrition Admixtures Germana Bersani1, Maria Luisa Forchielli2, Alessandra Stancari1, Silvia Maselli1, Annamaria Guarguaglini1, F Bongiovanni1, L Plate1, Andrea Pession3, Loris Pironi3, Cristina Puggioli1 1S Orsola Malpighi, Bologna, Italy; 2Ped Dept, Bologna, 3University of Bologna, Bologna, Italy

Introduction. Fast insulin is sometimes added to Parenteral Nutrition (PN) admixtures to ensure a continuous infusion to glucose intolerant patients. However, insulin, which is very sensitive to changes in pressure and temperature, is electrostatically attracted by ethyl-vinyl-acetate plastic bags and PN filling system tubes, where it is changed into biologically inactive form. Our goal was to quantify insulin degradation in parenteral admixture bags from preparation time (T0) to end of infusion (T24) in order to evaluate insulin bioavailability. Materials and Methods. Analyses were carried out at times T0 and T24 on undiluted samples of 12 different PN admixtures: 6 ternary admixtures with lipids (All-in-One) and 6 binary admixtures without lipids. All admixtures contained 250 g of glucose in a 2000 mL volume. Biosynthetic human recombinant fast insulin (100 IU/mL) was added to both types of admixtures at increasing doses [0 (as a benchmark), 6, 12, 24, 48 and 72 IU]. Every sample was tested four times. Binary and ternary admixtures containing the same insulin amount were compared. Analyses were conducted by an automated immunometric method detecting insulin bioavailability in organic matrices through the formation of a chemiluminescent complex (insulin and an anti-insulin monoclonal murine antibody on a luminescent phosphate substrate). Method sensitivity was set at 2 IU/mL. Results and discussion. Regardless of the amount provided, insulin was completely attracted by plastic bags and automatic system filling tubes after injection in PN admixtures without lipids. In admixtures with lipids, bio-available insulin was significantly lower than the injected amount even at compounding time (T0). In this case, the greatest insulin degradation occurred into filling tubes due to the strong pressure exerted by automatic filling system flow. At T0, insulin degradation was inversely proportional to the injected amount (20 - 97%), whereas, during the 24 hours of infusion, insulin, protected by lipids, decreased much less (about 10%-25%) (see Table 1). Conclusions. Insulin should not be added to admixtures without lipids. As for admixtures with lipids, it is advisable to add insulin only if high quantities are needed. In all other cases, insulin should be injected subcutaneously or through a second intravenous line in normal saline glass bottle.

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9 - Cholestasis is not associated with increased mortality in patients receiving long-term parenteral nutrition therapy John Siepler1, Reid Nishikawa1, Tom Diamantidis1, Rod Okamoto1 1Nutrishare, Inc, Elk Grove, CA

Background: Patients with intestinal failure often require long term home parenteral Nutrition(HPN). While effective and life sustaining, it is not without complications. The types of complications can be classified as metabolic, infectious or technical. While many of these complications are easily managed, some of the more severe complications may result in death. One severe complication of HPN is parenteral nutrition associated liver disease(PNALD). These patients often have significant cholestasis. Objective: The purpose of this study was to determine if the mortality rate was increased in HPN patients was associated with significant cholestasis. Methods: All HPN patients from one home care provider receiving HPN for at least one year qualified. Data collected included patient demographics, underling diagnosis, duration of HPN, mortality, intestinal anatomy, and an elevated total bilirubin(TB). The patients were divided into two groups. Those with two consecutive TB > 2.0 were placed in the HiTB group and the remainder were placed in the normal TB (nTB) group. Data were collected and analyzed using Student T test and Chi Squared. A statistically significant difference was defined by a p-value 2.0(HiTB). In the whole group the mean age was 39±2.8(range:1-84) and 124(64.2%) were female. The patients in the HiTB group were significantly younger than the nTB group (29.6±22.4 Vs 40.6±20.2years: p=0.01). There were more females in the nTB group than the HiTB group (111(54.1%) versus 13(44.8%), but the difference was not statistically significant (p=0.063). The HiTB group had significantly less small bowel length than the nTB group (99.33 +/-77;96.9cm Vs126.6 +/- 177;103.8cm: p = 0.005). There was no difference in the presence of an ileocecal valve or colon in either group. There was no significant difference in the survival rate in either group (25(86.1%) vs 158(89.7%)). Discussion: Patients on HPN are at risk for a variety of technical, metabolic, or infectious complications. significant complication is IFALD. This has been documented to be associated with poor survival in pediatric patients. We wanted to determine if an elevated TB was associated with poorer survival in a HPN patient population that was composed of both children and adults. We found that the survival rate for patients with HiTB was nearly identical to those with nTB. The two populations were quite similar except the HiTB group was significantly younger, and had a significantly shorter bowel length. Despite these results, it is possible that other factors could influence survival. We have demonstrated in the past that energy intake, CHO intake and catheter infection was associated with PNALD, but these data are not available in this database. Based on these data we can conclude that a HiTB in a HPN population is not an independent risk factor for a shorter survival.

Encore: Previously presented at National Home Infusion Association Conference, May 2011 10 - Evaluation of heparin addition to total parenteral nutrition in the homecare setting Caryn Dellamorte-Bing1, Badal Patel2, Robin Espiriti3, Penny Allen1 1Critical Care Systems, Inc., Nashua, NH; 2Children's Medical Center, Dallas, TX; 3Critical Care Systems, Tempe, AZ

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Title: Evaluation of heparin addition to total parenteral nutrition in the homecare setting Background: Safe and effective total parenteral nutrition (TPN) administration requires use of a dedicated central line. Occlusions and catheter-related infections are two of the major complications of central lines. Heparin is sometimes ordered as a TPN additive for prevention of occlusions and related infections. Some studies reported that heparin in TPN prolongs the time of line patency thereby reducing infection rates, while other trials report no difference.1-3 Objective: The purpose of this study was to evaluate the effectiveness of heparin added to TPN in the homecare setting in reducing catheter occlusion and infection rates. Methods: This retrospective observational study evaluated patients who received TPN from a national home infusion provider from December 1, 2009, to September 30, 2010. All patients who received TPN were identified through electronic medical record extraction. Exclusion criteria included patients recently diagnosed with acute myocardial infarction, deep vein thrombosis, pulmonary embolism, and/or prosthetic heart valves. After application of exclusion criteria, 756 TPN patients were separated into those with heparin added to TPN (with-heparin, n = 32) and those without heparin addition to TPN (no-heparin, n = 726). With-heparin patients were identified from TPN label instructions. Patient demographics collected included age, gender, diagnosis, type of IV access line, and number of catheter days. The primary outcomes measures included incidence of occlusions and line-related infections. Line occlusions were identified if intracatheter alteplase was dispensed during TPN therapy. Suspected or confirmed line infection data was gathered from adverse event, catheter infection, and discharge reports. The outcome data collected from with-heparin patients was compared to that of no-heparin patients. The efficacy and need for heparin in TPN was determined through comparison of central line occlusion and infection rates using Fisher’s exact test.4 All patient data was de-identified to maintain confidentiality. Results: The average catheter days for the with-heparin and no-heparin group were 79.3 and 86 respectively. There was a slightly higher rate of catheter occlusions for the with-heparin group (1.58 occlusions per 1000 catheter days vs. 1.15 for the no-heparin group, p = 0.69). The rate of suspected or confirmed line-related infection per 1000 catheter days was higher in the with-heparin group (1.18 vs. 0.30 for the no-heparin group, p = 0.73). Conclusion: Addition of heparin to TPN was not associated with a reduction in incidence of catheter occlusions. Although not statistically significant, heparin added to TPN was associated with higher incidence of suspected or confirmed line infection. Most with-heparin patients must add heparin to the TPN in the homecare setting rather than in the pharmacy sterile processing area. This could explain the reported higher line infection rate for with-heparin patients. Other possible contributing factors include patient education, compliance of heparin addition technique, and the large difference in sample size between the no-heparin and with-heparin groups. Prospective randomized controlled trials would need to be conducted to validate these results. With limitations, this study demonstrated no benefit of heparin addition to TPN in the homecare setting. Reference: 1. Birch P, Ogden S, Hewson M, et al. A randomized, controlled trial of heparin in total parenteral nutrition to prevent sepsis associated with neonatal long lines: the Heparin in Long Line Total Parenteral Nutrition (HILL)

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11 - The Impact of Parenteral Nutrition on Clinical Outcomes in Cancer patients Undergoing Hyperthermic Intraperitoneal Chemotherapy Pankaj Vashi1, Carolyn Lammersfeld1, Donald Braun1, Rohan Vashi1, Brenten Popiel1, Sadie Dahlk1, Digant Gupta1 1Cancer Treatment Centers of America, Zion, IL

Introduction: The combination of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) is one treatment option for selected patients with peritoneal carcinomatosis. This retrospective study investigated the effect of perioperative nutritional support on clinical outcomes in patients undergoing HIPEC. Methods: 60 patients undergoing HIPEC at a comprehensive cancer center between Jan 2009 and May 2011 were studied. Subjective Global Assessment (SGA) was used to assess nutritional status. Patients were classified preoperatively as: well nourished (SGA-A), mildly-moderately malnourished (SGA-B), and severely malnourished (SGA-C). Patients who received parenteral nutrition (PN) were divided into 2 groups: those who received PN postoperatively and those who received it both pre- and postoperatively. The primary outcomes of interest were length of stay (LOS), postoperative complications, ECOG performance status (PS) and survival. LOS was calculated as the number of days in the hospital post surgery. Performance status was measured on a scale of 0-4. Survival was calculated from the date of first visit to the date of death/last contact. Results: Of 60 patients, 19 were males and 41 females. The mean age at presentation was 50.3 years. The most common cancer types were colorectal (n=24) and ovarian (n=13) with the majority of patients (n=47) treated before coming to our institution. 33 patients were SGA-A, 22 SGA-B and 5 SGA-C prior to surgery. Per ASPEN guidelines, 23 patients received postoperative PN (13 SGA-A, 8 SGA-B and 2 SGA-C at admission) while 8 (7 SGA-B and 1 SGA-C at admission) received PN both pre- and postoperatively. The average duration of preoperative PN was 5.1 days while that of postoperative PN was 27.4 days. Mean LOS for the entire cohort was 16.2 days (SD=9.8). Mean LOS for preoperative SGA-A, SGA-B and SGA-C were 15.0, 15.2 and 27.8 days respectively (ANOVA p=0.02; SGA-A and SGA-B significantly different from SGA-C). Overall incidence of complications was 26.7% (16/60). Complications were recorded in 9 of 33 (27.3%) preoperative SGA-A

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patients and 7 of 27 (25.9%) SGA-B+C patients (p=0.91). Most common complications were sepsis, respiratory failure, bowel obstruction and wound dehiscence. The median overall survival was 16.1 months (95% CI = 11.2 to 21.1 months). Median survival for preoperative SGA-A and SGA-B+C cohorts was 23.3 and 10.4 months respectively (p=0.01). There were no significant differences in mean LOS (p=0.53) and occurrence of complications (p=0.94) between postoperative and pre- plus postoperative PN patients. For the entire population, the mean preoperative and postoperative SGA scores were 4.4 and 5.7 respectively, while the corresponding PS scores were 1.3 and 1.6 respectively, p0.05 for both. In patients with no PN (n=29), preoperative and postoperative SGA scores were not significantly different but postoperative PS score (1.4) was significantly worse than the preoperative PS score (1.1); p=0.001. Conclusions: The preoperative SGA predicts LOS and survival in cancer patients undergoing HIPEC. The average length of preoperative PN component (<7 days) in patients receiving both pre- and postoperative PN was probably too short to have an impact on clinical outcome as compared to patients who received postoperative PN only. Future prospective studies in this population should investigate the systematic provision of PN to all malnourished patients in the preoperative period for a minimum of 7-10 days with the continuation of PN in the postoperative

12 - Use of Soybean Oil, Medium Chain Triglycerides, Olive Oil and Fish Oil (SMOF) Lipid in Parenteral Nutrition-associated Liver Disease: A Case Study Chung Yan Tong1, Siang Nee Teoh1, Li Lin Lim1 1National University Hospital, Singapore

Introduction Parenteral nutrition-associated liver diseases (PNALD) is the most prevalent and challenging complication happening in patients receiving long-term parenteral nutrition (PN). Steatosis, cholestasis and gallbladder complications are common types of PNALD found in adults. Management of PNALD still lacks evidence and different lipid profiles may attribute to PNALD. Phytosterols found in soy-derived lipid used in most PN solution affect bile flow and reducing phytosterols content in PN solution may decrease the risk of PNALD. In contrast, medium chain triglyceride (MCT) is more readily oxidized than long chain triglyceride and may reduce hepatic complications. Omega-3 fatty acid may reduce steatosis by reducing triacylglycerol synthesis through stimulation of mitochondrial fatty acid oxidation. A new lipid emulsion based on soybean oil (30%), MCT (30%), olive oil (25%) and fish oil (15%) (SMOF) has been developed and proposed as a better choice of lipid source in PN solution. The results of using SMOF lipid in a patient suffering PNALD are discussed below. Description: A 23-year-old healthy Chinese female admitted to the hospital due to a serious motorcycle accident. She suffered haemoperitoneum with a mesenteric tear at the ileum, sigmoid colon and caecum. After a few operations to remove her ischemic bowels, she developed multiple enterocutaneous fistulae at jejunum with high output (> 2 Liters per day). The patient was kept nil by mouth. Total parenteral nutrition (TPN) was commenced to maintain her nutritional status, and replace electrolytes and fluid loss. The patient suffered cholestasis and steatosis after two months of TPN infusion. Cyclic PN infusion of 16 hours was arranged. Lipid infusion was decreased to twice a week and subsequently to once a week. Metronidazole was prescribed for one week to treat possible bacterial overgrowth. With the above interventions, her total bilirubin levels had dropped from 38 umol/L to 7 umol/L (normal range 5-30 umol/L) and triglyceride (TG) levels had decreased from 354mg/dL to 129 mg/dL (normal range <150mg/dL) (Figure 1). However, her liver function continued to deteriorate. At the sixth month, SMOF lipid (SMOFlipid®, Fresenius Kabi) was used as a lipid source in the PN solution once a week for one week (40g each time) and subsequently twice a week for four weeks until the central line was removed due to line sepsis. Alanine transaminase (ALT) levels decreased from 90 U/L to 50U/L (normal range 10-70 U/L), alkaline phosphate (ALP) levels decreased from 638U/L to 393U/L (normal range 40-130 U/L) and gamma-glutamyltransferase (GGT) levels decreased from 585 U/L to 307U/L (normal range 10-80 U/L) (Figure 1). TG levels initially dropped to 90mg/dL after one week and maintained at around 170mg/dL in the following weeks (Figure 1). Total bilirubin levels remained within the normal range. At the seventh month, TPN was discontinued and enteral nutrition was commenced, and the liver function of the patient returned to normal (Figure 1). Discussion SMOF lipid has reversed cholestasis in case reports and small cohort studies. It has also been found to be safe in adult patients. It has been shown to protect liver function, decrease total bilirubin levels and shorter hospitalization. In our case study, infusion of SMOF for five weeks improved ALT, ALP and GGT levels.

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More researches are needed to determine the ideal dosage and duration of using SMOF lipid and to support the regular use of SMOF lipid in patients suffering PNALD.

13 - Using the Social Media to Evaluate and Share Insights on Life on Home Parenteral Nutrition Deborah Pfister1, Abby Brogan1, Donna Noble1 1ThriveRx, Cincinnati, OH

Background: Initiation of Home Parenteral Nutrition (HPN) can be daunting for a new consumer who is faced with setting up IV nutrition and caring for their Central Venous Line (CVL) in the home. Health care teams are responsible for teaching consumers complications and issues that can arise as well as risks of HPN. A consumer is told that their lifestyle will be limited due to HPN however it’s often difficult for them to fully understand the impact. Healthcare professionals are often unable to personally understand these challenges and support the consumer. Description: To better understand the challenges faced, we utilized a social networking tool. An adaptive/interactive survey was created using the social media network Facebook, and was distributed to multiple individuals with HPN experience and with chosen HPN support groups. We posed the question: What should every new HPN consumer know about life on HPN? Respondents added personalized answers or voted for answers provided by other respondents. This created an evolving multiple choice survey. The flexibility provided by the social media networking platform, allowed current and past HPN consumers to share personal insight that would have been limited through the use of set survey responses. The 42 respondents created 10 answers. Discussion: To analyze the results we grouped the 10 answers in to 3 categories; Education, Therapy Importance and Quality of Life. Of those surveyed 61% had comments related to Quality of Life, 21% were related to Education and 18% were related to Therapy Importance. Conclusion: From this information, two educational tools were created to share this unique perspective. A Frequently Asked Questions tool designed for first-time HPN consumers is presented in writing format and as a guide for discussion as a part of our Consumer Advocacy program. The second tool will be developed to assist clinicians in understanding what new consumers need to be successful on HPN. It is hoped that these tools will help improve the quality of life, quality of care and ultimately affect patient outcome.

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14 - Short-Term Use of a Standardized Parenteral Nutrition Formulation in a Long-Term Consumer Deborah Pfister1, Jill Taliaferro1, Sheila Pedapati2 1ThriveRx, Cincinnati, OH, 2BioRx, Cincinnati, OH

Background: In 2007, ASPEN published a Statement Paper on Parenteral Nutrition (PN) Standardization that outlined the advantages and disadvantages of using these formulations. Advantages included: solution uniformity, efficiency and financial savings. Disadvantages included: the difficulty customizing for individuals with complex requirements, the need for additional monitoring and the importance of nutrition support expertise to implement. Overall, the recommendation was that the evidence on patient safety did not support the general use of standardized PN formulations especially in the following conditions: organ compromise, refeeding syndrome, glucose intolerance, large gastrointestinal losses and pediatrics. Description: Our patients are adult and pediatric long-term parenteral nutrition consumers with either intestinal dysmotility or short bowel syndrome, many of whom live in remote locations where shipping and refrigeration are possibly affected by extreme weather conditions. Although the standardized PN solutions may not be recommended, we evaluated the use of these solutions for back-up in emergency situations and for travel purposes. Standardized PN solutions are available in various dextrose and amino acid concentrations, with and without electrolytes in a shelf-stable form which allows ease of shipment and storage, ideal as a back-up alternative. Discussion: Two of our consumers recently embarked on cruises, to Alaska and Bermuda. In both cases, refrigeration was limited and the product was at risk of expiring due to Beyond-Use-Dating restrictions. Both patients were provided with a standardized PN solution containing 2000 mls, 20% dextrose and 5% amino acids with standard electrolytes, to most closely match their needs. MVI-13 and MTE5C were daily consumer adds. Client #1 was maintained at home on 2 lipid and 2 non-lipid bags per week. He required 5 days of the standardized lipid-free formulation which provided 100% of his IV fluid, 104% of his IV protein and 111% of his IV calorie needs. Monitoring at 7 days after his return, demonstrated a 2 kg weight gain and all routine PN labs stable and within normal limits. Client #2 was maintained at home on 4 lipid and 3 non-lipid bags per week. She received 7 bags of the standardized lipid-free formulation which provided 87% of her IV fluid, 111% of her IV protein and 100% of her IV calorie needs. Post-cruise, her weight was stable at 60 kgs and all labs were stable and within normal limits. Summary: Although standardized PN solutions may not be safe for long-term use in consumers with complex medical conditions, these formulations may be useful for short-term infusion in situations of weather-affected delivery or travel purposes. In both of these cases, labs were drawn at greater than six days after resumption of pre-trip formulation. Further investigation with lab testing closer to trip end may expose intolerances not captured in this study.

15 - Total Parenteral Nutrition at a Tertiary Medical Center: Evaluation of the Ability of a Nutrition Support Team to Predict Duration of TPN Yana Nikitina1, Elizabeth Paine1, Ramona Pleasant1, Zachery Somers1, J. Todd Dear1, Sumanth Daram1, Shou Tang1, Archana Kedar1, Thomas Abell1 1University of Mississippi Medical Center, Jackson, MS

Purpose: To assess the use of Nutrition Support Teams to predict duration of Total Parenteral Nutrition (TPN) and Length Of Stay (LOS) at the initiation of TPN. Methods: We studied 135 consecutive UMMC inpatients who required TPN on any hospital service. Prior to initiating TPN, an experienced nutrition support team, composed of gastroenterologists, nutritionists and pharmacists, assigned patients by clinical characteristics to either a positive group, predicted to receive early enteral feeding, or a negative group, predicted to require prolonged TPN. Patients in both groups received standard of care, irrespective of assignment. At discharge, each patient’s total number of days on TPN and length of stay were recorded. All data were analyzed by group, reported as median (inter-quartile) and mean (standard deviation) values, and compared by both non-parametric Wilcoxon and parametric student t-tests. Results: Data analysis showed a trend towards fewer days of TPN and a reduced LOS for patients in the positive group, with mean days on TPN at 11.78 (9.75), compared to 23.68 (44.91) for the negative group. Between groups, the differences were p=0.334 by the non-parametric Wilcoxon test and p=0.051 by parametric t-test. Patients in the positive group had a mean LOS of 30 (22.37), compared to 32.07 (44.39) for the negative group. Between groups, the differences were p=0.400 by the non-parametric Wilcoxon test and p=0.813 by parametric t-test. Discussion: Our study of consecutive patients with gut

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failure secondary to a wide range of etiologies shows that prospective identification of patients able to receive early enteral feedings may be possible, and may permit such patients to receive timely intensive intervention. Conclusion: An initial Nutrition Support Team determination of individual patients likely to be able to switch to enteral feeding in an expeditious manner may improve their care. Further investigation of clinical characteristics indicating TPN may help identify patient subgroups with the potential to benefit from earlier enteral feeding. Studies are also needed to assess physician understanding of indications for parenteral feeding, attitudes towards enteral vs. parenteral feeding, and knowledge of educational/clinical interventions that may improve TPN determinations, particularly among physicians without formal clinical nutrition training.

16 - Identification and Early Treatment of Dehydration in Home Parenteral Nutrition and Home IVF Patients Prevents Hospital Admissions Mandy Corrigan,1, Denise Konrad2, Cindy Hamilton1, Ezra Steiger1, Donald Kirby1 1Cleveland Clinic, Cleveland, OH, 2Job seeking, PA

Introduction: There are multiple methods to assess hydration status including changes in weight, labs, vital signs, fluid intake and output (I/O), and physical signs. Early identification and treatment of dehydration is prudent in patients requiring home parenteral nutrition (HPN) or home intravenous fluids (HIVF). Our home nutrition support service (HNS) developed a protocol to provide additional bags of HIVF to be kept on-hand for immediate use in those patients identified at risk of developing dehydration (e.g., high output ostomy, fistula, drain) to avoid emergency room (ER) treatment or hospital admission. Prior to discharge patients are instructed on signs and symptoms of dehydration and when to contact the HNS service if present. No studies have evaluated the frequency or patient characteristics associated with dehydration, or the effectiveness of treatment in the home setting in this population. Methods: A retrospective review was performed on all HPN and HIVF patients from a clinical database who received additional HIVF during 2010. Data collected included demographics, primary diagnoses, HPN/HIVF indication, presence of a fistula or ostomy, labs (Na, Cl, BUN, Cr), patient or clinician identification of dehydration, vital signs, physical signs (e.g., decrease in weight, lightheadedness, decreased or darker in color urine, increased ostomy output, excessive thirst, cramping in extremities), I/O data, dates of ER visits or hospital admission for dehydration, and compliance with infusion orders. Dehydration was defined as having a negative fluid balance on I/O records with at least one physical symptom and/or alteration in labs compared to baseline. Descriptive statistics were computed for all factors. Standard treatment was 1000mL HIVF daily for 3 days in addition to prescribed infusions. Dehydration was considered resolved as determined by normal labs drawn at completion of HIVF infusions and/or resolution of physical symptoms. Results: Of 308 HNS patients serviced during 2010, additional HIVFs were ordered in 161 patients to be kept on hand for immediate use to treat dehydration. The most common diagnoses were Crohn’s disease and cancer with malabsorption, fistula, or obstruction. 100% of HIVF and 65% of HPN patients had an ostomy. Of the 161 patients, 63% (n=102) required additional

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HIVF. Of the 102 patients treated with additional HIVF, 201 episodes of dehydration were recorded. Patients had between 1 to 8 episodes of dehydration; with a median of 1 episode (52% had 1 episode). For every five-year increase in age, the odds of having more than one dehydration episode increased 20% (OR 1.2). Increased ostomy output (p=0.021), negative I/O data (p=0.014), and age (0.021) were predictors of multiple dehydration episodes. Patients receiving HIVF were more likely than HPN patients to have increased ostomy output (73% vs. 32%, p=0.008) and become hypotensive (27% vs. 7%, p=0.022). I/O data was consistent with signs and symptoms of dehydration 80% of the time. 170 episodes (84.5%) of dehydration were successfully treated at home compared to 9 ER admissions (4.5%) and 22 hospital admissions for dehydration (11%). Sixteen patients had 22 admissions for dehydration, with 1 patient having 4 dehydration admissions due to non-compliance. Conclusion: Dehydration is common in HPN/HIVF patients, especially those with malabsorption and an ostomy. We show 84.5% of episodes of dehydration successfully treated in the home in patients initially identified at risk by our protocol. Education of patients at risk of dehydration prior to discharge and providing additional HIVFs on hand for immediate use can reduce the incidence of ER treatment or hospitalization and potentially save health care costs.

17 - Impact of a National Shortage of Sterile Ethanol on Catheter Sepsis in Home Parenteral Nutrition Patients Mandy Corrigan,1, Donald Kirby, MD1 1Cleveland Clinic, Cleveland, OH

Introduction: Catheter related blood stream infection (CRBSI) is a common and life threatening infectious complication of home parenteral nutrition (PN). CRBSI is associated with hospital admissions, morbidity, mortality, loss of venous access, and healthcare costs. Ethanol has bacteriocidal and fungicidal properties making it an ideal locking solution for prevention of CRBSI. We report 6 patients with a recurrence of CRBSI when ethanol lock (ETL) was withheld due to a National shortage. Methods: Six patients had a tunneled silicone catheter (4 single lumen, 2 double lumen), presence of an enterostomy, were receiving 3 mL 70% ETL daily prior to shortage, infused PN or fluids daily, and had positive blood cultures from the catheter once ETL stopped. Case 1: 63 yo female with Crohn's Disease (CD) and rheumatoid arthritis on home PN for 22 months due to malabsorption with no recurrent CRBSI following ETL after Enterococcus sp. Case 2: 63 yo male with CD, Type 1 Diabetes, on home PN for 24 months due to short bowel syndrome (SBS) with no recurrent CRBSI after ETL started following Malassesia furfur and Enterobacter aerogens CRBSIs. Case 3: 54 yo female with CD on home PN or fluids 8 years due to SBS and malabsorption complicated by 14 episodes of CRBSI until initiation of ETL decreased her frequency of infections to 4 episodes. Case 4: 30 yo female with CD, depression, on home PN due to malabsorption for 22 months started ETL after a polymicrobial CRBSI from Coagulase negative staphylococcus and Staphylococcus epidermidis. Case 5: 37 yo male with SBS on PN for 2 months started on ETL after CRBSI from Clostridium perfringes. Case 6: 56 yo male with CD on PN for 6 years due to malabsorption from SBS with PN-induced liver disease had 2 episodes of CRBSI from Acinetobacter lwoffii and an unknown species of gram negative bacilli prior to starting ETL. Results: Five cases had no episodes of CRBSI after starting ETL. Compliance may have been a factor in Case 3. After discontinuation of ETL, 5 of 6 patients developed CRBSI within 1 month (overall average of 32 days, range 12 to 89 days). All cases were hospitalized for treatment of CRBSI (average length of stay of 7.1 days). Three cases relapsed with a CRBSI from the same causative bacteria they had in a past episode of CRBSI when ETL was not given. Conclusions: This is the first known report of the ramifications of a National ethanol shortage on re-development of CRBSI in home PN patients with a history of CRBSI. This series further supports the existing literature showing that ETL is a viable therapy for prevention of CRBSI warranting prospective research. The impact of an ethanol shortage due to a sole source manufacturer supports the need for the Food and Drug Administration to regulate pharmaceutical products to avoid shortages.

18 - Home Parenteral and Enteral Nutrition Registry in Czech Republic, EU: the 2010 Data Pavel Tesinsky1, Adam Jirka1, Jan Svanda1 1ICU, Dept. of Medicine I, Charles University Hospital, Prague, Czech Republic

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Background: The Czech National Registry of home parenteral and enteral nutrition summarizes the data of patients who have been treated with home parenteral nutrition (HPN) and home enteral nutrition (HEN) in Czech Republic during the last year. The National Registry was founded in 1993. The results indicate the state of the art of home artificial nutritional support in Czech Republic in 2010. Methods: The data were acquired by means of electronic questionnaires based on the OASIS standards. Czech Republic (population 10 mil.) is covered by a network of 60 nutrition centers. The Registry summarizes data from 3511 patients on HPN and HEN which have been collected between January 1, and December 31, 2010. HPN has been provided by 13 centers, mainly associated with teaching hospitals. Results: I. Home parenteral nutrition: The HPN registry enrolled 139 patients: mean age 56.2 years (19-94), 52 male, 87 female. Prevalence of HPN was 13.9/mil. inhabitants with 35048 catheter-days/year. 13 patients (10%) have been weaned from HPN and 22 patients (16%) died during the year. Mean duration of HPN administration was 39 weeks (4-874). 48% patients have been on HPN for more than 52 weeks. The mean number of bags delivered per week was 6.0. Pharmacy-made bags were used in 35% patients, 65% patients were supplied with ready-made bags. The main indications were cancer (37%), post-operative complications (12%), vascular catastrophes (17%), Crohn disease (11%), post-radiation enteritis (12%), and other (11%). Short bowel syndrome as main diagnose was present in 65% patients, bowel obstruction in 19%, and malabsorbtion in 6%. Tunneled central venous catheters were used in 74%, implantable ports in 22%, and peripherally induced catheters (PICC) in 4% patients. The overall rate of complications was 58: catheter related infections 38 (65%), hepatobiliary complications 14 (24%), and catheter occlusion or thrombosis 6 (11%). Home parenteral nutrition for children has been provided in 11 patients by 5 centers. The number of patients was 11 (8 boys, 3 girls), mean age 5.73 years (1-15). The mean duration of HPN was 183 weeks (39-400). Nutrition was supplied by tunneled central venous catheters in all patients. II. Home enteral nutrition: The HEN registry enrolled 3372 patients. Sipping was the main route of delivery in 59%, percutaneous gastrostomy (PEG) in 29%, and tube feeding in 12% patients. The main diagnoses were cancer (45%), neurological lesions (34%), and Crohn disease (11%). Conclusion: The National Registry scans the status of HPN/HEN in Czech Republic periodically. The year-by-year increment in prevalence of HPN is 12%. HPN is mostly provided to patients with cancer. Tunneled central venous catheters are more frequently used than implantable ports and they have lower incidence of infectious complications. Supported by Charles University Research Grant MSM 0021620814.

19 - Consequences of Intravenous Fat Emulsion (IVFE) Shortage Shanna Hager1, Ainsley Malone1, Connie Brewer1, Marcy Chaney1 1Mt. Carmel West Hospital, Columbus, OH

Background: At our institution, intravenous fat emulsion (IVFE) is provided as a separate infusion (2 in 1). During 2010, a critical shortage of available IVFE occurred necessitating a need to ration IVFE. During this rationing period, our goal was to limit IVFE to 10% of total calories when clinically possible. IVFE was reserved for patients who were malnourished or receiving parenteral nutrition (PN) greater than 2 weeks. Patients who received enteral intake in addition to PN did not receive IVFE. Other patients received daily IVFE per clinical judgment. IVFE for neonates was already outsourced and not affected. Aim: To evaluate the affect of the lipid shortage on patient care in our institution. Methods: IRB approval for exempt status was obtained. Patients who received IVFE during the shortage were compared to a historical cohort. Patient monitoring profiles were reviewed. The following parameters was collected: baseline (day 1) and at follow up (closest to the last day of PN) of alkaline phosphatase (ALP), aspartate aminotransferase (AST), serum glucose (BG), and triglycerides (TG); weight in kilograms, grams of dextrose per day, grams IVFE per day, number of days on PN, infusion time of IVFE, number of days IVFE was held (i.e. due to critical illness, enteral intake), highest amount (in units) of insulin per day from an insulin drip or in the PN formula. The following were calculated and recorded: glucose infusion rate in mg/kg/min, percent calories from IVFE, volume of IVFE, and frequency of IVFE. Descriptive statistics were calculated. Results: 89 patient profiles were reviewed during the IVFE shortage with data collection from July 2010 to December 2010. 77 patient profiles were included in the historical cohort with the majority of them from August 2009 to December of 2009. Table One outlines mean laboratory parameters in the shortage group and historical cohort. Mean weight was 67.5 kg in the shortage group compared with 65.6 kg in the historical cohort. Table Two outlines mean nutrient and insulin intakes during the shortage period and the historical

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cohort. In addition, to better evaluate daily versus intermittent lipid infusion between the study periods, patients in the shortage period who received daily lipid were excluded and the above outlined parameters evaluated. Mean PN days were 9.9 in the shortage group compared with 9 in the historical cohort. Patients during the shortage received IVFE for a mean of 3.6 days, with a mean 7 days for patients in the historical cohort. During the shortage period, 27% of the patients received daily IVFE, 66% received intermittent infusion and 7% did not receive any IVFE. During the historical cohort, 93.5% patients received daily lipid infusion and 6.5% received no lipid. IVFE was held for a mean of 1 day in the shortage group compared to 0.3 days in the historical cohort. Conclusions: ALP, AST, BG, TG levels were similar at baseline and follow-up in both groups. As expected, percent calories from fat, g/kg/day fat received, and the number of days IVFE infused was lower in the shortage group compared to both the non-shortage group and the shortage patients who did not receive daily lipid infusion. Both GIR and insulin requirements were slightly higher during the shortage although this didn’t result in increased blood glucose levels or in larger insulin intakes. Overall, patient care does not appear to have been compromised during this shortage. Limiting IVFE to 10% of total calories and omitting IVFE in patients receiving enteral intake was a reasonable response to a critical IVFE shortage Intermittent use of IVFE may be a consideration as an alternative to daily intake.

20 - The Utilization of Parenteral Nutrition in Germany Robin Turpin1, Matt Prinz2, Cynthia Macahilig2, Alessandro Pontes-Arruda3, Frank Malinoski2, Peter Wolthoff2, Frank Xiaoqing Liu1 1Baxter Healthcare, Deerfield, IL; 2Medical Data Analytics, Parsippany, NJ;3Fernandes Tavora Hospital, Fortaleza, Ceara, Brazil

Objectives: Parenteral nutrition (PN) is provided to patients when the gastrointestinal tract is nonfunctional because of an interruption in its continuity, or because its absorptive capacity is impaired. It is a strategy that delivers nutrients directly into the bloodstream (intravenously) through a catheter inserted into the patient’s vein. Our objective was to explore PN as it is currently utilized in Germany in order to provide a baseline understanding of who is receiving PN in the hospital setting, describe PN utilization patterns, and identify PN-related complications. Methods: A retrospective, observational medical chart review was conducted in early 2011 across Germany. Fifty-two hospital-based medical doctors in Germany, representing 39 diverse institutions, were randomly selected to collect data on 1,995 adult patients. All medical doctors must have managed at least 20 hospitalized patients who received PN in the 12 months prior to study launch. Patients were included if they received PN > 4 days, and their PN was delivered by either ready-to-use 3-chamber bag, single bottle (Christmas tree), or hospital compounded admixture. Patient demographics, patient hospitalization characteristics, PN prescribing and utilization patterns, and hospital characteristics were collected. Results: Data were abstracted from 1017 male and 978 female patients, with an average age of 61.7 years. 70% of patients experienced an emergency admission, with neoplasm as the primary reason in 51% of cases. The second and third most common primary reasons for hospitalization were diseases of the digestive system (19%) and of the respiratory system (10%). The mean length of stay was 15.2 days, and 71% were discharged home. 9% expired in hospital. The mean duration of PN was 8.4 days, with 83% of patients receiving PN via central line. 49% received total PN, and 35% also received enteral nutrition (mean duration of enteral was 9.2 days). 6% of patients underwent surgery, 32% of whom experienced a post-operative infection (59% of which were surgical infectious complications). 12% of all patients experienced a complication, including bloodstream infections (74%); hyperglycemia (20%) hypoglycemia (4%); pneumonia (3%); and refeeding syndrome (3%). The BSI rate per 1,000 central catheter days was 10.52. Medical doctors identified 7% of BSIs as likely to be catheter-related, while 0% were identified as PN-related. Conclusions: This retrospective chart review provides extraordinary insights into the real-world use of PN among hospitalized adults in Germany. This will provide researchers with a baseline comparison for their own research populations and help to maximize the generalizability and validity of future research.

21 - Repair of Silicone Tunneled Catheters in a Home Parenteral Nutrition Population: An Outcomes Analysis Marianne Opilla1, Tom Diamantidis1, Rod Okamoto1, Reid Nishikawa1 1Nutrishare, Inc., Elk Grove, CA

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Introduction: Tunneled silicone central venous catheters (CVCs) are frequently placed for the administration of home parenteral nutrition (HPN). Silicone is a comfortable, soft, flexible material that is compatible with nutrients, disinfectants, and medications making it an ideal CVC choice for the HPN patient. Although fairly durable, small pin holes, tears, and cracks may occur during the life of the CVC. This may interrupt the infusion of HPN, as well as being a possible entry site for bacteria into the CVC lumen increasing the risk for a catheter related bloodstream infection (CRBSI). Silicone CVCs may be repaired by using sterile technique and a kit specific to the brand, model, and size of the CVC. The aim of this study was to determine frequency of catheter repair (CR), outcome (success or failure), and incidence of CRBSI in an HPN population. Methods: Patient demographics were collected by chart review for a 5 year period from one home infusion provider. CR data were collected including frequency, success or failure, and occurrence of an associated CRBSI. Successful CR was defined as repair lasting for greater than 1 year. CR was considered a failure when leaks, breaks, or clotting occurred at or near the CR site within one week of initial repair. Diagnosis of CRBSI within one month of CR was considered possibly related to the actual tear or CR procedure. Results: Females represented at 65% with an average age of 50 years (4 – 80 years). 54 patients had 75 repairs during a 5 year period. CR of 49 (65%) of the CVCs lasted for longer than one year. Failure of CR in 12 (16%) of the CVCs occurred because of breaking, leaking, ballooning, or separation at the repaired splice. Failure was usually attributed to inadequate gluing of the spliced segment or infusing through the CVC before the glue was set. 6 of the failed repairs occurred in 2 patients resulting in eventual CVC exchange. 5 patients had the repaired catheter removed prior to one year due to CRBSI. All 5 of these occurred at greater than 3 months following the CR and the CRBSI was not attributed to the repair. 9 patients lost their catheter at less than one year following CR for reasons unrelated to the repair. These included patient expiring, discontinuation of HPN, catheter falling out, and tunnel or exit site complications. Conclusion: Repair of silicone CVCs is an accepted procedure for the HPN patient requiring long term venous access. Despite careful handling, silicone may develop perforation or tears and CR can significantly extend the life of the CVC. In this cohort of patients, the majority had successful CR extending their CVC life a year or more. Failures were usually due to inadequate procedure techniques involving gluing, splicing, and early infusion. The CVC break and CR procedure did not increase the risk of CRBSI.

22 - Impact of a Clinical Pharmacy Nutrition Support Service on Adherence to Parenteral Nutrition Indications in Adult Hospitalized Patients Evangelia Davanos1, Mina Torabi2, Karina Muzykovsky1, William R. Vincent, III3, John Mitchell1 1The Brooklyn Hospital Center, Brooklyn, NY; 2Yale-New Haven Hospital, New Haven, CT; 3Division of Pharmacy Practice Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Brooklyn, NY

BACKGROUND: Parenteral nutrition (PN) is often necessary for patients with a non-functional gastrointestinal tract or contraindications to enteral nutrition (EN), but its use has been associated with hyperglycemia, infections, and electrolyte abnormalities. Multidisciplinary nutrition support services (NSS) have been developed to aid in the reduction of adverse events secondary to PN. Although literature suggests for a NSS to consist of a physician, pharmacist, nurse and a dietitian, a multidisciplinary approach is not always feasible. At The Brooklyn Hospital Center (TBHC), a multidisciplinary NSS was first created in May 2005, but in 2007 it evolved into a pharmacy driven consultative service consisting of pharmacists and pharmacy residents. At TBHC, a clinical pharmacist and/or pharmacy resident performs initial and follow-up consultations for all patients on whom a PN consultation is requested by a physician. Once PN is approved for a patient, the pharmacist/resident doses, orders and monitors the PN on a daily basis. We sought out to determine the impact of a clinical pharmacy NSS on adherence to PN indications, as well as on rates of infection and metabolic abnormalities. METHODS: This was a retrospective study that included all adult patients on total parenteral nutrition (TPN) or peripheral parenteral nutrition (PPN) admitted to TBHC before and after implementation of the clinical pharmacy service in nutrition support from February 2003 to 2005 (pre-NSS), and May 2008 to 2010 (post-NSS). Patients receiving PN prior to admission or for less than 48 hours, those receiving lipids alone, as well as pregnant or palliative care patients were excluded. The primary objective was the number of indicated PN orders based on indications stated in the NSS protocol and published guidelines and literature. A surgical intensivist performed a blinded analysis of this endpoint. The secondary endpoints were the rate of positive blood

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cultures while on PN and the number of metabolic abnormality days per PN days. Student's t-test was utilized to analyze continuous data and Chi square test and relative risk with 95% confidence intervals were used for nominal data. A sample size of 151 patients per group was estimated to detect a difference of 15% in primary endpoint with alpha = 0.05 and power = 80%. RESULTS: A total of 181 patients were included in the analysis, 80 patients pre-NSS and 101 patients post-NSS. There was no significant difference in rates of indicated PPN between the pre- and post-NSS populations, 2.4% vs. 12.5%, respectively (p=0.1879). However, there was a significant difference in indicated TPN (43.3% vs. 77.3%, p=0.0004) and combined PPN and TPN (19.4% vs. 71.9%, p<0.0001) between the pre-NSS and post-NSS groups, respectively. The rate of positive blood cultures was comparable between the two groups with a non-significant difference (p=0.208). The duration of PN was significantly longer in patients with at least one positive blood culture in comparison to patients with negative blood cultures (10 vs. 6 days, p<0.0001). An increased risk of metabolic abnormalities was found in patients not followed by the pharmacy nutrition service (RR=1.38, CI 1.29-1.49). CONCLUSION: In institutions where a multidisciplinary NSS approach is not feasible, the implementation of a clinical pharmacy NSS may be beneficial as it can lead to a reduction of non-indicated parenteral nutrition orders and a decrease in metabolic abnormalities.

23 - Evaluation of Peripheral Parenteral Nutrition (PPN) at an Academic Medical Center: Is there a role and are we optimizing use? Michael Kraft1, Jennifer Wooley2 1University of Michigan College of Pharmacy, University of Michigan Hospitals and Health Centers, Ann Arbor, MI; 2University of Michigan Hospital Patient Food and Nutrition Services, Ann Arbor, MI

Background: Nutrition support therapy is an important component of patient care. Oral or enteral nutrition (EN) is preferred over parenteral nutrition (PN) because it is associated with lower costs and improved outcomes. PN is a life-sustaining therapy when oral nutrition or EN is not feasible. PN can be provided via a central vein (CPN) or a peripheral vein (PPN). The osmolarity of PPN admixtures should be limited to 900 mOsm/L or less. Therefore, it is usually not possible to meet an adult patient’s full nutritional needs with PPN, and there is limited evidence supporting the efficacy of PPN. In addition, the A.S.P.E.N. Guidelines for the use of Parenteral and Enteral Nutrition state that patients are unlikely to benefit from a short duration of PN ( 7 days. Pharmacists and registered dietitians (RDs) advocate for appropriate nutrition support therapy in their interdisciplinary teams. We completed a multidisciplinary evaluation of PPN use over a 6-year period in order to guide more appropriate prescribing and use. Methods: We collected and evaluated PPN data from pharmacy records for calendar years (CY) 2003–2008. In addition, ICU RDs began collecting data on PN use in July 2008, including assessment of appropriateness and duration of therapy. We then implemented criteria for PPN prescribing and re-evaluated PPN use over an 11-month period. Results: We observed a decrease in the number of PPN prescriptions and number of patients receiving PPN, despite an overall increase in the number of PN orders (Table 1). The average duration of PPN therapy ranged from 3.0 – 3.9 days (range 1 – 38 days), and the percent of PPN orders relative to all PN orders ranged from 7.3 – 14.3%. We observed a reduction in the average duration of PPN (3.7 to 3.0 days) as well as an increase in the percentage of patients who received PPN for 1 day, < 3 days, and < 7 days, with over 90% of patients receiving PPN for < 7 days (Table 2). Based on ICU RD data collection over a concurrent 10-month period, we observed a decrease in the percentage of patients started on PN without evidence-based criteria. We also observed a decrease in the percentage of patients started on PPN and those receiving PPN < 3 days (Figure 1). Our evaluations revealed the vast majority of PPN therapy was for a short duration and a significant number of patients did not have evidence-based criteria for PN. Based on these data, we restricted PPN use to pediatric patients (< 30 kg) and PN-dependent patients who lose central venous access and will not be able to obtain central access for at least 5 – 7 days. After implementation, we evaluated PPN use over the following 11 months. During this period, there were a total of 113 PPN prescriptions in 30 patients. The average duration of PPN was 3.8 days (range 1 – 13 days). Seven patients (23.3%) received PPN for 1 day, 16 (53.3%) received PPN for < 3 days, and 27 (90%) received PPN for < 7 days. The approximate annual reduction in direct PPN costs was $68,000 compared to CY 2008. Conclusions: Multidisciplinary evaluation of PPN revealed the majority of use was for a short duration, and a significant number of patients did not have evidence-based indications for PN. PPN restriction effectively reduced

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PPN use and direct costs, but a large proportion of patients still received PPN for a short duration. Ongoing evaluations will include PN appropriateness, duration of PPN + CPN, placement of central venous catheters solely for PN, clinical outcomes, and strategies to guide more appropriate PN use.

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ICU Registered Dietitian PPN Data Collection 2008-2009

24 - Implementation and Assessment of a Comprehensive Parenteral Nutrition Education Program to Document Pharmacist Competency and Expand Clinical Services Christopher Miller1, Kimberly Flynn2, Rebekah Stover3, Jeffrey Jones2 1University of Kentucky, Louisville, KY; 2Norton Healthcare, Louisville, KY; 3Lexington Veterans Affairs Medical Center, Lexington, KY

Background: An academic partnership was developed between Norton Healthcare and the University of Kentucky, College of Pharmacy in 2007. As part of this agreement, a UK faculty member is based in close proximity to Norton Hospital in Louisville KY, a 450 bed community hospital. This faculty member developed an Advanced Pharmacy Practice Experience (APPE) in Nutrition Support for students at this site. The faculty member took a leadership role in the clinical management of parenteral nutrition (PN) patients. The Norton Healthcare System consists of four adult hospitals; however at the time of this project only Norton Hospital (clinical service facility) pharmacists were writing PN orders and engaged in managing these specialized patients. Therefore the objectives of this project were to: 1) develop a mandatory and comprehensive web based educational program on Norton’s system wide learning management system (LMS) to document PN competency for all pharmacists, at all facilities, to enable them to write PN orders and manage patients, 2) assess pharmacist baseline knowledge at the clinical service hospital versus the other three adult facilities, and 3) assess pharmacists perceived satisfaction and value of the web based PN education. Methods: The study design for this project was submitted to the University of Kentucky IRB and an exemption was obtained. A Norton LMS developer was consulted for assistance with design of the education program to be provided in a flexible format that would enable monitoring and tracking of progress. Two comprehensive learning modules were developed and placed on the Norton LMS. The first learning module incorporated an introduction and pre-test, PN overview and indications, macronutrient assessment, macronutrient dosing and limits, and micronutrient dosing and limits. The second learning module provided education on PN initiation and monitoring, PN complications, PN compounding and stability issues, and post-test. To establish PN writing competency, a 25 question pre/post-test assessment exam was developed with a passing score of 80% required on the post-test. Statistical analysis applied was a paired t-test for pre and post-test results (same pharmacist) and an unpaired t-test to compare Norton Hospital versus the other adult facilities. Results: Currently twenty-five individual pharmacists have completion scores documented as reported by the LMS; thirteen from the downtown service hospital and twelve from the other three adult facilities. All pharmacists thus far have scored 80% or above on the post-test achieving the required outcome competency. The average test score increased from 74.4% to 91.5% (p<0.001) among all four adult hospitals. The average test score increased from 61.6% to 90.6% (p<0.001) among the three hospitals previously not providing a pharmacist PN writing and management service which was the most significant improvement. The average test score for the downtown facility, where pharmacists routinely manage PN patients, increased from 83.4% to 92.3% (p<0.05) indicating educational value for this group. Conclusions: All NHC

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Pharmacists at the adult facilities who complete this PN education are qualified to write PN orders and manage these specialized patients. The results of this project demonstrate that the educational modules, partnership service and associated APPE rotation are having a positive impact on enhancing pharmacist PN knowledge. Post-test results are being further analyzed for follow-up education needs. The Norton LMS represents a viable mechanism to deliver professional development programs to a large number of pharmacists. A survey has been designed and is being administered to assess perceived value and satisfaction with this education

25 - Potential Aluminum Toxicity in a Home Parenteral Nutrition Patient Charlene Colison Harding1 1Walgreens Infusion Pharmacy, Annapolis Junction, MD

Introduction: Aluminum (Al) is a contaminant of all ingredients in parenteral nutrition (PN) solutions. Symptoms of Al toxicity are generally nonspecific and may include bone pain, premature osteoporosis, muscle weakness, mental status changes, dementia and anemia. Patients with impaired kidney function and premature neonates are most at risk for Al toxicity although long term PN patients may also be at risk due to prolonged Al exposure. The Food and Drug Administration warns that parenteral Al content >4-5 mcg/kg/d is associated with Al accumulation and central nervous system and bone toxicity in patients with renal impairment. The following is a case study of potential Al toxicity in a home PN patient. Description: J.B. is a 44 year-old female with past medical history including endometriosis, ventral and inguinal hernia repairs, multiple bowel obstructions and resections leaving her with 2-3 feet of small intestine and two-thirds of colon remaining. The patient was receiving home PN when, after 2 months, she began reporting “memory problems”. She described having a hard time remembering what she was saying, asking the same question multiple times and slurred speech. J.B. also reported generalized weakness, muscle aches and fatigue. A brain MRI was performed which showed no abnormalities. Her PCP felt her symptoms were related to PN and it was discontinued after 4 months. According to the patient, her memory subsequently improved although not completely. Two months later, after multiple consults to work up her memory complaints, a serum Al level was checked and came back 13 mcg/L (normal <7). Four months after PN was stopped, orders were received to restart PN at home and alternate with hydration every other day to minimize Al content. Whole blood Al level was checked at that time and came back 20.4 mcg/L (normal <20). Other notable lab values included low Hgb and Hct (11.6 g/dL and 33.5%), elevated TG (205 mg/dL), and elevated ALT (46 U/L). The patient’s kidney function was normal (BUN 9 mg/dL, Cr 0.7 mg/dL), and all electrolytes including serum Ca (8.8 mg/dL) were also within range. The patient was initiated on 1 L of a 2:1 premixed PN solution given 3 days per week and hydration on non-PN days. Her weight at that time was 64.5 kg and according to the package insert, the premixed PN solution provided no more than 25 mcg/L of Al (0.3 mcg/kg). Discussion: The overall incidence of Al toxicity is not documented. It is also not apparent whether blood levels of Al alone are reliable markers of toxicity. Better indicators may include a deferoxamine infusion test or bone biopsy. An assessment of the patient’s previous TPN formulas and weights showed a range of 3.9-5.6 mcg Al/kg over the 4 months she received PN. Her Hgb and Hct ranges over the 4 months were also reviewed and showed normal levels prior to PN and slightly low values while on PN. Kidney function (BUN and Cr) remained normal throughout her PN course. At present, the patient is receiving 1 L of the premixed PN solution and 125 ml 20% lipids 4 days per week and hydration on non PN days. Her current weight is 62 kg (0.4mcg/kg Al). Despite the PN providing Al <4 mcg/kg/d, her complaints of periodic episodes of memory loss, weakness and fatigue persist. Her PCP and neurologist are now considering other diagnoses including seizure disorder. While the homecare pharmacy has methods in place to alert clinicians to the Al content of PN solutions and this is not a clear case of Al toxicity, opportunities for clinical education and quality improvement are evident.

26 - Home Start Parenteral Nutrition--Yes We Can!! Lorene Jansson1, Susan Brand1, Renee Monahan1, Sheryl Knowles1 1Walgreens Infusion and Respiratory Services, Everett, WA

Introduction: Starting patients on Parenteral Nutrition (PN) in the home setting, especially those at high risk of refeeding syndrome (RS), requires a knowledgeable and experienced Home Nutrition Support

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Team (HNST). While some may argue that PN should never be started in the home, in the “real world” it happens fairly frequently. It behooves home infusion companies to familiarize themselves with the literature regarding home start PN and with identifying those at risk for RS. One must be very conservative when starting a patient on home PN (HPN). In the home, patients and caregivers are trained on all aspects of PN, including weight and blood sugar monitoring, along with signs and symptoms of electrolyte abnormalities. However, professional physical assessments and lab monitoring are less frequent than in the hospital setting. The current literature for starting PN patients in the home, especially those at high risk of RS, vary significantly. One source recommends starting all macronutrients at 25% of the total estimated amount, while another recommends starting at 100-150g dextrose, still another at 50% of carbohydrate goal. Carbohydrate dose and rate contribute to RS. Depending on the weight of the patient, these recommendations have patients at high RS risk starting at anywhere from 50 g to up to 200 g carbohydrate per day. Methods: An experienced home infusion company with a HNST developed conservative guidelines for starting patients on HPN. All such patients were screened to identify those at high risk of RS. All patients had baseline CMP, magnesium and phosphorus drawn within 48 hours of starting HPN. Any patient with severe electrolyte abnormalities were hospitalized and not started in the home. Those with mild to moderate electrolyte abnormalities were corrected prior to HPN start. Mild, moderate, and severe electrolyte abnormalities are described elsewhere. Those identified at high risk of RS were started very conservatively at 25% of total estimated dextrose needs, and one liter of volume, and gradually increased to goal. Thiamin at 100 mg/d was added for one week. All were started at 24 hour infusions. The guidelines included advancement of carbohydrate dependent on labs and patient’s clinical picture. Those not at high risk of RS were started at 50% of dextrose goal, with guidelines of when to draw labs and advance to goal. All patients were eventually cycled after PN formula goal was met. Data on HPN starts was collected from September 2009 through May 2011 in one office of a large home infusion company. Evaluated were percentage of patients deemed to be at high risk of RS and the number of hospitalizations within two weeks of HPN start. Results: A total of 19 patients were started on HPN. Of the 19, 15 (79%) were considered to be at high risk of RS. Of those 15, 2 (13%) were hospitalized within 2 weeks of starting the PN. One was hospitalized to rule out hip fracture after a fall, and the other was hospitalized for pelvic abscess. Neither were hospitalized within 2 weeks of starting PN for the reason of electrolyte abnormalities nor for fluid overload. Conclusions: PN patients can be started successfully in the home. It requires a knowledgeable HNST, a conservative process as outlined above, and excellent monitoring skills. In the above analysis, all 19 PN patients were successfully started in the home with good outcomes, even those at high risk of RS.

27 - Development of a Standardized Parenteral Nutrition Progress Note at a Community Hospital Jessica Johnson1, Patricia Grunwald1 1Frederick Memorial Hospital, Frederick, MD

Introduction Parenteral nutrition (PN) is prescribed by clinical pharmacists per Pharmacy & Therapeutics Committee policy at Frederick Memorial Hospital, a 315-bed community hospital. In the absence of a formalized nutrition support service, pharmacists collaborate with clinical dietitians and physicians to formulate a comprehensive patient-specific plan for nutrition support. A template for daily PN progress notes was developed for use in the patient’s electronic medical record to standardize patient documentation and to promote consistent PN management practices. Methods: The PN progress note template, created in SOAP note format, was designed to include the minimum information considered necessary to provide a comprehensive assessment of the PN regimen. The template was added to the hospital online documentation system used by CPOE prescribers. To further enhance standardization of note-writing within the template, clusters of data, known as “data formats”, were created within the hospital computer system to capture pertinent laboratory data. The template was designed to allow “free-texting” of patient information in conjunction with selection of specific data formats. Result: The standardized entries included within the template default into the progress note upon selection of the template by the prescribing pharmacist. In addition to patient demographic data, the “Subjective/Objective” portion of the note includes the following entries: Indication, interval history, type of access, parenteral nutrition day, current parenteral nutrition regimen (macronutrients), pertinent medications, pertinent laboratory data, prealbumin history, triglyceride history, 24-hour accucheck history, 24-hour sliding scale insulin requirements, input/output, estimated needs (caloric, protein, fluid), and goal

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PN regimen (macronutrients). The entries included within the “Assessment/Plan” portion of the note include: PN regimen (where changes to macronutrients are indicated), micronutrients, electrolyte replacement, glycemic control (including adjustments in sliding scale insulin), and “am labs”. These entries prompt the prescribing pharmacist to include the minimum necessary information for evaluation of a given regimen, and also to provide a comprehensive plan for patient management. A truncated version of an actual PN progress note is included in Figures 1 and 2. Conclusion The PN progress note template is an effective tool for promoting standardized PN documentation and management practices for hospitals without a formal nutrition support service.

Figure 1. Truncated version of Subjective and Objective portion of PN progress note

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Figure 2. Truncated version of Assessment and Plan portion of PN progress note

28 - Ultra Long-term Home TPN Recipients: Evaluation of Patient Demographics and Practice Management Variations Karen Sexton-Hamilton1, MARK H. DELEGGE1, Carl Fink1, Jennifer Grasso1, Melinda Parker2 1Coram Specialty Infusion, Denver, CO, 2Coram Healthcare, San Francisco, CA

Long-term total parenteral nutrition (TPN) patients rely on nutrition therapy to maintain their nutritional well-being and pursue satisfying lives. However, their care is generally not standardized, and there are wide variations in patient management. One national home infusion provider evaluated a sample of ultra long-term patients (with a >18 mos length of therapy [LOT]) to gain greater insight into the influence of demographics and care management on clinical outcomes. Manual medical record audits were performed on 25 patient records from one service center located in the Northeastern U.S. Gender, LOT, diagnosis, managing physician specialty, insurer, current TPN prescription, frequency of lab draws, number and type of access devices, frequency and reason for hospitalization, and affiliated nursing agencies were evaluated. A total of 30,512 TPN days were noted with a mean LOT of 1,220 days. 64% of patients were female. The mean age was 36.6 years with 24% <16 years of age. Home TPN reimbursement was comprised of 68% commercial insurance, 16% Medicaid and 16% Medicare. Twelve unique diagnoses were noted. Of the physicians who managed this population, 84% had nutrition support experience, with 44% having nutrition support certification. The mean TPN prescription was comprised of 64.78 g amino acids and 220.18 g dextrose and1939 ml, infused 6 days per week. 16% of patients received both TPN and enteral therapy. There was a mean of 7.12 dextrose prescription changes and 24.76 electrolyte prescription changes. 64% of patients had a double lumen (D/L) access device. Patients with double lumen (D/L) catheters experienced a greater rate of hospitalization (73.7%) related to catheter complications compared to those with S/L catheters (26.3%), but experienced shorter average LOS during hospitalization (6.5 days vs. 8 days). Lab monitoring frequency was weekly (52%), every 2 weeks (16%), monthly (8%) and quarterly (24%). Sixty-four percent of patients were hospitalized during their care, with 26.5% of these hospitalizations related to access device complications. Average number of hospitalizations was 14.4. Sixty-four percent of patients had a nursing agency, while 36% were considered independent and received intermittent follow-up care through their clinic and physician. Patients with nursing agencies experienced a 28.9% rate of hospitalization related to catheter complications. Long-term patients who were independent and had no at-home nursing care experienced

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a slightly lower rate of 25.2%. Ultra long-term TPN recipients have complex medical issues and diverse etiologies for TPN use. Hospitalization occurred in more than half of this population, and catheter complications represented more than a quarter of all hospitalizations. Those individuals who had no at-home nursing experienced a higher rate of average hospitalizations per patient, but a slightly lower rate of hospitalizations related to catheter complications. Evaluation of a larger sample of ultra long-term TPN recipients and their outcomes from a larger geographic area may be helpful to corroborate these findings. It may also help to delineate the relationship between the frequency of nursing visits and hospitalizations and catheter type and patient acuity so that standardized guidelines may be developed to reduce hospitalizations and catheter complications.

29 - Abbreviated ethanol lock (ETOH) dwell times reduces rates of central venous catheter-associated blood stream (CA-BSI) Conrad Cole1, Kim Klotz1, Kim Jerger1, Adam Mezoff1, Samuel Kocoshis1 1Cincinnati Children's Hospital Medical Center, Cincinnati, OH

Background: Recent publications have touted the use of ethanol locks within central venous catheters to reduce the rate of BSIs. However protocols for dwell times and frequency of use have varied from medical center to medical center. Dwell times in all previous publications were at least 2 hours. Our customary practice is to employ a one hour dwell time, so we conducted this study to ascertain whether our ethanol lock protocol impacted the BSI rate among our patients on chronic TPN. Methods: We conducted a retrospective review of all patients who had initiated ethanol lock therapy within our institution between 1/2010 and 6/2011. We calculated their individual BSI rates/1000 catheter days prior to starting ETOH and following the inception of ETOH. Indications for ETOH lock were two BSIs with the same catheter. Standard protocol was to fill the catheter with 70% ETOH plus 0.1-0.2 ml of overfill and to permit a one hour dwell followed by complete withdrawal. ETOH was avoided for polyurethane catheters due to concern about catheter integrity. Direct contact with heparin was avoided, but a heparin dwell was sometimes utilized following a 10 ml saline catheter flush. We tested significance of difference with paired T test for patients with pre-ETOH data. We also utilized T test of the means for all pre and post-ETOH. Results: Fifteen patients were studied. Inadequate pre ETOH data on 4 of them who had come from other medical centers precluded performing paired T tests on them, but none had BSIs post-ETOH. Of the other 11, the BSI rate was lower in 9 and higher in 2, but both of those two violated protocol (one because their home health agency could not provide ETOH and the second because the locks were administered every other day). The pre and post ETOH BSI rates were 8/1000 days and 4/ 1000days, respectively (p=0.05). When data from those with incomplete pre-ETOH data were included, the post–ETOH BSI rate was 3/1000 days (p=0.005). Conclusions: Our data confirm the results of previous studies of ETOH locks, but we have shown that ETOH locks dwelling for as little as one hour/day are related to reduced BSI rates. Further studies of the optimal dwell time, ETOH concentration, and frequency of dwells are clearly in order.

30 - A Multidisciplinary Approach Improves Parenteral Nutrition Ordering Practices in Adults at a Large Tertiary Care Academic Hospital Jennifer Wooley1, Michael Kraft2, Emily Haller2 1University of Michigan Hospital Patient Food and Nutrition Services, Ann Arbor, MI; 2University of Michigan Health System, Ann Arbor

Background: Parenteral nutrition (PN) is a life-sustaining therapy for specific patient populations who are unable to meet their nutrient needs via oral diet or enteral nutrition. However, inappropriate use of PN exposes patients to infectious, metabolic and mechanical complications, may not provide significant clinical benefit if the therapy is not received for at least 5-7 days, and may result in increased healthcare costs. A multidisciplinary approach was used to evaluate PN ordering practices at a large tertiary academic hospital. The objective of this continuous quality improvement study was to promote the use of evidence-based PN therapy and to reduce or eliminate inappropriate PN use. Methods: A retrospective review of adult patients being considered for PN between August 2008 and July 2011 was undertaken with the implementation of a PN quality survey that was filled out prospectively by a registered dietitian (RD) for each patient prescribed PN. For twelve consecutive quarters, data collection and analyses

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included: the indication cited by the prescriber for starting PN, route of PN (central vs. peripheral), duration of PN therapy, and whether a central catheter was placed solely for PN. The indication for PN was classified as “appropriate” or “inappropriate” based on the American Society for Parenteral and Enteral Nutrition 2002 guidelines. Results: A total of 1372 adult patient PN quality surveys were analyzed during a three year period of time (mean:114 surveys per quarter). After excluding home PN patients and PN starts prevented by the RD, data analysis revealed a decrease in inappropriately prescribed PN over time from 52% to 30% of patients. Peripheral PN (PPN) was restricted in 2009 after an analysis of PPN use and duration therapy, and this resulted in an immediate and significant reduction of PPN use. Following the restriction of PPN, we observed an increase in the percentage of peripherally inserted central catheters (PICCs) placed solely for PN. In addition, 38% of these patients received less than 7 days of PN. A multidisciplinary team evaluated and revised the PICC order form via our CPOE system to guide more appropriate prescribing. This resulted in a decrease in PICC placement solely for PN from 48% to 27% of patients. However, 50% of these patients still received less than 7 days of PN. Conclusions: These results show the benefit of a multidisciplinary approach to continuous quality improvement related to PN therapy in a large tertiary academic hospital. We were able to monitor and assess the use of PN, recognize and address the overuse of this therapy, and institute effective interventions to reduce inappropriate PN use. However, it appears that a significant number of patients (~30%) are still prescribed PN without an evidence-based indication. In addition, a large number of these patients (44%) are still receiving PN for a short duration (< 7 days). Furthermore, many of these patients (27%) are receiving central catheters solely for PN, yet 50% of these patients received PN for less than 7 days. Further interventions will evaluate complications associated with inappropriate PN use, as well as other interventions to decrease inappropriate PN use and central catheter placement solely for PN (e.g., multidisciplinary education, CPOE system). With increased pressure to contain costs while optimizing patient care and outcomes, it is essential for healthcare systems to undertake ongoing evaluation and optimization of PN utilization.

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31 - Incidence of Peripherally Inserted Central Catheter-Related Large Vein Thrombosis in Inflammatory Bowel Disease Patients Receiving Parenteral Nutrition Andreas Mykoniatis1, Edward Scott Lozano1, Nolan Jacob McAfee2, Carol Semrad1 1University of Chicago, Chicago, IL; 2Purdue University, West Lafayette, IN

Introduction: Peripherally inserted central catheters (PICC) are now utilized for parenteral nutrition (PN) in the inpatient and outpatient settings. The risk of thrombosis with PICC is known to be higher than with tunneled catheters and chest ports. Inflammatory bowel disease (IBD) is a known risk factor for thrombosis. It is unknown if IBD PN patients have a higher risk of PICC–related large vein thrombosis (PRLVT) compared to non-IBD PN patients. The aim of this study was to evaluate the risk of symptomatic PRLVT in IBD patients receiving PN. Methods: A retrospective study was performed on adult hospitalized patients (18 years or greater) receiving PN through a PICC between January 2010 and December 2010 at The University of Chicago Medical Center. Symptomatic PRLVT in PN patients was defined as a partially or totally occluding blood clot identified by vascular duplex study and pain or swelling of the involved extremity. Patients with primary hypercoagulable states (antiphospholipid syndrome, protein C and S deficiency), acute DVT in other central veins, or full anticoagulation for other conditions were excluded from the study. Results: One hundred sixty patients received PN through a PICC during the study period, 55 with IBD and 105 with other medical or surgical conditions (cancer, sepsis, post–surgical ileus or fistula, transplant, pancreatitis, autoimmune diseases). Thirteen of 160 (8.1%) patients were diagnosed with PRLVT, 4 IBD patients and 9 with other medical or surgical conditions. Patients with IBD had a 7.3% (4/55) incidence of PRLVT. Those without IBD (9/105) had a 8.6% incidence of PRLVT. Using the Fisher exact test no difference was found between the two groups (p value 0.99). Conclusion: The incidence of symptomatic PRLVT in IBD patients was not significantly different from other hospitalized patients on PN. Limitations to our study include small sample size, possible protective effect of prophylactic anticoagulation in IBD post-surgical patients, and the presence of DVT risk factors in some non-IBD patients.

32 - Saved by the lock: a case report Barbara Corey1, Penny Allen1 1Critical Care Systems, Nashua, NH

Introduction: Catheter-related blood stream infections (CRBSI) are common and costly complications of home total parenteral nutrition (TPN). CRBSI-related mortality rates range from 12% to 25% depending on co-morbidities, virulence of the infecting organism, and other factors. Costs associated with CRBSI can be staggering, presenting an even bigger problem in the oncology population where costs to the

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individual can be catastrophic. It is estimated that up to 50% of CRBSI may be preventable prompting major patient safety initiatives to address the complication. Deciding whether to treat with antibiotics alone vs. line removal with antibiotics is complicated, and must consider potential treatment delays, limited vascular access sites and a patient’s inability to tolerate line removal. Systemic antibiotics alone often result in a treatment failure. In one study of adult oncology patients (N=103) the CRBSI recurrence rate was >50% in the antibiotic alone group vs. 4% when lines were removed.* The high treatment-failure rate prompted consideration of intra-luminal therapy in addition to standard treatments. Lock therapies using antibiotics or ethanol have been studied in oncology, dialysis and TPN-dependent populations. Anecdotal results as well as several controlled studies suggest an impressive reduction in CRBSI when locks are used. Concerns regarding lock therapy include: development of antibiotic resistance, side effects, catheter stability, antibiotic selection, and administration methods. Studies are underway to clarify these questions. For now, lock therapy in the high-risk oncology population may have a role in preventing CRBSI, which may in turn decrease treatment delays, decrease the rate of readmission for infection and line changes, and enhance patient quality of life. Case Report: A 50 y.o. woman with adenocarcinoma of unknown primary (pT4pN2bM1) receiving intravenous chemotherapy, with white cell growth factor support was referred to a home infusion company for TPN in June 2010. She was post-hemicolectomy and ileostomy in January 2010; she lost 20 kg prior to referral and presented at 52 kg. From June to November 2010 this patient had five readmissions for confirmed CRBSI, with 3 PICC lines and 2 port-a-caths. In November 2010 after her 5th CRBSI and weight at 60kg, the decision was made to hold TPN. Lock therapy with vancomycin 5mg/ml (1.3ml) alternating with gentamicin 1mg/ml (1.3ml) was instituted through her existing port. She remained off TPN through January 2011, but suffered a 13 kg wt loss and TPN was reinstituted. She has remained on alternating vancomycin and gentamicin locks through July 2011 and on intravenous chemotherapy without any hospital readmissions, CRBSI, chemotherapy dose reductions or line changes since November 2010. The patient’s weight stabilized at 59kg. Conclusion: For this high risk patient, antibiotic lock therapy under the close observation of her oncologist and infectious disease physician has prevented CRBSI, hospital admissions and chemotherapy dose reductions. Her performance status remains high. She does remain TPN-dependent due to extensive bowel resection, high output ileostomy and chemotherapy side effects. Her primary disease remains stable. * Coyle VM, McMullan R et al. Catheter-related bloodstream infection in adult haematology patients: catheter removal practice and outcome. J Hosp Infection (2004) 57, 325-331.

33 - Total parenteral nutrition use in the oncology population: a snapshot of practice Barbara Corey1 1Critical Care Systems, Nashua, NH

Background: Many patients with cancer suffer from malnutrition. A number of factors may impact the degree of malnutrition: tumor type and burden, cachexia, metabolic changes, treatment side effects, GI obstruction, as well as psychological influences. The number of oncology patients treated with TPN at home has been steadily increasing. The goal of this abstract is to explore the clinical characteristics of oncology patients referred for home TPN and better understand the indications for which TPN is prescribed. Methods: The medical records of 30 cancer patients receiving TPN with one branch of a national home infusion provider were reviewed and the following data was collected: age/sex of patient, number of TPN days on service, primary cancer site, oncology treatment received concurrent to TPN, indication for initiation of TPN and referral source. Results: The patients included 14 men and 16 women; age range 8 to 83 years old. Twenty six patients (86%) receiving TPN were between the ages of 41 and 79 years old. The average length of service (LOS) was 112 days (range 10-547). Fourteen patients (47%) had a primary GI cancer, four patients (13%) had a primary gynecological cancer and twelve patients (40%) had other primary cancer sites (mesothelioma, breast, brain, bladder, melanoma, carcinoid, AML, prostate, and sarcoma). Sixteen patients (53%) were receiving concurrent chemotherapy, radiation or both and eight patients (27%) were receiving no concurrent treatment. Six patients (20%) were post-op. The majority of initial referrals were from the hospital setting (93%), the majority of these were tertiary care facilities (80%). The indications for starting TPN were: bowel obstruction (n = 12; 40%); severe cancer treatment-related side effects (n = 12; 40%); direct tumor-related indications (n = 4; 13%); enteral tube failure/issues (n = 2; 7%). Discussion: Although the role of TPN with regard to improving survival, improving performance status, and maximizing quality of life continues to be researched and debated, the

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patient population described here represents a snapshot of how TPN is being used in the setting of active treatment, rather than as a means to support patients unable to eat in a near-terminal state. TPN can be a life-sustaining therapy for a select group of oncology patients, particularly those with bowel obstruction who have no other options for nutritional support. Other patients actively receiving anti-neoplastic treatment but suffering from severe treatment-related side effects may receive TPN as a means of nutritional support in order to avoid dose-reduction of treatment. Patient selection is extremely important in order to avoid increasing the burden and cost of care and/or risking complications when there is minimal to no clinical benefit for the patient. Ongoing research is indicated to identify the most appropriate patient types, cancer diagnoses, and clinical settings in which the benefits and cost-effectiveness of TPN therapy can be maximized.

34 - Common Home Infusion Nutrition Support Team Challenges when Monitoring and Managing Pediatric Digestive System Transplant Patients Betty Leung1, Rene Korpolinski1, Cordia Bailey1, Denise Cipolla1 1Walgreen's Infusion Services, Miramar, FL

Introduction: When managing the care of pediatric digestive system transplant patients, the home nutrition support team (NST) (pharmacist, nurse, doctor, and dietitian) encounters many challenges and complications that must be detected early and managed safely to optimize clinical care. Providing home nutrition support to this pediatric population is a unique opportunity requiring a very skilled home NST accustomed to coordinating multiple therapies across multiple teams in a cost effective manner. Methods: This retrospective, descriptive study included a thorough chart review of ten pediatric intestine, stomach, liver, and multivisceral transplant (small intestine, large intestine, stomach, pancreas, liver, and spleen) patients receiving home parenteral nutrition (PN) support, from 2005 - present. The method of nutrition support therapy administered and the nature of challenges encountered by these patients, their families, and the clinicians managing their care were identified. Data collected included: diagnosis, age patient started service, patient’s current age, nutrition support therapy type, and the occurrence of complications. Results: Sixty percent of the patients reviewed were male and forty percent were female. Ages ranged from two months to seven years old. Initial diagnoses included intestinal gastroschisis or intestinal dysmotility; all patients were also diagnosed with short gut syndrome. Five patients initially came to the center for a multivisceral transplant surgery, but one became a rehabilitation candidate because she did not meet transplant criteria. Forty percent of the patients tested positive for Epstein-Barr Virus (EBV) or Cytomegalovirus (CMV) requiring ganciclovir and cytomegalovirus immuglobin therapy. Thirty percent of the patients reviewed developed Post-transplant Lymphoproliferative Disease (PTLD), requiring chemotherapy. All of the cases reviewed experienced multiple complications requiring multidisciplinary input and management. Sixty percent received multiple therapies including infusion and enteral. Common PN management challenges included: obtaining labs in a timely manner, management of electrolyte imbalances, managing multiple medications and multiple routes of medication delivery, and infections of multiple origin. Additionally, it was difficult for the NST to determine accurate absorptive capacity when managing the common complication of high gastro intestinal (GI) output, dehydration, and when intravenous, enteral and oral intake is provided in tandem. Due to the nature of the medical needs of these patients it was common to see multiple hospitalizations for various reasons during the transplant process. International patients provide a unique set of challenges such as language barriers, interpreter translation, and collection of payment. The Women’s Infant and Children (WIC) Program provided formula to many of the families until the child was five years of age, this proved challenging when tracking formula intake. Conclusions: Conducting case reviews and capturing the challenges nutrition support clinicians encounter when providing pre-transplant, acute post-transplant, and chronic post-transplant care to this population, demonstrates the complexity of care required and emphasizes the requirement for a highly skilled multidisciplinary team approach. A consistent multidisciplinary team approach establishes long term relationships and builds clinical respect within the healthcare community. Closely monitoring and building awareness of common complications and challenges clinicians manage in the pediatric transplant population will refine and customize best practices for this specialized population.

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35 - Electrolyte Impossible: Clinically Navigating through the National Drug Shortages Terrence Adams, PharmD1, Lisa Johnson RD, LD/N1, Deborah Zetterholm, RD, LD, CNSC2, Lynn Pollack, PharmD1, Melinda Parker, MS, RD, CNSC3, Toby Rutledge, PharmD1, Wanda Rogers, Rph, MS3 1Coram Specialty Infusion, Jacksonville, FL; 2Coram Specialty Infusion, Flowood, MS; 3Coram Specialty Infusion, Denver, CO

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Introduction: Drug shortages in the U.S. have been at a record high this year as recorded by the FDA. It is the opinion of The Institute of Safe Medication Practices (ISMP) that the ongoing drug shortages are reaching a level of disaster status. Drug shortages are affecting consumers and presenting unprecedented challenges for healthcare providers. In particular, electrolytes and trace minerals for PN solutions were limited or not available, a situation which has triggered multiple changes in PN prescriptions. This has led to an increase in labor for re-writing and checking new orders and compounding the PN. Clinicians must take proactive measures to conserve electrolytes and prioritize to the most clinically appropriate and vulnerable patients while developing oral nutrient recommendations for those who have some absorptive capacity. Although the FDA recognizes the significant public health impact caused by the recent drug shortages, the burden of addressing patient management during these shortages relies on the interdisciplinary team members' expertise. Patient safety is the clinician's primary concern and therefore more frequent monitoring recommendations may be prudent. Methods: To evaluate the impact of the PN drug shortages on patient care, labor and physician orders for clinical monitoring, a national home infusion company developed a survey for clinicians managing PN patients. The survey questions were sent to pharmacists and dietitians within the organization. The survey results indicated the following: 54.3% reported receiving change orders to the way trace minerals or vitamins were dispensed in an effort to conserve drug; 23% of PN consumers were able to take oral calcium and 67.4% of those on oral calcium consumed at least 100% or more of the RDI; and of the patients on oral calcium, 56.5% consumed calcium citrate while 43.5% consumed calcium carbonate. Lab monitoring was also assessed to determine if additional labs are being drawn during the shortage. Responses indicated that ionized calcium and parathyroid hormone levels were ordered in addition to standard calcium levels. In view of calcium gluconate being conserved for the pediatric population, ~70% of PN consumers were transitioned to IV calcium chloride as their source of calcium along with magnesium chloride instead of magnesium sulfate. Conclusion: During these drug shortages in the U.S., many factors impact the safe delivery of necessary nutrients for PN-dependent patients. Healthcare providers across the continuum of care should be aware of the increased clinical time that is required in managing these shortage issues. As the shortage continues, clinicians must continue to make adjustments in an environment of ever-changing availability of products in the electrolyte, vitamin and mineral supply market to ensure patient safety and optimal clinical outcomes. Evaluation of the management of recent drug shortages affecting PN patients will allow clinicians to develop algorithms of care to promote safe and efficacious delivery to the highest-priority patients, while finding oral substitutions for patients with limited absorptive capacity.

36 - Catheter related sepsis: use of single and multi lumen catheters. Prashanth Patel1, Sameer Nakedar1, Kate Pickering1, Webster Madira1 1University Hospital of Leicester, Leicester, U.K.

Introduction One of the most serious potential complications of parenteral nutrition (PN) is catheter related sepsis (CRS), which is not only associated with mortality rates of 10%-20%, but also with increased morbidity and health care costs [Maki et al, 1988]. The objective of our study was to determine the prevalence of CRS in our hospital and also to evaluate how this varied by the use of single and multi lumen catheters. Method An established PN team prospectively recorded data on all the patients receiving PN over a 9-year period. Further information was obtained from patients’ clinical and laboratory records. In total, 1069 patients were administered PN and 1206 feeding catheters were inserted with an average feeding duration of 17.5 days over the period of April 2002 to March 2011. Between April 2002 and March 2008, 724 feeding catheters were inserted of which 296 (40.9%) were multi lumen. However, from April 2008 to March 2011 there was a change in practice and the usage of multi lumen catheters increased to 62.2% out of a total of 482 feeding lines. A definite CRS was defined as a positive blood culture either from the tip or from the central line in a patient with sign/s or symptom/s of infection. Results The definite CRS rate was 8% (58/724) between April 2002 and March 2008, and this increased to 11.8% (57/482) for the period April 2008 to March 2011 following the increased usage of multi lumen catheters (Figure 1). Whilst there may be a cause for concern with the change in feeding catheter choice, the overall CRS rate over the 9-year period was still within the previously reported range (1.3 to 27%) [Lee et al, 1988 and Rose et al, 1988). Conclusion While it may sometimes be unavoidable to use multi lumen feeding catheters, it should be appreciated that their use may be associated with increased CRS rate. References 1. Lee RB, Buckner M, Sharp M. Do multi lumen catheters increase central venous sepsis

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compared to single lumen catheters? J Trauma 1988; 28:1472-1475. 2. Maki DG, Cobb L, Garman JK, Shapiro JM, Ringer M, Helgerson RB. An attachable silver-impregnated cuff for prevention of infection with central venous catheters: a prospective randomised multicenter trial. Am J Med 1988; 85:307-314. 3. Rose SG, Pitsch RJ, Karrer FW, Moor BJ. Subclavian catheter infections.Journal of Parenteral and Enteral nutrition 1988; 12: 511-512

Caption Figure 1: Definite CRS rate over a 9-year period

37 - Reduction of Inappropriate Parenteral Nutrition Use: Outcomes with Team Collaboration Susan Lessar1, Kristen Chang2, Paul Ulich1, Jeffery Spray1 1Winchester Medical Center, Valley Health, Winchester, VA; 2Virginia Tech, Winchester, VA

Introduction: It has been previously documented that appropriate nutrition support is essential to ensure optimal nutritional outcomes in hospitalized and critically ill patients. The appropriate selection of route of nutrition support, enteral nutrition (EN) versus parenteral nutrition (PN), can be associated with decreased complications and mortality rates. The Society of Critical Care Medicine (SCCM) and the American Society of Enteral and Parenteral Nutrition (A.S.P.E.N.) guidelines state: (1) patients with a functioning gastrointestinal tract should be provided with EN and (2) PN therapy provided for a duration of less than 5-7 days results in no change in outcome and may result in increased risk to the patient. Many hospitals are forming nutrition support teams (NST) to increase communication between providers and decrease improper PN utilization according to these guidelines. By improving the appropriateness of PN utilization, NST's at similar hospital networks have been shown to have a positive economic impact and improve patient care. To justify the formation of a nutrition support team and decrease inappropriate PN utilization facing the 2010 intravenous PN shortages, efforts were made by a pharmacy and dietitian subcommittee at our 411 bed, level two-trauma center to educate physicians on proper PN utilization and review all new PN requests. Using this approach, average monthly new PN prescriptions were reduced by 65% from 2009 to 2011. Our facility continues to promote a team approach towards the administration of nutrition support to improve patient outcomes, minimize unnecessary costs and more closely adhere to A.S.P.E.N. guidelines. Methods: A.S.P.E.N. guidelines were used to determine appropriate PN utilization (PN reserved for patients with a non-functioning gastrointestinal tract that would receive it for >5 days). New PN starts were tracked for the first six months of 2011 and compared retrospectively to the total PN census for 2009 and 2010, as obtained through pharmacy reports. The number of patients who received PN for five or less days was determined and average PN costs according to hospital charge codes were calculated and totaled per patient for a 5 day period. Results: The review of PN utilization from 2009 to 2011 revealed a 65% decrease in monthly average PN starts. This consisted of a 30% reduction from 2009 to 2010 and a 50% reduction from 2010 to 2011 (Table 1). The reduction in total PN starts from 2009 to 2010 was 69. A summation of PN costs for a 5 day course averages $5,646 per patient, allowing for a potential average annual savings of $677,542 with the reduction of 10 PN patients per month (Table 2). Other potentially significant cost savings that are difficult to quantify include savings associated with decreased incidence of PN-related hyperglycemia, Catheter Line Associated Blood Stream Infection (CLABSI), venous thrombosis and other related PN complications. Conclusion: Our data reveal significant

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cost savings associated with a total reduction in PN infusions for patients receiving treatments for 5 or less days. It is expected that patient safety and efficacy of care will also be enhanced when there is a collaborative team of providers to review new cases and determine the most appropriate route of nutrition. Future formation of a NST, consisting of a dietitian, physician, pharmacist and nurse, with the goal of reducing inappropriate PN utilization and more closely following A.S.P.E.N. guidelines, may result in additional costs savings and improved patient outcomes.

38 - Impact of a Parenteral Nutrition Education Program in Home Infusion Kevin McNamara1 1BioScrip, Tampa, FL

Background: Many prescribers have been trained to rely on the hospital based nutrition support team or clinical pharmacist/dietitian to provide guidance and recommendations to optimize parenteral nutrition (PN) solutions for their patients. Upon discharge, prescribers continue to look to pharmacists, nurses and /or dietitians to assist in monitoring, managing and making therapeutic recommendations to optimize the nutritional care of their patients. Some clinicians will embrace this responsibility; however, other home infusion clinicians may feel unprepared or intimidated when asked to make recommendations to improve the outcome of their patients. Clinicians who have not worked in a home infusion or hospital setting or are not a recent graduate from a professional training program may have very limited training in the area of

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nutrition support and be uncomfortable monitoring and managing these patients. Methods: In order to increase employee confidence and reduce intimidation when caring for PN patients, a mandatory educational program was developed. The overall goal of the 3 tier program is to improve the competency of the home care professional. The initial level, required for all employees, provides general information about the disease states which may lead to the need for PN, referral sources, reimbursement, the formulation and the necessary supplies to safely provide PN therapy in the home. The second tier, designed for all clinicians, reviews the major clinical aspects of PN. The third tier, required for pharmacists and dietitians, reviews special complications related to PN therapy. Each educational offering consists of a recorded power point program, a competency assessment and an optional impact survey. A score of 90% on the assessment is required in order for the employee to pass the program. The optional survey is presented, upon successful passing of the assessment, to evaluate the impact the training had on the employees comfort level with caring for patients receiving PN. In addition to the educational program, the organization implemented a monthly multi-disciplinary nutrition team meeting to discuss the PN patients and any concerns related to the care of the patients. Results: Results of the program were evaluated based on the individual’s reported confidence in caring for PN patients and if the increased clinical confidence could result in an increase in the number of PN patients serviced. Since the program was implemented in January of 2011, 1463 employees completed the initial competency program and 605 employees completed the optional program survey. In a random sample of 100 surveys, 86% of employees felt the program improved their confidence when caring for the patient receiving PN. The number of new PN referrals and overall number of PN patients monthly was reported by 28 of the 30 infusion sites. All sites showed an increase in new referrals for patients receiving PN as the program progressed. Prior to the implementation of the educational program across the organization, approximately 3.3% of patients were receiving PN (December 2010). Since the inception of the program, the percent of PN patients across the company was found to rise as high as 3.8% in April and 3.9% in May 2011. Conclusion: Based on the reported impact data, the education program has led to improved clinician self-perceived confidence and comfort when providing care to the PN patients. Further evaluation is needed to determine if this directly resulted in the observed increase in the number of PN referral for the overall organization.

39 - Collaboration Between Referring Providers and Home Infusion Company Clinicians Can Improve Outcomes and Avoid Hospital Admissions for Patients Requiring Home Parenteral Nutrition and May Represent a Safer, More Cost Effective Care Strategy Tia Bodkins1, Jason Foster2, Amber Burke2, Julie Tanner3, Patricia Skiendziel3 1InfuScience, Omaha, NE; 2University of Nebraska Medical Center, Omaha, NE; 3InfuScience, North Charleston, SC

Introduction: The central goal of the current healthcare environment is the development of systems that deliver high quality and cost effective therapy efficiently with care provider accountability. It is paramount that care is delivered safely and efficiently with the primary goal of improved patient outcomes. Currently, initiation of parenteral nutrition (PN) therapies often requires admission to the hospital followed by transition to home health services, generating significant cost to patients and providers and requiring at minimum a 24-72 hour in-patient stay. A viable and more cost effective alternative is home initiation of parenteral nutrition therapy. Established home PN protocols presented at Clinical Nutrition Week 2011 were employed for this project. In this study we explored the feasibility of home initiation of PN in Stage IV oncology patients with carcinomatosis perioperatively. We evaluated the success of home starts and outcomes in this high risk patient population. Methods: This retrospective study included perioperative patients with peritoneal carcinomatosis referred from a tertiary academic medical center for home initiation of PN. Data collected included: diagnosis, therapy goal, key nutritional parameters (weight change, prealbumin levels), and outcomes including hospital admission rates at thirty, sixty and ninety days. Results: Nine patients were referred for home initiation of parenteral nutrition. All nine patients were safely started on PN in the home per the company’s home initiation of PN policy previously presented at Clinical Nutrition Week. The goal for all patients was to improve nutritional status based on objective criteria: weight stabilization and prealbumin levels. Detailed results of data collection can be seen in Table One. Sixty-seven percent of patients experienced both weight gain and increase in prealbumin levels during the time period reviewed. The average weight increase was 2.28%. The average increase in

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prealbumin levels was 25.6%. Thirty, sixty and ninety day hospitalization rates were evaluated and the total events at ninety days revealed only three unscheduled admissions, two for serum catheter related blood stream infections and one for non-therapy related functional decline. Based on average purported cost data, 48-hour hospital admission for initiation of PN costs $7417 compared to $703 for an average home start. This data suggests initiating PN therapy in the home resulted in a cost savings of $66,753 on hospital admissions to initiate PN therapy for these nine patients. Conclusions: This retrospective study revealed that home initiation of parenteral nutrition is a safe and cost effective way to provide necessary nutritional support in a high risk patient population, eliminating the need for unnecessary hospitalizations. An important factor to ensure success, requires the referring team and home infusion clinicians work together seamlessly. Moreover, the cost of home initiated PN is significantly less than the current in-patient PN strategy. The thirty, sixty and ninety day hospital admission rates indicate this patient population, while at high risk for complications, can be effectively managed in the home. Efforts to increase application of this protocol may result in significant cost savings in the future for the care of malnourished patients.

40 - Home parenteral nutrition in adult and pediatric patients, 4 years of experience in Argentina Daniela Benvenuti1, Rosana Vagni2, Florencia Chaves Morelli1, Juan Restuccia1, Marcelo Puga1, Agustin Flores1

A78 1Nutrihome SA, Ciudad Autonoma de Buenos Aires, Argentina; 2Hospital Italiano de Buenos Aires, Ciudad Autonoma de Buenos Aires, Argentina

Objectives: To describe and analyze the characteristics of patients who received home parenteral nutrition (HPN) in the August 2006 to August 2011 period. Methods: A descriptive, observational and retrospective study with data from electronic medical records of patients who received HPN in 15 places of Argentina, from August 2006 to August 2011. We analyzed age, sex, diagnosis, type of access, days receiving home parenteral nutrition treatment, mortality, readmission associated with nutritional support and rate of catheter-related infection. Results: A total 555 patients, pediatric 35%, median age 2,8 ( range 0-15 years), Adults 65%, median age 57, 8 (range 16 to 90 years). Female 48%. The main diagnosis in pediatric patients were gastrointestinal diseases 94 patients (48.4%), metabolopathies diseases 78 patients (40%), respiratory disease 10 patients (5.1%), other diseases 42 patients (21.5%). In adults the main diagnoses were gastrointestinal disease 196 patients (53.2%), kidney disease, 114 patients (31.5%), other diseases 51 patients (14%) The most frequently central venous catheter used was semimplantable devise 38.6%. Total days of parenteral nutrition treatment were 105130, with an average of 189 days (range 1947-6) The Mortality was <5%, the readmission associated with nutritional support was <1.5%, and the rate of catheter-related infection was less than to 2.5 infections per 1000 catheter days. Of all the patients analyzed, 178 are still in treatment (32%), 105 died 19%, 156 stopped HPN for nutritional recovery (28%), 75 suspended for admission, lack of health insurance coverage or refusal to receive the treatment (13.6%) . Conclusion The home parenteral nutrition is a life sustaining mode of therapy which is compatible with social rehabilitation. It requires the learning of specialized skill though an intensive training program and carefully following this program in a home setting. This practice allows patients to receive a long term treatment with a lower rate of complications than in hospitalization. The most prevalent causes for HPN were the digestive pathologies, in both age groups as well as the use of semimplantable catheter.

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41 - Vitamin D Resistant Rickets Type 1 and Home Calcium Management Kerry Stone1, Neil Marshall2 1Walgreens Home Infusion, Carlsbad, CA; 2Walgreens Home Infusion, Sun Valley, CA

Vitamin D Resistant Rickets Type 1 and Home Calcium Management Introduction: The etiology of vitamin D Resistant Rickets Type I (VDRR-1) is a mutation in the Vitamin D receptor gene on chromosome 12q13.3 causing the inability of 1-α-hydroxylase enzyme to bioactivate Vitamin D. This is a rare autosomal recessive disorder. Symptoms include markedly elevated levels of serum alkaline phosphatase, parathyroid hormone, and 1, 25 – (OH) 2 vitamin D. Low levels of phosphorus, 25-(OH) vitamin D, and ferritin are also common. Patients develop bowing of the legs and short stature. Treatment includes high levels of vitamin D until epiphyseal closure. Caution must be taken with excessively high doses of vitamin D as this can lead to renal and bone calcification. Background: AB was diagnosed at 2 years of age with hypocalcemia, VDRR-1, Failure to Thrive and Iron Deficiency Anemia. AB had multiple hospital admissions for IV and G- tube access problems and low calcium levels. Prior to home care team involvement, calcium gluconate was given per G-tube every 2 hours around the clock (150 vials/ month) leading to the mother’s physical exhaustion. AB received home oral and enteral calcium administration as well as enteral feedings via G-tube. Eventually the calcium gluconate (100mg/ml) was decreased to run at 5 ml/hour for 8-hours at night via pump with additional boluses during the day. One month later, the patient was again admitted to the hospital for air bubbles in the tubing and inconsistent delivery of the calcium. Calcium gluconate crystallized causing the enteral pump to malfunction. It was determined that gastric administration of parenteral calcium solutions is an off label use for the enteral pump. A nationwide shortage of parenteral calcium gluconate occurred in February 2011. The hospital performed a trial administration using calcium chloride and was satisfied that calcium levels would be maintained. Methods: Enterally delivered calcium chloride is rarely used and the absorption rate is unknown. AB now receives calcium chloride at 230mg/hr and is maintaining his calcium levels without rehospitalization. A side effect of gastric administration of calcium is diarrhea which requires banana flakes to reduce stool volume and enhance calcium absorption. Results: A follow-up home visit by the Nutrition Support Team found a very active 3 year old that is walking, talking and eating an oral diet. AB is unable to run due to the development of rickets. Dental alterations and defects are noted and include enamel hypoplasia. AB will require calcium supplementation until 18 years of age. The primary care giver relies on the hospital and the clinical expertise of the nutrition support pharmacist, dietitian and nurse to coordinate care. This complex case will require close monitoring to identify and prevent complications, growth retardation, and caregiver burnout, and to promote compliance to the healthcare regimen. Conclusions: This case requires a unique approach and understanding of the psych-social impact a long-term therapy has on both family

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and patient. As home infusion professionals we continuously develop and coordinate plans of care that have the least potential to disrupting childhood and quality of life while reducing the burden of care.

42 - A Twenty Five Year Experience with Protocol Driven Parenteral Nutrition Lynn Hiller1, Peter Fabri1, Jane Nichols1, Jeremey Brown1 1James A Haley Veterans' Hospital, Tampa, FL

Introduction: For 25 years, the James A Haley Veterans' Hospital has had a centralized, multidisciplinary Nutrition Support Team, which is responsible for all parenteral nutrition. Standardized protocols have been used for solution formulation, nursing orders, and laboratory orders. Data, including complications, have been collected and aggregated by year. Methods: A 25 year retrospective review was conducted on QA data for patients admitted to the hospital for whom a consult for PN was placed. The standardized database includes demographic data, PN specifications, and outcome data, including infectious, metabolic and mechanical complications. Standardized solutions include: standard (25%dextrose- 4.25% crystalline amino acids with standardized electrolyte, trace metal, micronutrient and macronutrient additions); 3-in-1 (same as standard but with 50% of non-protein calories as lipid); high nitrogen (same as standard but with increased amino acids); renal (no additives and reduced nitrogen). Only central lines placed by the NST were used and PN was not administered through peripherally inserted central catheters. Complications were predefined and were attributable to the administration of PN or directly associated with the central line. Deidentified data were used for this 25 year summary. Applicable IRB and R&D committees determined that there was no need for IRB approval of this study. Results: The NST receives on average 74 consults per year, distributed between surgery (58%), medicine (36.5%) and all other services (5.5%). The NST approved 63.6% of all consults for PN and alternate forms of nutrition were recommended for the remainder. The average duration of PN was 13.5 days. Usage of PN formula were as follows: standard (57.7%), three in one (23.7%), high nitrogen (9.7%), renal (6.3%) or other (2.6%). The incidences of metabolic complications were: glucose (8.76%), sodium (11.5%), potassium (3.15%), blood urea nitrogen (7.26%), creatinine (3.01%), carbon dioxide (8.85%), phosphorus (1.42%), magnesium (0.44%) and total bilirubin (2.83%). The incidence of catheter related blood stream infections was 10%. The incidences of mechanical complications were: pneumothorax (1%), catheter emboli (0.1%), catheter occlusion (0.1%) and vessel thrombosis (0.4%). Patients were managed by daily review and assessment, but solution formulations were not modified. Electrolyte abnormalities due to intercurrent illnesses were managed separately from the TPN solution. Conclusions: Overall complications rates of all types were low. Patients were easily managed without need for changes in the TPN solution, which minimized formulation errors as well as solution wastage. Parenteral Nutrition can be provided safely and effectively using standardized solutions and a protocol driven patient management system.

43 - Parenteral Nutrition Component Shortage Affects Home Nutrition Support Patient Jennifer Piazza1, Marianne Duda2 1Artex Allied Infusion, A CarePoint Partners Company, Richardson, TX; 2CarePoint Partners, Cincinnati, OH

Introduction: This is a report of the effect of the national shortage of parenteral nutrition (PN) additives upon the treatment of a chronic home nutrition support patient with an identified copper deficiency. Case Summary JM is a 17 year old female with a history of acute congenital lymphatic malformations of the small bowel and extremities, and intestinal lymphangectasia. JM received a small bowel transplant in 1998, and two years later was the recipient of a second multivisceral transplant consisting of small bowel, liver, and pancreas. As of 2008, she has been dependent on enteral nutrition (EN) support consisting of an elemental formula. In June 2010, JM was admitted to the hospital with persistent leg pain, neurologic deficits, and vitamin, trace element, and IVIG deficiencies. Among other issues, a copper deficiency was identified and JM was sent home primarily on an enterally-fed elemental diet. After discussion with her home infusion provider, once-weekly PN was initiated to provide additional copper (2mg/day) and other nutrients. After three weeks, she was increased to two copper-containing PN infusions per week. After a total of nine PN infusions containing additional copper, the PN was discontinued due to a national shortage of the intravenous copper additive. JM’s only source of copper (0.15mg/day) came from her elemental enteral formula until an oral copper supplement was added several weeks later. JM continues

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on her EN of an elemental formula and an oral copper supplement is now administered via her feeding tube. Discussion: The national shortage of PN components has made providing PN for patients’ in the home more difficult and costly. Supplies of PN components are prioritized for the critically ill and pediatric population, making it a challenge for home infusion pharmacies to obtain the components necessary for their patients. Separate IV infusions of electrolytes may or may not be possible in the home, depending on line access and willingness of the patient to give themselves multiple infusions. Conclusion Patients on home PN therapy are at risk of vitamin and trace element deficiencies due to the national shortage of components. This risk is even higher in patients with malabsorption or other conditions that inhibit adequate uptake of orally administered nutrients and mineral supplements. Pharmacists and Registered Dietitians working in home infusion pharmacies must collaborate with healthcare providers to develop a plan of care for home nutrition support patients to ensure they will receive adequate and appropriate nutrition therapy. Home infusion pharmacies must approach the plan of care in a creative way that will keep patients healthy while also maintaining a level of convenience for patients to continue nutrition support in the home.

Encore: Previously presented at National Home Infusion Association Conference, May 2011 44 - Analysis of total parenteral nutrition interventions during point of care transition to the home setting Carolyn Timm1, Caryn Dellamorte-Bing2, Penny Allen2 1Critical Care Systems, Inc., Burlington, MA; 2Critical Care Systems, Inc., Nashua, NH

Background: Acute care hospitals maintain standardized total parenteral nutrition (TPN) support protocols. Home intravenous nutrition formulations require adjustments to accommodate site of care and patient-specific longer term therapy requirements. 1,2,4. Assessments and formulation changes of home nutritional support (HNS) prescriptions represent active clinical interventions by home infusion clinicians such as pharmacists and registered dietitians. Purpose: 1. Examine the clinical interventions created for home nutrition support (HNS) patients upon transition to the home care setting. 2. Review and analyze prescription changes recommended and documented by home infusion pharmacists and registered dietitians. Methods: 1. Retrospective, clinical documentation review of 72 HNS electronic medical records from four home infusion pharmacies located in the Boston/NH area. 2. Data collection tailored to identify patients initiating home nutrition support (HNS) or resuming HNS upon hospital discharge. TPN patients that were excluded did not receive 28 consecutive days of therapy post-discharge. 3. Geographic selection represents similar HNS practice patterns. 4. Interventions were identified as dose changes in TPN ingredients. 5. Interventions were individually reviewed and categorized by type: - Nutritional elements - Electrolyte elements - Other pharmacy additives - Other therapy interventions - Other patient additives Results: *Total of 496 interventions *Average number of interventions per patient: 6.88 *165 different prescriptions created *Average number of interventions per prescription: 3.01 *Average number of interventions for each patient during the first 28 days of therapy, by intervention category: a. Electrolyte elements: 5.03 b. Nutritional elements: 3.04 c. Other pharmacy additives: 1.67 d. Other patient additives: 1.23 e. 70 out of 72 patients (97.3%) received an intervention within the first 28 days of HNS. Conclusions: *The typical HNS patient requires an average of seven TPN formulation interventions within the first 28 days of service. *Pharmacists and registered dietitians play an integral role in monitoring and managing HNS patients. *All clinicians involved should anticipate TPN formulation changes to be made when HNS patients transition to the home setting. References 1. Supplement. Guidelines for the Use of Parenteral and Enteral Nutrition in Adult and Pediatric Patients. Journal of Parenteral and Enteral Nutrition. Volume 26, number 1, Supplement January/February 2002. 2. Kraft, MD, Btaiche, IF, et. al. Review of the refeeding syndrome. Nutrition in clinical practice. December 2005;20:625-633. 3. American Society for Parenteral and Enteral Nutrition board of directors and the standards of specialized nutrition support task force. Standards for specialized nutrition support: home care patients. Nutrition in Clinical Practice. October 2005;20:579-590. 4. Guenter P. Clinical Review: Monitoring Total Parenteral Nutrition Therapy in the Elderly. The Consultant Pharmacist. 1999;14:371-376.

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45 - Providing Safe Home Initiation of Parenteral Nutrition: A Positive Patient Outcome Sandy Schoepfel1, Joanne Berardi2, Sarah Recanati3, Cheryl Jarcik4 1Home Solutions Infusion Therapy, Canton, MA; 2Home Solutions Infusion Therapy, Horsham, PA; 3Home Solutions Infusion Therapy, Livingston, NJ; 4Home Solutions Infusion Therapy, Fairfax, VA

Introduction: Initiating parenteral nutrition (PN) at home is a well-accepted and viable option to meet patients’ nutrition needs outside of the hospital setting. However, it is important to recognize that home initiation of PN remains a highly selective procedure requiring caution. Feeling compelled to comply with the demand for cost-savings and convenience associated with home initiation of PN, clinicians with limited experience may not realize the risks involved, thus compromising patient safety and positive

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outcomes. The collaboration of an experienced Home Nutrition Support Team (HNST) using a standardized checklist for initiation and advancement of PN is instrumental in avoiding refeeding syndrome as well as producing successful outcomes. The following case study illustrates this practice. Case Study: A 20 year male recently diagnosed with ulcerative colitis, presented to the ED with a history of fever, abdominal pain, decreased oral intake, and bloody diarrhea requiring hospital admission. He received IV hydration via a single lumen PICC and was discharged home. Once home, the patient’s symptoms returned. Orders were received to initiate PN at home. A checklist used to evaluate the safety of starting PN at home was completed by the HNST’s Registered Dietitian, who determined the patient required IV fluids and electrolyte repletion prior to starting PN. The MD agreed to start the patient on IV hydration until PN could be safely initiated. The patient was prescribed a clear liquid diet and oral supplement. He received hydration for one week using 1.5 liters of D5 ½ NS @ 80mL/hr which provided 75g of dextrose a day infused over 20 hours. The initial PN solution contained 150g of dextrose, 40g of amino acids and 25g of lipids for a total of 920 calories which was infused over 20 hours. His blood glucose and electrolytes remained within normal limits. The admixture was increased to a goal of 300g of dextrose, 60g of amino acids and 35g of lipids for a total of 1610 calories. The PN infusion was cycled from 20 to 16 to 12 hours over 3 weeks. As oral intake improved, PN calories were decreased. Bowel movements improved, becoming more solid and frequency decreased to 3-4 a day. He weighed 130 lbs. when PN was initiated and after 3 months of home PN therapy, he weighed 145 lbs. or 98% of his ideal body weight. Discussion Healthcare reform is currently a major issue in the United States. Initiating PN at home can provide significant cost savings and patient satisfaction. The use of a standardized protocol, in conjunction with an experienced HNST working closely with the patient’s ordering physician can prove to have many positive advantages. Advantages include avoidance of costly hospital admissions with a reduction of hospital acquired infections, a decrease in overall expenses as compared to hospitalization, and improved quality of life for patients. Conclusion: This case demonstrates that home initiation of PN can be accomplished safely, while maximizing positive outcomes with the use of a standardized protocol by home nutrition support clinicians.

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Initiation of Home PN Checklist

46 - Development of a Teaching Checklist for Consumers Providing Self-Care Donna Kloth1, Mona Inocentes1, Carol Cheney1, Deborah Pfister1 1ThriveRx, Cincinnati, OH

Introduction: Many nutrition support consumers have limited nursing care in the home, often resulting from no insurance coverage or lack of homebound status. Also, long-term consumers frequently feel comfortable providing their own care and prefer to minimize the risk of multiple caregivers accessing their central venous catheters (CVL). As a home infusion provider who specializes in the care of complex

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gastrointestinal diseases, many of our long-term consumers do not have ongoing nursing coverage and wish to be active participants in their care. This requires that they perform nursing-focused tasks, such as dressing changes and lab draws, which require extensive education and evaluation of technique to ensure safety. Intervention: In an attempt to evaluate our current consumers’ self-care practice, we conducted a retrospective review of a segment of our parenteral nutrition (PN) population. We collected data regarding: demographics; central venous catheter (CVL) type, antimicrobial agents used; and frequency of occlusion and line infections in consumers receiving nursing only and consumer/family self-care. Our goal was to determine if there were any common factors which put self-care consumers at risk and, what criteria should be included in our educational practice and our teaching tools. Outcome: Fourteen long-term PN consumers were evaluated, with five (36%) receiving nursing care only, and nine (64%) receiving some combination of nursing, family and/or consumer self-care. Results are as follows: Summary: There are a number of factors which contribute to the safety of long-term PN consumers providing their own self-care including; age, diagnosis, number of lumens, frequency of CVL access and line care technique. Furthermore, there are no consistent national standards of care for CVL type, placement or line care management and these factors are often dictated by the clinical team following their care. We were unable to observe any one factor which stood out in this small study group. In response, we developed a Self-Care Teaching Checklist and have initiated a protocol for teaching all new self-care patients to ensure that the consumer and/or family are trained initially and monitored ongoing. Our goal is to compare outcomes in consumers before and after teaching with the self-care checklist.

CLINICAL NUTRITION WEEK 2012 POSTERS: CRITICAL CARE, TRAUMA, INFECTION, SURGERY, INFLAMMATION, TRANSPLANT 47 - Efficacy of formula diets in promoting wound healing at the site of intestinal anastomosis Masayasu Aikawa1, Isamu Koyama1, Yosuke Ueno1, Katsuya Okada1, Yasuko Toshimitsu1, Naoe Akimoto1, Mitsuo Miyazawa1, Shigeki Yamaguchi1 1Saitama Medical University, International Medical Center, Hidaka, Saitama, Japan

Background: Collagen synthesis is essential in wound healing processes for conferring strength. While the efficacy of formula diets for promoting collagen synthesis in subcutaneous soft tissues has been reported, there has been no such report for sites of intestinal anastomosis. We designed a large-animal experimental model to investigate the strength of wound healing and collagen deposition at the site of intestinal anastomosis following administration of a formula diet (Abound®, Abbott, Tokyo, Japan), which contains HMB, arginine and glutamine. Methods: Hybrid pigs (n = 6) were laparotomized under general

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anesthesia and the small intestines were divided at 3 sites in each pig. End-to-end anastomosis was performed by continuous suture using Vicryl Rapid (ETHICON). The pigs were divided into 2 groups: one fed the experimental formula (AB group) and the other not fed the experimental formula (control group). In the AB group, normal diet mixed with the formula (HMB 1500 mg/day, arginine 1700 mg/day, glutamine 1700 mg/day) was fed from the day after the operation. At one week after the anastomosis, relaparotomy was performed and the operated small intestine was extirpated. Then, the anastomotic segments were evaluated by the burst test (BT), tension strength test (TST) and pathologic examination. BT: The lumen at one end of the anastomotic segment was attached to an infusion pump via an 18-G silicon catheter fitted to a 50-cc syringe filled with air, while the other end was attached to a digital pressure transducer. The anastomotic segment was submerged in a water bath. The pressure in the segment was then increased slowly and the maximum pressure at the first sign of air leakage was immediately recorded. TST: One end of the anastomotic segment was fixed and the other end was connected to a digital force gauge for measurement of the tension. One end was then strained slowly and the force was recorded in newton units at the first sign of rupture and at complete division of the anastomotic site. Pathologic study: HE staining and EVG staining were performed. The collagen deposition was estimated quantitatively using the ImageJ software. The numerical data were expressed as the mean ± standard deviation. Results: All of the pigs survived without loss of appetite and weight until they were sacrificed for evaluation. The BT was 49.4 ± 12.2 mmHg in the AB group and 35.9 ± 13.1 mmHg in the control group. The TST at the first sign of rupture was 6.07 ± 1.43 N in the AB group and 4.07 ± 1.70 N in the control group. The TST at complete division was 10.2 ± 2.07 N in the AB group and 7.54 ± 1.71 N in the control group. The amount of collagen deposition was 4627 ± 1368 N in the AB group and 2834 ± 1099 N in the control group. The TST and amount of collagen deposition in the AB group were significantly larger than the corresponding values in the control group (P < 0.05). Conclusion: The formula diet may promote wound healing by stimulating collagen deposition at sites of intestinal anastomosis site and thereby strengthen the anastomoses.

48 - Calcitriol-Complement Relationship Operative in Apolipoprotein-Mediated Coronary Disease Risk Demetrios Perdikis1, John Ricci1, Ayesha Ayub1, Vladimir Berkovich1 1Atlantic Foundation for Clinical Science, Wall, NJ

The active vitamin D metabolite 1,25-dihydroxyvitamin D (calcitriol) has been increasingly connected to cardio-protective phenomena. Among the more important of these observations suggests calcitriol’s modification of a set of immunologic processes that may be operative in coronary atherothrombosis. We therefore sought to identify putative patterns between measures of immune system activity, coronary risk and calcitriol in community patient populations. Specifically, we hypothesized that in such populations clinically consequential relationships between complement proteins, globulins and lipochemical characteristics of coronary risk (CHD Risk) are biochemically observable. We studied a population of 287 men (age 49.6±13.4; mean±SD years) and 355 women (age 50.5±13.5; mean±SD years) with Framingham-based suspicion of elevated coronary disease risk. In these patients, we measured the complement proteins C3 and C4 via enzyme immunoassay, calcitriol via high-performance liquid chromatography followed by tandem mass spectrometry, apolipoproteins A1 and B via nephelometry and globulins via serum protein electrophoresis. We observed that while complement C4 was directly related to CHD Risk (Pearson coefficient=0.60, n=58, p≤0.05), C3 was unrelated to CHD Risk. Additionally, calcitriol was unrelated to CHD Risk in this population. However, the calcitriol precursor 25-OH Vit D was strongly related to CHD Risk (Pearson coefficient=0.88, n=510, p≤0.05), globulin (Pearson coefficient=0.87, n=58, p≤0.05) and C4 (Pearson coefficient=-0.44, n=58, p≤0.05), but not C3 (Pearson coefficient=0.60, n=58, p≤0.05). Interestingly, C3 and calcitriol showed a strong direct relationship (Pearson coefficient=0.92, n=19, p≤0.05). Additionally, both apolipoprotein A1 and B were directly related to C4 (Pearson coefficient=0.66, n=58, p≤0.05; Pearson coefficient=0.76, n=58, p≤0.05, respectively) but not C3. Suggested in these results is the clinically observable association between a complement-VitD relationship operating concurrently with a complement-apolipoprotein relationship in patients with elevated CHD Risk. Characterizing the interactions between these phenomena can add understanding to any causal relationships between the complement system and apolipoprotein expression. Therefore,

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studying these phenomena in greater detail and perhaps mechanistically might be of further clinical importance.

49 - Glutamine Treatment Decreases Nuclear Localization of BACH1, a Transcriptional Repressor of Heme Oxygenase-1, in Non-Stressed Intestinal Epithelial Cells Christine Baird1, Alyssa Kallweit1, Diana Stutzman1, Paul Wischmeyer1 1University of Colorado Anschutz Medical Campus, Aurora, CO

Objective: Glutamine (GLN) protects cells from heat stress via induction of protective heat shock proteins (HSPs). In oxidant injury, GLN can enhance HSP32, or heme Oxygenase-1 (HO1), in the intestine. The mechanism of this induction is currently unknown and GLN’s effects on the antioxidant response element (ARE) remain to be elucidated. Nuclear Factor (Erythroid-Derived 2)-like 2 (NRF2), the primary transcription factor for HO1, can only bind after the transcriptional repressor, BACH1, vacates the ARE. No literature exists about GLN’s effects on BACH1, or NRF2 levels and cellular localization in intestinal epithelial 18 cells (IEC18). The purpose of our study was to elucidate the mechanism by which GLN increases HO1 by examining cellular localization and total levels of intracellular BACH1 and NRF2 in both stressed and non-stressed IEC18 cells. Methods: Cells were treated for 15 min with either 0mM (CT) or 10mM GLN, subjected to non-lethal injury (HS-43º for 45 min or 800uM H2O2 for 30 min), and allowed to recover (either 5 min for nuclear translocation experiments, or 3 hours for protein expression experiments). BACH1, NRF2 and HO1 expression levels and/or cellular localization were determined by western blot. HO1 messenger RNA levels were analyzed to assess if GLN affects HO1 at a transcriptional level. Results: Although total BACH1 levels did not change, GLN decreased BACH1 nuclear content in non-injured and HS cells (p=0.002 vs. CT). GLN treatment increased HO1 expression in all groups (p<0.05 vs. CT groups). Total NRF2 protein levels increased more than 3 fold with GLN treatment in non-injured cells (p=0.003 vs. CT cells). H2O2 injury alone increased nuclear NRF2, however HS decreased levels (p<0.05 vs. CT cells). GLN treated cells showed a significant increase in nuclear NRF2 (p<0.05 vs. HS CT). HO1 mRNA increased with GLN treatment in both stressed and non-stressed cells (p<0.05 vs. non-GLN treated groups) indicating GLN’s affect on HO1 is at a transcriptional level. Conclusions: GLN can upregulate HO1 gene expression. Although total BACH1 content does not change, GLN can decrease nuclear localization of BACH1 in both stressed and non-stressed cells possibly leading to an increase in NRF2 DNA binding and subsequent HO1 protein expression. GLN also increases total NRF2 levels in non-stressed cells and enhances nuclear NRF2 content in stressed cells. These are the first data showing GLN can decrease nuclear BACH1 and increase NRF2 in intestinal cells. GLN’s ability to decrease nuclear BACH1 in non-stressed cells is likely part of the mechanism of GLN mediated HO1 induction.

50 - In Women with Systemic Lupus Erythematosus, Red Blood Cell's Phosphatidyl-choline to Phosphatidyl-ethanolamine Ratio May Predict the Presence of Plaques in the Carotid Arteries Ellie Aghdassi1, David Ma2, Lihi Eder1, Stacey Morrison1, Amaris Balitsky1, Michael Frattasi1, Jiandong Su1, Paula Harvey3, Dafna Gladman1, Paul R. Fortin1 1The University Health Network-TWH, Toronto, ON; 2University of Guelph, Guelph, ON; 3The Women's College Hospital, Toronto, ON, Canada

Background and Purpose: The ratio of Phosphatidylcholine (PC) to Phosphatidyl-ethanolamine (PE) and the composition of PC and PE are important determinants of the cell membrane integrity. Alterations in PC to PE ratio have been reported in patients with chronic inflammatory conditions associating with adverse disease outcomes. Presence of antibodies to both PC and PE are reported in patients with systemic autoimmune rheumatic disorders including those with systemic lupus erythematosus (SLE). This may lead to changes in blood and cell membrane PC to PE ratio. The purpose of this study was to determine whether in women with SLE who were found to have carotid plaques on ultrasound, PC to PE ratio is altered when compared to those without carotid plaques. Method: SLE women (n=210), meeting the ACR criteria for classification of SLE who were attending the University of Toronto Lupus Clinic were enrolled. To date 67 of these women have had a vascular ultrasound in which the carotid intimal medial thickness (CIMT), the presence of plaques and the plaque area (CPA) were estimated. Of those with carotid ultrasound, phospholipid profile was determined in a subset of patients (18 with carotid plaques

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and 18 without) in red blood cells (RBC) using thin layer and gas chromatography. Demographic variables, cardiovascular disease (CVD) risk profile and SLE disease activity index-2000 (SLEDAI) as well as fasting blood lipid profile, glucose and insulin were collected. CIMT, traditional CVD risk profile and RBC PC to PE ratio were compared between patients with and without carotid plaques using un-paired student t-test. Results: Among 67 subjects, 28 (41.8%) had carotid plaques and 36 subjects (18 with and 18 without the presence of plaques) had data available on their RBC phospholipids profile. Among the traditional CVD risk factors, only age [57.5 (10.2) vs. 45.2 (9.5) year, p=0.001] and the systolic blood pressure [129.5 (21.3) vs. 113.0 (18.7) mmHg; p=0.041] were significantly higher in SLE women with carotid plaques compared to those without. Blood total cholesterol, LDL and HDL cholesterol, glucose and insulin as well as body mass index, smoking prevalence and waist to hip ratio were all similar between the two groups. However, CIMT was significantly higher [670 (122) vs. 585 (79) mm, p=0.02] and the PC to PE ratio [1.20 (0.16) vs.1.40 (0.28), p= 0.014] was significantly lower in women with the carotid plaques compared to those without. The mean (SD) plaque area in patients with carotid plaque was at 0.23 (0.19) cm2. There was no correlation between PC to PE ratio and systolic blood pressure or age. Conclusion: Although the majority of the traditional risk factors were not different between patients with and without carotid plaques, the PC to PE ratio discerns these two patient populations. A larger study is ongoing to determine whether PC to PE ratio could independently predict the presence of carotid plaques in a multivariate analysis correcting for age and systolic blood pressure. PC and PE ratio may play a role in the pathophysiology of atherosclerosis in patients with SLE.

51 - Long-term decrease of fecal short-chain fatty acids in the gut in critically ill patients with severe SIRS. Tomoki Yamada1, Kentaro Shimizu2, Hiroshi Ogura1, Takashi Asahara3, Koji Nomoto3, Tomoya Hirose1, Yoshifumi Ogawa1, Mitsuo Ohnishi1, Masami Morotomi3, Yasuyuki Kuwagata1, Takeshi Shimazu1 1Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School; 2Department of Clinical Quality Management Osaka University Hospital , Osaka; 3Yakult Central Institute for Microbiological Research, Tokyo, Japan

Backgrounds; The gut is an important target organ for injury after severe insult. SCFAs are utilized mainly by intestinal epithelial cells as energy substrates, and influence not only the motility of the intestinal tract and increase intestinal blood flow but also modulate the gene expression and transport capacity of transluminal nutrients. Especially butyrate has many roles including anti-inflammatory effect, and also carcinogenesis, intestinal barrier function and production of intestinal hormone. The role of SCFAs in the gut, however, has not been clarified in critically ill conditions. In this study, we evaluated the serial change of the fecal SCFAs in patients with severe SIRS(systemic inflammatory response syndrome). Patients and Methods; One hundred and forty ICU patients with severe SIRS, who fulfilled the criteria of SIRS, had a serum CRP level>10 mg/dL were included in our study. SIRS was a result of infection in 84 patients, trauma in 30, burn in 12 and others in 14. Average APACHEⅡscore on admission was 17.0±7.2(mean±SD). Fecal SCFAs were measured by high speed liquid chromatography and evaluated weekly for 6 weeks from admission. The incidences of gastrointestinal(GI) complications including enteritis and dysmotility were evaluated. Enteritis was defined as watery diarrhea more than 12 hours, and dysmotility was defined as gastric residual volume more than 300ml per day. Results; Two hundred and twenty-seven fecal samples were collected. The fecal concentrations of butyrate decreased significantly to 4.2±5.9* within 1st week (normal 16.6±6.7), they remained at low values in their ICU stay (4.2±5.5*, 3.1±3.9*, 2.9±4.7*, 3.8±5.9*, 4.1±4.7* (2nd, 3rd, 4th, 5th, 6th week))(Figure). The fecal concentrations of propionate decreased significantly to 7.4±7.8* within 1st week, and they remained at low values (8.6±8.4*, 8.6±7.7*, 8.3±9.3*, 9.0±9.6*, 7.8±8.8* (2nd, 3rd, 4th, 5th, 6th week; normal 18.7±6.8)). The fecal concentrations of acetate decreased to 34.2±23.2* within 1st week, they did not decrease severely as other SCFAs (43.6±23.9, 40.2±22.4, 39.5±26.9, 43.6±27.7, 42.5±26.6 (2nd, 3rd, 4th, 5th, 6th week ;normal 50.8±13.1)). (*p<0.05 vs. normal; the results are expressed as mean ±SD (μmol/g of feces )). The incidence of diarrhea and dysmotility in 6 weeks after admission were 25.7% and 10.0% respectively. The incidences of GI complications gradually increased. Conclusion; The fecal SCFAs especially butyrate and propionate in patients with severe SIRS were significantly lower than normal for a long term. The maintenance of SCFAs could be an important target for future intestinal therapy to prevent GI complications in critically ill patients.

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Serial changes in the fecal concentrations of SCFAs and the accumulated incidence of GI complications.

52 - The Effects of Fish Oil (EPA & DHA) on Chronic Ventilator Patients in a Long Term Acute Care Setting: A Randomized Clinical Trial Mary Kaplan1, Jessica Harvey2, Sarah Couch3, Kari Dunning1, 3 1Drake Center Inc., Cincinnati, OH; 2Children's Hospital Medical Center,Cincinnati, OH; 3University of Cincinnati, Cincinnati, OH

Objectives: Administration of Omega 3 fatty acids (eicosapentaenoic acid and docosahexanoic acid) has been associated with improved outcomes in acute lung injury in the ICU setting when studied as components of a commercial formula. Fish oil has not been studied in the critically ill chronic ventilator population in a long term acute care hospital setting as an independent treatment. We therefore sought to determine the effects of enteral fish oil alone on systemic inflammation and on ventilator weaning time. Design: Randomized controlled trial. Specific aims were to determine the effect on: 1) days to wean and length of stay, 2). inflammatory markers, and 3). number of infectious events (i.e. pneumonia, blood stream infections, and other infections). Setting: Long Term Acute Care Hospital. Patients: Mechanically ventilated patients 18-80 age range. Interventions: Subjects were randomized to receive fish oil enterally (9.26 g eicosapentaenoic acid and 6.75 g docosahexanoic acid) daily or saline placebo for up to 14 days. Results: Nine subjects were enrolled. Five subjects randomized to treatment (fish oil) and 4 randomized to control (saline placebo). See Table 1 for participant characteristics. Subjects randomized to the treatment group demonstrated shorter length of stay (by average of 8 days) compared to the control subjects (Table 2). This value was not statistically significant but may represent a cost savings value. No benefits were observed on inflammatory markers or on number of infectious events. If decreased length of stay is reproduced in future studies with larger subject size, the clinical use of fish oil supplements or specialty formulas containing EPA and DHA may be beneficial for vent weaning in the LTAC ventilator population.

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53 - Hypocaloric Nutrition Therapy for Older Critically Ill Patients with Obesity Theresa Medling1, Ashley Smith1, Rex Brown1, George Maish, III1, Martin Croce1, Gayle Minard1, Roland Dickerson1 1University of Tennessee, Memphis, TN

Introduction: Previous data suggests older obese patients do not respond as effectively to hypocaloric nutrition as younger patients. However, these data were limited by a small study population and sub-optimal protein intake for hypocaloric feeding. The intent of this study was to ascertain if older, critically ill trauma patients with obesity achieve a similar net protein anabolic response and clinical outcomes as younger trauma patients with obesity with the use of hypocaloric, high-protein nutrition therapy. Methods: Adult (> 18 yrs) obese (BMI > 30 kg/m2) patients with traumatic injury admitted to the Presley Regional Trauma Center from January, 2009 to April, 2011 and referred to the Nutrition Support Service were evaluated. Only patients who received hypocaloric, high-protein nutrition therapy ( 2 g/kg IBW/d of protein) for at least 10 days and had a nitrogen balance (NB) determination were included. Patients were stratified according to age as older (> 60 yrs) or younger (18 to 59 yrs). Nutritional and clinical outcomes were compared between groups. Results: A total of 74 obese patients (33 older, 41 younger) were identified for evaluation. Older and younger patients were similar in weight, BMI, and severity of injury. Other demographic data are given in Table 1. When given similar protein intakes (2.3 g/kg IBW/d), NB

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were similar between groups (e.g., -3.2 g/d versus -4.9 g/d, respectively, p=NS) during the second week post-injury (Table 2). About half of the patients from each group (55% vs. 56%) achieved nitrogen equilibrium (NB -4 g/d or better; p = NS). Older patients experienced a greater maximum serum urea nitrogen (SUN) concentration (43 + 19 mg/dL vs. 28 + 12 mg/dL, respectively, p = 0.001) compared to younger patients (Table 2). This effect was likely due to a significantly lower glomerular filtration rate as estimated by measured creatinine clearance in older versus younger patients (p < 0.001). No significant differences were observed for nutritional or clinical outcomes between older and younger patients (Table 2). Conclusions: Older critically ill trauma patients with obesity respond similarly to younger patients during hypocaloric nutrition therapy when adequate protein is given. However, older patients require close monitoring to avoid clinically relevant azotemia during hypocaloric, high-protein nutrition therapy.

54 - Effects of a New Immune-Modulating Diet Enriched with Whey-Hydrolyzed Peptide, Fermented

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Milk, and Isomaltulose on Gut Associated Lymphoid Tissue in Mice Masashi Yanagawa1, Kazuhiko Fukatsu2, Takashi Mitsui3, Etsushi Ogawa2, Takashi Fukuda3, Tomoyuki Moriya4, Satoshi Murakoshi5, Midori Noguchi5, Ryohei Nishimura1 1Laboratory of Veterinary Emergency Medicine, The University of Tokyo, Japan; 2Surgical Center, University of Tokyo, Japan; 3Department of Surgery, The University of Tokyo, Japan; 4Department of Surgery, National Defense Medical College, Tokorozawa, Japan; 5Division of Traumatology, National Defense Medical College Research Institute, Tokorozawa, Japan.

Background: Gut associated lymphoid tissue (GALT) is a center of systemic mucosal immunity. Reinforcement of GALT may play an important role in preventing infectious complications in immune-compromised host. An enteral immune-modulating diet enriched with whey-hydrolyzed peptide, fermented milk, and isomaltulose (IMD) has been demonstrated to reduce liver injury in various surgical insult models and have trophic effects on gut mucosa. The present study aimed to examine whether the IMD enhances GALT mass as compared with a standard enteral diet containing Na caseinates and dextrin (STD). Methods: Male ICR mice were randomized into the IMD (n=10) or STD (n=10) group. After 7 days of each feeding, whole small intestine was harvested. GALT lymphocytes from Peyer patches (PPs), intraepithelial spaces (IE) and the lamina propria (LP) were isolated, counted and analyzed for their phenotypic determination by flowcytometry (alpha-beta-TCR+, gamma-delta-TCR+, CD4+, CD8+ and B cells). Results: There was no significant difference in body weight change during each feeding between the two groups. Total lymphocyte numbers in PPs, IE and LP were higher in the IMD than in the STD group. The numbers of B cells in PPs, gamma-delta-TCR+ cells in IE and alpha-beta-TCR+, gamma-delta-TCR+, CD4+, and CD8+ cells in LP were significantly higher in the IMD than in the STD group. Conclusions: The new IMD enlarges GALT mass as compared with STD, possibly improving gut immunity and host defense against infections. Its effects on GALT function need to be elucidated in a future study.

55 - Effects of Surgical Stress on Serum and Intestinal Secretory IgA: Concept of Mucosal Immunity in Humans Woodae Kang1, Hiroshi Miyake1, Moritaka Ohara1, Kei Kimizuka1, Takeshi Kikuchi1, Michitaka Ogura1, Manabu Hanada1, Hironobu Sato1, Masayoshi Kura1 1Kasukabe Municipal Hospital, Saitama, Japan.

Background: According to the common mucosal immune system hypothesis, sensitized lymphocytes derived from gut-associated lymphoid tissue (GALT) migrate to intestinal and respiratory mucosal sites via blood and then secrete IgA. IgA on mucosal surfaces prevents pathogen invasion of tissues. In animal studies, lack of enteral nutrition (EN) decreased GALT lymphocyte numbers thereby depressing respiratory and intestinal IgA secretion. This is thought to cause infectious complications in critically ill patients receiving parenteral nutrition. Previously, we demonstrated IgA levels in intestinal fluid on postoperative day (POD) 1 to be significantly higher than on POD3 and POD7 in humans. Moreover, intestinal IgA secretion on POD1was significantly lower in patients with restricted oral intake than that in patients fed enterally without restriction. Therefore, we suspected IgA secretary responses soon after surgery to be blunted by lack of EN. However, perioperative IgA changes remain unclear in humans. We aimed to confirm whether surgical stress increases IgA secretion. Methods: Data were obtained from 7 consecutive patients (4 men, 3 women, 67 ± 4 years) with intestinal obstruction. All patients received parenteral nutrition without oral intake over 8 days and underwent surgery with or without intestinal

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resection. Intestinal fluids before and after surgery were collected via naso-intestinal tubes for ileus. We evaluated perioperative serum and intestinal fluid IgA levels. Since intestinal fluid after surgical relief of obstruction was not fully drained via the ileus tube, perioperative IgA levels were analyzed. Results: Intestinal fluid and serum IgA levels are shown below. IgA in intestinal fluid on POD1 was significantly increased compared to 1 and 0 days before surgery. Serum IgA did not change significantly with surgical injury. Perioperative IgA changes in serum did not correlate with those in intestinal fluid. Intestinal IgA in a pneumonia case did not increase with surgical stress (81 mg/dl, 77 mg/dl, and 61 mg/dl 1 and 0 days before surgery and POD1, respectively). Intestinal fluid was collected for 6 days before surgery in 2 cases. In these patients, the total IgA amount in intestinal fluid was time-dependently decreased until the operative day (61800 ± 4200 mg, 28710 ± 2310 mg, and 6349 ± 3731 mg 6, 3 and 0 days before surgery, respectively). Serum albumin (g/dl) on 1 day (3.3 ± 0.3) before surgery and on POD1 (2.6 ± 0.2) was below normal. Conclusions: Intestinal IgA secretion rose with surgical stress even in diet-restricted patients. We previously showed lack of EN-induced depressed intestinal IgA secretion after surgery. Herein, decreased enteral stimulation was shown to blunt IgA secretary response after surgical stress. It was also suggested that mucosal IgA secretion is needed for host immune defense after injury. Perioperative intestinal IgA changes do not seem to be influenced by serum IgA. Intestinal IgA secretion in response to surgical stress might result directly from IgA-secreting lymphocytes in gut mucosa. These data support the existence of a human mucosal immune system, consistent with the theory of IgA secretion from disseminated lymphocytes after migration via blood to mucosal surfaces.

56 - Identifying Critically Ill Patients Who Benefit the Most From Nutrition Therapy: The development and initial validation of a novel risk assessment tool Daren Heyland1, Rupinder Dhaliwal2, Xuran Jiang2, Andrew Day2 1Queen's University, Kingston, ON, Canada; 2Clinical Evaluation Research Unit, Kingston, ON, Canada

Introduction: To develop a scoring method for quantifying nutrition risk in the intensive care unit (ICU). Methods: A prospective observational study of patients expected to stay in the >24 hours. Variables considered for inclusion in the NUTRIC score were based on a conceptual model linking acute and chronic starvation and inflammation with outcomes and included the following candidate predictor variables: age, baseline APACHE II, baseline SOFA score, number of comorbidities, days from hospital admission to ICU admission, Body Mass Index (BMI) <20, CRP, IL-6 , PCT, estimated % oral intake in the week prior to enrolment and weight loss in the last 3 months. We developed various regression models and conducted correlation analysis to determine which variables correlated with 28 day outcome and included these in the final score. Approximate quintiles of each variable were assigned points based on the strength of their bivariate association with 28 day mortality. The score was then refined by dropping variables whose inclusion did improve the overall predictive ability of the score. To validate the score, we then explored the relationship of the score to mortality and duration of mechanical ventilation. Among the 211 mechanically ventilated patients who stayed in ICU for three days or longer, we examined the interaction between nutrition risk score and nutritional adequacy. A priori we hypothesize that in patients with a high score, not those with a low score, increased nutritional adequacy would be associated with reduced mortality only. Results: A total of 597 patients were enrolled in this study. In only 171 (28.6%) patients were we able to obtain a history of recent oral intake and weight loss from next-of-kin. All of the candidate variables were significantly associated with 28 day mortality except BMI, CRP, recent oral intake and weight loss whereas all variables were significantly correlated with ventilator free days at 28

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days except BMI. Based on the statistical significance in the multivariable model, the final scoring system used all candidate variables except gender, BMI, CRP, PCT, estimated % oral intake and weight loss. The risk score was then calculated as the sum of the points assigned to each variable. Scores ranged from 0 (lowest risk) to 10 (highest risk) and the scoring system was found to be moderately predictive of 28 day mortality (AUC=0. 783). As the score increased, so did the mortality rate and duration of mechanical ventilation. The performance of our scoring algorithm was cross-validated by two random split samples; scoring was similar in both split samples. Regression model indicates that nutritional adequacy modifies the association between nutrition risk score and 28 day mortality (p=0.01). While higher level of nutritional adequacy was associated with an reduction in 28 day mortality among patients with higher NUTRIC Scores (i.e. NUTRIC Score ≥ 6), this result was not observed among patients with lower scores. Conclusions: This scoring algorithm may be helpful in identifying critically ill patients most likely to benefit from aggressive nutrition therapy.

57 - The Medical Nutrition Therapy Provided to Adult Patients Undergoing Hematopoietic Stem Cell Transplantation Mary Habschmidt1, Cheryl Bacon1, Mary Gregoire1, Heather Rasmussen1 1Rush University Medical Center, Chicago, IL Introduction: There is limited literature on the medical nutrition therapy (MNT) provided to hematopoietic stem cell transplant (HSCT) patients and strong evidenced-based practice guidelines are lacking. The objective of this study was to determine the current MNT provided to adult patients undergoing HSCT and to compare dietitian and physician perceptions regarding MNT. Methods: This study was a cross-sectional survey research design. A total of 60 (57% response) Registered Dietitians (RDs) and 11 (10% response) physicians responded to an electronic questionnaire on current practices with and perceptions about MNT for HSCT patients. The Statistical Package for the Social Sciences (SPSS; version 17) descriptive statistics and chi-square analyses were used. Results: RDs and physicians strongly agreed that nutrition is important in the clinical outcomes of adult HSCT patients (mean = 4.82 on 5 point scale). There was no clear preference by RDs and physicians for the form of MNT that should be provided to autologous HSCT patients; responses were fairly evenly distributed among oral nutrition only (29%), oral nutrition with parenteral nutrition (PN) as needed (27%) and oral nutrition with enteral nutrition (EN) as needed (29%). For allogeneic patients, RD responses were distributed primarily between oral nutrition with EN as needed (28%) and oral nutrition with PN as needed (42%), while the most common physician response was oral nutrition with PN as needed (73%). The use of nutrition support (PN or EN) occurred in less than one-third of patients, regardless of transplant type. Significantly more (p≤0.05) patients were placed on PN compared to EN. Within the past year, approximately 16% to 31% of patients were placed on PN compared to 5% to 9% on EN. Patient length of time on nutrition support was similar between donor types; however, patients on EN had a more variable range. Decisions to initiate nutrition support were individualized to the patient and not by established protocol or policies. The most common reasons for implementing PN included mucositis (31%), gastrointestinal toxicities such as nausea and vomiting (19%) and graft-versus-host disease (17%) while the most common responses for implementing EN included if the patient was intubated or in the intensive care unit (28%), if oral intake was inadequate (23%) and if the physician had requested EN to be initiated (10%). The most common feeding tube used was a small bore feeding tube (58%) and more than half (53%) preferred the stomach as the primary feeding site. Conclusion: The use of an oral diet is the primary form of nutrition provided to HSCT patients. For nutrition support, PN is being used significantly more than EN for all donor types. Physicians and RDs agree that nutrition is important in the outcome of adult HSCT patients.

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58 - Arginine supplementation increases intestinal polyamine synthesis Lara Eliza Quirino1, Rosana Santos1, Warlley Evangelista1, Valbert Cardoso1, Maria Beatriz Glória1, Jacqueline Fiúza2, Maria Isabel Correa3 1Faculdade de Farmácia / Universidade Federal de Minas Gerais, Belo Horizonte, Brazil; 2Centro de Pesquisas René Rachou, Belo Horizonte; 3Faculdade de Medicina / Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.

Introduction: Arginine, a conditionally essential amino acid, has attracted great interest for its properties. It seems to promote nitrogen retention and wound healing in the form of increased wound tensile strength and reparative collagen. Arginine from dietary proteins is actively metabolized in enterocytes and supports several gut functions under stressful and inflammatory situations. Arginine is converted into ornithine by arginase. Ornithine, in turn, origins polyamines. Many of these effects of arginine are associated to polyamines. There are evidences that polyamines are necessary for the growth and repair of gastrointestinal mucosa by enhancing cell migration and proliferation as well as the regulation of apoptosis. In intestine, increase of polyamines synthesis is related with increase of villi mucosa after injuries. Thus, the aim of this study was to assess the effects of arginine supplementation on polyamine concentration in intestinal fluid. Methods: Male C57BL6 wild-type mice were randomized into 3 groups

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with 5 animals each: Sham (standard chow), IO (standard chow + intestinal obstruction), Arg (standard chow supplemented with 2% of arginine + intestinal obstruction). Conventional and supplemented chows were isocaloric and isoproteic. Water was given ad libitum. The animals were fed these diets for 7 days. Caloric, protein, nitrogen intake and body weight were monitored daily. After 7 days, all groups, except the Sham, underwent intestinal obstruction by ligature of terminal ileum. Eighteen hours later, the animals were euthanized. Small intestine was removed and the contents were withdrawn, weighed and suspended in PBS (500 mg of intestinal content/ 2.0 mL PBS). After centrifugation at 2000 x g for 30 min at 4ºC, the supernatant was collected and kept frozen at -70ºC until polyamine determination by high performance liquid chromatography (HPLC). The presence of putrescine, spermidine and spermine was assessed. Concentration of polyamines in the intestinal fluid, weight changes, caloric, protein and nitrogen intakes were compared using the ANOVA test and a post hoc analysis using the Tukey’s test. Data were expressed as mean ± standard deviation (SD). Differences were considered statistically significant when p values were less than 0.05. Results: There were no differences on mean weight gain, caloric, protein and nitrogen intake among the groups (Table 1). Putrescine was not identified in any group. Mice that received arginine had higher levels of espermin and espermidin in the intestinal fluid (Figures 1 and 2). These findings may be attributable to enhanced substrate arginine availability for polyamine synthesis via arginase. Conclusion: Arginine supplementation increased intestinal polyamine synthesis. Therefore, it can be indicated under stressful conditions in order to preserve one of the key elements of the intestinal structure.

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59 - Education and Implementation of an ICU Feeding Protocol Decreases the Delay of Feeding Critically Ill Patients Elizabeth Pash1, Renee Welsh1, Christy Hummel1, Arlene Escuro1, Diane Nowak1, Denise Cole1 1Cleveland Clinic, Mansfield, MA

Introduction: ASPEN/SCCM Critical Care Guidelines suggest enteral feeding start within 24-48 hours following admission or the onset of a hyper metabolic insult, advancing toward goal rate within 48-72 hours. Incidence of prolonged NPO status in the critical ill population may have adverse outcomes, affecting quality of care. Early intervention is a proactive therapy that influences patient treatment, recovery and outcome. Methods: This prospective study tested the hypothesis: Implementation of an ICU early enteral feeding protocol with direct ICU team education will decrease the delay of feeding the critically ill patient. Initial data was collected from 5 ICUs with 158 total beds that included the coronary intensive care unit (CICU), cardiovascular intensive care unit (CVICU), medical intensive care unit (MICU), neurology/neurosurgery intensive care unit (NICU), and the surgical intensive care unit (SICU) during a three week period to determine the number of patients who were not receiving any nutrition support and had been NPO or on a clear liquid diet order greater than 3 days compared to the total number of critically ill patients admitted to the ICU during that time frame. An early feeding protocol developed by dietitians was then implemented with educational sessions conducted across the ICU’s over a three month period. This effort was led by the ICU dietitians who instructed ICU medical and nursing staff about the importance of early enteral feeding, techniques used to achieve early feeding as well as the results of the initial NPO/clear liquid data collection. Following completion of the education sessions, data was collected from the same ICUs over a three week time frame regarding NPO/clear liquid status of patients compared with the pre-education results. Results: A total of 130 out of 676 total ICU patients (19%) had NPO/clear liquid diet orders greater than 3 days in the pre- early feeding protocol implementation phase. Post-education, 84 of 518 total ICU patients (16%) had NPO/clear liquid diet orders > 3 days resulting in a 35% reduction of prolonged NPO/Clear liquid status. Hemodynamic instability, pre-operation/post-operation, unknown, and “other” were common reasons for NPO/clear liquid orders greater than 3 days. The most common “other” reason for NPO/clear liquid was lack of enteral feeding access. Similar reasons for NPO/clear liquid status were the same in both before and after implementation of the early enteral feeding protocol. Conclusions: Implementing a feeding protocol and providing targeted education to a multidisciplinary ICU team can facilitate initiation of feeding the ICU patient. However, further efforts are planned to address common reasons for continued delay. These include training a dedicated enteral access team in each ICU in attempt to obtain timely enteral access, increasing dietitian staffing in the ICU, and online training modules for nursing, residents, fellows, and staff physicians.

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60 - Reduction of peri-operative fasting time enhanced early recovery after open colon surgery in colon cancer patients. Nobuya Ishibashi1, Naotaka Murakami1, Shinji Uchida1, Tetsushi Kinugasa1, Yoshito Akagi1, Kazuo Shirouzu1, Yutaka Ogata1 1Department of Surgery, Kurume University School of Medicine, Fukuoka, Japan

Aim: Early recovery after surgery (ERAS) program has been recommended by ESPEN guide line. One of the important factor is reducing peri-operative fasting time. We proposed to investigate the effect of reduction of peri-operative fasting time after open colon cancer surgery. Methods: Colon cancer patient who were planed to receive surgical treatment in Kurume University Hospital, were enrolled in this study. Patients (n=30) were allow to eat liquid diet until midnight before surgery (Short fasting group). Previously treated patients (n=30, control group) who were received conventional our program, in which patients were received mechanical bowel preparation using with Polyethylene glycol and were starved from the morning one day before surgery, were randomly selected as becoming same characteristics as Short fasting group patients. Inflammatory responses, incidence of surgical site infection (SSI), removal time of naso-gastric tube, time to start drinking water, time to start eating, time until stopping the intra-venous fluid administration, total amount of intra-venous fluid received, time until eating enough food, time of hospital stay after surgery, and incidence of complication were evaluated. Studentfs t-test and Mann-Whitney test and chi-square test were employed for statistical significance. Values of p<0.05 were considered statistically significant. Results: There was no difference in inflammatory responses between groups. SSI could be evaluated 3.3 % in Short fasting group, while control group had shown about 10 % incidence of SSI (p<0.004). Time until eating normal food , time to start drinking, time to stop intra-venous fluid administration and time of hospital stay after surgery were significantly shorter in Short fasting group than in control group (p<0.05). Total amount of fluid administration was also significantly reduced in Short fasting group (p<0.01). An incidence of complication was significantly higher in control group (23.3%) than in Short fasting group (10%) (p<0.02). Conclusion: Reduction of peri-operative fasting time could reduce an incidence of complication and shorten hospital stay, suggesting that fasting time is an important factor for recovery after open colon surgery in colon cancer patients.

Encore: presented at the 2010 Cincinnati Surgical Society Resident Research Competition. 61 - Effect of IV Glutamine supplementation on clinical outcome in critically ill patients: A randomized pilot study Elliot Fegelman1, Farshad Farnejad1, Hiral Patel1, Dina Dakar1, Wallace Sergent1, 1Jewish Hospital / Mercy Health Partners, Cincinnati, OH

Recent data suggest reduce mortality, and better clinical outcomes when intravenous glutamine given during critical illness. Glutamine is the most abundant amino acid in the blood and the free amino acid pool in the body. During critical illness glutamine utilization by the immune system, gut mucosa and other tissues exceed endogenous production and plasma glutamine concentrations decrease, which may contribute to cellular dysfunction and increase nosocomial infection risk and mortality. In addition, the majority of glutamine is synthesized in skeletal muscle, and due to skeletal muscle wasting during severe illness the body is unable to produce sufficient amounts of glutamine where supplementation is warranted. Animal and human data suggests that glutamine supplementation enhances the up regulation of cyptoprotective molecules in blood and tissues, as well as improved epithelial barrier defense and immune cell number and function. We proposed a randomized prospective trial of parenteral glutamine supplementation in selected critically ill patients. The objective was to evaluate the effectiveness of Glutamine supplementation on patient outcomes. Method: Patients randomized to one of the two groups (glutamine and control). One group received 25 grams of IV glutamine for seven days. Blood was drawn for lab test at baseline and eight day after completion of IV glutamine. Serum glutathione levels a marker of physiologic ability of the body to fight oxidative stress was considered as primary outcome in this study. The interim analysis is carried out to assess the trend in efficacy or futility. Percent relative change from baseline was used to describe the effect of treatment in each group separately. Results: Twenty patients (11 in IV glutamine and 9 patients in control group) were included in the interim analysis. Out of 11 patients, 8 (73%) had improved serum glutathione levels in IV glutamine group whereas only 2 (22%) of 9 had elevated serum glutathione levels in control group. Mean percent improvement in serum glutathione

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levels was 11% in IV glutamine group whereas mean reduction of 1%was found in control group. After adjusting for the affect of APACHE score, 10% improvement in serum glutathione levels in IV glutamine group and 10% reduction in control group were found. An additional 40 (20) patients would be needed for significant differences in serum glutathione levels at 1% (5%) level respectively with more than 80% power. Conclusions: There is an efficacious trend of IV glutamine supplementation on serum glutathione levels after a seven day course in this interim analysis.

62 - Comparison of Measured and Estimated Energy Expenditure In Mechanically Ventilated Pediatric Intensive Care Patients Elizabeth Tenison1, Michael Bandy1, Karen Shambaugh1, Ronald Dechert1 1University of Michigan Health System, Ann Arbor, MI

Introduction:Nutritional support of the critically ill, pediatric patient offers many challenges to nutritionist and healthcare teams alike. Among those challenges is the determination of nutritional need. There are two basic approaches commonly employed to determine individual caloric requirements; measured via indirect calorimeter or estimated via standardized equations. Although both techniques have advantages and disadvantages, little information is currently available that compare the two techniques in this specific population. The purpose of this study is to compare results obtained by both techniques as part of a quality assurance project in our PICU. Methods: Thirty mechanically ventilated pediatric ICU patients were included in our comparison. Estimated energy requirements were determined by a clinical nutritionist prior to determining measured energy expenditure (using the Vmax metabolic cart, CareFusion, Yorba Linda, CA) via indirect calorimetry. Comparison of these two measurement techniques of caloric expenditure were performed using the technique described by Bland and Ultman. Results: The thirty patients included in this analysis ranged in age from 1 year of age to 18 years of age. All were mechanically ventilated with a variety of modalities selected by the attending service per their (medical team) standard of care. The set FiO2 ranged from 0.30 to 0.60on these patients at the time of performing the indirect calorimetry assessment, with a minute ventilation ranging from 1.5 to 33.6 Liters/minute. The median difference (kcals/24 hours) between the two measurements (EEE-MEE) was 318 kcals/24 hours with MEE generally demonstrating lower caloric needs than EEE. There appears to be closer agreement between the two results as age increases. Conclusions: Indirect calorimetry has been advocated for determining caloric needs in mechanically ventilated populations. This study demonstrates substantial differences between caloric expenditure determined by standardized equations (EEE) and measured via indirect calorimetry (MEE). It is beyond the scope of this study to attempt to determine if either method should be adopted as standard of care in energy expenditure assessment in the critically ill, mechanically ventilated, pediatric population. Further testing is warranted to illuminated the potential causes of the observed differences and the impact on nutritional management practices and patient outcomes.

63 - The antimicrobial resistance of nosocomial Enterococcus faecium infection in patients received probiotics containing Enterococcus faecium Jeongwook Kim1, Young Sun Kim2 1Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea; 2Seoul National University Hospital, Healthcare System GangNam Center, Healthcare Research Institute, Seoul, Korea

Background: Probiotics are live microorganisms which when administered in adequate amounts confer a health benefit on the host. Bacteria used for probiotics are Lactobacillus, Bifidobacterum, Enterococcus, Bacillus and Clostridium in Korea. Enterococci form part of the lactic acid bacteria of importance in foods and used as human probiotics. However, they are important nosocomial pathogens, such as vancomycin-resistant enterococcus in nosocomial infection. Therefore, we investigated the antimicrobial resistance of Enterococcus faecium (E. faecium) nosocomial infection in patients received probiotics containing E. faecium. Methods: We analyzed 234 patients with E. faecium infection who were hospitalized in Chung-Ang Univerisity Hosptial. Results: Infection developed in 171 patients during hospitaliztion and 22 (12.6%) of these received probiotics E. faecium before infection. 71 (41.5%) of the171 patients had urinary tract infection; 44 (25.7%) had biliary tract infection; 19 (11.1%) had infection of blood; 15 (8.8%) had infection of wound and bedsore; 11 (6.4%) had hemo-bag infection; 6 (3.5%) had intravenous hyperalimentation

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infection; 3 (1.8%) each had pneumonia, vaginal discharge and spontaneous bacterial peritonitis. There was no difference in source of infection between group with probiotics and group without probiotics. Frequency of antimicrobial resistance to ampicillin, chloramphenicol, ciprofloxacin, gentamycin, streptomycin, vancomycin and teicoplanin and use of these antibiotics were no difference between group with probiotics and group without probiotics. Conclusion: Probiotics containing E. faecium did not increase antimicrobial resistance of nosocomial infection by E. faecium.

64 - Protein and Energy Intake and Associations with Mortality in Intensive Care Patients Negar Esmailzadeh1, Matilde Jo Allingstrup2, Anne Wilkens Knudsen2, Kurt Espersen, Tom Hartvig Jensen, Jørgen Wiis3, Jens Kondrup2 1Nutricia A7S, Allerød; 2Copenhagen, Denmark

Rationale: Adequacy of nutritional support in intensive care patients is still a matter of investigation. This prospective observational cohort study aimed to relate mortality to provision, measured requirements and balances for energy and protein in ICU patients. Methods: 113 patients were consecutively selected in the ICU of a tertiary referral hospital. REE was determined by indirect calorimetry and protein requirement was determined by using 24 h urea. Initial recordings were ICU admission diagnosis, co-morbidity, age, sex, weight, height and APACHE II score within 24 h of ICU admission. All patients were followed until discharge or death. Results: Patients were ranked into three groups according to decreasing protein&AA provision, Low (n=37), Medium (n=38), and High (n=38). Mean provision of Protein&AA (g/d, mean ± SD) was 54 ± 18, 84 ± 8 and 115 ± 14, respectively. Hazard of death was significantly related to provision of protein&AA, being higher in the Low group (Mantel log rank from Kaplan-Meier survival analysis: p = 0.03; Log-rank test for trend between the three groups: p = 0.01). Cox regression analyses showed a significantly decreased hazard ratio of death with increased protein&AA provision, also when adjusted for baseline prognostic variables (APACHE II, SOFA scores and age). The total ICU mortality did not differ significantly between the three subgroups 10(27%), 10(26%) and 6(16%) in the low, medium and high protein&AA groups, respectively. Provision of energy, measured resting energy expenditure or energy and nitrogen balance were not related to mortality. Conclusion: In these ICU patients, provision of protein was related to hazard of mortality. This was not the case for provision of energy or measured resting energy expenditure, or energy or nitrogen balances. Disclosure of Interest: None Declared

65 - Enteral Nutrition using Immuno-Modulating Diet in Perioperative Patients of Esophageal Cancer: A Randomized Controlled Study Michitaka Suzuki1, Haruhiro Inoue1, Shin-ei Kudo1 1Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Kanagawa, Japan

Background: We conducted a prospective randomized study to examine the efficacy of immuno-modulating diet(IMD) in perioperative patients of esophageal cancer. This IMD(MHN-02) is enriched with whey-hydrolyzed peptide, prebiotics and anti oxidizing vitamines and has low glycemic index. Methods: 24 patients of esophageal cancer were randomly assigned to IMD group (n=12) or standard group(n=12). Before operation, they drank 600ml feeding per day for 5 days. From POD2, feeding was administrated by jejunostomy tube. The laboratory data and the incidence of complications were compared between the two groups. Results: There were no significant difference in body temperature, CRP, WBC, lymphocytes, IL-6, TNF-alpha. SIRS durations were 1.9days in IMD group and 3.1days in standard group, but no significant difference existed. Albmin in POD4 is significantly higher in IMD group compared with standard group. Retinol binding protein is higher in every postoperative day in IMD group, but no significant difference existed. Blood glucose levels in POD1,3,5,9 are significantly lower in IMD group compared with standard group. Major complications in IMD group were two anastomotic leakage, one pneumonia, while in standard group two leakage, one wound infection and one pneumonia. Conclusions: This IMD is useful in postoperative blood glucose control. Albmin and Retinol binding protein level suggest this IMD sustain nutritional state well. Effect on anti-inflammatory action and postoperative complications are unclear. To confirm these findings, it is needed to add more cases and continue this study.

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66 - A Simple Technique for Management of Hyperkalemia with Enteral Feeding David HIll1, Rex Brown1, George Maish, III1, Gayle Minard1, Roland Dickerson1 1University of Tennessee, Memphis, TN

Introduction: Hyperkalemia (serum potassium concentration > 5mEq/L) has been reported to occur in up to 40% of enterally fed patients. This prevalence is most likely attributable to pharmacotherapy or renal dysfunction with concurrent enteral feeding. Methods: Three critically ill trauma patients receiving enteral nutrition therapy with hyperkalemia associated with heparin pharmacotherapy and concurrent enteral feeding were identified. Exogenous sources of potassium outside of the enteral feeding formula, if present, were previously eliminated. The enteral formula was changed to a 2 kcal/mL enteral formula which was diluted with water to ½ strength. The modified enteral formula was prepared in a clean environment in the pharmacy. Additional liquid protein supplements were given by the feeding tube to meet goal intakes. Results: Patient data and a comparison of feeding regimens are given in Table 1. Heparin therapy continued and renal function did not change during the observation period. Daily potassium intake was substantially reduced without compromising nutrient or fluid intake. Serum potassium concentrations significantly decreased while receiving the modified (reduced potassium content) formula (Figure 1). Serum concentration changes were not attributable to changes in daily arterial pH, insulin intake, or drainage/diarrheal losses. Conclusion: This simple enteral feeding formula modification resulted in a substantially reduced potassium intake and decreased serum potassium concentration for hyperkalemic patients without compromising nutrient or fluid intake.

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Figure 1. Potassium intake and serum potassium concentration changes.

67 - Thiamine and lactate in patients admitted to emergency services in Manaus, Amazon, Brazil. Isolda Prado de Negreiros Nogueira Maduro1, Luiz Fernando Junges Filho1, Luciano Pereira do Nascimento Borges1, Jane Menezes1, Henri Horstmann1 1Amazon State University, Manaus, Brazil

Thiamine and lactate in patients admitted to emergency services in Manaus, Amazon, Brazil. Introduction: Thiamin is involved in several metabolic processes and total organic reserves are approximately 30mg, with a half-life of 9-18 days. The primary sources are meats, vegetables, whole grains and nuts. Thiamine deficiency is more common in cultures where the staple diet is polish rice. Photosensitive, heat denatures and destroys up to pH> 8 and can be inactivated by thiaminase-rich foods (tea, coffee, raw fish, shellfish). Its decline is caused to low intake, alcohol consumption and chronic diseases. This is a clinical study to evaluate the intake of thiamine in patients from the Emergency Room, its relation to the normal feed intake, and indirect measures of activity (serum lactate). Methods: In a cross-sectional study, 15 patients treated at the Emergency Room (ERG) underwent collection of blood lactate (changed values above 2.0 mMol / L), arterial blood gases (except for lactate analysis was ≤ 70 mmHg PO2), usual food recall (analysis by software NutWin), verified the underlying disease, symptoms, nosographic data, medications, food intake and alcohol intake. The control group (CG), 22 healthy, young adults, students of health’s area, no underlying disease reported was submitted by the survey and the usual food recall. Excluding those using multivitamins or thiamine, respiratory failure, acute coronary insufficiency, unconscious, pregnancy, indigenous ethnicity, younger than 18 years. Results: Group ER (age 51.3 ± 16.3 years), the adequacy of thiamine to food intake (DRI) was 60.48 ± 23.6%, without significant differences with the CG (age 22.4 ± 17 years) 69.13 ± 44.4%. There was significant correlation between lactate and thiamine (r = -0.60) and between fat intake and thiamin (r = 0.72) but not total energy, carbohydrates and protein and thiamin. The food intake of the participants (ERG and CG) equipped with a higher frequency of fish, chicken, flour and white rice. Conclusions: The data suggest a low intake of thiamine, and lactate levels as a usable, compared with symptoms suggestive of thiamine deficiency. Project supported in part by Foundation to Support Research in the State of Amazon (FAPEAM).

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68 - Efficacy of an enteral feeding protocol in patients admitted in a private intensive care unit Luciana Rahal1, Diogo Toledo1, Simone Gomes1, André Nunes1 1São Luiz Hospital, São Paulo, Brazil

Introduction: Protein deficiency is a major problem in hypercatabolic patients in intensive care units. Early enteral nutrition has proved to be beneficial, with positive effects on septic complications and has been shown to improve outcome. Enteral nutrition guarantees the preservation of gut mass and prevents increased gut permeability to bacteria and toxins. Moreover, the gut associated lymphoid tissue is better maintained when enteral nutrition is early started. The most important goal of nutritional therapy in critical illness is to protect lean tissue mass and function. Lean tissue loss is unavoidable in septic and trauma patients and the rate and the magnitude of the loss are greater when the injury is severe and persistent. The purpose of nutritional therapy in this setting is to minimize ongoing lean tissue loss through appropriate provision of energy and amino acids. Setting: a 37 bed general ICU in a 434 bed private hospital. Objectives: Evaluate the efficacy of an enteral feeding protocol in ICU patients. Methods: Between April and August 2011, 119 patients admitted to ICU receiving enteral feeding for at least 48 hours were included. The caloric goal for these patients was 25 kilocalories per kg body weight per day and the protein intake goal was1.2g per kg body weight per day. The goals should be achieved in three days. Data are expressed as MEAN. Results: From the total group 108 patients (91%) achieved the caloric goal. 79 patients (73%) achieved the caloric goal in less than 3 days and the protein intake goal was achieved in 76 patients (70%). In this subgroup mean age was 75 years old;mean APACHE IV was 64 and mean lenght of intensive care unit stay was 10days,45% were male and 55%female, 12% were admitted for surgical reasons and 88% for clinical diseases. Nutritional data are shown in tables 1 and 2. Conclusions: The enteral feeding protocol was considered efficient once 91% of our patients achieved the caloric goal and from these 70% achieved the protein intake goal.

69 - Clinical benefits of omega 3 fatty acids, derived from fish oil in severe burned patients Serrana Tihista1, Estrella Echavarria1 1Centro Nacional De Quemados (Cenaque), Montevideo, Uruguay

Immune – enhancing diets have several pharmaconutrients, which increase costs and make difficult to know their specific effects or their proper dosing. The literature in this area has been criticized for the heterogeneity of studies with variety of patients and diets. The purpose of this prospective, double – blind study was to evaluate in severe burned patients, the effect of ω- 3 fatty acids, derived from fish oil, as the only pharmaconutrients in the diet Methodology: From 2006 to 2010, patients admitted with burned surface area (BSA) ≥ 15%, inhalation injury and enteral nutrition were randomized into 2 groups. Patients in group 1 received the modular tube feeding in routine use and created in our center. This diet contains

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62 % of total calories as carbohydrates, 20% as protein. It is low fat, 18% of total calories, as fat derived from sunflower oil, rich in ω- 6 fatty acids. The only difference in tube feeding of patients in group 2, was the oil, the diet had half, sunflower oil, half fish oil. Per 1000 Kcal. ω- 3 fatty acids, dropped from 0.3 to 3.62 g and 12 to 6.34 g ω- 6 fatty acids. The cost increased half dollar. We analyzed first 14 days even though intervention and follow-up lasted until discharge from hospital. For comparison of variables, non parametric tests were used. Statistical significance was considered when p ≤ 0.05 The characteristics of patients and nutritional support received are presented in Table 1. Patients did not differ with respect APACHE II, energy expenditure, beginning of nutrition, amounts of calories and protein received. Mayor outcomes for the two groups are listed in Table 2. It was less frequent in group 2, without statistical significance, pneumonia, bacteremia, and respiratory infection. Together, wound infection and colonization are greater in group 2. Sepsis was significantly less frequent in group 2. Total number of ventilator days, was in group 1, 27 days, while in group 2, 21 days. In the first two week, 8 patients were weaned from the ventilator (26%) in group 1, 14 (44%) in group 2, p 0.13. The status at discharge was 9 and 11 deaths, group 1and 2 respectively. Conclusions: We studied burned patients with similar characteristics; the sample size is greater than others studies. The diets of patients were identical. The only one difference was the pharmaconutrient that we were studying, so we can compare effects of this specific component in outcome of patients. Clinical benefit was obtained only increasing, ω- 3 fatty acids. Infectious complications were less frequent, sepsis was significantly lower. Lasting of mechanical ventilatory assistance was shorter and there were more patients weaned from the ventilator.

CLINICAL NUTRITION WEEK 2012 POSTERS: ENTERAL NUTRITION 70 - Nasogastric Tube Clogging: What Are the Causes and What are the Answers. A Bench Top Analysis Mark DeLegge1, Janice Penrod2, Lisa Kitko3, Gabriela Hernandez Meza4, Katherine Mitchell4, Maureen Mulvihill4 1Medical University of South Carolina, Charleston, SC; 2Center for Nursing Research Pennsylvania State

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University, University Park, PA; 3Pennsylvania State University, University Park, PA; 4Actuated Medical, Bellefonte, PA

Introduction: Nasogastric (NG) tube clogging is a burden on care givers and patients. The goal of this investigation was to evaluate a) the effect of NG tube properties and b) the effect of infused material properties on the development of tube occlusion. Separately an evaluation of 3 de-clogging strategies was performed. Methods: A prospective, observational analysis of 25 various NG tube sizes, composite materials and tube shaping (a curve was made) were evaluated for their impact on tube occlusion. Substances common to enteral feeding or representative of materials commonly placed through NG tubes were injected into tubes on the bench top. At various time sequences tubes were analyzed for clogging by attempting to inject water into the tube using an enteral syringe. Occluded tubes were analyzed. Separately, in-vitro created tube occlusions were subjected to 3 de-clogging methods; 1. Water 2. A commercial de-clogging formulation/system 3. A mechanical de-clogging system (AMI NG-Clear). Tube occlusion resolution success and time to tube clearance were recorded. Results: Smaller tubes clogged more frequently than larger tubes. Tubes that have “funneling” profiles (larger at the proximal end and narrower at the distal end) were more likely to clog. Polyurethane tubes were less prone to clogging than silicone tubes. Curved sections of NG tubes (simulating entry into the nostril or through the hypopharynx) were more prone to clogging Tube feeding occlusion often formed from the compaction of materials on top of an initial partial tube obstruction. Clogging was more likely to occur; a) during interrupted feeding as the formula thickens and dries on the walls or b) chemical and particulate interaction when medications are not thoroughly flushed away before feeding is resumed. 5 tubes with occlusions were treated with each de-clogging method. Clearing of NG tube occlusion was 60% successful when plain water was used. Water dwelled in the tube and high levels of pressure on an enteral syringe were employed. Average time to clearance was 7 min 8 sec of active nursing effort and 23 minutes of overall procedure time (including dwell times). A commercially available de-clogging formulation/system had an 80% success rate with an average time to clearance of 9 min 8 sec of active nursing time and 84 minutes overall time (including dwell times). The mechanical de-clogging device had a tube occlusion clearance success rate of 100% with an average active nursing and total time of 3 min 27 sec. Conclusions: Reducing the occurrence of occlusions in NG tubes improves patient and clinician experience. Several factors impacted tube clogging rates including tube inner diameter (size), profile (bends in the tube) and tube material composition. In addition, the type of materials introduced into the feeding tube and the methodology/order for introducing materials also had an impact on tube occlusion. There was a wide variability in the success of tube occlusion clearance, time to clearance and nursing time required when various tube occlusion applications were utilized. The mechanical de-clogging device had a very high success rate of tube occlusion clearance over a short period of time with the least amount of nursing time expended.

71 - Use of Technology to Provide Faster and More Accurate Care to Home Tube Feeding Patients Cynthia Reddick1, Cara Larimer2, Jodi Nix-Nelson3 1Apria Healthcare, Sacramento, CA, 2Apria Healthcare, Santa Rosa, CA, 3Apria Healthcare, Littleton, CO

Introduction: Home enteral nutrition (HEN) can improve patient quality of life, but it also brings a variety of questions and issues that may arise with therapy provided outside the clinical setting. A national home tube feeding company handles these issues by triaging patient questions and complications to the clinical team, led by registered dietitians (RDs). Cases are then either triaged to a field dietitian to provide an assessment in the home, or patients or their caregivers are asked to email or text pictures of the device or tube issue to the dietitian to assess remotely. Currently available technology such as email and texting of visual images has become a valuable resource in providing HEN patients effective and efficient clinical care and device troubleshooting. The use of technology has resulted in quicker resolution with device issues, more accurate diagnoses, and continuity of care with primary care providers and re-enforcement of patient education to ensure proper technique and self-care as demonstrated in the cases below. Case Reports: Patient 1: On post-op day six, this patient complained of severe pain with ongoing drainage from a stoma site. An RD confirmed this and reported it to the patient’s physician with a picture that showed that the tube was placed too tightly. The patient was seen by the physician the next day and the bolster was adjusted, allowing the cyst to drain and the pain to resolve. This resulted in a healthy stoma site.

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Patient 2: On post-discharge day one, this patient complained of a leaky tube and a big mess with every feeding. The patient’s caregiver contacted the HEN provider’s RD and provided a camera phone picture taken by the patient’s wife. This picture revealed that the ancillary medication port cap was open during feeds, causing the “leaky tube.” The RD advised the patient’s wife to close the medication port cap, which resolved the issue. A subsequent home visit was made by the RD to reinforce that tube site care instruction was followed. Patient 3: At midnight on post-discharge day one, this patient complained of a malfunctioning feeding pump. A new pump was provided; however, the patient called again with a complaint of a malfunctioning pump. A picture of the feeding tube was requested later that morning and was evaluated by the home tube feeding RD. The picture revealed that the patient’s access device, an IV catheter, was inadvertently placed as a feeding tube. The pump alarmed appropriately due to a flow error related to the small diameter of the device. The patient was instructed to return to the physician for proper feeding tube placement. Conclusions: Most patients or caregivers seem to have access to email and/or a camera on their phone, which allows remote transmission of data to a clinician. Using visual images can assist in providing timely and accurate solutions to the HEN patient population, whether they live local to medical care or in remote areas with limited healthcare access. Expertise in HEN and the related access devices is required to answer the complex challenges that arise in the home setting. Successful management of the HEN patient requires agile, accurate, and expedient solutions to everyday feeding and device issues, including the use of technology.

Patient 1: Bolster Too Tight

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Patient 2: My Tube is Leaking

72 - So You Think You Can Advance? Ability to Return to an Oral Diet after Initiation of Home Enteral Therapy Allyson Stout1, Jodi Carr1, Steve McGill1, Kathryn Cathcart1, Jacklyn Vaughn1 1Walgreens Infusion Services, Louisville, KY

Introduction Provision of enteral nutrition therapy in the home is a viable option for meeting the nutrient needs of patients unable to do so by oral intake alone. The purpose of this review was to describe home enteral nutrition patient demographics and primary outcomes including duration of therapy and ability to return to oral diet. Methods A retrospective review of a national home infusion company’s (single-location) enteral nutrition patients, admitted within a twelve month period, was completed. All patients receiving enteral nutrition were reviewed. Patients were excluded from the monitor if they were less than eighteen years of age or receiving home enteral nutrition when admitted to this home infusion company’s service. Patient data collected and evaluated included primary diagnosis, anthropometrics, enteral access, route of administration, formula type, duration of therapy, and end of therapy ability to return to an oral diet. Results One hundred twenty-three patients met inclusion criteria, of which 51.2% were female with mean age of 62.1 years (range 25 to 98). Cancer was the most common diagnosis for therapy (22.8 % for head and neck, 17.9% for gastrointestinal (GI) and 2.1% for other cancers), followed by dysphagia (13%), GI dysfunction (12.2%) and cerebrovascular events (10.6%). Mean length of enteral therapy was 177.8 days +/- 219.0 days. The greatest percentage of patients (37.5%) were able to return to an oral diet in a mean length of 83.2+/-86.3 days, while 13.8% remained on therapy eighteen months (ongoing) after initiation. Twenty-seven percent of patients expired or withdrew care for end of life, 13.8% did not return to service after admission to an inpatient facility and 8.1% were transitioned to another provider or lost to follow up. Gastrostomy tubes were the primary route of administration (66.7%) with jejunostomy and gastrojejunostomy tubes comprising 20.3% and 5.7% respectively. Of short term access routes, nasojejunal tubes were slightly more common (4.9%) than nasogastric tubes (2.4%). Sole pump, gravity, or syringe bolus route of administration represented 62.6%, 0.01% and 27.6% of the population respectively, while 8.9% utilized multiple delivery methods over the course of therapy. The majority (68.3%) of patients were able to complete therapy with the sole use of a standard enteral formula, while 22% utilized specialty formulas for the entire duration. Mean BMI for all patients at initiation of enteral therapy was 22.6 +/- 6.5 and was unchanged at completion of review (22.2+/-6.2). Forty-five patients

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(36.6%) had a BMI ≤ 19 at start of therapy and did have a mean increase from 16.6 to 17.4. Fifteen patients (12.2%) had a BMI ≥ 30 at start of therapy and had a mean decrease from 34.8 to 33.1. Conclusions Although enteral nutrition can sustain patients for life, greater than one third of those initiating therapy in the home setting are able to return to an oral diet in less than sixteen months. Syringe bolus of a standard enteral formula via gastrostomy tube is the primary means of enteral nutrition delivery in the home. Maintenance or the progression toward weight goals is observed, but may not be achieved due to the relatively short duration of therapy. Chronic disease and/or events resulting in permanent gastrointestinal dysfunction are suggested reasons why patients are not able to advance to an oral diet after initiation of home enteral nutrition.

73 - Gastrostomy and Jejunostomy Tube Challenges and Resolutions in Patients Receiving Home Enteral Nutrition Angela Stephens1, Leanne Saxton1, Heather Marees1 1Apria Healthcare, Littleton, CO

Introduction: Little data exists regarding patients receiving tube feedings in the home setting. Once transitioned to the home, patients have few healthcare professionals to help with tube feeding intolerance, tube site concerns, or tube connection issues. Patients contact physicians first when patients may have resources within the home health agency that is providing care. Methods: Patients of a national home healthcare company were surveyed regarding questions about their tube and their tube feeding in the home. Included in the survey were patients residing in the states of Arizona, New Mexico, Utah, Nevada, Idaho, Washington, Oregon, Alaska and California who received enteral supplies from July to August of 2011. Each patient or caregiver was asked a set of clinical questions to determine tolerance of the tube feeding, as well as questions about tube patency and the care and condition of the access site. Additional follow-up questions were then asked when the patient or caregiver answered yes to the trigger questions. For example, if the patient had a tube feeding intolerance, the patient was asked if he or she thought it was related to the tube feedings, and what interventions were instituted to resolve the issue. Results: Of the 872 (712 tube-fed and 160 oral) patients surveyed, 77 (10.8%) reported nausea, vomiting, diarrhea, and/or abdominal pain during the last 90 days. Of those 77, only 26 believed the issue was related to their tube feedings. Of these 26 issues, 14 had been resolved in the last 3 months (20% resolved by change of formula, 28% resolved by medication changes, 4% resolved with use of probiotics, and 15% resolved by slowing down the feedings). Most patients reported that they contacted their doctors to help resolve the issue. Of the 9 patients who stated that their issues were unresolved, 4 spoke with an RD regarding their issue. Fifty-one (7.1%) patients stated they had tube site-related complaints such as clogging, leaking, or connections problems during the last 90 days. Of the 19 patients who had a clogged tube, 16 of them were able to get the tube unclogged. The most common method to unclog was the use of warm water. Twenty-five patients stated they had leaking problems. Most patients (40%) contacted their doctor regarding this issue. Nine patients received replacement pieces from the home healthcare company. Conclusion: In-home support for enteral patients may be limited. Most patients are not reaching out to their home healthcare company for help. Rather, most are contacting a physician. Ensuring at the start of care that patients are aware of the clinical support offered by the home health company will likely help identify complications and issues earlier and allow for prompt intervention and correction, and therefore compliance to regimen. Additionally, earlier correction will help promote better outcomes and likely save healthcare dollars by minimizing ongoing complications and averting further complications.

74 - The Impact of a Home Tube Feeding Provider's Registered Dietitian Anne Brettschneider1, Cynthia Reddick2 1Apria Healthcare, Littleton, CO, 2Apria Healthcare, Sacramento, CA

Introduction: In the homecare setting, there is limited data regarding the availability and efficacy of clinical programs that can effectively reduce the frequency of unplanned hospital readmission rates in home tube feeding (TF). We seek to show that providing clinical management in the home care setting and continuity of care during the transition to home promotes a reduction in hospital readmissions. Methods: A national homecare company provides a coordinated program that includes initial and ongoing clinical monitoring to optimize clinical outcomes and reduce the incidence of readmission to the hospital. As part of the

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program, patients are evaluated in the hospital, and prior to discharge, teaching about administering tube feeding in the home begins. For this study, data was collected on existing patients referred for home tube feeding, including tracking all nutrition support clinician-recommended changes to the prescribed feeding regimen. A nutrition screening tool was used to monitor patients’ tolerance of therapy and compliance, and helped identify any need for a referral to the registered dietitian. Hospital readmission rates and reasons for readmission were also tracked. Results: Approximately 3,173 patients were provided with TF formula, supplies, or both. Of these, 458 patients received a change in their TF prescription. Of the 458 prescription patient changes, 51% were initiated by the home TF provider’s registered dietitian, 44% by a physician in the outpatient setting, 3.7% as a result of a re-hospitalization and subsequent discharge, and 2% by an outpatient dietitian. Of the change orders initiated by the homecare company’s dietitian, 35% were for inadequate weight gain, 15% were for a decrease in TF due to undesirable weight gain, 28% were for an order clarification or for insurance purposes, 14% were due to intolerance issues, and 8% were deemed “other,” which included changes to accommodate flavor preferences, trial of a formula, or for bowel management. Examination of the formula intolerance reasons revealed that 58% of them were GI-related intolerances including diarrhea, constipation, and cramping. Finally, an evaluation of the readmission reasons reflects that 35% of patients had a planned procedure unrelated to TF, 29% were readmitted due to an unrelated disease, 12% were readmitted with GI complications unrelated to TF, 12% were readmitted due to stoma site or access device complications, and 6% graduated off of TF. Conclusions: Providing initial, ongoing education and clinical monitoring may result in lower readmission rates for home tube feeding patients. Careful and continual oversight identifies the need for tube feeding prescription changes in an effort to promote appropriate therapy utilization and to meet the patients’ goals of therapy. Without identification of the need for prescription changes, patients may receive inappropriate tube feeding regimens.

75 - Nasoenteric Feeding Tubes: Blind Placement is Suboptimal Michael Coronado1, Emlyn Carbajal1, Snorri Olafsson1, Emanuel Engracia1, Dottie Gibson1, Jenifer Pelster1, JiYung Jung1, Rebecca Estanque1, Kristine French1 1Loma Linda University Medical Center, Loma Linda, CA

Introduction The Nutritional Support Team (NST) nurses at Loma Linda University Medical Center (LLUMC) are responsible for nasoenteric feeding tube placement in the adult population. The original plan was to provide a backup for resident physicians encountering difficulty in placing the tubes. However, the NST nurses have, since 2003, become the primary staff called for feeding tube insertion. The placement process is done in accordance with an approved standardized clinical procedure for blind placement. In an effort to save our staff time, improve efficacy, and hopefully decrease hospital expense, we have investigated the possibility of using a new technique that involves placement with a magnetic tracking system. The purported advantages include accuracy in placement as well as cost savings by virtue of decreasing/eliminating radiological confirmation. Thus, in order to determine whether a transition to that method at LLUMC is justified, we reviewed our placement process for the period January 2010 through June 2011. Results There were 121 consults for a nasoenteric feeding tube placement. Thirty-two placements were not done due to patient/family refusal, cancellation of request, or other reasons. Three requests were changed to nasogastric tubes and 3 tubes were placed by the surgical team. Thus, 83 feeding tubes were placed as described below. The gastroenterology team, upon referral by NST, placed 13 of the tubes via endoscopy for the following reasons: difficult anatomy in 6 patients, abnormal coagulation in 3, cough in 2, hematemesis in 1 and patient refusal in 1. Thus 70 tubes were placed by the nurses. The procedure time by the NST nurses is approximately 15 min. After placement, we ordered radiological confirmation of location. The tip location is described in Table 1. A postpyloric tube placement was thus reached in 92% of cases by GI and in 60% by NST nurses. The jejunum was reached in 38% by GI and 17% by nurses. Conclusions The goal of the tube placement was to reach the jejunum. This was only attained in 17% of cases by NST nurses. They reached a postpyloric position in 60% of cases. Since the results are not optimal, we believe that there is room for improvement. We have looked at various systems to facilitate deeper placement. We are in the process of evaluating a magnetic tracking feeding tube placement system once it becomes non-luer lock compatible.

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76 - Enteral Nutrition in Intensive Care Unit: follow-up of six years Lucia Caruso1, Maria Carolina Vale1, Nágila Damasceno1, Francisco Soriano1 1University of São Paulo, Brazil

Introduction: Monitoring the adequacy of enteral nutrition is indispensable for severely ill patients, who presents metabolic response, generally featuring hypermetabolism and nutritional status depletion risk. Early and appropriate enteral nutritional therapy has been correlated with decrease in the incidence of infections and hospital stay length. Nutrition support interruptions are another cause of procedures inadequacies to be analyzed. To investigate the adequacy of Enteral Nutrition (EN) in Intensive Care Unit (ICU) and improve the quality of nutritional assistance this study was conducted. Methods: observational and prospective trial approved by Institution’s Ethics Committee, that was conducted since 2005 until 2010 in a teaching hospital. Patients above 18 years with exclusive EN for at least 72 hours were included. The percentage of adequacy for values of energy and protein calculated, prescribed and administered were analysed, as well as the causes for feeding interruptions, that were classified into intensive care unit extrinsic or intrinsic. Apache II were calculated for patients followed from 2008.The quality indicators proposed by the International Life Sciences Institute Brazil were applied. The statistical analysis used the confidence interval; Student t test; Mann-Whitney U(p≤ 0,05) and SPSS 15.0 data. Results: We followed up 178 patients, and the nutritional requirements were 24.9 (± 2.77) kcal/kg/day and 1.1 (± 0.15) g of protein/kg/day. There were an increase in the administered/prescribed ratio from 74% in 2005 to 87% in 2009 (statistically significant) and 82,3% in 2010. The most frequent causes of diet interruptions were problems with tube and gastrointestinal complications. Three quality indicators: frequency of individual estimative of energy and protein requirements (>80%); of loss of EN tube (<5%) and of diarrhea(<10%) were on target in the six years analyzed. The frequency of patients with fasting for more than 48h before EN was in line with the target (<20%), except in 2010 (22,6%), when the patients had the higher Apache II. The frequency of days with inadequate energy intake was on target (<20%) only in 2008. There was a trend toward the goal (< 10%) of the frequency of days with inadequate protein intake. These results reflected that is necessary to review the early introduction of EN protocol and that routine accompaniment of non-conformity must be done. Conclusion: Continuous monitoring of EN, with the application of quality indicators allows the review of the processes and development of strategies to correct inadequacies and establishment of education programs when necessary. This process is fundamental to Multidisciplinary Team to optimize the delivery and ensure nutritional practices in line with the guidelines.

77 - A Pilot Study of Fiber Containing Enteral Tube Feeds in Patients Receiving Head and Neck Radiotherapy Lisa Epp1, Adele Pattinson1, Yolanda Garces1, Lisa Lammert1, Heather Bamlet1, Vandana Nehra1 1Mayo Clinic Rochester, Rochester, MN

Background: It is well known that a large percentage of patients receiving concurrent chemotherapy and radiation for head and neck (H&N) cancer develop the need for percutaneous endoscopic gastrostomy (PEG) tube feeding to meet nutrition and hydration needs. These patients are usually taking pain medication along with a stool softener and/or laxative. Currently, our standard of practice is to choose a fiber-free enteral tube feeding formula as to not worsen their constipation. Currently, there are no

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guidelines as to which patients are good candidates for fiber containing enteral tube feeding formulas. Methods: A pilot, single arm, observational study of patients at Mayo Clinic Rochester undergoing H&N radiation therapy were identified during routine clinical appointments for pre-feeding tube education. From January 2010 to June 2011 nineteen patients were enrolled. No patients canceled or dropped out of the study. Beginning four days after tube placement patients were expected to be at target tube feeds with a fiber containing formula and had bi-weekly face-to-face contact or phone call with a home enteral nutrition dietitian for two weeks. During this contact, dietitians recorded bowel movements using the Bristol Stool Chart (range: 1-7), pain medication use and stool softener/laxative use of the previous day and current day. Normal bowel movements were defined as being rated between 3-6 on the Bristol stool chart and having at least three bowel movements weekly. Results: After reviewing all the stool records, five patients (26%) had bowel movements that were in unfavorable categories (hard lumps or liquid) at some point during the study period. One of the five experienced diarrhea and four patients got constipated on the fiber containing formula. However, only one of these four patients was taking stool softeners as directed. No patients had to stop or change the fiber formula due to constipation. It was evident from the records that using Magnesium Hydroxide or Senna was the best way to prevent or manage constipation without getting diarrhea. Conclusions: Fiber containing enteral tube feeding formulas can be used in patients undergoing radiation therapy for head and neck cancer without significantly increasing constipation. Attention should be given to advising patients on consistent stool softener/laxative use.

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Caption Figure 2: Change in Stool Softener Use

78 - Barriers to Enteral Therapy Compliance in the Home Setting Valerie Chaube1, Katie Willman1 1Walgreens Infusion and Respiratory Services, Seattle, WA

Introduction: Malnourished patients have more medical complications and greater mortality than do patients with optimal nutrition status. Patients that have issues with nutrient absorption and/or swallowing dysfunctions frequently are placed on home enteral nutrition (HEN) therapy and in many cases are managed by a home infusion company. This patient population is a high-risk group that requires adequate monitoring to achieve desired outcomes. Patients receiving HEN may have decreased caloric and nutrient intakes due to not ordering and administering the prescribed amount of formula. Non-compliance to HEN therapy orders can cause negative outcomes for patients who are at risk for malnutrition. HEN patients face many challenges during the course of their therapy. The investigators in this study sought to identify reasons HEN patients were not compliant with enteral therapy. Methods: Physician orders for HEN were compared with patients’ order history to determine compliance. For the purposes of this study, non-compliance has been defined as a patient who did not accept their monthly order of enteral formula after two consecutive follow ups. After reviewing the data, 46 patients were found as being non-compliant with their HEN therapy as prescribed by their physician. Patients deemed non compliant were categorized based on their rational for not following their nutrition prescription (Figure 1). Results: Of the 46 patients in the study, 24 were excluded after further investigation determined that they had a valid reason for refusal. This was often due to increased oral intake and/or tube removal. The remaining 22 patients demonstrated non-compliance with HEN therapy. The largest category of non-compliance was patient or caregiver refusal at 30%, followed by clinical issues/changes at 15% and the smallest category of financial barriers at 7%. (Figure 2) Patient refusal involved psychological or social issues regarding tube feedings such as depression following diagnosis, poor prognosis or isolation from family and friends. Caregiver refusal was presented primarily by parents of children who chose to follow their own tube feeding regimen rather than observing MD orders or RD recommendations. The clinical issues/changes group consisted of patients who were unable to administer feedings based on physical problems or intolerance as well as tube access problems. Lastly, financial barriers resulted in non compliance for patients who were under-insured and not able to afford HEN. Conclusion: The results of this study revealed that the majority of patients that were non-compliant with HEN were due to patient or

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caregiver refusal. These cases are unique challenges for the home care clinician due to complex psychosocial issues. Home care clinicians closely monitor patients and are able to intervene to prevent many clinical issues from becoming reasons for non-compliance, however, potential for psychosocial issues should also be included in the overall care plan. Future studies should include larger samples, examine changes in compliance over time and disease progression. In conclusion, more in depth, frequent intervention by a multidisciplinary team of healthcare providers and more intensive training of patient and caregivers in regards to their nutritional needs may result in higher rates of compliance.

79 - Clinical Dietitian Interventions in Home Enteral Nutrition Recipients Renee Brunelle1 1Bioscrip Corporation, Pepperell, MA

Background: The hospitalized patient coming home on enteral therapy often experiences difficulty adapting to the home setting. These challenges may involve complications relating to feeding tolerance, mechanical issues with the feeding tube and/or pump, undesirable weight changes, and discrepancies related to physician feeding orders and insurance reimbursement. A clinical dietitian is instrumental in helping new and long term enteral feeding patients in the home setting deal with these issues. While many patients have access to an outpatient dietitian to help in this transition, many are not set up with this service during discharge planning, or the designated dietitian is not trained to answer the kind of questions that may arise after discharge. Our organization, a large home infusion company, provides

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telephonic access to nutrition support certified registered dietitians (CNSC). The dietitian completes an initial nutrition assessment on all new enteral patients, and may provide ongoing follow up per physician request and/or clinical judgment. Patients and caregivers are screened for nutritional complications monthly by service staff and can call the office to speak with their assigned dietitian any time they have concerns or questions. Purpose: To identify the reasons and types of patients needing dietitian intervention in order to better focus our organization’s clinical nutrition program. Method: A retrospective review of requested dietitian consults was done to determine the source and reason for the dietitian consult, the age and diagnosis of the patient needing a consult, and the percentage of consults that were for new patients (<90 days on service). Dietitian consults originated from many sources. During monthly reorder calls, trained non-clinical service staff used a scripted series of questions to determine tolerance to therapy. Patients that identified complications were transferred to their dietitian. Consults were also placed by medical staff, caregivers, and other sources. Data was collected for 10 months. Results: Of the average number of dietitian consults each month (n=66), most originated during the monthly reorder calls (60%). The most common reasons were unwanted weight changes (32%) and complications such as vomiting, diarrhea, constipation and tube occlusion (31%). Most patients needing consults were adults (62%), and cancer (35%) was the most common diagnosis. A high percentage (36%) of the dietitian consults generated was for patients new to home enteral therapy, on service for less than 3 months. In addition to these findings, data showed that the majority of dietitian consults resolved without unnecessary formula changes (64%), which often cause further intolerance issues and financial consequences due to formula wastage. Conclusions: We concluded that our current program of initial dietitian assessment and monthly review of tolerance by reorder staff has been successful at identifying patient problems that arise in the first few months of enteral therapy. Further research will help identify our highest risk patient populations and show additional evidence that early CNSC dietitian intervention and structured follow up benefits outcomes.

80 - A Retrospective Study of Bleeding during Surgery in Variant Introducer Technique of Percutaneous Endoscopic Gastrostomy for Tube Feeding Naohiro Washizawa1, Yoko Oshima1, Tatsuki Nanami1, Takashi Suzuki1, Yasuo Nagashima1, Satoshi Yajima1, Kunihiro Yamazaki1, Hideaki Shimada1, Hironori Kaneko1 1Toho University Medical Center Omori Hospital, Tokyo, Japan

Background : There are four techniques (pull, push, classical introducer, variant introducer) on percutaneous endoscopic gastrostomy (PEG). Variant introducer technique became popular recently as direct insertion through the abdominal wall in Japan. This method is useful because of being able to do with trans-nasal slim endoscope and to do without threading the catheter through pharynx, larynx and esophagus. On the other hand, gastro-abdominal fixation is necessary for safe procedure. But, this technique with a Direct Ideal PEG KitTM (Olympus Medical Systems co) is often said to have been bleeding. We examined the background with focusing on gastro-abdominal wall fixing stitch and intraoperative bleeding. Methods : Material and Methods. 305 patients underwent PEG with a Direct Ideal PEG KitTM from April 2006 until March 2011 in Toho University Medical Center Omori Hospital. One method of gastro-abdominal wall fixing stitch was chosen from four techniques as two stitches, three round stitches, three radial stitches and four round stitches. The correlation of number of bleeding cases and methods of gastro-abdominal wall fixing stitch was investigated. And the correlation of bleeding and usage history of anticoagulants was investigated. If it showed a small amount of blood lines or drop the mucous or skin bleeding after inserting the catheter, the bleeding was determined. Results : 87 patients showed bleeding as 28.5% of objects. Nobody showed bleeding in 9 patients with two stitches. 29 patients bled in 99 (29.3%) with three round stitches. 44 patients bled in 123 (35.8%) with three radial stitches and 9 patients bled in 48 (18.8%) with four round stitches and immediate removal two of all stitches. However, 5 patients showed bleeding in 26 (19.2%) with four round stitches and no immediate removal for the purpose of arresting hemorrhage. 66 patients had no usage history of anticoagulants in 87 bleeding cases. 7 cases with aspirin (100mg/day), 1 case with clopidogrel sulfate (75mg/day), 5 cases with cilostazol (100mg/day, including overlapping cases), 1 case with aspirin dominate 81mg and 10 cases with warfarin potassium showed bleeding. 6 cases needed to be additional suture but other 81 cases got complete hemostasis after compression for 3 to 10 minutes. Conclusions : The patients with three radial stitches indicated highest bleeding rate. These data show that even the patients who receive

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anticoagulants medication can undergo variant introducer technique in PEG with a Direct Ideal PEG KitTM (Olympus Medical Systems co) safely.

81 - Evaluation of a Protocol for Restoring Patency of Enteral Feeding Tubes Vanessa Kumpf1 1Vanderbilt University Medical Center, Nashville, TN

Background: Due to changes in the FDA approval of pancreatic enzyme replacement products, the product that had traditionally been used to unclog enteral feeding tubes was removed from the market. A new FDA-approved formulation of pancrelipase (Creon®) is currently available in a delayed-release capsule that contains enteric coated pellets. Data available evaluating its efficacy in unclogging feeding tubes is limited to anecdotal reports. A protocol involving the use of pancrelipase (Creon) mixed with sodium bicarbonate to unclog feeding tubes was approved by the Vanderbilt Medical Center P&T Committee in December 2010 and implemented in January 2011. Protocol: When Creon is ordered for unclogging the feeding tube, the following instructions are provided: 1. Flush the tube using warm water and moderate pressure. Use a 20 ml syringe that will fit on the feeding tube. Clamp for 5 minutes. Attempt to flush with tap water. If the tube fails to clear, proceed to step 2. 2. Open a Creon 12,000 capsule, crush the pellets and mix the contents with 5 ml of sodium bicarbonate injection. An acceptable alternative to sodium bicarbonate injection is to crush a sodium bicarbonate 325 mg tablet and mix with 5 ml warm tap water. Clamp for 10-30 minutes. Attempt to flush with tap water. Repeat x 1 if necessary. Methods: The computerized order entry screens were updated to incorporate the above protocol. Nursing education flyers were distributed to all adult nursing units. Over a 1-month period, all adult patients who received an order for Creon via feeding tube were evaluated for efficacy. Results: From 3/10/11 to 4/12/11, Creon via feeding tube was ordered on 27 occasions for 20 patients. Patients were located hospital-wide and not isolated to select areas. Of the 27 occurrences, Creon was not successful in restoring patency in 15 (56%), successful in 10 (37%), not determined in 2 (unable to evaluate prior to discharge), and not applicable in 1 (tube was kinked and not clogged). Of significance, 3 patients required replacement of their G/J-tube or J-tube in radiology due to the occlusion and resulted in delay of discharge for 2 of these patients. Six patients required replacement of their nasoenteric tube due to occlusion. At least one abdominal KUB was done after each replacement to verify appropriate position. Of note, the bedside nurse is using a 60mL catheter tip syringe for administration of the Creon/bicarb solution via PEG, G/J- or J-tubes as it is the only size available that will fit. Some expressed concern that it did not exert enough pressure to instill the solution into the tube. Conclusions: The use of Creon/bicarbonate solution for tube feeding occlusion was often not successful. Replacement of the feeding tube was required in a number of these patients. Alternative agents and/or methods for unclogging feeding tubes, such as the use of a smaller sized syringe or the use of a commercially available kit that contains an enzyme powder, may be warranted.

82 - Self Advanicng Post Pyloric Feedig Tube in Critically Ill CHildren Julie Khlevner1, Janice Antino2, Rahul Panesar1, Anupama Chawla1 1Stony Brook Children's Hospital, Stony Brook, NY; 2Stony Brook University Medical Center, Stony Brook, NY

Introduction: Nutrition requirements are increased in trauma patients in the Pediatric Intensive Care Unit (PICU). Early nutrition support is an integral part of the care of critically ill children. Early enteral feeding (EF) is associated with significant advantages over late EF or total parenteral nutrition (TPN). It improves nitrogen balance, and prevents bacterial translocation and gut mucosal atrophy. Adequate EF is often not achieved as gastric feeds are not tolerated and placing postpyloric feeding tubes can be difficult. Spontaneous transpyloric passage of standard feeding tubes after 24 hours is only in the order of 30% and does not seem to be affected by tip profile or weight added to the tip of the feeding tube. The Tiger2 self-advancing nasal jejunal feeding tube is a 14Fr polyurethane feeding tube with flaps that gently drag the catheter into the jejunum. Tiger2 tubes have been used in the adult population with great success but to our knowledge there have been no reports of its use in pediatric age group. Description: We present 7 critically ill patients 8-19 years old, admitted to PICU, in whom prolonged recovery, inability to tolerate gastric feeds or dependence on ventilator was predicted at the outset. Self advancing nasojejunal feeding

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tube was successfully placed on first try at the bedside in all of the seven patients within the first 24hrs without the use of promotility agents. Radiograph confirmed the tip of the tube in the 3rd portion of duodenum in all 7 patients. Percent of nutrition goal achieved within 48hrs of admission to the PICU was compared between the 7 critically ill Tiger2 tube patients and 7 patients who received nutrition via nasogastric route +/-TPN. Results: Comparison of nasogastric feeds +/-TPN vs. postpyloric feeds (Tiger2) showed that children with postpyloric feedings reached their nutritional goal much earlier (Table1) and did not require TPN. Conclusion: Tiger2 tube can be used effectively to establish early enteral nutrition in critically ill children.

83 - Delivery of Bolus Enteral Nutrition to Increase the Proportion of Calorie and Protein Intake in Hospitalized Patients Elizabeth Sims1, Diane Sowa1, Sarah Peterson1, Kathyrn Keim1, Christine Hartney1 1Rush University Medical Center, Chicago, IL

Introduction: Frequent enteral nutrition (EN) feeding interruptions due to tests, procedures, nursing practices and gastrointestinal complications can lead to patients only receiving 50-70% of their prescribed calories and protein. The purpose of this study was to compare the calorie and protein delivery and tolerance of continuous versus bolus EN in general medical/surgical patients to determine if bolus EN is associated with improved calorie and protein delivery. Methods: A retrospective chart review was conducted of medical records from general medical/surgical subjects over two time periods. Subjects received continuous EN from July 2008 through November 2008 and bolus EN from July 2010 through July 2011. Demographic information, calorie and protein delivery over days one through 10, and reasons for EN interruptions, including tube feeding complications such as feeding tolerance, were collected. Calorie and protein delivery was expressed as a percentage of the prescribed calorie and protein needs. Descriptive statistics were performed; chi-square test of association was utilized to determine differences in categorical variables and independent t-tests were utilized to test difference in continuous variables. Results: A total of 201 subjects were included in the analysis; 51 subjects received continuous EN and 150 subjects received bolus EN. Study groups were comparable in demographic and clinical characteristics with a proportion of ethnic and past medical history differing between groups (Table 1). More Whites, fewer African Americans, and fewer subjects with a history of cancer were in the continuous group compared to the bolus group (Table 1). The mean calorie prescription for the entire sample was 2030 ± 410 kcal/day. The average calorie prescriptions between groups were significantly different; 1862 ± 383 kcal/day and 2088 ± 405 kcal/day for the continuous and bolus groups, respectively. The mean protein prescription for the entire sample was 98 ± 25 grams/day. The average protein prescriptions between groups were not significantly different; 99 ± 32 grams/day and 97 ± 23 grams/day for the continuous and bolus groups, respectively. Subjects who received bolus EN feeding compared to those who received continuous EN feeding received a significantly higher percentage of prescribed calories (Figure 1). Subjects who received bolus EN feeding as compared to continuous EN feeding had a significantly higher percentage of prescribed protein on days one through six, eight and ten (Figure 2). There were no significant differences between groups in the reasons for EN interruptions and tube feeding complications. Conclusions: Results of this study showed bolus EN to be more effective in

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delivering the prescribed calories and protein to general medical/surgical subjects. Use of bolus EN in general medical/surgical subjects was not associated with increased tube feeding complications and may also improve subject outcome by providing a higher percentage of calorie and protein needs.

Caption Figure 1: Figure 1: Difference in percent calorie delivery for subjects receiving continuous verses

bolus enteral nutrition on days one through ten

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Caption Figure 2: Figure 2: Difference in percent protein delivery for subjects receiving continuous verses

bolus enteral nutrition on days one through ten 84 - Is Diarrhea Truly More Common Than Constipation after Percutaneous Endoscopic Gastrostomy Creation in The Elderly Patients and Why These Diarrhea Occur? Mikako Hayashida1, Toyomi Fukushima1, Kenji Yamagata1, Maki Wakita2, Teruyoshi Amagai2 1Kobe Adventist Hospital, Kobe, Japan; 2Mukogawa Women’s University, Nishinomiya, Japan

Introduction: In hospital for the elderly, diarrhea is thought to be a major complication after percutaneous endoscopic gastrostomy creation (PEG-C),and this seems to cause much burden for nursing staffs and caregivers. However, whether diarrhea is truly common complication or not is still not clear. Aim: To clarify patients’ change of bowel habits after PEG-C in the elderly. Methods: All patients, who underwent PEG creation in a single institute between Jan,2006 and Jun,2010. Methods, were studied. Retrospective chart reviews were conducted in the following items-1,Subjects were divided into two groups-one was diarrhea (D) group and another was constipation(C) group, where D was defined more than three times defecations with loose stool and C was defined absence of defecation during more than three consecutive days, 2, Demographics two groups in age, sex, weight before PEG-C, fashions of nutritional support(NS: starvation vs. oral/tube feeding), ADL, and durations between admission and PEG-C(days), 3, Laboratory data-serum-albumin (Alb), Hb, Ht, MCV,MCH, and MCHC. 4, Clinical outcomes- starvation days after PEG-C, durations between PEG-C and discharge from hospital, and Alb at discharge.5, if some parameters show a statistically significant difference, then divides all subjects into two groups according to its difference and compared outcomes among them. Statistical analysis: Mann-Whitney U test was employed and p<0.05 was identified as a significant different. Results:1,Subjects consisted of 35 (Table1). 2, Among C and D group, no significant differences were observed in their demographics except NS (p=0.014, Table1).3,D group showed a significantly longer starvation days (14 vs.0 day, p=0.004,Table1). 4,NS, which was significantly different between C and D group, after all of subjects with C and D groups were divided again according to NS, a starvation group showed a significantly high incidence of D (4 vs.0 patients, p=0.033,Tbale2). Conclusions: In the present study, 1, constipation was more common than diarrhea in the elderly patients who underwent PEG-C. 2, Prevention of extended starvation may reduce diarrhea after PEG-C. 3,Altough constipation were more commonly formed in the elderly patients after PEG-C, among those were noted with diarrhea, extended starvation appeared to be a significant risk factor for diarrhea after PEG-C.

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85 - Nutrition in Home Care and the Healing of Pressure Ulcers Valeria Alves1, Graziela Lima1, Gisela Baptista1 1ProCare Saude, Rio de Janeiro, Brazil

Background and Objective Home care (HC) population is at increased risk of malnutrition and the development of pressure ulcers (PU). In developing countries, like Brazil, enteral nutrition is expensive and patients frequently go to HC in use of normal liquid diet through gastrostomy. In this study we intended to evaluate 3 types of nutrition and their relation to the improvement in the nutrition status of the patients and the healing of the PU. Methods Seventy-six HC patients were evaluated in the period of April 2009 through February 2010. All of them were admitted after a hospital stay and had a nutritional visit at admission to HC and monthly. Data was collected at the first visit and with six months of HC. Arm circumference (AC), body mass index (BMI) and the presence of pressure ulcers was registered. Patients received either enteral nutrition (EN), normal liquid diet (ND) or normal liquid diet + enteral supplements (NDS). Mean calories offered were 30-35kcal/d and 1,2±0,06g/kg/d of protein. Results Age was 73,03±11,85, 37(48,7%) were female and 39(51,3%) male. Chronic neurologic diseases predominated (72%), and all of them were fed through a gastrostomy. Malnutrition, determined through the BMI and AC, was present in 42(55,3%) patients at admission and only 16 (21%) were still malnourished after 6 months (p<0.0001). PU were present in 45(57,9%) patients, but only 2(4,5%) of these were not healed after the 6 months period, both in use of ND (p<0.0001). Eight patients developed PU during HC, 6 in use of ND and 2 in use of NDS. The type of nutrition at admission was: 34(44,7%)ND, 31(40,8%)NE and 11(14,5%)NDS. Nineteen(55,9%) patients of the ND group worsen their nutritional status after six months and 6 of them had PU. All of the EN and NDS groups improved their nutritional status, all the EN patients healed their PU and only 2 of the NDS patients had PU after the six months period. Outcome was discharge of HC of

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3 patients, death of 6 and 67 persisted in HC after six months. Conclusion It is possible to improve nutritional status and heal PU with the 3 types of nutrition, although ND failed in a significant number of patients. In the presence of PU, EN is the best choice, healing 100% of the PU, although NDS presented a good response as well.

86 - EVALUATION OF A SHEAR RATE FOR THICKENED LIQUID SWALLOWING BY A NEW SENSORY VISCOSITY TEST USING TWO DIFFERENT NON—NEWTONIAN FLUIDS Shohei Iijima1, Junko Fujitani2 1Minoh City Hospital, Department of Surgery, Minoh, Osaka, Japan; 2National Center for Global Health and Medicine, Department of Rehabilitation, Tokyo, Japan

Purpose: The viscosity of thickened liquids for transfer from enteral feeding to eating orally for dysphagia patients is very important. It is generally measured at a shear rate, examining the sensation of the viscosity on swallowing using Newtonian and non-Newtonian fluids in healthy. But, this method is not easy enough to test to the elderly and dysphagia patients. So, it is usually to accept the evidence from healthy. We examined a new method for the sensation of the viscosity on swallowing using two different non-Newtonian fluids, in order to set a common shear rate for the viscosimetry in the elderly and dysphagia patients. Method(s): Tamarind gum as a non-Newtonian fluid is lower decrease of the viscosity compared with guar gum as another non-Newtonian fluid in response to the higher shear rate. Six tamarind gum thickened liquids with concentrations of 1.73, 1.63, 1.50, 1.42, 1.35 and 1.27%, and 1.4% guar gum thickened liquids were used and measured each viscosity at several shear rates. The curves of viscosity with those 6 tamarind gum liquids crossed that of viscosity with guar gum liquids at about 20, 30, 50, 70, 100, 200/sec. 43 panelists, colleagues in several hospitals (Tokyo and Osaka), blindly swallowed one of the tamarind gum sample and the guar gum one, and chose the higher viscosity sample between those. The shear rates on swallowing were estimated from the cross range and the chosen side from the cross point. If guar gum sample was higher than one of the tamarind gum one, the shear rate was detected at the lower side than the cross point with those. But, if lower, the shear rate was detected at the higher. Result(s): The shear rates for swallowing of thickened liquids were estimated as 50-70 /sec. Conclusion: The shear rates from this study were associated with results of old reports. This simple method will fit the elderly and dysphagia patients for further evaluation of a shear rate of them.

87 - Head and Neck Tumor Seeding at the Perctuaneous Endoscopic Gastrostomy (PEG) Site: A Review of the Literature and Case Report June Greaves1 1Apria Healthcare, Lake Forest, CA

More than 15,000 cases of head and neck cancers are diagnosed each year and patients often require enteral nutrition (EN) via gastrostomy tube. The percutaneous endoscopic gastrostomy (PEG) tube has become the preferred technique for EN access because placement is a minimally invasive procedure. There are three methods of PEG placement: Gauderer-Ponsky “pull,” Sachs-Vine “push,” and Russell “introducer” method. Approximately 1% of those head and cancer patients who have PEG placement using the Gauderer-Ponsky pull method develop metastatic cancer at the PEG site that is consistent with head and neck cancer morphology. This method places the PEG tube through the mouth where it is pulled into position by passing by the tumor. A 68-year-old male who had T2N0M0 squamous cell carcinoma of the hypopharynx , was referred to a large national home enteral provider for enteral nutrition therapy (EN). The patient underwent PEG placement for EN in November 2009. Unfortunately, the method of PEG placement was not noted. On February 23, 2010, he reported that the PEG site was red, blistered, and painful, adding that he had been treated for local infection twice since PEG placement. He was advised to contact his physician for biopsy of the site. According to the patient, the physician was not overly concerned. The patient completed chemotherapy and radiation therapy and began to transition to oral intake. On March 2, 2010, the patient reported that he had not used his feeding tube for nearly 1 week, was able to maintain weight with an oral diet, and was scheduled to have the PEG removed. However, he added that the PEG site remained red and raw, with granulating tissue that was bleeding. After the PEG was removed, the patient reported to the dietitian that the PEG site was beginning to heal and that the breakdown was responding to antacid liquid applied to the skin for what was diagnosed as

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an ulcer at the PEG site. The patient was discharged from the home enteral provider in March 2010. The patient suffered a recurrence of pharyngeal cancer and underwent a total larngopharyngectomy and right radical neck dissection on June 9, 2010. The previous PEG site was biopsied intraoperatively, and results confirmed metastatic carcinoma consistent with hypopharyngeal cancer. The abdominal wall contained a large mass extending from the skin surface down through the wall of the stomach. The patient required a subtotal gastrectomy with sleeve reconstruction of the abdominal wall, and a tracheoesophageal puncture was performed for enteral feedings. In March of 2011, the patient died from complications related to his metastatic carcinoma. Clinicians working with head and neck cancer patients should be aware of all potential complications of PEG placement, and should be aware of this unique complication in order to provide early intervention. Evaluation of the PEG site should be conducted if persistent or recurring redness or induration, skin breakdown, bleeding, or unusual changes are noted to the skin or stoma site and tumor seeding should be a serious consideration in these rare cases.

88 - Complications of Nutritional Therapy Raise Hospital Mortality Maria Claudia Ortolani1, Humberto Benedetti1, Ana Patricia Muniz1, Viviane Satyro Mota1, Rafael Sanchez Neto1, Roberto Hiroshi Ieiri1, Paulo Sallum1, Dan Waitzberg1 1Hospital Santa Catarina, São Paulo, Brazil Introduction: Nutritional Therapy (NT) is not exempt of complications whose frequency can vary according group care experience, type of treated patient, diet and method used. Complications of NT contribute to reduction of protein-energy supply, may increase morbidity and mortality besides the hospitalization period of patients hospitalized. Gastrointestinal abnormalities are the most common complications of enteral NT (E), while metabolic complications of parenteral NT (P) are more common¹. Hyperglycemia is the most common complication of PNT. The maintenance of blood sugar between 80 and 110mg/dl is associated with decreased mortality and morbidity in critically ill patients undergoing surgical procedures². Objective: Identify the association between complications of NT and mortality and hospital discharge on General Hospital. Material and methods: In 2010, we followed up 362 adult patients hospitalized in Intensive Care Units (ICUs) and Hospitalization Units of the Hospital Santa Catarina in São Paulo, Brazil, who received ENT, PNT, ENT and PNT. Results: The most frequent complications of ENT were: constipation (16%), abdominal distension (12%) and vomiting (12%). In relation to metabolic complications, hyperglycemia occurred in 28.5% of inpatients receiving ENT and PNT. There was an association between the occurrence of complications and deaths (p<0.05) according to the table. Conclusion: The nutritional therapy is not free of complications. Among the most frequent are the gastrointestinal and hyperglycemia. The presence of complications is associated with mortality. It is interesting to avoid, minimize and promptly treat the NT complications. Complications Death Hospital discharge

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>2 44 38 89 - Secrets to Success in an Outpatient G-tube Program for Head and Neck Cancer Patients Katelynn Maniatis1, Elaine Posluns1, Edith Stokes1 1Sunnybrook Health Sciences Centre- Odette Cancer Centre, Toronto, ON, Canada

Introduction: Gastrostomy (G) tubes providing intermediary nutrition support have become an integral component of head and neck cancer treatment protocols. To improve patient care and reduce hospital costs, Sunnybrook’s Odette Cancer Centre Dietitians advocated to the Head & Neck Oncology Physicians and partnered with Gastroenterology (GI), and more recently Interventional Radiology (IR), to develop an outpatient G-tube placement program. This interdisciplinary program is an innovative model for patient-centered care. Description: Patients with head and neck cancer identified in the ambulatory Head and Neck Clinic as requiring concurrent radiation and chemotherapy are offered a G-tube as part of the treatment protocol. Dietitians co-ordinate subsequent activities, including preoperative patient education outlining risks, benefits and process, liaising with GI and IR to aid in the determination of tube selection and suitability, scheduling tube insertion appointments, and postoperative teaching and review

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of G-tube feeding and care. Given the intermediary nature of G-tube placement during cancer treatment, our practice diverges from standard G-tube feeding practices. Outpatients form a collaborative partnership with dietitians and the interdisciplinary team and are involved in every step of the transition from oral intake to G-tube feeding (predominantly via bolus syringe to closely mimic meals) to resuming adequate oral intake as appropriate. The partnership helps to empower patients through education and shared understanding and addresses intricate patient needs, including cultural and individual factors. Based on quantitative and qualitative practice-based research, the placement of G-tubes has been well received and shown to be beneficial in our ambulatory population. Experiences of living with a G-tube from the patient's perspective have been explored. Outcomes of reduced weight loss, improved compliance to treatment protocols and decreased hospital admissions (and associated costs of a 4-7day length of stay) have been shown. Our team acknowledges effective communication is dynamic and as a result we are continuously adapting communication and education strategies. Currently, patients are provided with hands-on education supplemented with written resources regarding feeding through and caring for G-tubes. It has been recognized that patients would benefit from electronically-accessible audio/visual communications to introduce concepts and reinforce learning. As such, interdisciplinary team members are collaborating to create G-tube educational videos and electronic resources. The goal of this creative endeavor is to provide further depth to the educational experience by addressing varying learning styles. Lessons Learned: Recognition of cost savings associated with decreased hospital stays has drawn organizational attention and facilitated our program’s growth. Qualitative and quantitative practice-based research has provided the program with a unique insight to the patient experience, allowing improvement and adaptation. Knowledge transfer and effective communication provide greater awareness, enhance inter-professional care and practice, and are vital to the empowerment of patients in their journey through nutrition support during cancer treatment. Continuous communication, research, evaluation and adaptation have assured a successful outpatient G-tube program valued by patients, health care team members and the organization alike.

90 - Evaluation of the quality of enteral nutrition therapy in patients hospitalized in the clinical cardiology intensive care unit Helenice Costa1, Marcela Calsa1, Juliana Maldonado1, Aparecida Oliveira1, Liliane Kopel1, Silvia Lage1 1Heart Institute, School of Medicine of University of São Paulo, São Paulo, Brazil.

INTRODUCTION: Enteral Nutrition Therapy (ENT) has been suggested as the first choice in the inability to use the oral route. Delivering early nutrition support therapy is seen as a proactive therapeutic strategy that may reduce disease severity, diminish complications, decrease length of stay in the intensive care unit, and favorably impact patient outcome. The incorporation of quality indicators in nutritional therapy aims to identify strategies to prevent non-conformities related to nutrition and increase the efficiency of ENT through interventions that reduce complications. OBJECTIVE: To evaluate the adequacy of enteral nutrition therapy in adult patients hospitalized in the clinical cardiology intensive care unit. METHODS: This is a prospective longitudinal study. The clinical data, medical and dietary prescriptions, and nursing data were obtained from the patients chart. Were applied the quality indicators in nutritional therapy proposed by the "International Life Science Institute". The variables were analyzed using absolute and relative frequency for checking the adequacy frequency and the goals set by the indicators of quality. RESULTS: 16 patients and the mean age were 65 years (SD = 14.56 years), being 63% male. The average of APACHE II found were 23.4 (SD = 6.8) and the average mortality risk were 44.8% (SD = 19.18%); 37.5% of patients died. The adequacy of calories and proteins observed were respectively 90.8% and 46.5% for prescribed / calculated, 69.4% and 69.6% for administered / prescribed and 65.3% and 35.7% for administered / calculated. The frequency of complications observed were 37.5% of abdominal distention, constipation 18.8%, 25% of gastric residue and 43.7% of diarrhea. CONCLUSION: The inadequacies observed show the necessity for better monitoring of clinical course of these patients, considering the poor prognosis and the mortality risk, and this highlights the nutritional vulnerability of the group studied.

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CLINICAL NUTRITION WEEK 2012 ABSTRACTS: MALNUTRITION – NUTRITION ASSESSMENT 91 - Use of Combined Nutritional Assessment and Physician Order Form Improves Physician Acknowledgement and Nutritional Outcomes in Hospitalized Patients Michael Zaccagnino1, Judith Allaire-Pittz1, Diana Bond1, Deborah Kuhls1 1University Medical Center of Southern Nevada, Las Vegas, NV

Background: Several publications correlate appropriate nutritional assessment and therapeutic intervention with positive outcomes in malnourished hospitalized patients. Many authors have demonstrated that clinical outcomes are improved when Registered Dietitian (RD) inpatient nutrition recommendations are followed, as well as reduced expenses and hospital resource utilization. Problem and Solution: Physician acknowledgement and implementation of RD nutrition recommendations for high nutritional risk inpatients was demonstrated to be poor at a tertiary care hospital. Hospital procedure consisted firstly of a nutritional assessment completed by a RD, and secondly physician interpretation of the recommendation resulting in a separately transcribed order. We hypothesized that compliance with nutritional recommendations would improve by combining the RD nutritional assessment with a physician order form. Methods: This is a prospective interventional design study. IRB approval was obtained. A pre-interventional, year-long chart review of physician nutrition orders and RD recommendations was conducted. All hospital patients who were considered at high nutritional risk were included in the baseline survey. A newly designed, combined assessment and order form was implemented and another year-long chart review was conducted to provide comparison data. Categorical comparisons were made using GraphPad's two-tailed Fishers exact test. Results: Pre-implementation RD recommendations were acknowledged by physicians in 50% of patients. Post-implementation physician acknowledgement of RD recommendations was 95%, nearly double the rate observed during the comparison period (Fishers exact two-tailed test, p = 0.0001). Additionally, the investigation discovered that with specific recommendations for type of diet, laboratory assessments, and vitamin and mineral recommendations, non-compliance decreased to 2%, 0.5% and 1% respectively (Fishers exact two-tailed test; p = 0.0001, p = 0.0001, p = 0.0001, respectively). Continued monitoring reveals exceptional physician acknowledgement of RD recommendations for enteral nutrition, ranging from 95% to 99% for 2008-2011. Conclusion: This study demonstrated that utilization of a combined nutritional assessment/physician order form completed by a RD significantly improved physician acknowledgement and implementation rates of RD recommended interventions while reducing negative nutritional outcomes.

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Caption Figure 1: Percent RD recommendations for level 1 nutritional risk patients acknowledged by

physicians before and after implementation of combined RD assessment and physician order form. Data for this figure can be found in Table 1.

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Caption Figure 2: Nutritional outcomes of level 1 nutritional risk patients when RD recommendations not followed: before and after implementation of combined RD assessment and physician order form. Data

for this figure can be found in Table 1. 92 - Health Systems Improvement in Canadian Patients with Foregut Tumors: A Local Initiative with International Reflectivity Leah Gramlich1, Cathy Alberda2, Adam Henley3, Jennifer Kwan4, Yvonne Suranyi2, Shelley Warden1 1Alberta Health Services, Edmonton, AB, Canada; 2Royal Alexandra Hospital, Edmonton, AB,Canada; 3University of Alberta, Edmonton, AB, Canada; 4Kwan Consulting, Edmonton, AB, Canada

Background: Despite a documented high prevalence of malnutrition in patients with head & neck or esophageal cancers, an evidentiary review demonstrated a lack of consistency with regards to optimal nutrition care before, during and following cancer treatment. A health systems improvement review was undertaken to assess the current processes of nutrition care in the Edmonton region, to define “optimal” nutrition care for patients with foregut tumors, and to analyze the gaps in our system, thereby providing opportunities for quality improvement. Methods: Members of the interprofessional team were identified, and were asked to consider patient, provider and systems perspectives across the trajectory of cancer care. Process mapping was completed, documenting the people and professions involved in care; communication and interfaces with the patient and each other were identified Focus groups were conducted with frontline physicians (oncologists, surgeons, gastroenterologists), dietitians, nurses, occupational therapists and speech language therapists who are involved at all phases of the patient’s cancer treatment (staging and assessment, chemotherapy and/or radiation therapy, surgery, and rehabilitation.) The process maps were shared with the interdisciplinary clinical team for revision and identification of the “pain points” or the gaps in the system. Key health care managers and decision makers in each clinical area were also identified. Results: Process mapping has highlighted the complexity of the environment that is involved in managing patients with foregut tumors and in developing an interprofessional integrated nutrition care plan. Patients access care at three different hospital sites for diagnosis, surgery, chemotherapy, radiation therapy, rehabilitation and follow-up. There is a wide distribution of nutrition therapy across multiple professions and sites. Although the literature supports integration of nutrition therapy into mainstream cancer care, we found deficiencies in nutrition screening, assessment and follow-up in our current system. Duplication of some clinical services was also

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highlighted. Definitions of success and prioritization of care differed amongst professions and over course of treatment phases. The role of individual members of the interprofessional team relative to nutrition care is not clear. Communication of patient concerns and nutritional goals is not consistent, particularly where multiple hospital sites are involved with treatment. We identified the prospective audit as being a critical part of the larger picture for health systems improvement, utilizing the audit as a quality improvement initiative to capture local data in real time. Conclusions: Optimizing nutrition care during cancer therapy for patients with foregut tumors requires that we understand the patient needs, inclusive of patient’s baseline demographics and nutrition risk throughout the cancer care trajectory. Provider practices and effectiveness need to be reviewed, helping to define roles in nutrition practice, including optimal, individualized oral feeding and non-volitional feeding (NG or PEG). By refining current conceptualizations of clinical risk, we hope to identify factors associated with deleterious outcomes. By analyzing system processes, we can assess the timeliness of care and system organization. A prospective audit with benchmarking is needed to aid in the development of gold-standard, efficient, patient-centered integrated nutrition care across a variety of healthcare systems.

93 - Identifying and Describing Local Barriers to Optimal Nutrition Therapy among Esophageal, Head and Neck Cancer Patients Leah Gramlich1, Adam Henley2, Karin Olson2, Cathy Alberda4 1Alberta Health Services, Edmonton, AB, Canada; 2University of Alberta, Edmonton, AB, Canada; 4Royal Alexandra Hospital, Edmonton, AB, Canada

Background: Esophageal, head and neck cancer patients continue to experience a protracted period of recovery from multiple symptoms, inflammatory processes and swallowing deficits in the presence of diverse anti-cancer therapies. Consequently, this patient group frequently reports reductions in health-related quality of life as well as marked declines in oral intake and weight. Local clinical experience suggests that it may be possible to increase oral intake and reduce weight loss by optimizing practices to maintain nutritional status, but a paucity of evidence has significantly constrained the development and design of clinical practice guidelines in this population. Moreover, given the increasing complexity of cancer care pathways for esophageal, head and neck cancers, practical barriers to optimizing nutrition therapy continue to exist. Methods: Twenty-eight local team members were engaged in informal pre-study planning interviews. An inclusive sample was sought by receiving feedback from all disciplines involved in the care, treatment or management of nutritional issues for this population from multiple sites in Edmonton, Alberta, Canada. This sample included representation from gastroenterologists, medical and radiation oncologists, thoracic and ENT surgeons, dietitians, speech-language pathologists, Registered Nurses, and a social worker. Results: Alterations in nutrition-related care were routinely reported during times of transition to new team members and sites. Patients were perceived to be followed by multiple professionals over the course of their therapy regarding nutritional issues, with moderately variable processes identified for transfer of care between providers and sites. Informants consistently identified: persistent identifiable risks from malnutrition, a lack of individual responsibility for nutrition-related care, multiple potential nutrition-related care processes. Informants did not consistently identify best practices associated with nutrition assessment or intervention in this population. Conclusions: A qualitative approach helped to identify and describe local barriers to optimal nutrition therapy prior to designing a prospective audit protocol for use in esophageal, head and neck cancers. An integrated nutrition care plan was perceived to better coordinate care between all providers and points-of-care. Local team members disagreed on what best practice constitutes for nutrition therapy in this population, suggesting that a prospective audit protocol remains a useful endeavour to generate relevant research hypotheses and improve the quality of care in this population.

94 - Folic acid supplementation for improving homocysteine levels and depressive status in Eating Disorders Viviana Loria-Kohen1, Carmen Gomez-Candela1, Samara Palma-Milla1, Blanca Amador-Sastre1, Angel Hernanz1, Laura Bermejo1 1La Paz University Hospital, Madrid,Spain

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Introduction: It has been suggested that symptoms of depression in patients with ED are related to neuroendocrinological disorders induced by food restriction. The food restriction causes energy and micronutrients deficiencies, among them folate deficit. Homocysteine provides better data on folate deficiency and the presence of high homocysteine levels in ED patients have been associated with high rates of depression. Objective: The aim of this study was to determine the effect of folic acid supplementation on homocysteine levels and depression markers in a group of patients with eating disorders (ED) with low folate intake. Methods: We designed a randomised, prospective, clinical trial that included 24 males and females who were assigned to two treatment groups for six months: a supplemented group (SG) (10 mg/day of folic acid [ACFOL®]) and a placebo group (PG). Both groups continued with their medical, nutritional and psychological treatment. At the start and end of the intervention, we recorded anthropometric, dietetic and biochemical parameters (plasma homocysteine [Hcy], serum and red blood cell folate and vitamin B212). We also administered a depression questionnaire (Beck Depression Inventory [BDI]). Results: Twenty-two patients completed the study (SG: 12, PG: 10, mean age: 24.2 ± 8.8 years, BMI 18.9 ± 3.5 kg/m2. Folate intake by food record showed that half of the group did not meet 30% of the recommended daily intake for their age (400 µg/day). After six months of intervention, the SG significantly increased their serum and red blood cell folate levels (9.4 ± 3.6 ng/ml vs. 19.6 ± 1.3 ng/ml and 634.3 ± 300.0 ng/ml vs. 1521.7 ± 167.0 ng/ml, P212 levels in either group. In terms of the assessment of depression symptoms based on the BDI at the start of the study, 20.8% scored in the moderate range of depression and 58.3% scored in relevant or severe ranges of depression. After intervention the SG reduced their BDI scores (22.9 ± 8.1 vs. 15.2 ± 9.9, P212 levels were not affected.

95 - Digestive neoplasia, low body mass index and weight loss as an indicator of the length of hospital stay in patients with neoplasia Laiz Saragiotto1, Vania Leandro-Merhi1, José Luiz Braga Aquino1 1Pontificia Universidade Católica de Campinas-SP-Brazil, Serra Negra, Brazil

Background: The nutritional condition (NC) of patients with neoplasia is susceptible to much depletion, due to metabolic abnormalities of the disease and the treatment applied. The objective of this work was to study the risk factors for malnutrition and length of hospital stay for patients with neoplasia, during the hospitalization period. Methods: It was investigated in a prospective study the nutritional condition by classic anthropometry, energy intake, gastrointestinal disorders, indicators of nutritional risk and the length of hospital stay of 93 patients with neoplasia (digestive neoplasia, head and neck neoplasia, gynecological neoplasia among other types), being after studied the risk factors for a longer length of hospital stay. For statistical analysis, the Chi-square test was adopted to check the association or compare proportions and the Kruskal-Wallis or ANOVA to compare the continuous measures among 4 groups with neoplasia. And to identify the factors associated with the length of hospital stay (gender, disease, age, BMI, risk indicators for malnutrition), the multiple logistic regression analysis was applied. Initially, the univariate analysis was applied in each of the interest factors and after, the multiple analysis. The significance level adopted for the statistical tests was 5%. Results: Comparing the variables as for neoplasia types, a significant difference was noticed (p<0.0001) related to the length of hospital stay, for the patients suffering from digestive neoplasia. Through the multiple logistic regression, for the risk factors study for the length of hospital stay, it was verified that patients with digestive neoplasia presented 26 times more chances of being hospitalized for 7 days or more if compared with the patients with gynecological neoplasia (p=0.00047; RR=26.058; 95% CI= 2.724; 249.223). Those with BMI< 18,5 presented 8 times more chances of being hospitalized for 7 days or more (p=0.0070; RR=8.173; 95% CI=1.776; 37.622). The patients who presented recent weight loss presented 4,5 times more chances of being hospitalized 7 days or more than those who did not present weight loss (p=0.0181; RR=4.500; 95% CI= 1.293; 15.660). Conclusions: Patients with digestive neoplasia, those with low BMI and those who presented recent weight loss are considered risk factors for a longer length of hospitalization.

96 - Interleukin-10 Improves Glucose Tolerance by Downregulation of Genes Involved in Gluconeogenesis and Lipogenesis in The Liver Agussalim Bukhari1 1Dept. of Nutrition, Faculty of Medicine, Hasanuddin University, Makassar, South Sulawesi, Indonesia

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Introduction: Insulin resistance is associated with obesity-induced chronic low-grade inflammation with reduced glucose uptake in skeletal muscle, increased gluconeogenesis and lipogenesis in the liver and increased expression of proinflammatory cytokines such as TNF-α, IL-6, and MCP-1 in adipose tissue. Recent studies reported two different subset of Adipose Tissue Macrophages (ATMs); M2 macrophage with anti-inflammatory and insulin sensitizer properties and the M1 macrophage with proinflammatory effect which induces insulin resistance. M2 ATMs are the predominant macrophages in lean, insulin sensitive mice while M1 ATMs dominate ATMs in obese, insulin resistant mice. Exercise has been reported to improve insulin action and increases glucose uptake in skeletal muscle. Studies have shown a correlation between improved insulin action and Interleukin-10 (IL-10) including after exercise. In the current study we examined the effects of the anti-inflammatory IL-10 on obesity-induced insulin resistance in mice. Methods: Six-week-old male C57BL/6J mice were fed with normal diet or high fat diet for 12 weeks to induce insulin resistance. The mice were then intraperitoneally injected with either adenovirus encoding human IL-10 (Ad-hIL-10) or control vector. Glucose tolerance were evaluated by Intraperitoneal Glucose and Insulin Tolerance Test (IP-GTT and -ITT). Plasma insulin levels during IP-GTT were assayed by ELISA. Insulin signaling in skeletal muscle and liver were examined by immunoblot analysis. Expression of the gluconegenic & lipogenic genes in liver were analyzed by Real Time RT-PCR. The number of total ATMs and expression of proinflammatory M1 ATMs markers and anti-inflammatory M2 ATMs markers in abdominal fat tissues were examined by Immunohistochemistry (IHC) and flow cytometri. All data are presented as mean±SEM and each group contains 4-5 mice in triplicate. Unpaired t test was used for statistical analysis. p<0.05 was considered significant. Results: There were no significant difference in body weight and food intake between IL-10 overexpressing mice and control mice. Obesity clearly induced insulin resistance as shown by increased blood glucose and insulin levels and inhibited insulin signaling in skeletal muscle and liver. In addition, the number of macrophage (F4/80 as marker) in abdominal fat tissue was significantly higher in obese mice. In contrast, blood glucose and insulin levels during IP-GTT/ITT were lower in Ad-hIL-10 injected mice. Improved insulin signaling were observed in skeletal muscle and liver of Adh-IL-10-injected mice. Expression of the gluconeogenic genes (G6Pase and PEPCK) as well as the transcription factor gene for lipogenesis (SREBP1c) were lower in the liver of IL-10-overexpressing mice. The latter effects were confirmed by in vitro studies using HepG2 cell lines and were mediated by STAT3, suggesting anti-inflammatory independent actions of IL-10. Expression of proinflammatory macrophage (M1) markers i.e. TNF-α, IL-6, MCP-1, CD11c were all upregulated in obese mice compared to lean mice. Treatment with IL-10 overexpression did not downregulate the proinflammatory macrophage (M1) markers but upregulated marker of total macrophage number (F4/80) and the anti-inflammatory macrophage (M2) markers including CD163, CD206, CD 209a. Conclusions: Overexpression of IL-10 was capable of recovering the obesity-induced insulin resistance with improved insulin signaling in skeletal muscle and liver which was associated with suppressed expression of gluconeogenic and lipogenic genes in the liver and upregulation of anti-inflammatory ATMs.

97 - Catastrophic Complications of Bariatric Surgery Can Lead to Consideration for Intestinal Transplant Sulieman Abdal Raheem1, Mandy Corrigan1, Omer Deen1, Neha Parekh1, Cristiano Quintini1, Donald Kirby1 1Cleveland Clinic Foundation, Cleveland, OH

Introduction: Obesity is a major chronic disease affecting patients worldwide, and many patients in the United States. Bariatric Surgery (BRS) is superior to other conservative weight loss techniques for the morbidly obese. However, severe catastrophic complications can occur as a result of BRS leading to short bowel syndrome (SBS) and even the need for small bowel transplantation (SBT). Our goal was to evaluate the complications post BRS in patients cared for by our Intestinal Rehabilitation Program (IRP) and Home Parenteral Nutrition (HPN) and to evaluate the number of patients being considered for SBT due to complications from BRS. Methods: A retrospective review was performed on a clinical database including IRP and HPN patients with a history of obesity leading to surgical intervention, and patients evaluated for SBT due to complications from BRS. Results: Of the current 163 patients on our HPN service, 136 (83%) patients receive HPN and 27 (17%) patients receive home IV fluids. Six patients had BRS for morbid obesity and developed postsurgical complications leading to HPN dependency. Four

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cases were identified as having developed severe complications. Two patients were approved and awaiting SBT and 2 have undergone SBT. One of the cases developed a small bowel obstruction secondary to adhesions and 3 case developed volvulus leading to SBS resulting in intestinal failure (IF). Each patient received HPN, failed to respond to IRP conservative management including the dietary modifications and antidiarrheal agents. Catheter related blood stream infection (CRBSI), a complication of HPN, occurred in 3 patients despite extensive patient education on catheter care and use of ethanol lock. Three cases had CRBSI caused by fungemia; with one having tricuspid valve endocarditis secondary to fungemia. Of the 3 cases with fungemia, meeting criteria for failure of HPN, 2 patients received SBT and one has been approved for SBT. Conclusion: Surgical interventions to treat morbid obesity are common, growing in popularity, but are not without risk of serious complications including IF. Despite methods to prevent complications, failure of HPN leads to the need for SBT evaluation. In selected cases, the best therapeutic treatment may be SBT to resolve irreversible, postbariatric IF.

98 - Validation of Sentinel Markers For Malnutrition Dottie Gibson1, Michael Coronado1, Snorri Olafsson1, Stanley Condon1, Aurea Burgos1, Emlyn Carbajal1, Manny Engracia1, Cindy Figueroa1, Yoshie Ichiwaka1, Peng Mitchell1, Renee Piazza-Barnett1, Cynthia Salcedo1, Pam Short1, Andrea Williams1, Rebecca Estanque1 1Loma Linda University Medical Center, Loma Linda, CA

Validation of Sentinel Markers for Malnutrition Introduction/Background Defining and determining the degree of malnutrition has been a challenge for many years and has stimulated controversy as to how to treat and document for such patients. Medical literature has provided little consensus on how to define adult malnutrition syndromes, and until recently offered no standardization to identify characteristics of malnutrition. As part of an International Guideline Committee, the ADA and ASPEN convened to offer standardized definitions and markers that may be used to classify and code adult malnutrition. They have suggested an etiology-based approach that includes the incorporation of the role of inflammation on the pathophysiology of malnutrition. The proposal includes three categories: 1.Starvation related malnutrition: chronic malnutrition without inflammation, 2. Chronic disease related malnutrition; chronic inflammation of mild to moderate degree, 3. Acute disease or injury related malnutrition; acute severe inflammation is present. Methods As part of our Quality Improvement process, we gather data/information for patients starting parenteral nutrition (PN). We reviewed data from 562 patients looking at age, gender, hospital length of stay (LOS), PN start date, days on PN, enteral nutrition start date, serum albumin (Alb), serum transthyretin, BMI, weight changes, complications and patient demise. We categorized the patients as either acute or chronic. For the purposes of this study, acute was defined as an illness or injury that began rapidly and chronic as persistent or lasting 3 months or more. We analyzed the data for patient characteristics that may be suggested as sentinel markers of malnutrition in acute vs chronic disease or illness. Results The acute patients are more numerous with males accounting for 75% of count. The chronic patients were more often females at 25% of count with a significant difference by gender (p = <0.0001). The chronic patients started nutritional support slightly earlier (p = 0.17), and had a significantly lower BMI (p = 0.006). The acute patients had significantly more weight loss based on UBW (p = <0.0001) and a slightly longer LOS compared with the chronic (p = 0.18) but if the analysis is restricted to the acute patients with a serum albumin levels of 3.0 or less then, we show a significant increase in LOS (p value 0.03). Discussion/Conclusion • The acute vs. chronic patients showed insignificant differences in LOS unless stratified by serum alb levels. Otherwise the acute group with low alb levels had a significantly longer LOS. • The acute patients had significantly more weight loss. • The chronic patients had a significantly lower BMI. • Albumin levels rather than being a marker for malnutrition may reflect severity of illness/injury d/t reprioritization of hepatic protein production from transport to acute phase proteins thus demonstrate inflammation and resulting in an increased LOS and resource intensity. • Unintended weight loss, changes in body composition, compromised nutritional intake coupled with low serum alb levels may predict a prolonged LOS and should be considered as outcome markers used in diagnosis of the severity of malnutrition in acute vs chronic injury or illness.

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99 - Quality of life using a validated obesity-specific questionnaire improves early after gastric bypass surgery Lauren Beckman1, Shalamar Sibley2, Carrie Earthman1 1University of Minnesota, Saint Paul, MN, 2University of Minnesota, Minneapolis, MN

INTRODUCTION Gastric bypass (GB) imparts substantial weight loss in a relatively short time period. Surgical success has typically been defined by weight loss or resolution of co-morbidities. However, quality of life (QOL) improvements have also been reported by 6 months post-GB, and QOL is now considered another measure of bariatric success. The objective of this analysis was to assess the time course and clinical relevancy of QOL changes immediately following and up to 1-year post-GB. METHODS Twenty women (BMI: 48±1 kg/m2; age: 48±2 years (mean±SE)) were studied before GB (V1) and approximately 2 weeks (V2), 6 weeks (V3), 6 months (V4), and 1 year (V5) postoperatively. QOL was examined at each visit with the obesity-specific Impact of Weight on Quality of Life-Lite questionnaire (IWQOL-Lite, Duke University), which has been demonstrated to be reliable and valid, correlating significantly with weight loss. It has 31 items with 5 scales (physical function, self-esteem, sexual life, public distress, and work). Each scale and the total score were transformed, with 100 being the best QOL possible. Clinically meaningful improvement in overall QOL is defined as a 7.8-12 point increase in the transformed total score. Longitudinal changes were analyzed using a mixed effects linear model with a random effect for subject to model the correlation of repeated measurements within each subject.

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RESULTS Body weight decreased at all visits after V1 (p<0.05), with an average loss of 44±2 kg by V5. The IWQOL-Lite scores for the five scales and overall QOL increased in the early (V2, V3) and/or late post-operative period (V4, V5) compared to V1 (p<0.05). Cronbach alpha scores ranged from 0.88 to 0.95. Physical function, self-esteem, public distress, and the total scores increased from V1 early post-GB (p<0.05). These changes were maintained at V4 and V5 (p<0.05). Sexual life and work scales only increased in the later post-operative period. Clinically meaningful improvement in overall QOL occurred in 29%, 90%, 100%, and 100% of subjects at V2, V3, V4, and V5, respectively, while 65% remained obese at V5. CONCLUSIONS QOL increased, in a clinically relevant manner, in the early and up to 1-year post-operative period. Overall QOL improved before substantial weight loss and when subjects were still considered obese. QOL assessment is important in the post-GB population, as the ramifications of obesity go far beyond morbidity and mortality and include diminished physical function and emotional well-being. While weight loss describes the crude success of the surgery, it fails to capture patient perceptions of the treatment’s impact on psychosocial health. The early increase in perceived QOL found here is encouraging, as it might promote increased self-efficacy to maintain the lifestyle changes so crucial to the long-term success of the surgery. Future large-scale studies on QOL in the long-term are needed in post-GB patients to better understand how the surgery impacts QOL after weight loss has stabilized (e.g. ≥ 2 years). The IWQOL-Lite appears to be a robust tool to evaluate patient adjustment to treatment and should be integrated into assessment protocols for bariatric weight loss programs.

100 - Influence of Obesity and Weight Loss Induced by Roux-en-Y Gastric Bypass Surgery on Zinc and Copper Levels. Andrea Pereira1, 2, Gláucia Carneiro2, Julio Marchini3, Luciana Umeda2, Olga Amâncio2, Maria Teresa Zanella2 1Hospital Bandeirantes, São Paulo,Brazil; 2UNIFESP, SÃO PAULO, Brazil 3USPRP, Riberiao Preto, Brazil

Introduction: Micronutrient deficiencies are common complications of bariatric surgery. The aim of this study was to evaluate and correlate the changes that occur in serum copper and zinc in obese patients before and after Roux-en-Y gastric bypass surgery. Material and Methods: We studied 18 patients undergoing Roux-en-Y gastric bypass. There were four males and 14 females with a mean age of 44 ± 13 years (19-59 years). The patients’ fasting serum copper, iron and zinc levels were measured before the operation and at 30, 90 and 180 days postoperatively. Results: Prior to the operation, 50% of the patients had elevated serum copper levels and 22% had reduced serum zinc levels. In the first 30 days after surgery, there was an elevation of serum zinc and copper. After 90 and 180 days, the serum levels of zinc and copper returned to levels similar to the pre-surgical levels. A positive correlation was found between serum zinc and copper (rest = 0.261, p = 0.039).Conclusion: Supplementation of these elements in obese patients should not be routine but should be based on clinical follow-up and the confirmation of serum levels, taking into account the postoperative changes in mineral absorption.

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Encore: previously presented at ESPEN 2011 conference. Published: Clinical Nutrition Supplements, 2011, Vol.6, No.1 page 211. Available at http://clinicalnutritionsupplements.com. 101 - Physician perceptions regarding the identification and management of malnutrition in Canadian hospitals Donald Duerksen1, Heather Keller2, Johan Allard3, Paula Bernier4, Leah Gramlich5, Khursheed Jeejeebhoy6, Mann Laporte7, Helene Payette8 1University of Manitoba, Winnipeg, MB, Canada; 2University of Waterloo, Waterloo, ON, Canada; 3Toronto General Hospital, University Health Network, Toronto, ON, Canada; 4Jewish General Hospital, Montreal, QC,Canada; 5Alberta Health Services, Edmonton, AB,Canada; 6 St Michael's Hospital, Toronto, ON,Canada; 7Hôpital Regional de Campbellton / Campbellton Regional Hospital, Campbellton, NB,Canada; 8Research Centre on Aging, Sherbrooke, QC.Canada 102 - Effect of Ramadan Fasting on Renal and Liver Functions in Diabetic Adolescents Nagat Eltoum1, Sidiga Washi2, Abdulaziz AL Twaim1 1King Saud Bin Abdulaziz University for Health Sciences, National Guard Health Affairs., Jeddah, Saudi Arabia; 2United Arab Emirates University, Alain, UAE.

Introduction: More than one and a half billion adult Muslims around the world observe Ramadan fasting. Ramadan is the ninth month of the Muslim lunar calendar. It is a fundamental principle in Islam to fast from dawn to dusk for 29-30 days during this particular month. Although patients with chronic illnesses, such as diabetes mellitus, are exempt from fasting to avoid complications, but most of them do not accept this exemption including diabetic adolescents. This kind of practice creates a challenge for the medical team members due to the risk of short and long-term metabolic changes that might occur because of fasting. There is clearly a dearth in studies explaining such changes among diabetic adolescents. The aim of this study was to examine the effect of prolonged intermittent fasting on renal and liver functions in diabetic adolescents. Methods: A group of 54 diabetic adolescents (13-18 years old) participated in the study. They had no signs of diabetes complications or any other medical condition. All participants were permitted by their physicians to fast during Ramadan. Data collection conducted during two Ramadan seasons (2007 & 2008) at King Abdulaziz medical city-Jeddah, KSA. Participants were evaluated before and after Ramadan. The following parameters were measured: anthropometric measurements, glycated hemoglobin, renal and liver functions tests. Results: The participants managed to fast 21.7±7 days. There was a slight significant loss in weight (-0.45 kg) and Body Mass Index by the end of Ramadan Glycated hemoglobin did not change significantly as compared to before Ramadan. Ramadan fasting did not impose negative effect on the renal and liver functions profile of the participants. Moreover, the majority of changes in liver functions remained within the reference range for age. A favorable significant effect on

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the abnormal elevated liver function parameters took place. Furthermore, examining the effect of the number of fasting days on liver function revealed that participants who fasted more days had a significant decrease in globulin (P=.014), alkaline phosphatase (P=.023), alanine transferase (P=.029), Aspartate aminotranferase (P=.045) and Gamma-glutamyl transferase (P=.001). Renal function test showed no significant changes in serum Sodium, Potassium, Chloride and urea except for creatinine that decreased significantly by the end of Ramadan (p =.00) but it was within the reference range, which might be due to weight loss. Conclusions: The general picture reflects that Ramadan fasting created a positive effect on the metabolic profile of the participants. Moreover, the majority of changes kept the mean results within reference range for age. The results of this study indicates that the intermittent type of Ramadan fasting observed by type I diabetic adolescents is feasible and safe if they receive proper medical care.

103 - Effect of TNT seminar on knowledge level about clinical nutrition for Japanese physician Yoshifumi Inoue1, Masato Iwasa2, Koichi Hirata3 1Kawasaki Hospital, Kobe, Japan; 2Sakura Hospital, Agawa-gun, Japan; 3Sapporo Medical School, Sapporo, Japan

Background: Malnutrition is common in hospitalized patients, however, it is not always identified and treated appropriately by physicians. One of the reasons is lack of clinical nutrition education for physicians. Firstly, physicians are generally unaware of the incidence of malnutrition and its impact on their patient's health and the treatment outcomes. Secondly, most physicians have limited nutrition knowledge. Total Nutrition Therapy (TNT) is a 2-day, postgraduate, continuing educational seminar developed for physicians to learn the global standard of clinical nutrition. Objective: To evaluate the effect of TNT seminar on the knowledge of clinical nutrition in Japanese physicians. Design: The TNT seminar in Japan was started in 1999 and has been held more than 400 times and educated more than 15,000 physicians. Since 2004, the participants in the Kinki area have completed a short pre and post test about clinical nutrition knowledge. The content of the test includes the definitions for abbreviations, the composition of TPN solutions, energy produced by 1 gram of carbohydrate, protein, and fat, and other basic knowledge related to clinical nutrition practice. The pre and post test scores were compared to

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evaluate the seminar outcome. Results: The number of physicians who attended TNT seminars in the Kinki area for last 6 years were 1024. The average pretest score was very low: only 50% of the physicians correctly estimated the energy yield per gram of macronutrients. The rate of correct answer about the composition of TPN solution was 48.8%. 41.9% of the participants correctly selected the definitions for abbreviations and 67% correctly answered questions about other basic nutrition knowledge. The scores significantly improved after the seminar: 98% of the physicians correctly estimated the energy yield per gram of macronutrients, 81.2% answered correctly about the composition of TPN solution, 77.8%correctly selected the definitions for abbreviations and 83% correctly answered questions about other basic nutrition knowledge. Conclusion: We may conclude that nutrition education for physicians with TNT seminar can improve the physician's knowledge regarding clinical nutrition and also can raise the awareness of the importance of clinical nutrition.

104 - Objective criteria for nutritional assessment and for the initiation of non-volitional feeding in patients with head and neck cancer receiving chemo-radiotherapy Tanadech Dechaphunkul1, Leah Gramlich2, Vickie Baracos1 1Cross Cancer Institute, Alberta Health Services, Edmonton, AB, Canada; 2Alberta Health Services, Edmonton, AB, Canada

Background: Patients with cancer of the head and neck are often malnourished at diagnosis. Although chemo-radiotherapy significantly improves survival among these patients, it directly interferes with intake further increasing nutritional risk. Assessment of nutrition risk prior to chemo-radiotherapy is not well defined across the range of patients and treatment plans and there is a lack of objective criteria to guide decisions for non-volitional (nasoenteric, gastrostomy) feeding. Methods: Retrospective cohort (n=92) patients with cancers of the larynx, pharynx, and oral cavity treated with chemo-radiotherapy (06/2004 – 10/2009 were reviewed. Data were collected for disease site and stage, demographics, treatment, tube feeding history and weight history. The presence of sarcopenia was assessed using computed tomography images in the patient record. Results: A trivial proportion (5%) of patients were clinically underweight (BMI15% and 2 patients with BMI 15% (33% of patients) are quantifiable nutritional risks in this population however the placement of feeding tubes was not tightly associated with these features. Defining goals/strategies to support nutrition therapy and non-volitional feeding in this high-risk group is a priority.

105 - Outcomes of Systematic Nutritional Assessment and Intervention in an Oncology Setting Pankaj Vashi1, Carolyn Lammersfeld1, Donald Braun1, Swetha Nutakki1, Digant Gupta1, Ryan McCabe1 1Cancer Treatment Centers of America, Zion, IL

Introduction: There is strong evidence in the literature demonstrating a positive correlation between well-nourished status and better clinical outcomes in oncology. However, very few studies have documented the benefits of systematic nutritional assessment and intervention by a dedicated nutrition and metabolic support team (NMST) in an oncology setting. This study investigated whether or not nutritional intervention by NMST can improve nutritional status during cancer treatment. Methods: A retrospective analysis of 1056 patients undergoing treatment at a comprehensive cancer center was conducted between March 2008 and May 2011. The Subjective Global Assessment (SGA) was used to assess nutritional status at baseline and follow-up. Patients were classified as: well nourished (SGA-A), mildly-moderately malnourished (SGA-B), and severely malnourished (SGA-C). Patients received nutrition intervention according to an algorithm based on SGA. All patients had a minimum of 3 SGA assessments done within 6 months from the date of baseline SGA assessment. 1056 patients met that criterion during the specified time period. Using the baseline and last SGA, patients were categorized into 3 groups: improved SGA, deteriorated SGA and unchanged SGA. The baseline characteristics of the “improved SGA” group were compared with those of the “deteriorated SGA” group. Results: Of 1056 patients, 489 were males and 567 females. 546 were newly diagnosed while 510 had recurrent disease. Most common cancer sites were breast (171), pancreas (159), lung (152), colorectal (146) and prostate (50). The mean age at diagnosis was 53.4 years. The median number of total patient visits were 4 (range 3 to 10). Median time between the baseline and last SGA visit was 131 days (range 13 to 184). At baseline, number of patients with SGA-A, SGA-B and SGA-C were 600, 357 and 99 respectively. At the last follow-

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up, number of patients with SGA-A, SGA-B and SGA-C were 597, 363 and 96 respectively. Between the baseline and last SGA, 641 (60.7%) patients had their SGA unchanged, 210 (19.9%) had an “improved SGA”, while 205 (19.4%) had a “deteriorated SGA”. Table 1 describes the differences in patient characteristics between the “improved SGA” and “deteriorated SGA” groups. Interestingly, there were no statistically significant differences between the 2 groups. Conclusions: The majority of our patients (>70%) undergoing nutrition assessment and intervention by NMST either maintained or improved their nutritional status during cancer treatment. However, some patients deteriorated, despite intervention. Since there were no differences observed between those who improved versus those who deteriorated, it might be a little early to predict patient response to nutritional intervention. Therefore, as ASPEN recommends, all oncology patients should receive nutrition assessment and intervention during cancer treatment. This analysis has limitations, including the lack of specific data on the treatment received, treatment response, and patient compliance to nutritional intervention.

106 - Fish oil-containing nutritional supplement attenuates weight-loss, inflammatory parameters, and increases energy intake in patients with non-small cell lung cancer treated with chemotherapy: A posthoc analysis. 1K Sánchez-Lara, J. Turcott, E. Juárez,  G. Villanueva, M.Garralda, O. Arrieta. 1Hospital Medica Sur, Mexico City, Mexico

Background: Cancer induced weight loss is associated with increased morbidity and diminished quality of life. Eicosapentaenoic acid (EPA) is of interest in cancer patients as it has potential to impact the inflammatory response and reduce catabolism. The aim of this study was to evaluate the impact of an EPA-containing oral nutritional supplement (EPA-ONS) on body composition, inflammatory parameters and energy intake in non small cell lung cancer (NSCLC) patients being treated with chemotherapy. Methods: NSCLC patients naïve to treatment were randomly assigned to receive 2 cans of EPA-ONS (2g of EPA daily) or isocaloric diet during 2 patlin/taxane chemotherapy cycles. Anthropometric measurement, dietary intake, and biochemical parameters were performed. Results. This abstract reports the findings of a posthoc analysis of patients included in EPA-ONS clinical trial, this further analysis showed that outcomes were significantly improved in when recommended dose EPA-ONS was consumed (80.6% and 67.8% after 1st and 2nd chemotherapy cycle respectively). 112 patients were

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included, (51 EPA-ONS and 61 control groups respectively) with no differences between groups at baseline. After the 2nd chemotherapy cycle, the EPA-ONS group had less weight loss (-0.42kg vs -1.86 kg, p<0.05) (Figure 1), reduction in weight loss percentage (0.67% vs 2.61% p<0.05), and improved dietary intake in total energy (+14.95 vs -242.87 kcal/day p=0.02), proteins (+5.11 vs -8.6 g/day p=0.05) and albumin levels (+0.11 vs -0.2 g/dl p=0.04); as well as significant, improvement in inflammatory parameters (IL-6, PCR, and neutrophil/lymphocytes index) compared to ONS group. There was no significant difference in overall survival between groups. Conclusion: comparisons indicated that EPA-ONS provides a therapeutic advantage by reducing inflammatory parameters, attenuating weight loss and improving energy and macronutrient intake in NSCLC patients undergoing chemotherapy. Nutritional intervention with EPA-ONS is safe, well-tolerated and provides a therapeutic advantage over standard ONS even when taken at 80.6% of the recommended dose.

107 - Effect of a Protein and Energy Dense Eicosapentaenoic Containing Oral Supplement on Loss of Weight and Inflammation in Cancer Cachexia Anne Voss1, Andrea Scripekova2, Tibor Csoka3, Ivan Kecskes4, Peter Vanek5 1Abbott Nutrition, Columbus, OH; 2Hospital Nov, Bratislava, Slovakia; 3NsP Dunajsha Streda, Dun. Streda, Slovakia; 4Hospital, Zukuba,Slovakia; 5Central Military Hospital-Teaching Hospital, Ruzomberok, Slovakia

Introduction: Unintended weight loss is evident in up to 80% of people with cancer and is associated with reduced response to therapy and poor outcomes. A protein and energy dense eicosapentaenoic acid containing oral nutritional supplement (ONS-EPA) has been shown to improve nutritional and physical outcomes in small randomized controlled trials of single tumor types. The purpose of this study was to evaluate the effect of ONS-EPA on weight, inflammatory blood parameters, compliance and quality of life in a larger sample size of weight-losing patients being treated for varying types of solid tumor malignancies. Methods: Adult patients undergoing anticancer treatment for solid malignant tumors and having lost > 5% of pre-illness weight in the previous 6 months, Karnofsky performance score >70 and life expectancy > 4 months were recruited to the study. Patients were excluded if they had diabetes or BMI > 30kg/m2. Patients were asked to take 2 containers of ONS-EPA (660kcal, 32g protein, 2g EPA; ProSure® Abbott Nutrition, USA)/day for 4 months and anthropometrics, blood parameters, quality of life, patient compliance, and adverse events were measured monthly (M1-M4). Data was analyzed by nonparametrical analysis of variance or two-way nonparametrical analysis by ranks. Results: From January 2009 to June 2010 482 patients (58% had gastrointestinal or lung cancer) from 53 oncology sites in the Slovak Republic were enrolled in the study. Patients on average were 61 years of age, had BMI of 22, and had lost an average of 8kg in the previous 3 months. Patients received anticancer therapy in the form of chemotherapy (55%), radiotherapy (22%), surgery (14%) and 10% had no or other treatment. Following a 10% weight loss prior to study entry, weight stabilized at all 4 time points during the study. There were small non-significant improvements in arm circumference (predominately in men) and waist circumference (predominately in women). Although neutrophils, leucocytes and lymphocytes, all inflammatory markers, decreased, C - reactive protein was the only one that showed a significant decrease (p=0.01) and albumin showed an increase (p 1.5 containers/day in 77% of patients after the M2, 75% after M3 and 69% after M4. The main reason for discontinuation of ONS-EPA (M1=14, M2=17, M3=15) was loss of appetite or nausea. There were no serious adverse events related to ONS-EPA intake. Conclusions: A protein and energy dense eicosapentaenoic acid containing oral nutritional supplement taken over a period of 4 months by weight losing patients being treated for solid tumor malignancies was well tolerated and stabilized weight loss. Inflammation improved demonstrated by a significant decrease in CRP and an increase in serum albumin.

108 - Nutritional screening is predicting use of health care resources and mortality in a university hospital population. A one-year follow up study. Randi J Tangvik1, Anne Berit Guttormsen2, Grethe S Tell2, Roy M Nilsen1, Andreas Henriksen3, Anette H Ranhoff3 1Haukeland University Hospital, Bergen, Norway; 2 University of Bergen, Norway; 3Kavli Research Centre, Bergen, Norway.

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Background and Aims: Disease related malnutrition is common in hospitalised patients and is associated with adverse outcome. Causes are complex and multifactorial. Tailored nutritional treatment, such as protein- and energy-enriched food and oral supplements, have been shown to improve nutritional status, prevent loss of body mass and function, reduce inflammation, complications and mortality in hospitalized patients. However, improving nutritional care in hospitals is a challenge. To improve practice at Haukeland University Hospital, Bergen, Norway, a campaign entitles “Good nutritional practice” was introduced. The goal was to provide proper nutritional care to patients with such needs, and nutritional screening were introduced to identify these patients. The aim of this study was to investigate whether the chosen screening tool could predict use of health care resources and mortality in a university hospital population during a one-year follow up. Methods: A total of 3034 adult, somatic inpatients were screened during seven repeated point prevalence surveys in 2008-9. The Nutritional Risk Screening (NRS2002) was used to identify patients at nutritional risk. Data on the utilization of hospital services and mortality over a one-year period were obtained from the patient-administrative database. Results: Patients at nutritional risk had increased median length of stay (16 vs 9 days, p<0.001), more days in hospital during one-year follow up (25 vs 14, p<0.001), more new admissions (2 vs 1, p<0.001), higher estimated costs of hospital services (36.600 vs 24.900 €/year, p<0.001) and increased mortality (36.4% vs 11.5%, p<0.001). After adjusting for age, sex and illness score, the difference were still significant. For patients at nutritional risk aged 40-60 years, mortality was four times higher. Near half of the patients at nutritional risk who were 60 years and older, died the following year. Conclusion: Being at nutritional risk, identified by NRS2002, was associated with increased mortality and use of hospital services in a University hospital population. One year mortality was four times higher for patients aged 40-60 years being at nutritional risk.

Encore: previously presented at ESPEN 2011 conference. Published: Clinical Nutrition Supplements, 2011, Vol.6, No.1 page 208-209. Available at http://clinicalnutritionsupplements.com. 109 - Malnutrition in Canadian Hospitals: Preliminary Results from the Canadian Malnutrition Task Force (CMTF) Johane Allard1, Khursheed Jeejeebhoy2, Manon Laporte3, Leah Gramlich4, Donald Duerksen5, Helene Payette6, Paule Bernier7, Heather Keller8 1Toronto General Hospital, University Health Network, Toronto, ON, Canada; 2St Michael's Hospital, Toronto, ON, Canada; 3Hôpital Régional de Campbellton / Campbellton Regional Hospital, Campbellton, NB, Canada; 4Alberta Health Services, Edmonton, AB, Canada; 5University of Manitoba, Winnipeg, MB, Canada; 6Research Centre on Aging, Sherbrooke, QC, 7Jewish General Hospital, Montreal, QC, Canada; 8University of Waterloo, Waterloo, ON , Canada 110 - Association of vegan diet with RMR and oxidative stress Saeed Hosseini1, Hoda Nadimi2, Mostafa Hosseini2, Abolghasem Jazayery2 1The Endocrinology and Metabolism Research Centre (EMRC), Tehran University of Medical Sciences (TUMS), Tehran, Iran; 2The School of Public Health and Institute of Public Health Research, Tehran University of Medical Sciences, Tehran,Iran.

Background: There is increasing evidence to suggest that a vegetarian diet low in fat and high in complex carbohydrates offer the potential for decreasing the risk of chronic disease .However, there is little information about the effect of vegetarian diets on resting metabolic rate (RMR) .The objective of this study was to determine the association of vegan diet with RMR and oxidative stress. Methods and materials: Participants were divided into two groups: vegetarian (VEG) (N=20) and non vegetarian (NVEG) (N=20). Resting metabolic rate (RMR), markers of oxidative stress related to lipids (malondyaldehyde) and proteins (protein carbonyl) and total antioxidant capacity (TAC) were measured in the two groups. RMR was determined by indirect calorimetry. The two groups were matched regarding to body mass index, sex and menstrual cycle. Energy and macronutrient intakes were determined using a 3-day food record and body composition was determined by bioelectric impedance. Results: VEG reported a significantly lower relative intake of protein (40.45 ± 19.41 gr/d vs. 56.96 ± 11.94 gr/d, p=0.04), whereas no differences were observed between daily energy, carbohydrate or fat intakes and body composition. NVEG exhibited a higher absolute RMR (1569.10 ± 348.24 Kcal/24h vs. 1354.7 ± 192.6 Kcal/24h, p=0.02)and a higher plasma concentration of protein carbonyl (1.09 ± 3.6 ng/mg vs. 0.81 ± 0.42 ng/mg,

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p=0.02) than VEG .No significant differences were observed in plasma TAC concentration and VEG exhibited a higher plasma concentration of malondyaldehyde (MDA). Conclusion: These results suggest that the lower RMR observed in VEG is partially mediated by differences in dietary macronutrient composition. Furthermore the lower plasma protein carbonyl concentration in VEG may be mediated by a higher intake of lipophilic antioxidants. A Higher intake of unsaturated fatty acids in VEG may cause a higher plasma MDA concentration.

Encore: previously presented at ESPEN 2011 conference. Published: Clinical Nutrition Supplements, 2011, Vol.6, No.1 page 114. Available at http://clinicalnutritionsupplements.com. 111 - Improved environment and individualized serving increased nutrition intake in hospitalized patients Tina Beermann1, Marie Mortensen1, Lotte Skadhauge1, Henrik Rasmussen2, Mette Holst1 1Aalborg University Hospital, 9100 Aalborg, Denmark 112 - Survival in Breast Cancer by Body Composition: Questioning the Obesity Paradox Maria Cristina Gonzalez1, Silvana Paiva Orlandi2, Denise Halpern-Silveira2, Carla Alberici Pastore1 1Universidade Católica de Pelotas, Pelotas,Brazil; 2Universidade Federal de Pelotas, Pelotas, Brazil

BACKGROUND: Malnutrition and loss of fat-free mass are often found in patients receiving chemotherapy, but breast cancer patients usually have a different behavior, with weight increment during the treatment. Obesity Paradox shows that patients with chronic obesity have a better chance of survival than normal-weight ones, but usually body mass index (BMI) is used to define overweight and obesity. The aim of the study was to evaluate the association between obesity as an excess of fat mass, from Bioelectric Impedance Analysis (BIA) and survival in breast cancer patients undergoing chemotherapy. METHODS: A prospective cohort was conducted with breast cancer patients starting a chemotherapy protocol in a Universitary Hospital. Bioelectrical impedance analysis was used to assess body composition and FFM index (FFMI = FFM (kg)/height2) and FMI (FMI = FM (kg)/ height2) were estimated. Low FFMI and high FMI were defined according to Kyle, 2005. Values of FFMI2 were considered low FFMI and FMI ≥ 8.2 kg/m2 were considered high FMI. The time of survival was monitored during 3 years after the first assessment. The Kaplan-Meier method was used to calculated survival and the multivariate Cox regression was used to evaluate the independent prognostic effect of the BMI, FFMI and FMI after adjustment for other variables. RESULTS: Seventy-three patients were evaluated with mean age of 55.8 ± 11.1 years old. According to the Patient Generated Subjective Global Assessment (PG-SGA) only 4.1% were severe malnourished and only 16.2% had lost weight in the first assessment. The mean fat mass was 36.8 ± 6.6% and 76.7% had overweight or obesity. Only 12.3% of the patients had lost weight in the previous months at the first assessment. Most of them were undergoing adjuvant chemotherapy and 78.8% were in tumor stage I or II. Only one patient (1.4%) had low FFMI and 74% had high FMI. There is a trend for a lower survival of patients with BMI2 (p = 0.06 for log-rank test). The Cox regression also showed no significant differences among the three BMI groups. When it was created only 2 BMI groups, (BMI2) then we found a higher mortality in women with normal BMI (p = 0.02). The median survival was lower in the normal BMI women than overweighed/obese ones (2.61 X 2.78 years, respectively) and overweight/obesity seems to be a protection factor for mortality (HR=0.30, p=0.03). When analysed by FFMI, only one patient has low FFMI, with a significantly higher mortality (p = 0.0001) and a shorter median survival than normal FFMI patients (1.07 X 2.71 years, respectively). Low FFMI seems to be a significantly risk factor, with a HR = 23.2 (p = 0.006). When obesity is defined as high FMI, there is no significantly difference between the two groups (high X normal FMI), with a similar median survival (2.65 X 2.78 years, respectively) and a no significant HR = 0.44 (Ci = 0.15 – 1.27). CONCLUSIONS: The breast cancer´s patients have special nutritional characteristics. Weight loss, severe malnutrition and low FFMI seem to be rare in this group of patients. Most of them are overweighed or obese, and this seems to be a protective factor for their survival. However, body composition analysis showed that an excess of FM is not a significant protective factor. Although it is not frequent, low FFMI influences the survival, instead of fat mass.

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113 - Phase Angle: Indicator of Nutritional Status and Prognosis for Hospitalized Dysphagic Patients Marina Carreira1, Francile Duarte1, Mariana Costa1, Ana Silva1 1University Hospital of São Paulo University, São Paulo, Brazil

Introduction: Dysphagia is defined as a difficulty in swallowing process that can lead to malnutrition, lowered immune function and increased mortality. Dysphagic patients often have high nutritional risk associated to anorexia, decreased ability to eat and drink or increased risk of pulmonary aspiration. In order to prevent nutritional depletion, it is necessary to identify individuals at nutritional risk and institute early appropriate nutritional strategies. The goals of this study were to assess the nutritional status of hospitalized patients with dysphagia, to determine its phase angle and correlate them with prognosis. Methods: A prospective study with hospitalized patients in general medicine of a university hospital admitted during the period 2008 to 2010. Anthropometric data were collected (weight, height, arm circumference, triceps skinfold thickness and arm muscle circumference), and biochemical data (albumin, hemoglobin, hematocrit, and C-reactive protein). The phase angle was determined by bioelectrical impedance analysis following a standardized protocol. SPSS 17.0 for Windows was used for statistical analysis. Results: The sample was consisted of 91 patients with dysphagia, equally distributed between the genders, mostly white (n = 67) and elderly (n = 73). Dysphagia was detected in acute form in 62.6% of subjects (n = 57). Analyzing the clinical outcome of the patients, it was found that 11.2% evolved to death (n = 11) and 88.8% were discharged. The anthropometric values were inadequate in more than 40% of individuals. This profile was confirmed by biochemical variables, where 66.0% of subjects had hemoglobin values below the reference standard. Hematocrit (72.5%) and albumin (68.9%) showed a similar trend. The mean phase angle was 4.66 ° (± 1.79 °), and 63.2% of patients presented values > 4°. It is noteworthy that the 11 individuals who died, only 3 had phase angle > 4°. The values of phase angle showed strong correlations with anthropometric data, biochemical data and age. Conclusion: In this study there was significant degree of depletion of nutrition reserves in dysphagic patients hospitalized with low values of body mass index, arm muscle circumference and triceps skinfold thickness. The phase angle showed positive association with the nutritional status and clinical prognosis.

114 - Association between Framingham risk score with dietary intakes and inflammatory markers in men with metabolic syndrome Kim Misung1, Cheongmin Sohn1, Woori Na1 1Wonkwang University, Iksan, South Korea

According to the Korean National Health and Nutrition Examination Survey, the prevalence of metabolic syndrome (MS) has been estimated 32.9% of the Korean men and cardiovascular disease (CVD) is among the main causes of death in Korea. The Framingham risk score (FRS) has long been used to assess the risk of a cardiovascular event and to identify patients for risk factor modification in health practice. Few data are available directly comparing the association between the FRS with habitual dietary intake and inflammatory markers of MS patients. Therefore, the purpose of this study was to evaluate the relationship of the FRS with dietary intakes and inflammatory biomarkers in men with MS. We conducted a cross-sectional study of 170 men (43.9±10.0 years) with MS; metabolic syndrome was defined as having three or more metabolic syndrome risk factors. Serum levels of high sensitive C-reactive protein (hs-CRP), interleukin-6 (IL-6), and adiponectin were examined. For nutrients intake analysis, participants were asked to complete the food frequency questionnaire (FFQ) using the prior 1-year as a reference time point. In order to estimate the FRS, the absolute CVD risk percentage in 10 years was calculated, which can be classified as low risk (20%). The participants with the lower risk had significantly lower systolic blood pressures, triglyceride, LDL-cholesterol, total cholesterol and IL-6 compared with participants with the higher FRS (p<0.05). FRS was negatively correlated with percentage of energy from protein(r=-0.155, p<0.05), vitamin C(r=-0.153, p<0.05), and polyunsaturated fatty acid intake (r=-0.186, p<0.05) after adjusting energy consumption. Serum IL-6 was positively associated with FRS (r=0.176, p<0.05). NO significant associations were observed between FRS and hs-CRP or adiponectin. IL-6 and dietary intake of polyunsaturated fatty acids together explained 6.6% of the variation in FRS levels in a stepwise multiple regression models. Our results provide some evidence that dietary fat intakes and IL-6

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are associated with FRS, and dietary modification may be a predictor to decrease the risk for CVD in MS patients.

Encore: previously presented at ESPEN 2011 conference. Published: Clinical Nutrition Supplements, 2011, Vol.6, No.1 page 212. Available at http://clinicalnutritionsupplements.com. 115 - What Do Patients Say About Nutrition Care in Canadian Hospitals? Heather Keller1, Johane Allard2, Paule Bernier3, Donald Duerksen4, Leah Gramlich5, Khursheed Jeejeebhoy6, Manon Laporte7, Helene Payette8 1University of Waterloo, Waterloo, ON, Canada; 2Toronto General Hospital, University Health Network, Toronto, ON,Canada; 3Jewish General Hospital, Montreal, QC,Canada; 4University of Manitoba, Winnipeg, MB,Canada; 5Alberta Health Services, Edmonton, AB, Canada; 6 St Michael's Hospital, Toronto, ON,Canada; 7Hôpital Régional de Campbellton / Campbellton Regional Hospital, Campbellton, NB, 8Research Centre on Aging, Sherbrooke, QC, Canada Encore: previously presented at ESPEN 2011 conference. Published: Clinical Nutrition Supplements, 2011, Vol.6, No.1 page 67. Available at http://clinicalnutritionsupplements.com 116 - Short bowel syndrome and home parenteral nutrition: an unusual complication related to bariatric surgery John Siepler1, Reid Nishikawa1, Andrew Ukleja2, Tom Diamantidis1, Rod Okamoto1 1Nutrishare, Inc, Elk Grove, CA, 2Cleveland Clinic Florida, Weston, FL 117 - Investigation of Risk Factors Associated with Objective Parameters of the Nutritional Status in Hospitalized Patients Vania Leandro-Merhi1, José Luiz Braga Aquino1 1Pontificia Universidade Católica de Campinas-SP-Brazil, Campinas, Brazil

Background: The investigation of risk factors associated with nutritional status could contribute for better knowledge of the malnutrition. The objective of this study was to investigate the incidence of malnutrition and its possible association with many parameters that assess nutritional status and to identify the associated risk factors. Methods: The nutritional status was assessed in 235 hospitalized patients. The malnutrition was defined as present when the patient presented at least 2 anthropometric criteria below the normal range and habitual energy intake below 75% of the energy requirement (HEI/ER<75%). Gender, age, type of disease, recent weight change and dental problems were investigated as possible associated risk factors. The chi-square and Mann-Whitney tests were used to compare the data and univariate and multiple logistic regressions were used to identify the factors associated with malnutrition. The odds ratio (OR) and confidence interval (CI) of 95% were calculated with the significance level set at 5% (p<0.05). Results: One fifth (20%) of the patients were malnourished on admission to the hospital and 27.5% reported recent weight loss. The malnutrition (p<0.0001) which was greater in patients with malignant diseases. The only variables significantly associated with malnutrition according to univariate logistic regression were recent weight loss (p=0.0058; OR=2.909; IC95%=1.362; 6.212) and malignant disease (p=0.0001; OR=3.847; IC95%=1.948; 7.597). When multiple regression was used in the model which included type of disease, malignant disease was shown to increase the chance of malnutrition fourfold (p=0.0002; OR=3.855; IC95%=1.914; 7.766). When disease was excluded, recent weight loss also increased malnutrition fourfold (p=0.0012; OR=3.716; IC95%=1.677; 8.236). Conclusions: Patients with a history of recent weight loss and those with malignant diseases are more susceptible to malnutrition.

118 - Teaching Nutrition Support and the Nutrition Care Process: A Case-Based Approach Elizabeth Emery1 1La Salle University, Philadelphia, PA

Introduction: Case-based learning gives students the opportunity to apply classroom knowledge to patient scenarios in a structured learning environment. The case-based approach promotes active learning, helps students to identify important elements of care, and builds critical thinking and problem solving skills. The case study approach can be used as a novel method to teach the Nutrition Care Process and

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Model (NCPM). The NCPM was introduced by the American Dietetic Association (ADA) in 2003 as a problem solving method that is intended to, amongst other things, facilitate communication and outcomes research. Dietetic practitioners and educators have been challenged to adopt this model and its associated standardized terminology. The joint standards task force of the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) and the ADA developed standards of practice for Registered Dietitians in Nutrition Support that are based on the NCPM and include the use of standardized language to identify a nutrition diagnosis. It is incumbent upon Nutrition Support Dietitians to follow the NCPM in order to practice in compliance with professional standards. Description: 21 case studies were developed based on the experience of practicing clinicians and structured around the format of the NCPM. Case studies ranged from basic nutrition assessment and care to pediatrics, cardiology, endocrine, renal, oncology, hematology, gastrointestinal disease, and nutrition support in trauma and burns. Learning objectives were identified, data was presented in a format consistent with the NCPM, and a series of questions were asked. Students were required to use standardized terminology to identify an appropriate nutrition diagnosis and to suggest intervention and monitoring strategies for patients. Sample Case Study: A 77-year old man with a history of smoking, hyperlipidemia, and hypertension was admitted to the ICU after a left hemispheric stroke. He was intubated and sedated. A small bore nasogastric tube was placed for enteral feedings. Nutritional assessment data included a height of 175 cm and a weight of 79 kg, unremarkable biochemical data and nutrition-focused physical findings, and treatments that included propofol at 15 mL/h and normal saline at 60 mL/h. Students used the data to assess nutritional status, calculate nutritional needs, and write a problem, etiology, and signs and symptoms (PES) statement. In addition, they determined an appropriate enteral feeding progression considering the caloric content of the intravenous medication. Five days later, sedation was lifted and the patient was extubated. A bedside swallowing evaluation revealed minimal delay in swallowing and appropriate management of oral secretions. Students were asked to discuss transition to a dysphagia diet and to identify monitoring and evaluation strategies for their interventions. Discussion: Presenting students with case study problems prepares them to solve similar situations in clinical practice. In addition to predetermined questions, other aspects of patient care can be explored through classroom discussion. Both students and seasoned clinicians could benefit from tangible examples of the use of the Nutrition Care Process in medical nutrition therapy. We intend to evaluate the use of this applied approach prospectively with dietetic interns and preceptors to document the outcomes of case-based learning in the clinical setting.

119 - Elderly nutritional status impacts on mortality? Telma Roberto1, Celso Cukier1, 2, Daniel Magnoni2, Karla Achkar3, Regina Stikan3, Marenice Azanha3, Jerlandia Souza4, Maete Requena4 1Instituto de Metabolismo e Nutrição, São Caetano do Sul, Brazil; 2Hospital Bandeirantes,São Paulo, Brazil; 3Hospital São Camilo Pompéia, São Paulo, Brazil; 4Hospital Estadual de Vila Alpina, São Paulo, Brazil

Introduction / Objectives Nutritional status has prognostic correlation in hospitalized patients, so that malnutrition is directly related to mortality in adults, but few studies have been validated in elderly subjects. The aim of this study is to compare the population of malnourished and not malnourished elderly in relation to their impact on mortality. Methods There have been evaluated 551 elderly patients (52.9% women) with mean age of 81 +7 in two hospitals in the city of São Paulo (Brazil). Patients underwent objective nutrition evaluation at hospital admission and were divided into groups: undernourished (D) and non-malnourished (ND) and each group were analyzed for the variable mortality. All patients received early enteral nutrition (within 48 hours). Results The mortality found in group D was 47.5% higher than the ND group (40% vs. 21%, respectively). Conclusions The nutritional status of elderly patients that are obtained through objective nutrition evaluation should be done at hospital admission and their results have prognostic correlation.

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CLINICAL NUTRITION WEEK 2012 ABSTRACTS: PEDIATRIC / NEONATAL 120 - Outcomes of Parenteral Nutrition-Associated Cholestasis in Children: A Retrospective Analysis Mark MacKay1, Emily Gish1, Daniel Jackson1, Christian Larsen1, Katie McDonald1 1Primary Children's Medical Center, Salt Lake City, UT

Background: Hepatic dysfunction secondary to parenteral nutrition PN is commonly encountered and has been identified as a source of severe morbidity and a life-threatening complication in neonates, infants, and children. Studies indicate that approximately 40-60% of children on long-term PN therapy will develop hepatic dysfunction. Cholestasis is the most common parenteral nutrition-associated hepatobiliary dysfunction in children. Cholestasis is defined as having a conjugated bilirubin level ≥ 2 mg/dL and occurs most commonly after the first 2 weeks of PN therapy. A recent retrospective study found that infants with parenteral nutrition-associated cholestasis (PNAC) had a high rate of mortality. The purpose of this retrospective analysis was to determine the outcomes (i.e., morbidity, mortality) of PNAC in pediatric patients receiving long-term (≥ 2 weeks) PN in a large, non-profit, pediatric tertiary medical center. Methods: This retrospective, observational study utilized data obtained from the corporate electronic data warehouse. Exempt status was granted by the local IRB. Pediatric patients (≤ 18 years of age) receiving PN ≥ 2 weeks with an average conjugated bilirubin concentration ≥ 2 mg/dL between March 2007 and November 2010 were identified for inclusion. The primary outcome measures were morbidity (i.e., liver transplant) and mortality related to an average conjugated bilirubin concentration ≥ 2 mg/dL in pediatric patients with PNAC. Secondary outcome measures were the correlation between morbidity/mortality and the following: conjugated bilirubin concentration, age, prematurity ( 2 weeks on PN and < 1 year of age have weekly conjugated bilirubin levels. Possible interventions include macro- and micronutrient adjustments in PN and initiation of trophic feeds.

121 - The Efficacy and Safety of High Dose Amino Acid Administration to Preterm Infants in the Early Neonatal Period Park Hyo Jung1, Yoon Ji Hye1, Chung Seon Young1, Chang Hyo In1, In Yong Won1, Sohn Kie Ho2, Lee Young Mi1 1Samsung Medical Center, Seoul, Korea; 2Kyungsung University, Busan, Korea

Introduction: In preterm infants, high dose amino acid administration is strongly recommended from the first day of life for growth of lean body tissue and synthesis of hormones and enzymes without adverse effects such as azotemia, hyperammonemia, and metabolic acidosis. Methods: In the neonatal intensive care unit (NICU) at Samsung Medical Center, the initial postnatal dose of parenteral amino acid was changed from 0.5 g/kg/day to 1.5~2 g/kg/day in June 2009. This study retrospectively evaluated the efficacy and safety of increased initial dose of parenteral amino acid, comparing an historic control group (initial parenteral amino acid was 0.5 g/kg/day) and the study group (initial parenteral amino acid was 1.5~2 g/kg/day). The efficacy of high dose amino acid was assessed by growth for 28 days after birth, nutritional outcomes and length of stay in NICU. Biochemical data, parenteral nutrition (PN)-induced complications, and diseases that occurred during PN administration were investigated to evaluate safety. Results: Demographic characteristics in the two groups were similar except for the longer gestational age in the study group (p<0.05). Weight gain in the study group was much higher than that in the historic control group (p<0.05). In multivariate analysis, the only influencing factor on weight gain was the initial dose of parenteral amino acid. Although total calories supplied and days to achieve effective oral or enteral feeding were not different between the two groups, days to reach nutritional goal and length of stay in the NICU were shortened in study group (p<0.05). No difference was observed in the incidences of metabolic acidosis, respiratory distress syndrome and necrotizing enterocolitis between the two groups. Incidence of infection, hyperglycemia, bronchopulmonary dysplasia and intraventricular hemorrhage were reduced in the study group (p<0.05). Conclusions: High dose of parenteral amino acid improved weight gain in the early neonatal period and reduced the length of stay in the NICU and days to reach nutritional goal without adverse effects. Therefore, 1.5~2 g/kg/day of parenteral amino acid as the initial dose is efficient and safe for preterm infants.

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122 - Quality Improvement Strategies Can Improve Nutrient Delivery in Mechanically Ventilated Children: Single Center Results from the Pediatric International Nutrition Study 2009 and 2011 Heather Skillman1, Lori Bechard2, Angela Czaja3, Peter Mourani3, Nilesh Mehta2

A144 1Children's Hospital Colorado, Aurora, CO; 2Children's Hospital Boston, Boston, MA; 3University of Colorado Denver, Aurora, CO

Introduction: Barriers to optimal nutrition delivery in critically ill children may result in worse outcomes. Therefore, we initiated a quality improvement (QI) intervention to improve nutrient delivery for pediatric intensive care unit (PICU) patients. Methods: The Children’s Hospital Colorado PICU participated in two international multicenter pediatric nutrition studies (2009 and 2011) conducted by Children’s Hospital Boston investigators. With institutional review board approval, consecutive patients aged 1 month to 18 years requiring mechanical ventilation within the first 48 hours of PICU admission were enrolled. Clinical and nutrition data [nutrition prescription, total daily energy (Kcal) and protein intake (grams)] were recorded daily for up to 10 PICU days. Based on barriers identified in the 2009 study, a systematic intervention to improve nutrition delivery was designed and implemented 6 months prior to the 2011 study (Table 1). The main components included clinician education and the introduction of a revised PICU nutrition support protocol. We then assessed the 2011 cohort data for changes in PICU nutrition practices and nutrient intake following the intervention. Results: Compared to the 2011 cohort (n=40), the 2009 group (n=42) had more medical patients (particularly those with respiratory failure during the H1N1 pandemic), with higher severity of illness (median PRISM III, 12.5 in 2009 vs. 3.5 in 2011), ventilator days (9.5 days in 2009 vs. 5 days in 2011), and PICU length of stay (12 days in 2009 vs. 6.5 days in 2011). The 2009 data revealed inadequate energy and protein delivery, and highlighted barriers and deficiencies in bedside nutrition practice. After implementation of QI interventions, enteral nutrition (EN) was initiated earlier in the PICU course (average PICU day 3.4 in 2009 vs. PICU day 2.1 in 2011). Furthermore, the percentage of patients receiving EN increased from 52.4% to 62.5%, while parenteral nutrition (PN) use decreased from 35.8% to 12.5%. As a result, nutrient intake in the 2011 group was much closer to the prescribed energy and protein goal than in the 2009 cohort (Figure 1). Conclusions: Improvements in energy and protein delivery were achieved in our PICU following implementation of targeted QI strategies, possibly secondary to better adherence to nutrition protocols, faster EN initiation, fewer avoidable EN interruptions, and increased involvement of the PICU dietitian. The lower severity of illness in the follow-up cohort may have also enhanced adherence to nutrition guidelines. Future efforts will be aimed at continued advances in nutrition care with particular attention to their impact on outcomes in critically ill children.

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123 - Breast Milk Stored at 4ºC or -20ºC Causes Cell Death: Implications for Necrotizing Enterocolitis and Current Storage Practices Alexander Penn1, Angelina Altshuler1, James Small1, Sharon Taylor1, 2, Karen Dobkins1, Geert Schmid-Schönbein1 1UCSD, La Jolla, CA; 2Rady Children's Hospital San Diego, San Diego, CA

Introduction: Necrotizing enterocolitis (NEC) is the leading cause of death from gastrointestinal disease in premature infants and is characterized by hemorrhagic necrosis primarily in the small intestine. We have recently shown that lipase digested formula, but not lipase-digested fresh human breast milk or breast milk stored at -80ºC, is cytotoxic via the detergent action of unbound free fatty acids (FFAs), and thus could contribute to intestinal damage in NEC. Though the risk is lower than if fed formula, infants fed breast milk sometimes develop NEC. As breast milk contains its own lipase capable of generating FFAs, we wished to determine if storage of breast milk at 4 ºC or -20 ºC (current practice), would also result in cytotoxicity. Methods: We digested fresh or stored (3 or 7 days at 4 ºC or -20 ºC) human breast milk (N=12) for 2 hrs at 37 ºC with phosphate buffered saline (as control), pancreatic lipase, protease (trypsin and chymotrypsin), or lipase + protease and tested for cytotoxicity on isolated human neutrophils and concentration of total and unbound FFAs. We also measured lipase activity in fresh and 7 day stored milk. Results: Control breast milk became cytotoxic when stored for 7 days at 4 ºC (46.6±38.1% cell death vs 3.0±1.7% with fresh milk; P<0.0024), but not if stored at -20 ºC (3.7±2.4% cell death). However, milk digested with lipase was significantly cytotoxic by day 3 if stored at either 4 ºC (43.1±22.9%; P<0.0002) or -20 ºC (18.5±12.2%; P<0.002 vs fresh, P<0.0008 vs 4 ºC). FFAs were significantly elevated after storage for 7 days at 4 ºC (1.62±0.86 mM in control stored milk vs. 0.12±0.11 mM in control fresh milk; P<0.00008) and the concentration of unbound FFAs correlated well with cell death (correlation coefficient = 0.71). Lipase inhibition with 0.25 mg/ml orlistat prior to storage or glass fiber filtration to remove unbound FFAs reduced cell death in milk stored for 7 days at 4 ºC (P<0.016 and P<0.05, respectively, for both control milk and milk digested with lipase + protease), supporting a role for FFAs as the cytotoxic mediator. Though cell death from control milk stored 7 days at 4 ºC did not correlate with the lipase activity at that time (2581±1919 relative fluorescent units [RFUs]), or with lipase activity at the time the milk was fresh (2700±1217 RFUs), we observed that freezing significantly increases lipase activity (3838±2329 RFUs after 7 days at -20 ºC; P<0.0006). Protease digestion of stored milk at all temperatures decreased cytotoxicity (P<0.01), likely through exposure of FFA binding sites. Conclusions: We conclude that current storage practices for human breast milk can result in free fatty acid formation and cytotoxic milk and thus could contribute to NEC. Current storage practices may need to be reevaluated in light of these findings.

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124 - No Association of Bisphenol A with Obesity or Metabolic Function in Children Cade Nylund1 1Uniformed Services University of the Health Sciences, Bethesda, MD

Background: Bisphenol A (BPA) is a chemical found in the polycarbonate plastics such as those used in baby bottles, and the epoxy coating of food and beverage cans. BPA is suspected of causing metabolic disruption in animals and humans, and previous studies of adults have found elevated BPA levels to be associated with obesity, heart disease, diabetes, and elevated liver enzymes. The effect of BPA on obesity and metabolic function in children is not known. This study seeks to evaluate the association of BPA with obesity and with other markers of metabolic dysfunction in children. Methods: Cross sectional analyses of urinary BPA concentrations and age-adjusted body mass index (BMI) percentiles were performed utilizing pooled data from the 2003/04, 2005/06, and 2007/08 National Health and Nutrition Examination Surveys. Participants ages 6-18 years old who had a measured urinary BPA level, weight and height were evaluated. Participants who were pregnant were excluded. Data provided by the Centers for Disease Control and Prevention were utilized to calculate BMI percentiles for each participant. BPA was evaluated as a continuous variable and BMI was evaluated both as a continuous variable and a categorical variable with BMI categories of over 85% (overweight) and 95% (obese). Additionally, the association of BPA and serum levels of glycohemoglobin (HgbA1c), glucose, alanine aminotranferase (ALT), aspartate aminotransferase (AST), triglycerides, total cholesterol and HDL cholesterol were evaluated. Results: A total of 1860 children were evaluated. The mean BPA level was 4.97 ng/ml (+/-0.21). BPA concentrations did not vary by sex, or age. Non-Hispanic Black children had significantly higher levels of urinary BPA (mean 6.36 +/- 0.63 ng/ml; p = 0.029)compared with Caucasian children (mean 4.76 +/- 0.24 ng/ml), Mexican American children (mean 4.07 +/- ng/ml), and Other Hispanic children (mean 4.90 +/- 0.32 ng/ml). BPA levels were not associated with BMI (p =0.680), and elevated BPA was not associated with the classifications of overweight (p=0.874), and obese (p=0.363). BPA levels were not associated with serum levels of HgbA1c (p = 0.906), glucose (p =0.4257), ALT (p=0.566), AST (p=0.4122), triglycerides (p =0.737), cholesterol (p=0.216) and HDL cholesterol (p=0.131). Conclusion: In the U.S. pediatric population urinary BPA concentrations are not associated with BMI or classification as overweight or obese. Non-Hispanic Black children have a higher urinary BPA level. This may be due to differences in processed food intake or metabolism of BPA. BPA is not associated with abnormalities in serum glucose, lipids or liver enzymes. The study is limited by the cross sectional design and relatively small number of subjects. Future longitudinal studies of BPA in children are needed to sort observed differences seen in ethnic populations and determine whether there are potential consequences of these differences.

Encore: Previously presented at NASPGHAN Oct. 2011 Conference. Predecessor abstract available at: http://www.naspghan.org/user-assets/Documents/pdf/Annual%20Meeting%202011/Speaker%20presentations/2011%20NASPGHAN%20abstracts_JPGN.pdf 125 - PICCing the Right Catheter Russell Merritt1, Li Hong2, Pui Yuk Yan1, Choo Phei Wee1, Kim Rinauro1, Phillip Stanley1, Tracy Grikscheit1 1Childrens Hospital of Los Angeles, Los Angeles, CA, 2Shanghai Children’s Medical Center, Shanghai

Introduction: Infants and children with severe, chronic intestinal failure require long-term intravenous access for parenteral nutrition. Intravenous catheter options include percutaneously inserted central catheters (PICC) and surgically tunneled catheters (Bro). Methods:We retrospectively compared adverse events from PICC and Bro in 25 children (15 females, 10 males) aged 3 months to 19 years in a pediatric home parenteral nutrition program over a 30-month time period. During this interval, we collected data on 52 PICC and 28 Bro including 3755 PICC and 5311 Bro days. Adverse events were characterized as mechanical, metabolic, or infectious and were tabulated per 1000 catheter days. Results: There were 79 adverse events in 19 patients. There were no adverse events in 6 patients. In total, 23 catheters were censored at the end of study. There were more mechanical complications in PICC with incidence rate of 7.46 per 1000 catheter days compared to Bro with incidence rate of 1.13 per 1000 catheter days (p <0.0001). Presumed catheter infections expressed per 1000 catheter days (positive blood culture drawn through the catheter) were higher in PICC with incidence rate of 6.39 vs. 3.77 in Bro (p=0.0824). The

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incidence rates for mechanical complications were higher in PICC than BRO across the age groups. Mechanical and infectious adverse event rates for PICC was highest in 0-0.5 year olds. Infection rates tended to be higher for PICC than for Bro for all but 0.5 to 3 year olds. Discussion: The data demonstrated that in children with long-term access for parenteral nutrition and intestinal failure, PICC has a higher adverse event rate than Bro (p <0.0001). When selecting the most appropriate catheter, the potential for complications requiring therapy at various ages, including hospitalization, as well as vein-sparing considerations, need to be factored into the decision.

126 - Evaluation of parenteral nutrition-associated liver disease in infants with necrotizing enterocolitis before and after the implementation of feeding guidelines Johanna Norman1, Emma Tillman2, Catherine Crill2, Linda Lazar1, Eunice Huang2 1Le Bonheur Children's Hospital, Memphis, TN; 2The University of Tennessee Health Science Center, Memphis, TN

Background: Parenteral nutrition-associated liver disease (PNALD) occurs in 40-60% of children on long-term therapy for intestinal failure, and there is an even higher incidence in preterm neonates. Resolution of PNALD normally requires advancement of enteral nutrition (EN) with concomitant discontinuation of PN. In 2009, a multi-disciplinary intestinal rehabilitation team developed and implemented feeding guidelines based on disease state, residual small bowel length, bowel continuity with colon, and patient weight. Clinical observations suggest that there was a greater incidence of PNALD in infants with necrotizing enterocolitis (NEC) before the implementation of feeding guidelines at our institution. The purpose of this study was to determine the effect of enteral feeding guidelines on the incidence of PNALD in infants with NEC. Methods: This retrospective study included infants treated for NEC at a regional surgical referral center during 18 month time periods before and after the implementation of enteral feeding guidelines for post-surgical gastrointestinal patients (November 2007–April 2009 and January 2010–June 2011, respectively). Infants were excluded if they were transferred to another facility or expired before they had been treated for 14 days. Demographic, laboratory, surgical, and nutritional data were collected. PNALD diagnosis was based on elevated bilirubin and transaminases in the absence of other causes of liver disease. PNALD was defined as a total bilirubin >3 after ≥14 days of PN exposure. Direct bilirubin measurements are not routinely used at our institution; however, patients were outside the time period of physiologic jaundice so assessment of total bilirubin was used as a surrogate for direct bilirubin. Results: Ninety-four infants with NEC were included in analysis (39 male/55 female). Forty-six were treated before and 48 were treated after the implementation of feeding guidelines. Of the 48 infants treated after guideline implementation, 31 were placed on a feeding guideline, and 17 were not because they did not have surgery (n=16) or were omitted (n=1). Gestational age and birth weight were similar between the two groups, 29.2 ± 4.6 weeks vs. 29.1 ± 4.6 weeks and 1440.5 ± 923.3 grams vs. 1390.7 ±

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907.6 grams, respectively. Mean age at diagnosis was 17.7 ± 13.6 days vs. 14.1 ± 12.9 days. The severity of NEC was not significantly different between the two groups. The period of time NPO was longer prior to the implementation of feeding guidelines, 29.3 ± 19.8 days vs. 19.2 ± 9.7 days, respectively (p=0.002). The duration of PN was also longer with 25 infants (54%) vs. 13 infants (27%) still dependent on PN at 90 days (p=0.007). Thirty-six infants (78%) developed PNALD before the feeding guidelines vs. 21 infants (44%) after the guidelines (p=0.001). Conclusions: Implementation of feeding guidelines at our institution resulted in a decreased duration of time NPO and PN support. Significantly fewer infants developed PNALD once enteral feeding guidelines were established at our institution. These data suggest that the use of feeding guidelines may expedite the transition from PN to EN and improve patient outcomes.

127 - Elevation of Serum Chromium Levels in Pediatric Home Parenteral Nutrition Patients After Trace Elements Adjusted Due to National Shortage Jessica Monczka1, Tejas Mehta1 1Orlando Health - Arnold Palmer Hospital for Children, Orlando, FL

Background Long term home parenteral nutrition (HPN) patients often require adjustments to their trace elements (TE) to avoid toxicity. Chromium (Cr), which is generally provided as part of a multi-trace element (MTE) product, is also present as a contaminant in many HPN component solutions. Elevated Cr levels may lead to toxicity. In 1992 Moukarzel et al studied 15 children receiving HPN for a median of 9.5 years and found an inverse correlation between glomerular filtration rate (GFR) and serum Cr. They also noted that the study patients had serum Cr levels 20 times higher than non-HPN controls.(1) Similarly, Howard et al measured Cr levels in heart, skeletal muscle, liver, and kidney tissues at autopsy of 8 patients with short bowel syndrome (SBS) who had received HPN for an average duration of 14 years. Tissue Cr levels were found to be 10 to 100 times higher than age-matched controls.(2) Because of these known problems with Cr toxicity in long term HPN and correlating biochemical evidence of excess Cr among our patients, we had adjusted the TE to reduce the amount of Cr provided. By giving individual zinc, copper, and selenium, we had been able to avoid giving additional Cr from the MTE (American Regent, Trace Elements Injection 4 USP Pediatric, Product Number 0517-9310-25). Unfortunately, with recent national shortages of HPN products, we have had to revert back to a MTE product which once again provides Cr. Methods Retrospective chart analysis was performed to determine the trend in measured serum Cr levels (Mayo Clinic Department of Laboratory Medicine and Pathology, Unit Code 8638, normal less than 0.3 ng/ml) in current HPN patients who have had TE adjusted in the HPN solutions. Results We present a case series of 3 pediatric SBS patients aged 2 to 5 years, receiving a combination of oral, enteral, and HPN. The HPN contained individual copper, zinc, and selenium in lieu of the MTE product for 33 months in patient A, 20 months in patient B, and 16 months in patient C. Despite receiving no Cr in their HPN for an average of 23 months, the patients maintained elevated serum Cr levels of 0.9 ng/ml, 1.6 ng/ml, and 1 ng/ml respectively. Due to national product shortages, the patients were then converted back to MTE. Serum Cr levels subsequently increased to 2.2 ng/ml, 4 ng/ml, and 1.9 ng/ml respectively. These elevations occurred after an average of 64 days on the MTE. Serum creatinine levels were also collected and were unchanged at 0.3 mg/dl for all 3 patients. Conclusions The amount of Cr in HPN solutions is likely higher than prescribed due to contamination of component solutions. Elevated levels of Cr in HPN patients could lead to impaired renal function. The available MTE solutions do not seem optimal for providing appropriate doses of the necessary TE, and many facilities have therefore adjusted the TE composition for their long term HPN patients by providing individual components separately. With the recent national shortages, practitioners have been forced to revert back to MTE solutions that may contribute to worsening elevations of certain TE, including Cr. Clinical working groups are addressing these issues and should continue to work towards improving the available MTE products and reducing national shortages. References 1) Moukarzel AA, Song MK, Buchman AL, et al. Excessive Chromium Intake in Children Receiving Total Parenteral Nutrition. Lancet 1992;339:385–388. 2) Howard L, Ashley C, Lyon D, et al. Autopsy Tissue Trace Elements in 8 Long-term Parenteral Nutrition Patients who Received the Current U.S. Food and Drug Administration Formulation. JPEN 2007;31:388–396.

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128 - Nutritional Management and Growth of Infants with Failure to Thrive and Severe Combined Immunodeficiency Mary Barron1, Lorrie Hagen1, Paul Pencharz1, Melanie Makhija2, Eyal Grunebaum1, Chaim Roifman1 1The Hospital for Sick Children, Toronto, ON, Canada; 2Children's Memorial Hospital, Chicago, IL

Background: Severe combined immunodeficiency (SCID) is a group of inherited diseases that present in infancy with pneumonia, chronic infections, diarrhea and failure to thrive (FTT). The only cure for SCID is Bone Marrow Transplant (BMT). In our recently published study (J Pediatr) we showed that infants with SCID are hypermetabolic, adding to the difficulty of providing adequate nutrition. Our abstract outlines the nutritional management and growth parameters of infants with FTT and SCID pre-BMT. Methods: All infants (< 12 months of age) diagnosed with both SCID and FTT who received BMT at The Hospital for Sick Children (SickKids) over a 13-year period were included. Weight (Wt) and Length (Ht) data were collected at diagnosis; when energy goals were achieved then 1 month and 2 months later. Indirect calorimetry was done on all patients to determine resting energy expenditure (REE). Energy goal was determined by REE x factor of 1.7 for catch-up growth. The data was analyzed by repeated measures ANOVA with the PROC GLM procedure to assess the effect of time on changes in Wt and Ht. When significant differences were identified, individual differences were assessed by post hoc analysis with Bonferroni correction for multiple comparisons. Results: Twenty-six patients were diagnosed with SCID; and 15/26 (58%) were FTT. Of the 15 FTT patients, 7/15 (47%) had serial growth data available for analysis. All study patients (n=7) were hypermetabolic. The mean measured metabolic rate was 154% (range 124-196%) predicted for age/gender based on the WHO predictive equations. There were 2 females; 5 males with a mean age of 6.1 months (range 3-10 months). The genetic defects included: IL2Rg (5/7, 71%); ADA deficiency (1/7, 14%) and ND (1/7, 14%). The most common phenotype was T- SCID 5/7 (71%). The presenting features at diagnosis were FTT 7/7 (100%); diarrhea 6/7 (86%) and pneumonia in 4/7 (57%). Actual energy intakes at diagnosis were significantly lower (75-145 kcal/kg/day; mean=105) compared to energy goals (114-166 kcal/kg/day; mean=134) (p <0.0001, t test). Energy goals were achieved by a combination of methods; 5/7 (71%) required Total Parenteral Nutrition (TPN), 5/7 (71%) required an elemental formula and 3/7 (43%) required nasogastric tube (NG) feeding. One patient met their goal with oral elemental formula at 1.0 kcal/ml. Six of 7 (86%) patients required more than one feeding method to achieve their goal: TPN/oral formula (3), TPN/NG (2), oral/NG (1). Six of 7 patients had the energy density of the formula increased: 0.8 kcal/ml (2) and 1.0 kcal/ml (4). Energy goals were achieved at a mean 22 days (range 7-39 days) after diagnosis. Wt and Ht were measured again at 1 month (mean 43 days) and 2 month (mean 36 days) intervals after energy goals were achieved. Mean Ht at diagnosis was 66 cm (range 56.5-73cm); mean wt at diagnosis was 6kg (range 3.8-7.6kg). There was a significant difference in length (p<0.0001) from diagnosis to 2 months; and from goal to 2 months. There was no difference in length from diagnosis to goal; from goal to 1 month; and from 1 month to 2 months, see Table 1. There was a significant difference in weight (p<.0001) at all time points except diagnosis to energy goal, see Table 2. Conclusion: It was previously thought that weight gain and growth was not expected in infants with SCID prior to transplantation and immune reconstitution. We provided adequate energy to meet patient’s increased metabolic needs which resulted in significant weight gain and growth prior to BMT. Therefore, nutrition intervention should commence as soon as possible after the diagnosis of SCID in those infants presenting with FTT.

129 - Re-infusion of Chyme Through Mucous Fistula Decreases the Dependence on Parenteral Nutrition in Neonates Douglas Drenckpohl1, Mark Holterman2, Huaping Wang2, Kamlesh Macwan2, Richard Pearl2 1Children's Hospital of Illinois, Peoria, IL; 2University of Illinois College of Medicine at Peoria, Peoria, IL

Background: Neonates undergoing a bowel resection may require a creation of an ostomy and mucous fistula. Ostomies that are proximal to the stomach, can cause functional short bowel syndrome (SBS) and require neonates to receive long term parenteral nutrition (PN). Neonates with functional SBS have decreased surface area for absorption, especially if the distal bowel is not being utilized. Case reports have shown re-infusing chyme into the mucous fistula improves feeding intolerance in neonates and decreases or eliminate their dependence on PN. Hypothesis: The primary hypothesis was that neonates who have re-infusion of chyme into the mucous fistula would have less dependence on PN. Secondary

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outcomes were that neonates will have appropriate weight gains during re-infusion of chyme, and tolerance to the type of ostomy placement. Methods: This was a retrospective cohort study from January 2000 to December 2010 reviewing medical records of neonates who received mucous fistula feedings during their hospitalization. The Community Institution Review Board approved this study as exempt status. Descriptive statistics were used to analyze the data. Fisher test and Chi square were used for categorical variables, and t-test and Mann Whitney U were used for continuous variables. Results: Twenty nine infants who had mucous fistula refeedings ordered were analyzed. Seventy nine percent of the neonates were premature (37 weeks). Sixty five percent of the premature infants had their PN discontinued during mucous fistula refeedings. Sixty-seven percent of the term infants were able to have their PN discontinued during mucous fistula refeeding (Table 1). Of those infants who remained on PN during re-infusion of chyme, premature infants were able to receive 80+30% from enteral nutrition and term infants were able to receive 85+24% from enteral nutrition. The average weight gain during mucous fistula refeeding for premature infants was 22+8 grams/day and 24+14 grams/day for term infants. Significantly more infants with ileostomies (Table 2) were able to have PN discontinued than infants with jejunostomies 80% versus 37% (p=0.042). Weight gains were similar between the two types of ostomies. Infants with ileostomies and mucous fistula refeeding averaged 22+8 gm/day, while infants with jejunostomies and mucous fistula refeeding averaged 20+9 gm/day. Conclusions: Re-infusion of chyme into the mucous fistula decreases or eliminates a neonate’s dependence on PN without compromising weight gains.

130 - Adding Dietary Green Beans to Formula Resolves The Diarrhea from a Bowel Resection in Neonates Douglas Drenckpohl1, Kamlesh Macwan2, Huaping Wang2, Richard Pearl2 1Children's Hospital of Illinois, Peoria, IL, 2University of Illinois College of Medicine at Peoria, Peoria, IL

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Background: Neonates who undergo a bowel resection due to a congenital anomaly or necrotic bowel may be at risk for developing diarrhea, due to decreased absorptive surface area or a nonfunctioning gastrointestinal tract. Neonates with chronic diarrhea can become dependent on long term parenteral nutrition (PN), which can place them at higher risk for PN-related morbidities, such as cholestatic jaundice (direct bilirubin >1.5 mg/dl). The effectiveness of prescribing dietary fiber to correct diarrhea in neonates is limited. This abstract will describe our unit’s experience using dietary fiber (green beans) to correct diarrhea in neonates after a bowel resection. Objective/Hypothesis: Our primary hypothesis was by adding dietary fiber (greens beans) to neonates formula would correct the diarrhea resulting from a bowel resection and reduce their dependence on PN. Methods: This was a retrospective cohort study from November 2003 to April 2011 of neonates who had dietary green beans added to their formula to improve feeding intolerance and reduce their dependence on PN. The Community Institution Review Board approved this study as exempt status. Descriptive statistics were used to analyze the data. Results: Eighteen neonates were prescribed dietary green beans be added to their formula during this study period. Forty-four percent of the neonates were diagnosed with short bowel syndrome. Before the addition of dietary green beans 67% of neonates experienced liquidy stools and 33% of neonates experienced loose stools (Table 1). After the addition of the dietary green beans to their formula, their stool consistency improved. Fifty-six percent of the neonates had mushy/soft stools and 44% of the neonates had formed stools. Seventy eight percent of the infants were diagnosed with cholestatic jaundice during their hospitalization, but the incidence decreased to 33% at the time of discharge (Table 2). Sixty percent of neonates had PN discontinued because enteral feedings were able to meet 100% of their nutritional needs. Sixty-one percent of the infants were discharged home at >10th percentile for weight-for-age. Conclusions: Neonates who develop diarrhea as a complication from a bowel resection, have improved feeding tolerance once dietary green beans are added to their formula. This improved feeding tolerance decreased their dependence on long term PN and may improve long-term PN-related morbidities.

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131 - Impact of Parenteral Nutrient Shortages on Infants in the Neonatal ICU Leonor Massieu1, Keli Hawthorne1, Jessica Iselin1, Amy Carter1, Erica Mills1, Jennifer Gardner1, Kimberly Le1, Steven Abrams1 1Texas Children's Hospital, Houston, TX

Background: Components of intravenous nutrition including calcium, phosphate, acetate, and cysteine have been in critical shortage nationwide in 2011. Methods: We investigated the impact of this shortage in infants in the Neonatal ICU at Texas Children’s Hospital receiving total parenteral nutrition (TPN) for > 5 days. During the shortage period (April-Sept. 2011) we restricted calcium and phosphorus administration to 1.2 mmol/100 mL and were unable to use acetate in TPN. Results: Our Neonatal ICU averages 20 infants on TPN daily. During the past 3.5 months (116 days), 94 infants had significantly limited intake of key nutrients due to the shortage. Of these, 78 infants (31 with birth weight ≤ 1500g, 47 with birth weight > 1500g) received calcium and phosphorus that deviated from our standard intake. Additionally, 32 infants had acidosis for which acetate would have been provided if available. Instead, the infants received separate infusions of sodium bicarbonate. During the shortage, infants had a 34 ± 19% cumulative deficit for calcium intake by TPN and a 33 ± 17% cumulative deficit for phosphorus. Infants > 1500g birth weight had a larger cumulative deficit in calcium than infants ≤ 1500g birth weight, 38 ± 19% vs 27 ± 16% respectively (p=0.01). This difference was similar for phosphorus as well, 37 ± 17% vs 27 ± 15% (p=0.007). Eighteen infants had an abnormally low serum phosphorus < 4mg/dL at least once during the shortage. Conclusion: The lack of parenteral nutrient components presents a serious problem for Neonatal ICU infants. Additional sources of these key nutrients should be identified for use in the hospital setting.

132 - Cyproheptadine and poor growth: is it useful? Ana Sant'Anna1, Mafalda Porporino1, Chantal Martel1, Catherine Zygmuntowicz1, Lara Yapar1, Maria Ramsay1

1McGill University, Montreal, QC, Canada

Background: Cyproheptadine (CY), a known antiserotoninergic and antihistaminergic agent, has been used as an appetite stimulant and orexigenic agent in elderly patients with gastroenterologic problems, as well as in anorexia nervosa, pulmonary consumptions and cancer patients. No recent report has described its use for pediatric patients with feeding difficulties and poor growth. Aims: To review the data on cyproheptadine use for patients with poor growth with or without medical condition, as well as the safety of its use. Methods: Chart review of all patients that were followed in the Feeding Disorders Clinic of the Montreal Children’s Hospital during the period of 2006 and 2011 who received a prescription of cyproheptadine. Demographics of the patients were reviewed, including sex, age, maternal characteristics, presence of a medical condition, presence of side effects and change in feeding behaviours. The rate of weight gain was calculated and compared with the minimum standard rate of weight gain/age group, at 3 months prior, 3 and 6 months post starting CY. Results: From a total of 1,126 new patients referred, only 181 (16%) were prescribed cyproheptadine (dose=0.25mg/kg/day). Of the 181 patients with CY, only 82 used the medication regularly and had poor growth. From this group, 55% were boys, 52% were first born, and 72% were between 1-4 years old. The maternal ethnicity was North American in 44 (55%), South Asian in 13(16%), East Asian in 12(15%) and 13(16%) came from other geographic areas. Mean maternal age was 34 yo with 15 years of education (mean). Thirty-eight percent of the patients were healthy; the primary medical diagnosis were prematurity/IUGR (16%), GI related (13%), developmental delay or autism (11%), among others. Side effects of cyproheptadine were observed in 11 (13%) patients, and included irritability in 7 (8%) and sleepiness beyond 2 days in 4 (5%). The parents reported changes in feeding behaviours in 77 (93%) patients, including eating more (39/ 48%), increase in variety (11/13%), asking for more food (9/11%), self feeding (9/11) and easier to feed (9/11%). Only five (6%) patients did not present with any change. Figure 1 shows the mean rate of weight gain with CY compared to the minimum standardized rate/age at 3 months prior, 3 and 6 months post use of CY. Conclusion: Cyproheptadine is safe for use in patients with poor growth (with and without a medical condition) and showed catch-up weight gain during the observational period of 6 months. Future studies are needed to evaluate the long term side effects of cyproheptadine.

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133 - Switching from a General Purpose to a Specialty Amino Acid Formulation for Parenteral Nutrition of Very Low Birth Weight Infants Christina Nguyen1, Maxime Thibault1 1CHU Sainte-Justine, Montreal, QC, Canada

Introduction Specialty amino acid solutions intended for parenteral nutrition (PN) of neonates have a number of theoretical advantages over general purpose products in this population. While studies have evaluated various biological and biochemical benefits, advantages related to PN formulation have not been extensively studied. Our center added a specialty amino acid solution for neonates to its formulary in May 2010. Higher calcium-phosphate solubility and a lower osmolality are some theoretical advantages of the selected product. The purpose of this study was to determine if these advantages led to higher energy, calcium and phosphorus intakes through parenteral nutrition for very low birth weight infants in clinical practice. Methods: All infants receiving PN were switched to the specialty product at its introduction on May 5th, 2010, and new neonatal patients received it systematically. We performed a retrospective cohort study with historical controls, comparing PN formulations during a 6 month period before the introduction of the product, to those during a 6 month period after. All patients weighing less than 1500 g at birth, who received PN within 48h of birth were included. A 1 month period was allowed between the two cohorts to prevent the inclusion of a patient in both groups. Normally distributed variables were compared between groups using Student’s t test. Results: We included 229 patients. 125 (54.6%) received general purpose amino acids, and 104 (45.4%) specialty amino acids. Mean birth weight (p=0.785) and gestational age (p=0.954) were comparable between groups. When all included PN orders were compared, both groups had similar energy intakes, but patients who received specialty amino acids had higher calcium and phosphorus intake (Table 1). When restricting analysis to PN orders during the first week of life, energy and phosphorus intake were comparable between groups, while calcium intake was higher in the specialty amino acids group (Table 2). Conclusion Using a specialty amino acid solution with lower osmolality and higher calcium-phosphate solubility for parenteral nutrition of very low birth weight infants was not associated with a change in energy intake in our cohort. However, it was associated with higher calcium intakes during the first week of life, and higher calcium and phosphorus intake overall.

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134 - Within a trace - Implementing a pediatric home parenteral nutrition trace element monitoring protocol Dan Durham1, Sheryl Wear2 1Walgreens Infusion Services at Legacy Health, Portland, OR; 2Optioncare at Legacy LLC, Portland, OR

Introduction Micronutrients are essential for the support of normal body systems and functions. Long-term parenteral nutrition (PN) patients are at increased risk for the development of micronutrient deficiencies and/or toxicities. Numerous factors can contribute to these abnormalities, including the patients underlying disease processes and possible contamination from PN components with hidden unknown amounts of trace elements (TE). Although measuring serum TE levels have limitations and lack sound scientific literature, assessing serum levels with skillful clinical judgment is an important component of PN therapy. Pediatric patients are particularly vulnerable to micronutrient abnormalities due to their small body size, rapid growth rates, and their developing body systems. A review of PN orders and lab monitoring by home infusion project investigators revealed a need for a standard protocol for improved monitoring and tracking of TE’s. It was noted that PN patients discharging from hospitals had variable commercial TE additives or received varying individual TE amounts with no commercial TE additives. In addition, serum micronutrient levels were ordered on an inconsistent basis, varying by hospital and/or clinic. Methods: Eleven pediatric patients receiving home PN for a minimum of three months were included in this project. Patients’ diagnoses varied, including small bowel obstructions, short gut, and gastroschisis. A comprehensive TE lab monitoring protocol was developed by a home infusion nutrition support team and approved for use by four pediatric gastrointestinal physicians. A comparison table was also initiated that included current TE products with recommended iv trace element requirements. A patient specific monitoring form was developed that contained due dates of TE labs, the normal range for labs, and frequency of monitoring. Patient lab orders were updated with pending TE studies in accordance with the protocol. Current orders were reviewed to determine if TE content was appropriate.

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Further recommendations were made to the prescribing physician if necessary. Results TE’s were ordered and monitored on a more regular basis per our new protocol. Adjustments were made to PN recipes for those with abnormal lab results as clinically assessed and ordered by the physician. In addition, patients not receiving 5 component TE solutions were reassessed by the team to determine if additional TE’s were needed to be added to their PN. Selenium was the most common TE found to be absent from patients PNs. An overall improved consistent level of care was provided. Conclusion Patients receiving PN require specialized clinical monitoring. The use of a TE monitoring protocol helped to provide an improved guideline for monitoring TE levels. It was also an educational tool to enhance clinician awareness of TE PN content. Future studies are needed to further investigate appropriate TE needs of critically ill patients, in particular for those that are exclusively receiving PN as their sole source of nutrition.

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135 - Total Body Sodium Depletion and Poor Weight Gain in Adolescents with Intestinal Failure Mary Beth Harris1, Megan Perkowski1 1University of Michigan, Ann Arbor, MI

Objective: Failure to thrive (FTT) has been well-reported in neonates who have total body sodium depletion (TBSD); however, this entity has not been well described outside of the neonatal period. We report two cases of weight loss in the presence of TBSD, defined as a urine sodium <10mmol/L, in adolescents with intestinal failure (IF). Case Presentations: Case # 1: An 18 year-old female with IF secondary to a small bowel resection with colectomy due to a small bowel obstruction. The patient presented to clinic with a 2.2kg weight loss, despite receiving 130% estimated calorie needs from a combination of parenteral nutrition (PN) and reported oral intake. Both serum and urine sodium were collected and were 138 and <10mmol/L , respectively. Calorie provision from TPN was left unchanged and patient was instructed to add 1.5 tsp. of table salt (77meq of sodium) to foods daily. One month later the patient demonstrated a 4.8kg weight gain, stable serum sodium, urine sodium of 129mmol/L, and stable oral intake. PN calories were decreased by approximately 15%. The following month the patient gained 1.2kg, despite a urine sodium of 10mmol/L, and PN calories were decreased by 20%. One month later the patient had lost 3.2kg. A urine sodium was requested at that time, but never received due to non-compliance. PN calories were increased by 10% and the addition of salt to foods was reinforced. Two months later the patient gained 5.1kg, and urine sodium was 79mmol/L. Case # 2: A 12 year-old female with IF secondary to dysmotility with chronic intestinal pseudoobstruction and creation of end-ileostomy. The patient presented to clinic with a 5.2kg weight loss. Both serum and urine sodium were collected and

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were 135 and <10mmol/L, respectively. The patient was admitted, received 154meq of sodium supplementation, and initiated on TPN. Her urine sodium 5 days later was 203mmol/L and patient had gained 0.67kg. Discussion: Studies have examined the effect of sodium depletion on weight gain in infants with ileostomies, but this has not yet been described in adolescents. Both patients described demonstrated unintentional weight loss that correlated with urine sodium levels < 10mmol/L, despite a normal serum sodium level. With sodium supplementation, both patients exhibited weight gain and correction of urine sodium. The possibility of confounding factors affecting changes in weight cannot be ruled out by these case reports. The exact mechanism by which sodium depletion influences weight gain is unclear, but infant studies have suggested decreased glucose absorption due to impaired sodium-glucose cotransport. Conclusion: Total body sodium depletion may play a role in unintentional weight loss or poor weight gain in adolescents with SBS. Further research is needed to better understand this relationship and to develop treatment guidelines.

Case # 1 weight trend over time

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Case # 2 weight trend over time

136 - Identification of Periods of Growth Failure in Preterm Neonates Malki Miller1, Ruben Vaidya1, Alok Bhutada1, Shantanu Rastogi1 1Maimonides Infants and Children's Hospital, Brooklyn, NY

Background: While the goal of nutritional management of premature infants is to achieve postnatal growth velocity that mimics the intrauterine growth rates of the developing fetus, extrauterine growth failure (GF) remains a widespread concern, related in part to suboptimal nutrient provision. The aim of this study was to identify the time periods during the nutrition care process in the neonatal intensive care unit during which the preterm neonate is most vulnerable to GF. Methods: A retrospective chart review was conducted on all infants born AGA at </= 30 weeks gestation, admitted to our NICU over a one-year study period and discharged with weights less than the 10th percentile. The NICU stay was divided into 4 periods based on the mode of nutrition given: parenteral nutrition only (PN; period 1); PN volume-adjusted to maintain prescribed total fluid allowance as enteral feeds (EN) of expressed breast milk or preterm infant formula (20kcal/oz) were advanced at rates < 20ml/kg/day (period 2); discontinuation of PN and transition to fortified breast milk or hypercaloric preterm infant formula (24kcal/oz) once EN of 100ml/kg/day were achieved with continued advancement of EN to goal (period 3); and goal EN of 24kcal/oz fortified breast milk or preterm formula at 160 ml/kg/day (period 4). Growth was examined one week postnatally (to account for normal post-birth diuresis) until either discharge or a weight of 2 kg was achieved, and for each nutrient period, the incidence of growth failure, defined by growth < 10g/kg/d over a 7-day time frame, was determined. Infants with short bowel syndrome were excluded; time periods of GF coinciding with the use of either steroids or diuretics, or a diagnosis of necrotizing enterocolitis, sepsis or resolving edema, were excluded. Results: A total of 53 eligible infants were identified, out of which 38 infants had discharge weights below the 10th percentile (72% of total). 42% of infants did not regain birth weight within 14 days, as we had aimed. The incidence of GF during each nutrient period is illustrated in Table 1, with the most vulnerable period represented by period 3, followed by period 2. Conclusion: Growth during the transition process of weaning infants from PN and advancing to full enteral feeds may be compromised. A more aggressive approach to deliver nutrition during these vulnerable time periods may help to prevent growth failure.

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137 - A Case of Hyponatremia in a Preterm Infant Fed Exclusively Donor Human Milk Katherine Lehman1, Laurine Cetovich1, Brett Payne1, Debra Gardner1, Kristen Gawronski1 1The Ohio State University Medical Center, Columbus, OH

Objective: To report a case of hyponatremia in an infant resulting from the exclusive use of donor human milk. Case Summary: 26 weeks Gestational Age (GA) 890gm birth weight (BW) infant. Parenteral Nutrition (PN) was initiated according to standard practice on day of life (DOL) 1. On DOL 3 trophic feeds with Donor Human Milk (DHM) were started. Feeding was advanced as tolerated per protocol using DHM exclusively. The sodium content of the PN ranged from 2-6 mEq/kg/day during the entire course. Sodium chloride levels ranged from 132-146 mEq/L while the infant received a combination of PN and DHM. Patient surpassed BW by DOL 14 at 1134gm representing an average weight gain of 22 gm/kg/day over 7 days. On DOL 18 the feeds were increased 120 ml/kg/day of DHM and the PN was discontinued. On DOL 20 the sodium level was 132 mEq/L and DHM (150 ml/kg/day) was fortified to 24kcal/oz. with Human Milk Fortifier (HMF) which added 1mEq/kg/day of sodium chloride. Weight on DOL 21 was 1233gm with an average weight gain of 12gm/kg/day over 7 days. On DOL 27 the sodium level had decreased to 128 mEq/L and oral sodium chloride supplement was started at 2mEq/kg/day. The weight gain at this time was 1gm/kg/day over 7 days. On DOL 32 per protocol the infant was transitioned to a 24kcal/oz. premature infant formula which contained 2mEq/kg/day of sodium chloride. In response to a sodium chloride level of 125mEq/L the oral sodium chloride supplement was increased to 4 mEq/kg/day .Weight on DOL 35 was 1318 gm with an average weight gain of 8gm/kg/day over 7 days. Oral sodium chloride supplementation was continued until DOL 42 (sodium level 142mEq/L). Weight on DOL 42 was 1444gm with average weight gain of 12gm/kg/day over 7 days. From that date until discharge at DOL 80 (37 weeks GA) the average weight gain was 16gm/kg/day while sodium levels remained normal. Figure 1 shows a correlation between the period of hyponatremia and poor growth. Discussion: Sustained hyponatremia in the preterm infant can lead to negative sequelae including worsened neurodevelopment outcome and slower growth. Premature infants require 105-130kcal/kg/day to achieve optimal growth with an average weight gain of 15gm/kg/day over 7 days. Despite providing adequate energy requirements, this patient fell below optimal growth. Preterm infants are at risk for hyponatremia. The advantages of administering human milk to premature low birth weight infants have been well documented in the literature. Increasingly, when the mother is unable to supply her own milk or the quantity is insufficient, clinicians have begun using DHM. The protein, fat and caloric content of DHM are well defined but the electrolyte composition has not been defined. The sodium content of human milk is known to be low but it is unclear how the pasteurization process affects the sodium content of DHM. Conclusion: The exclusive use of DHM, even with the addition of HMF may lead to hyponatremia in the preterm infant. Clinicians should follow sodium levels closely in patients receiving DHM and supplement as necessary to maintain normonatremia.

Caption Figure 1:

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Encore: Presented at Russian Congress – Innovative Technologies in Pediatrics and Pediatric Surgery on October 18-20 2011 in Moscow, Russia. Reprinted with permission of the Congress Executive Director Vladimir Dlin 138 - Effects of nutritional supplementation on prealbumin levels in pediatric burn patients treated in Russian burn centers Jennifer Williams1, Anna Yankina2, Yong Choe1, Lyudmila Dokukina3, Marina Brazol4, Evgeniy Altshuler5, Mikhail Gordon6, Nikolay Ostrovskiy7, Evgeniy Kuraev8, Barbara Marriage1 1Abbott Nutrition, Columbus, OH; 2Abbott Nutrition International, Moscow; 3Nizhniy Novgorod Research Institute of Traumatology & Orthopedics, Nizhniy Novgorod, Russia; 4Children's City Hospital #1, St. Petersburg, Russia; 5City Clinical Hospital #2, Kemerovo,Russia; 6First Republic Clinical Hospital of Ministry of Healthcare of Udmurtia Republic, Izhevsk,Russia; 7City Clinical Hospital #7, Saratov, 8City Hospital #20, Rostov-na-Donu, Russia

Introduction: Because of the relationship among nutrition, immunity and wound healing, optimal nutritional support is extremely important for the recovery of burn patients. Hypercaloric and higher protein diets are often designed and prescribed by hospital personnel for burns; and, these diets can be more crucial for pediatric burn patients given that children are more vulnerable than adults to burn injuries because of their limited energy reserves, thinner dermis, greater relative body surface area, and the body’s dramatic shift from growth to cellular survival. This study was designed to measure the effect of nutritional supplementation on serum prealbumin (transthyretin) in pediatric burn patients. Methods: Fifty-four children age 1-10 years (mean ± standard error 2.7 ± 0.25 y) with a TBSA burn of least 15% (range of 15-50%), at least some 2nd degree and no more than 5% at 4th degree or higher, were enrolled into this 14-d prospective, randomized, dual-treatment, parallel study. Patients included in the study had baseline serum prealbumin levels < 10 mg/dL and were capable of exclusive oral feeding within 72 hours of hospitalization. Patients from seven burn centers in Russia were randomized to receive hypercaloric, high protein hospital diet or the same prescribed hospital diet plus additional enteral supplementation. The additional enteral supplementation was 299 kcal/day for 24 subjects ages 1-4 y and 598 kcal/day for 2 subjects ages 5-10 y. The enteral supplement contains 299 kcal, 8.4 g protein, 14.9 fat, 32.8 carbohydrate and 1.5 g fiber per 200 mL serving. The primary variable was the change in serum prealbumin from baseline to Day 7. Results: Enteral supplementation significantly increased the concentration of serum prealbumin levels of pediatric burn patients from baseline to Day 7 compared with the hospital diet alone. At Day 7, children consuming enteral supplementation plus hospital diet had least squares mean ± standard error change in prealbumin concentrations of 7.84 ± 0.98 mg/dL and children on hospital diet without supplementation had least squares mean ± standard error change in prealbumin of 4.69 ± 1.03 mg/dL at Day 7, with a least squares mean ± standard error difference of 3.15 ± 1.37 mg/dL (p=0.0265). There were no significant differences in baseline serum prealbumin concentration between the two groups, with mean ± standard error concentrations of 7.60 ± 0.33 mg/dL and 7.84 ± 0.26 mg/dL for the hospital and supplemented groups respectively. Additionally, there was a non-significant positive trend for weight change due to enteral supplementation, with a mean increase in body weight of 148 g at Day 7 and 179 g at Day 14 compared with a mean decrease of 57 g at Day 7 and 56 g at Day 14 in the hospital diet group. Conclusions: Serum prealbumin is considered a sensitive indicator of nutritional status, and also serves as a prognostic indicator for identifying mortality and infection risk in patients with burn injuries. The increase of this analyte directly related to enteral supplementation may provide future guidance for the nutritional management of pediatric burn patients or in other patients with increased energy and protein needs.

139 - Analysis of Patient Age at Time of Serial Transverse Enteroplasty (STEP procedure) as it Relates to Wean Off Parenteral Nutrition: The Texas Children's Hospital Experience Kristi King1, Sarah Phillips1, Beth Carter2 1Texas Children's Hospital, Houston, TX, 2Baylor College of Medicine, Houston, TX

Background: The Serial Transverse Enteroplasty (STEP), first described in 2003, has since become a revolutionary bowel-lengthening procedure for short bowel syndrome patients, which in many instances, facilitates weaning off of parenteral nutrition (PN). Limited data is available in regards to patient’s age at

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time of the STEP procedure and the ability to wean off PN in a timely manner. After anecdotally observing that our pediatric patients who underwent the STEP procedure at younger ages had more difficulty weaning off PN, we decided to analyze this further. Methods: Retrospective chart reviews were conducted in patients that have had a STEP procedure and are currently being followed by the Intestinal Rehabilitation Center at Texas Children’s Hospital. Patients were divided into two groups: Group 1-- those that had the procedure at age of 12 months (n=4), mean chronological age of 26 months (range 12-35 months). Comparison of calories provided by PN was made at post-operative 3, 6, 9, and 12 months in order to determine if the younger patients (Group 1) were transitioning to full enteral autonomy as efficiently as the older patients (Group 2). Results: Three of the procedures done while still in neonatal intensive care units (Group 1) were performed at outside hospitals followed by prompt transfer of patients for medical and nutritional management within our specialized Pediatric Intestinal Rehabilitation Program. Prior to the STEP procedure, the Group 1 was receiving an average of 99% of their calories via PN vs the Group 2 which received an average of 52% of total calories from PN. At 3 months post-operative, our younger (Group 1) patients were still receiving an average of 97.5% of total calories from PN compared to the older (Group 2) patients who were receiving 44%. 6 months post-operative Group 1 patients were receiving an average 91% of total calories from PN versus 24% of total calories from PN in Group 2 at the 6 month post-operative time point. At time of submission, no data is available for 9 months post-operative for Group 1, as they are not yet 9 months out, but for 9 months post-operative in Group 2, two patients were completely weaned off of TPN, one has not yet reached the 9 month post-operative milestone, and one patient was receiving 10% of total calories from PN (not for calorie reasons, but rather for electrolyte abnormalities). There is no data from the 12 month post-operative time point for Group 1, but for Group 2, two patients remain off PN at 12 months, one is on 8% total calories from PN, and one patient has not reached the 12 month milestone. Conclusions: This is one Center’s experience; however, our analysis raises the question as to what is the optimal time point for a STEP procedure to occur in a patient with short bowel syndrome. Based on our review, it appears that those who had the procedure performed at <12 months of age (in reality, all 4 patients in Group 1 were <3.5 months chronological age) have a more difficult time transitioning to full enteral/by mouth feeds. We theorize that a STEP procedure performed too early in the neonatal period hinders the adaptive capabilities of the intestines. Future research is indicated to uncover potential reasons for delayed ability to efficiently advance enteral feeds and if optimal timing of the STEP procedure better predicts the ability to wean off PN within the one year post-operative period.

140 - Diet Prescription Tool to Personalize Ketogenic Therapy Hannah Allen1, Dylan Lennon1, Peggy Borum1 1University of Florida, Gainesville, FL

Background: The diet prescription for Ketogenic Therapy (KT) to treat epilepsy traditionally includes adequate Calories and protein at a specified KT ratio. The University of Florida Ketogenic Therapy Research Program (UFKTRP) calculates meals with brand specific foods to the nearest tenth of a gram using the Nutrition Facts label (NFL). Our experience has been that the NFL values for foods change regularly and our food database must be updated frequently to maintain efficacy of KT for seizures. Our working hypothesis is that a KT diet prescription with specific recommendations for fatty acid profile and/or amino acid profile would facilitate personalization of KT for each patient at any given time. The objective of this study was to develop a method to add this level of detail to the KT diet prescription. The NFL does not provide the needed data. The Nutrition Data System for Research (NDSR), created at the University of Minnesota, is a dietary analysis software program designed to analyze the nutrient composition of a diet and provides the detailed data needed. NDSR contains many brand specific foods consumed by KT patients but there are many brand specific foods not present in NDSR and the frequency of updating NDSR data is less than what is required for KT. Methods: 24-hour diet diaries were provided for patients by their caregivers. The diet prescription was calculated using the usual NFL method (NFLM) and the dietary intake was calculated using the NDSR method (NDSRM). A hybrid method (HM) utilizing the “User Recipe” record format procedure of NDSR was developed. Data for brand foods not present in the NDSR food database were calculated by making the macronutrient data of a NDSR base product proportional to the information provided by the NFL for that brand of food. Results: 109 24-hour diet diaries were evaluated using the NFLM, NDSRM, and HM. The KT ratio of the NDSRM was 77.5% of

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the NFL KT ratio that is used clinically, but the KT ratio of the HM was 98.8% of the NFL KT ratio. Conclusions: Use of the HM allowed adjustment of the macronutrient composition of the NDSR data to the most recent NFL data for a specific brand of a food. Assuming that the specific nutrient profile of a macronutrient is fairly consistent across brands of the same type of food; the HM allows estimation of fatty acid profile and amino acid profile of different foods. A tool has been developed to address the hypothesis that a KT diet prescription which includes recommendations for fatty acid profile and/or amino acid profile facilitates personalization of KT for each patient at any given time. Supported in part by the National Institutes of Health (NIH) and National Center for Research Resources (NCRR) CTSA grant 1UL1RR029890

141 - Home Infusions of Intravenous Albumin in a 7-month old girl with Congential Nephrotic Syndrome of the Finnish Variety, a Case Study Sheryl Wear1 1Optioncare at Legacy LLC, Portland, OR

Introduction: We report a case of clinical improvement with the initiation of home IV albumin infusions in a patient with congenital nephrotic syndrome of the Finnish type (CNF). This is a rare autosomal recessive disease which occurs in approximately 1 in 10,000 births. It is a defect in the protein nephrin which is found in the kidney. Nephrotic syndrome is characterized by massive proteinuria, hypoalbuminema and severe edema caused from an increase in glomerular permeability. The clinical course includes poor nutritional status, growth delay, recurrent infections, thromboembolism and hypothyroidism. Treatment includes intravenous albumin supplementation, nutritional support, aggressive treatment of complications and early renal transplantation. A review of the literature shows IV albumin is a highly soluble globular protein accounting for 70-80% of the colloid osmotic pressure of plasma. Albumin infusions help to restore intravascular volume by creating an osmotic force and thereby decreasing the edema associated with CNF. Description: A.O is a 7 month old girl born with congenital nephrotic syndrome of the Finnish variety with persistent hypoalbuminemia and resolving bone disease/vitamin D deficiency. Our home infusion team was asked to start her on an indefinite course of IV albumin infusions at home. She had a Broviac single lumen central catheter placed on May 19th, 2011. Patient’s height and weight at the beginning of therapy were 23.2 inches and 5 kilograms. On May 20th she received her first home infusion dose of IV Albumin 25 % 5 grams in 20mL infused over 1 hour on a syringe pump. The infusion nurse was present during the infusion and for one hour afterwards for observation and treatment in case of any adverse reactions. The patient tolerated the infusion well. The parents were instructed to withdraw the albumin from the single use vial and add it to a 20mL syringe just prior to giving the infusion each day. Home labs orders were for CBC with differential and renal panel weekly. The patient’s albumin level improved from a baseline of 2.4gm per dl on April 29th to 3.9gm per dl on August 2nd. Her height and weight on August 2nd were 26 inches and 6.1 kg. The physician adjusted the dose of the albumin from 20ml to 16ml per day on July 19th. The patient is showing remarkable clinical improvement, she is more

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active and is eating well. She continues to tolerate the albumin infusions without any adverse effects. Her long term plan was originally for eventual renal transplant but her current status is observation to see if her kidneys can maintain adequate function with the help of the albumin. The family is very appreciative and satisfied with all of the care that they have received Discussion: Treatment with home infusions of IV albumin were well tolerated in this patient and provided a life saving therapy for this rare disorder. This treatment has allowed the patient and family to receive care within the comfort of their home with the ongoing support of their physician and the home infusion team of pharmacists and nurses.

142 - Walking through the barriers, achieving major milestones for a home pediatric nutrition support patient Pam Garmire1, Dan Durham1 1Walgreens Infusion Services at Legacy Health, Portland, OR

Introduction: Patients requiring home nutrition support are presented with unique challenges. In particular, parents and caregivers of pediatric patients who require both PN and EN therapies must learn how to properly manage and live with numerous foreign tubes. We report on a case of a two year old female with short gut syndrome who has required both PN and EN since birth. Description: AL was born prematurely at thirty four weeks with ileal atresia. She received an emergency ileocecectomy and ileocolic anastomosis surgery within the first week of life. Six months later she required another emergency surgery due to volvulus which resulted in a small bowel resection that left fifty five centimeters of remaining intestine. Her complex medical condition has required her to be dependent on PN and EN therapies. A home infusion company in conjunction with AL’s Gastrointestinal (GI) clinic has provided home nutrition support since she was first discharged home from the hospital. Weekly nursing visits from home infusion pediatric nurses provided valuable education to AL’s parents who were eager to learn how to best care and enhance the quality of life for their child. One of the biggest challenges for the Nutrition Support Team and parents was how to insure that AL could achieve important milestones such as crawling and walking. Her attached tubing, pumps, and small body size added significant barriers. When the child began to crawl, it became apparent that tubing was hindering her mobility. She was not yet able to wear a backpack because of her small size and needed a way to receive her feedings while still supporting mobility. After discussion with the team and family, her home infusion company provided a longer tube extension which helped to allow more freedom to crawl without disconnecting the tube feeding. A few months later, AL again needed a revision in her tubing arrangement to better support walking. Her home infusion company provided her with the lightest feeding pump possible with a mini backpack. Her parents started by placing her backpack on for one to two hours per day in order to allow her body to get used to this new added weight. They gradually were able to progress her up to comfortably wearing the backpack all day. A home infusion nurse also recommended a line vest device in order to safely organize and hold in AL’s IV lines and feeding tube in place. This device further allowed for increased mobility to support growth and development. . Discussion: Our case demonstrated how PN and EN therapies must be provided in the least restrictive manner possible in order to promote normal growth, development, and a higher quality of life for pediatric patients. A team approach with a home infusion company and GI clinic helped to provide parents with the tools they needed to successfully care for their child and allow her to achieve significant milestones.

143 - Recommended Nutritional Feeding Guidelines for infants born with single ventricle anatomy, a result of a collaborative Feeding Work Group Megan Horsley1, Julie Slicker2 1Cincinnati Children's Hospital, Cincinnati, OH; 2Children's Hospital of Wisconsin, Milwaukee, WI

Background: Infants with hypoplastic left heart syndrome (HLHS) are known to have difficulty with growth. Infants with this physiology who have poor growth go on to have worse short-term outcomes following surgical palliation and poor growth early in life. Improvements in medical and surgical management of infants with HLHS have led to dramatic improvements in survival over the past two decades. The interstage period, the time between hospital discharge following initial surgical palliation, or Norwood procedure and presentation for the volume-unloading superior cavopulmonary connection (SCPC), typically performed at 4 to 6 months of age, remains a high-risk time for this population, as mortality

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across many centers approximates 10%.20. The National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC) is the first multicenter quality improvement collaborative within pediatric cardiology and was organized under the leadership of the Joint Council on Congenital Heart Disease. 21 The aim of the initial collaborative project is “To reduce mortality and improve the quality of life of infants with HLHS during the interstage period between discharge from the Norwood and admission for the SCPC.” 21 The collaborative is a nationwide network currently comprising 44 pediatric cardiology centers in North America who contribute to a registry of infants who have HLHS. One of the primary drivers of reduction in mortality was felt to be improvement in growth. The purpose of this project was to review the literature and gather expert consensus to provide nutritional recommendations for those caring for infants with single ventricle physiology. Methods: In order to identify best nutritional practices in infants with HLHS or variants the NPC-QIC leadership sought volunteers from centers participating in the collaborative to form a Feeding Working Group (FWC). The FWG included a multidisciplinary team of dietitians, physicians and nurse practitioners from 10 centers caring for children with congenital heart disease. The FWG met via several conference calls over 3 months to research the following question: What is the most effective way to feed single ventricle infants in order to achieve improved survival and growth with minimal complications? This question was approached using two different methodologies: First, an in-depth literature search using databases: PubMed, Scopus and CINAHL were searched to identify publications related to nutritional practices in infants with single ventricle anatomy. Second, a collection and assessment of current feeding practices among centers participating in the NPC-QIC was performed. Unpublished individual institution guidelines and policies related to feeding infants with congenital heart disease were contributed by various members of the collaborative and reviewed by the FWG. The FWG next categorized current practices into those that were consistent among sites and those that were variable among sites. Practices that had a scientific basis in the literature and those that were consistent among sites were discussed and used to form the foundation for the recommended feeding programs. Practices that were variable among sites were discussed at length and only added to the feeding program once a consensus was reached. Nutrition recommendations were divided into three separate time periods: 1) Pre-Norwood, 2) Post-Norwood, and 3) Interstage. Some recommendations are based on expert opinion and clinical practice as there is no current published research on the subject for infants with single ventricle physiology heart disease. As a result of the Feeding Work Group, four recommended feeding guidelines were developed in the form of algorithms.

144 - Posttraumatic Pancreatic Pseudocyst Managed Conservatively Doris Mae Dimatatac1, Kannan Laksmi Narasimhan1 1KK Women's and Children's Hospital, Singapore

Introduction: Pancreatic pseudocysts in children are rare and known as complications of acute pancreatitis and pancreatic trauma. Treatment options range from conservative, nonoperative management to operative drainage. Pseudocysts larger than 10 cm in diameter required surgical intervention. Objective: To present a case of posttraumatic large pancreatic pseudocyst managed successfully with bowel rest, total parenteral nutrition and octreotide. Case Presentation: We present a case of a 9-year-old girl who sustained abdominal trauma secondary to bicycle handlebar. A pancreatic pseudocyst developed on 5th day post injury, with complete transection of the distal pancreas. The pseudocyst was monitored using serial ultrasound with the largest size measuring 13.4 x 10.7 x 9.3 cm on 20th day post injury. The pseudocyst was managed conservatively with bowel rest, total parenteral nutrition and octreotide. Octreotide was given at 0.3 ug/kg/hour as a continuous intravenous infusion for 24 days. Total parenteral nutrition was given for 32 days and oral feeding was restored on 26th hospital day. She was discharged well on 36th hospital day. Complete resolution of pseudocyst was noted after 6 months on repeat ultrasound. Discussion: The published literature regarding octreotide therapy for pediatric pancreatic pseudocyst is limited. Octreotide is a somatostatin analogue and it inhibits many enzymes including pancreatic enzymes. Previously reported cases demonstrated successful resolution of pancreatic pseudocysts with octreotide in combination with traditional surgical approaches; however, with our patient the pseudocyst resolved without needing surgical intervention. Operative management has a high level of success; however, morbidity rates have ranged from 4% to 30%. In any event, it is clear that a conservative or nonoperative measure would be more desirable. Conclusion: Large pancreatic pseudocyst can also be treated conservatively. Octreotide along with bowel rest and total parenteral

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nutrition is a safe and effective treatment of pediatric pancreatic pseudocyst and should be added to the management of pseudocyst.before considering drainage procedures.

145 - The beneficial of zinc, iron and Food Supplementation on Malnourished Pregnant Women on Birth Weight and Nutritional Status of Babies Nur Daud1 1School of Medicine, Hasanuddin University, Makassar

Randomized double blind pre-post controlled design was conducted in malnourished pregnant women in Takalar District, Indonesia. The purpose of the study was to identify the effect of zinc supplementation on nutritional status babies of malnourished pregnant women. The samples were divided into three groups. All groups were given food supplement containing 600-700 Calories, 15-20 grams of protein, and iron tablet containing 60 mg of elemental Fe and 0.25 mg of folic acid. The first group received 40 mg of zinc, second group received 20 mg zinc, and third group as control received placebo. The food supplements, iron pills and zinc supplements were given regularly for the period of three months. The nutritional status was assessed anthropometrically by measuring weight and mid-upper arm circumference, zinc concentration using Colorimetric, while IGF-1 by using ELISA. Hemoglobin assessed using cyanmeth-hemoglobin. Food intake was estimated using 24 hours recall. The measurement of all variable (zinc, Hb and IGF-1)were taken before and after intervention, the same measurements (birth weight and lab analysis) were performed for the babies after delivery. Data were analyzed using the SPSS program, Wfood2 program, Pearson correlation and regression test. Analyzed the effects of food supplements before and after using Paired T-test and ANOVA. The study showed, zinc level were increased in all the three groups. However, there were no differences observed in the group receiving 40 mg(p>0.05) zinc compared to those received the 20 mg doses of zinc (p<0.001) and placebo (p<0.0001). There is a significant differences among the three groups (P=0.014). There is no significant difference of birth weight among the three groups (birth weight are 3157 gram, 3137 gram and 3094 gram) and IGF-1 babies (58.0 ng/dl, 51.5 ng/dl, and 40.6 ng/dl) respectively. This study found additional effect of zinc to anemia, anemia were decreased by 38%, 60% and 39% from pregnant women who receiving zinc 40 mg, 20 mg and placebo respectively. Conclusion, dose of zinc 20mg, iron and food supplementation prevent low birth weight and decreasing anemia deficiency 60% . Keyword; zinc, iron, food supplemention, malnourished pregnant women

CLINICAL NUTRITION WEEK 2012 POSTERS: GI / HEPATIC Encore: Presented at the ACG 2011 Annual Scientific Meeting: Printed in October 2011 - special issue of the American Journal of Gastroenterology. 146 - Teduglutide, a Novel Analog of Glucagon-Like Peptide 2, Reduces Parenteral Volume in Short Bowel Syndrome-Intestinal Failure Subjects: Results From a 24-Week, Placebo-Controlled Phase 3 Trial Douglas L. Seidner1, Kishore R Iyer2, Bo Joelsson3, Stephen J O'Keefe4, Bernd Pfaffenberger5 1Vanderbilt University Medical Center, Nashville, TN, 2Mount Sinai Medical Center, New York, NY, 3NPS Pharmaceuticals, Bedminster, NJ, 4University of Pittsburgh, Pittsburgh, PA, 5Nycomed GmbH, Konstanz Encore: Presented at the ACG 2011 Annual Scientific Meeting: Printed in October 2011 - special issue of the American Journal of Gastroenterology. 147 - Fluid Composite Effect Outcomes in Adult Subjects With Parenteral Support-Dependent Short Bowel Syndrome Treated With Teduglutide Charlene Compher1, Ken Fujioka2, Nader N Youssef3, Peter Berghoefer4, Palle B Jeppesen5 1University of Pennsylvania School of Nursing, Philadelphia, PA; 2Scripps Clinic Del Mar, San Diego, CA; 3NPS Pharmaceuticals, Bedminster, NJ; 4Nycomed GmbH, Konstanz, 5Rigshospitalet, Copenhagen, Denmark 148 - Effects of Early Enteral Nutrition on Systemic Inflammatory Response Syndrome After the

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Operations for Obstructive Jaundice Chen Qiangpu1, Fu Tingliang1 1Shandong Provincial Key Lab of Nutrition and Metabolism, Clinical Nutritional Support Center & Pediatric Surgery, Binzhou Medical University Hospital, Binzhou, China

Introduction: Studies have shown that early enteral feeding after severe trauma and major surgeries may decrease the high post-operative metabolic rate and the rate of infection from intestinal sources, thus accelerating recovery . Early enteral feeding after surgery for obstructive jaundice(OJ) has been shown to be safe and effective in providing nutritional support. The purpose of this study was to investigate the effects of early enteral nutrition on system inflammatory response syndrome(SIRS) and clinical outcome after the operations for OJ patients. Methods: A total of 60 patients after the operations for obstructive jaundice were divided into three groups : a control group (C) containing 18 patients; a parenteral nutrition group (PN) containing 21 patients; and an enteral nutrition group (EN) containing 21 patients. There were no statistical differences between the groups in patient age, sex, pathology, surgical procedure, length of surgery, blood loss, or hemobilirubin level. This study was approved by the institutional review board and all patients signed an informed consent form. C-reactive protein (CRP), Interleukin-6 (IL-6) and tumor necrosis factor-α(TNF-α;)were measured on the day before operation and on the postoperative day 1, 3 ,5,7and 9. At the same time, patients were carefully observed for possible SIRS for 9 days after surgery. The occurrence and duration of SIRS were recorded. Postoperative complications were observed for two weeks and recorded. Results: There was a significant increase in CRP, IL-6, and TNF-α levels on the first postoperative day in all patients. After that, levels decreased to various degrees. The CRP, IL-6, and TNF-αlevels on postoperative days 3, 5, 7, and 9 were significantly lower in the EN group than the other groups. These levels were slightly lower in the PN group than in the control group but the differences were not significant. There was no perioperative mortality. All patients in all three groups developed SIRS. The duration of SIRS was 3.26 ± 1.27 days in the EN group, 5.31 ± 1.47 days in the PN group, and 5.69 ± 1.58 days in the control group. The differences between groups were highly significant. Two patients in the EN group developed MODS. Five patients in the PN group and five patients in the control group also developed MODS .The overall complication rate was 55.6% in the control group, 38.1% in the PN group, and 19.0% in the EN group. The complication rate in the EN group was significantly lower than in the PN and control groups. The complication rate in the PN group was also lower than in the control group. The infection rate in the EN group was lower than in the other groups but it those of the PN and control groups were similar. Conclusion: Early EN after operations on the patients with OJ can positively modulate SIRS, decrease the morbidity of MODS and postoperative complications, and improve the clinical outcome.

149 - Effects of Early Enteral Nutrition on T-lymphocyte Subsets in Patients with Gastric Carcinoma After Operations Chen Qiangpu1, Fu Tingliang1 1Shandong Provincial Key Lab of Nutrition and Metabolism, Clinical Nutritional Support Center & Pediatric Surgery, Binzhou Medical University Hospital, Binzhou, China

Objective To study the effect of early enteral nutrition on T- lymphocyte subsets in patients with gastric carcinoma after operations. Methods 30 patients with gastric carcinoma were divided into three groups after radical resections: control group, PN group, and EN group. The changes of T-lymphocyte subsets were determined by APAAP method at postoperative 0,1,3,6,9 days. Results The number of CD3 and CD4 positive cell and CD4/CD8 rate decreased significantly, and CD8 cell number increased markedly in control group and PN group after operations. In EN group, the number of CD3and CD4 positive cell and CD4/CD8 rate decreased at the 1st day after operation, but then recovered gradually from the 3th day after operation. The number of CD3 and CD4 positive cell and CD4/CD8 rate in TEN group were higher than those of in control group and PN group at the 3th, 6th, 9th days after operations( p<0.05). Conclusions Early enteral nutrition can enhance T-lymphocyte immune function and improve lymphocytic immunosuppression after operations in patients with gastric carcinoma.

150 - Insulin Sensitivity Indices in European Americans and African Americans Veeradej Pisprasert1, Timothy Garvey1 1Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL

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Objective: Insulin resistance is central to the pathogenesis of cardiometabolic disease, and confers increased risk of Type 2 Diabetes (T2DM) and cardiovascular disease. However, measurement of insulin resistance is problematic since the gold standard approach, the hyperinsulinemic clamp, is laborious. Several indices employing fasting glucose and insulin levels have been devised as alternative measures suitable for nutrition and epidemiological studies. However, these indices have not been carefully examined for predictive valuable when comparing European- and African-Americans, who exhibit differences in metabolism (e.g., AA hypersecrete insulin) and T2DM prevalence (higher in AA). This study aims to compare several common insulin sensitivity indices with clamp measurements among nondiabetic EA vs. AA. Methods: In this study, 241 nondiabetic participants (141 EA, and 100 AA) were studied. Fasting plasma glucose (FPG) and fasting insulin level (FIL) were obtained and euglycemic hyperinsulinemic clamps were performed to assess glucose disposal rates (GDR). The homeostatic model assessment (HOMA) and the quantitative insulin-sensitivity check index (QUICKI) were calculated based on FPG and FIL. Log HOMA was applied to transform HOMA to normal distribution. FIL, log HOMA, QUICKI, and GDR of each ethnicity were evaluated by correlation analysis. Results: The EA and AA had similar mean GDR normalized per lean body mass (P = NS). GDR was correlated with BMI when adjusted for age and gender (r = 0.38, P2, P < 0.0001) and FIL (15.34 vs. 9.26 µU/ml, P < 0.0001), while FPG values were similar (90.75 vs. 90.17 mg/dl, P = 0.62). Despite similar GDR, AA had lower QUICKIE values (0.33 vs. 0.36, P < 0.0001), and higher log HOMA values (3.47 vs. 2.12, P < 0.0001), than EA. GDR was significantly correlated with FIL (r = 0.56, P < 0.0001), log HOMA (r = 0.61, P < 0.0001), and QUICKI (r = 0.58; P < 0.0001), and the correlation coefficients were comparable in EA and AA (table 1). Conclusions: (1) EA and AA exhibited similar degrees of insulin sensitivity by GDR; (2) in these subjects, FIL, HOMA, and QUICKIE values were consistent with greater insulin resistance in AA. (3) HOMA and QUICKIE were similarly correlated with GDR in both racial groups with r values ranging from 0.50 to 0.57, and were no better in predicting GDR values than FIL alone. The data suggest that the EA and AA subgroups had equal insulin sensitivity at the level of skeletal muscle (clamp), and that the differences in FIL, HOMA, and QUICKIE between EA and AA could have resulted from hypersecretion of insulin or greater hepatic insulin resistance in AA. FIL, HOMA, and QUICKIE should be used cautiously in studies that include multiple racial groups and when results are interpreted to indicate muscle insulin sensitivity.

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Encore: Presented at ESICM, European Society of Intensive Care Medicine, October, 2011. Preceeding abstract available at: http://www.springerlink.com/content/m0xth64u3885w270/fulltext.pdf 151 - Investigating Reasons for Hospital Cost Savings due to Immunonutrition in Gastrointestinal Cancer Patients: Beyond a Complication Risk Reduction? ` Helene Chevrou-Severac1, Juan B. Ochoa2, Josephine A. Mauskopf3, Sean D. Candrilli3 1Nestle Health Sciences, Vevey, Switzerland; 2Nestlé Health Care Nutrition, Florham Park, NJ; 3Research Triangle Institute, RTI, Research Triangle Park, NC

BACKGROUND: Immunonutrition intervention has been demonstrated to be effective and cost-savings by relieving the burden of post-surgical infectious complications for gastrointestinal cancer patients (Waitzberg et al., 2006; Cerantola et al. 2011; Mauskopf et al. 2011; Chevrou-Severac et al. 2011). OBJECTIVES: The aim of this study was to investigate whether the hospital savings estimated for gastrointestinal (GI) cancer patients undergoing a major surgery when using immunonutrition (IN) peri-operatively can be explained fully by the reduction in risk of complications. METHODS: Based on the meta-analysis results of Waitzberg et al. (2006) and US hospital costs data (HCUP NIS 2008), the savings due to the observed reduction in hospital length of stay (LOS) for GI cancer surgical patients using IN were estimated. Secondly, the reduction in complication rates (anastomotic leak, wound infection, pneumonia, urinary tract infection, and sepsis) presented in the Waitzberg meta-analysis were combined with estimates of the incremental hospital costs for each calculation from the HCUP data to estimate the cost savings due to reduced complications. Finally, the HCUP dataset were used to estimate the reduction in LOS expected with the observed reduction in complications and the related cost using hospital cost per day. RESULTS: The estimated cost per day in the hospital was $2,948 for GI cancer surgical elective admission patients. The observed reduction in LOS from the Waitzberg meta-analysis was 2.18 days and the estimated hospital costs savings with IN were $6,021 per patient-stay. The estimated cost savings attributable to the reduced cost of complications was $4,227 per patient stay. The estimated reduction in LOS attributable to the reduced complication rate was 1.39 days giving estimated hospital costs savings with IN of $3,702 per patient-stay. CONCLUSIONS: Use of IN for patients undergoing surgery for GI cancer is an effective and cost-saving intervention whatever costing method is adopted. However, the observed reduction in LOS and estimated hospital cost savings were greater than those attributable to the reduction in complications alone. This indicates that the effect of IN may go beyond a reduction in complications, possibly accelerating the recovery of all patients.

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152 - Treatment With Lactobacillus Rhamnosus GG and Bifidobacterium Longum Decreases Mortality and Reduces Bacteremia and Colonic Apoptosis in a Weanling Mouse Model of Septic Peritonitis Ludmila Khailova1, Paul Wischmeyer1, Jessica Dominguez1 1University of Colorado Anschutz Medical Campus, Aurora, CO

Background: Sepsis is common in infants with a mortality rate of >30%. The intestine plays a central role in the pathophysiology of sepsis. Probiotics ameliorate symptoms of various intestinal diseases; however, their role in septic peritonitis is unknown. Objective: To evaluate the effects of Lactobacillus rhamnosus GG (LGG) and Bifidobacterium longum (BL) treatment in a weanling mouse model and in an in vitro model of septic peritonitis. Methods: 3-week old FVB/N weanling mice were subjected to cecal ligation and puncture or sham laparotomy and treated with or without LGG (109 CFU/ml, o.g.) or BL (107 CFU/ml, o.g.). At 24h, blood and liver homogenates were cultured on blood agar plates. Epithelial apoptosis in the colonic tissue was evaluated via H&E and caspase-3 staining and western blot analysis of P-Akt/Akt. Gram staining was used to determine bacterial colonization of the colon. Survival studies were performed in a separate cohort of FVB/N mice followed for 7 days and given probiotic treatment every 24h. In addition, YAMC cells were treated with LGG or BL (105 CFU/ml) for 30min followed by exposure to TNF-alpha + IFN-gama(400 ng/ml each) for 4h. Cells were then labeled with annexin V-FITC/propidium iodide and analyzed by flow cytometry. Results: At 7 days, BL or LGG treated septic mice exhibited significantly lower mortality (p<0.03) when compared to untreated septic animals. Bacteremia was markedly reduced in septic mice treated with LGG or BL compared to untreated septic mice. Results from liver cultures showed increased bacterial growth in the septic mice compared to shams and septic mice treated with LGG or BL. Colons of septic mice treated with probiotics were colonized with fewer bacteria than those of septic mice which showed overgrowth of both, gram positive and gram negative strains. In comparison to shams, septic mice had increased colonic apoptosis (p<0.001), while LGG and BL normalized apoptosis to sham levels. Increased p-Akt/Akt ratio in probiotic-treated animals suggests involvement of PI3K pathway in prevention of sepsis-induced colonic apoptosis. Consistent with these results, apoptosis was significantly decreased in cytokine-injured cells treated with LGG or BL compared to untreated cells (p<0.05). Conclusions: LGG or BL treatment of septic peritonitis improves survival and prevents bacteremia and colonic apoptosis in weanling mice. The anti-apoptotic effect was confirmed in our in vitro model. Thus, either LGG or BL may be used as a novel therapeutic agent for the treatment of sepsis.

153 - Addition of both fish and soybean oil to parenteral nutrition improves resistance to intraportal bacterial challenge in mice Tomoyuki Moriya1, Kazuhiko Fukatsu2, Midori Noguchi3, Youjiro Hashiguchi1, Koichi Okamoto1, Satoshi Murakoshi3, Hiroshi Yasuhara2, Daizoh Saitoh3, Kazuo Hase1, Jyunji Yamamoto1 1Department of Surgery, National Defense Medical College, Tokorozawa, Saitama, Japan; 2Surgical Center, University of Tokyo, Tokyo, Japan; 3Division of Traumatology, National Defense Medical College Research Institute, Tokorozawa, Saitama, Japan.

(Background) Fat free parenteral nutrition (PN) is associated with impaired hepatic immunity. However, adding fish oil (FO) but not soybean oil (SO) to PN partly normalizes hepatic mononuclear cell (MNC) function, while adding SO but not FO partly preserves the number of hepatic MNCs. We thus examined the optimal ratio of FO to SO for reversing PN-induced impairment of hepatic immunity by observing survival in a murine intra-portal bacterial challenge model. (Methods) Male ICR mice (n=72) were randomized to chow, 67%, 33%, 16%, 8%, 4% and 0%FO-PN groups. The chow group was fed chow ad-libitum. The PN groups were given isocaloric and isonitrogenous nutritional support with 20% of total calories from fat emulsions via jugular vein catheters. Fat emulsions consisted of various FO to SO ratios (67:33, 33:67, 16:84, 8:92, 4:96, 0:100). After 5 days of each feeding, mice were given 1.0 x 107 live P. aeruginosa via the portal vein and survival was observed for 168 hrs (7days). (Results) Survival times were significantly shorter in the 4% and 0%FO-PN groups than in the other 5 groups, with no significant differences among the 5 groups (log-rank test P<0.001). Survival rates at 168 hours were 100%*, 64%*, 85%*, 72%*, 67%*, 11% and 10%in the chow, 67%, 33%, 16%, 8%, 4% and 0%FO-PN groups, respectively.( * P<0.01 vs. 4% and 0%FO-PN) (Conclusion) Adding both FO and SO to PN at a ratio of at least 8:92 improves resistance to intraportal bacterial challenge, though complete restoration of hepatic

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immunity may be difficult. The optimal ratio appears to be 33:67, but further study is needed to verify this finding.

154 - A Diet of Docosahexaenoic Acid and Arachidonic Acid Maintains Normal Growth and Reproductive Function over Multiple Generations in a Mouse Model Deepika Nehra1, Hau Le1, Erica Fallon1, Sarah Carlson1, Amy Pan1, Scott Rodig2, Mark Puder1 1Children's Hospital Boston, Boston, MA, 2Brigham and Women's Hospital , Boston, MA

Introduction: Essential fatty acids (EFAs) are considered the “essential” nutrients required for growth, development, and reproduction. Traditionally, alpha-linolenic acid (ALA, omega-3) and linoleic acid (LA, omega-6) are considered the only EFAs, however, recent evidence regarding fish oils [containing primarily docosahexaenoic acid (DHA; omega-3) and arachidonic acid (AA; omega-6)] may redefine what is truly an EFA. The purpose of this study was to determine whether mice maintained on a diet containing DHA and AA (without ALA or LA) develop any evidence of EFAD by evaluating growth, reproductive function and fatty acid profiles. Methods: Adult C57BL/6 female mice were randomized into one of three different groups: soybean oil (360kcal/kg soybean oil; omega-6 rich diet; “SOY”); hydrogenated coconut oil (360kcal/kg hydrogenated coconut oil; EFAD diet; “HCO”) or a 20:1 ratio of DHA:AA (72kcal/kg DHA,

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3.6kcal/kg AA, 284.4kcal/kg HCO; omega-3 rich diet; “20:1 DHA:AA”). Each of these diets contained 10% of total calories as fat. After 4 weeks of dietary treatment, breeding was initiated for all animals and the offspring were termed the F1 generation. Litter size and viability were recorded for F1 animals. The growth of the F1 animals was monitored from wean to adulthood. After reaching reproductive maturity, the F1 animals were bred to generate an F2 generation. Following completion of breeding trials, five F1 animals from each group were sacrificed at 5 months of age and serum and ovaries were collected for fatty acid and ovarian analyses. Subsequently, breeding trials were continued to the F3 generation for SOY animals and the F6 generation for 20:1 DHA:AA animals. HCO animals were unable to successfully breed beyond the F1 generation. Litter size and viability for each successive generation were recorded. Serum was collected from subsequent generations of SOY (F2) and 20:1 DHA: AA (F2 and F5) animals for fatty acid analysis. Results: There was no difference in average weekly weight from wean to adulthood between F1 SOY and 20:1 DHA:AA animals and these weights did not differ from those of animals on a standard rodent chow. F1 HCO animals had a lower average weight at most time points (Figure 1). Subsequent consecutive generations (F2 to F6 generation) of 20:1 DHA:AA animals had normal growth patterns with no evidence of stunted growth. Litter size and viability of F1 animals was comparable between all groups with an average litter size of 7.5 (81% survival) in the SOY group, 7.0 (76% survival) in the HCO group, and 7.0 (76% survival) in the 20:1 DHA:AA group. These findings did not differ from animals on a standard rodent chow with an average litter size of 8.0 (75% survival). Additionally, the F4 and F5 generation 20:1 DHA:AA animals had preservation of litter size (6.0 and 7.0, respectively) and viability (92% and 100%, respectively). Ovarian analysis of the F1 generation animals at 5-months of age demonstrated a trend towards a higher total oocyte count in 20:1 DHA:AA (n=5) compared to SOY (n=5) animals, although this difference did not achieve statistical significance (1533±624 vs 1075±726, p=0.15). There was no evidence of EFAD (based on triene:tetraene ratio; T:T ratio) in any animal on the SOY (F1 or F2) or 20:1 DHA:AA (F1, F2 or F5) diets. F1 generation animals on the HCO diet had evidence of biochemical EFAD with an average T:T ratio of 1.07±0.17. Conclusion: A diet consisting of 2.1% of total calories provided as DHA and AA in a 20:1 ratio maintains normal growth and reproductive function without any evidence of biochemical EFAD through 6 generations in a murine model. These findings suggest that DHA and AA alone may be sufficient to prevent EFAD.

155- Oral Supplements in Liver Disease: A Systematic Review of the Medical Literature Ronald Koretz1, Timothy Lipman2, Alison Avenell3 1Olive View-UCLA Medical Center, Sylmar, CA; 2Veterans Affairs Medical Center, Washington, DC; 3Health Services Research Unit, Aberdeen, MD

Background: In 2007, a systematic review of the randomized clinical trials (RCTs) of oral supplements (OS) in patients with liver disease failed to show any consistent effect of this intervention, although benefits in different outcomes were found in individual trials. The objective of this study was to update that review. Methods: RCTs comparing OS to no nutritional intervention in patients with liver disease were sought via computer searches of MEDLINE, EMBASE, Science Citation Index Expanded, Cochrane

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Hepato-Biliary Group (CHBG) Controlled Trials Register, and the Cochrane Central Register of Controlled Trials through August 2011. In addition, hand-searches of specific journals and Index Medicus, including abstracts of both the American and European nutrition support societies, Digestive Disease Week and the annual meetings of both the American and European liver societies were done. OS were defined as liquid formulations containing a source of nitrogen (as amino acids, protein hydrolysates, or intact protein) and a non-protein source of calories (as fat or carbohydrate). These formulations could be commercially available or be ones compounded by the investigators. (Supplements consisting only of additional food or only vitamins or minerals were excluded.) In order to qualify, the trial had to have been randomized (quasi-randomized trials excluded), include a control group that received no more nutrition than regular food and up to 5% dextrose intravenously, and report at least one clinical outcome (mortality, ascites, gastrointestinal bleeding, encephalopathy, postoperative complications, duration of hospitalization, or cost). The identified trials were separated into those including medical or surgical patients. The estimated effect was expressed as the relative risk (RR) for dichotomous data or as a weighted mean difference (WMD) for continuous data; the 95% confidence interval (CI) was calculated (Revman 5.0, Cochrane Collaboration). Risk of bias was determined by CHBG criteria. Results: Seventeen RCTs were identified (14 medical, 3 surgical); all were at high risk of bias. The estimated effects from the various analyses are summarized in the table. No cost data were available. Conclusions: Any conclusions are limited by the fact that the RCTs were at high risk of bias (which may produce an overestimation of the treatment effect). In medical patients, OS reduced infections and the appearance of ascites, but also may have minimally elevated the serum bilirubin. The effect of OS on improving nitrogen balance just missed achieving statistical significance. No apparent effect of OS was seen in surgical patients, although only 3 RCTs were available. Larger and better designed RCTs which demonstrate that OS improves clinical outcomes are needed before this intervention can be recommended in patients with liver disease.

156 - Validation of 13C-Acetic Acid Breath Test to Evaluate Gastric Emptying of Liquid Diet in Conscious Mice Shinji Somekawa1, Yumi Ando1, Tatsuro Tanaka2, Kunio Torii1, Hisayuki Uneyama1 1Institute for Innovation, Ajinomoto Co., Inc., Kawasaki-shi,Japan; 2Exploratory Research Laboratories, Ajinomoto Pharmaceuticals Co., Ltd., Kawasaki-shi

Background: Well balanced nutritionally dense liquid diet is necessary for the nutritional support of the malnourished elderly. One of its demerits is the delayed gastric emptying, which often discourage elderly patients from continuing proper nutritional intake. The 13C isotope- labelled acetic acid breath test is a common clinical method to evaluate gastric emptying. Ingested 13C-labelled acetic acid is not absorbed in the stomach, but rapidly absorbed in the duodenum and then metabolized in the liver to be released as 13CO2. The 13C- acetic acid breath test is a non-invasive and repeatable method in rodents that can be

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used without physical restraint. However, the sensitivity of this test to detect changes in gastric emptying of liquid diet has not been studied thoroughly. Hence, the present study aimed to validate this method by using pharmacological agents, hormone and taste solution. Methods: Male C57BL-6J mice (BW 20-25) after overnight fasting were placed in the metabolic chamber (0.4 L). Baseline breath sample was taken at 0.1 L/min flow rate for 1.5 hr. Commercial liquid diet (Medi-F, Ajinomoto Co., Inc) containing 13C- acetic acid (7.5 mg/mL) was used as the test meal. After intragastric administration of the test meal (0.2 mL), the expired air was collected at 5-min intervals by a fully automated system. The 13CO2 / 12CO2 levels were measured by the mass spectrometer for Respiratory Analysis and Bioprocess Monitoring (ARCO-2000, Arcosystem Inc.). The 13CO2 excretion data were analyzed for calculation of gastric half excretion time (T1/2) as the gastric emptying parameter. To validate this method, Bethanechol chloride (20 mg/kg) and Atropine sulfate (1 mg/kg) were subcutaneously administered 20 min before intragastric administration of the liquid diet and Clonidine hydrochloride (0.2 mg/kg) was subcutaneously administered 30 min before the liquid diet. CCK-8S (15 μg/kg) was administered subcutaneously 10 min before liquid diet, and CCK1 receptor antagonist, Devazepide (1 mg/kg), was administered intragastrically 30 min before administration of CCK-8S. Bitter tastant, Phenylthiocarbamide (PCT, 10 mM, 0.2 ml) was administered intragastrically 20 min before liquid diet. Bethanechol chloride, Atropine sulfate and CCK-8S were dissolved in saline, Devazepide was dissolved in 0.5 % methylcellulose and PCT was dissolved in distilled water (DW). T-test was used to compare between test conditions (p1/2 of liquid diet compared with saline. Atropine sulfate and clonidine hydrochloride increased T1/2 compared with saline. CCK-8S increased T1/2 compared with saline and Devazepide attenuated the delay of gastric emptying by CCK-8S. PCT increased T1/2 compared with DW. Conclusions: Our study indicated that the 13C-breath test in mice was sensitive to detect difference in gastric emptying of liquid diet induced by pharmacological agents, hormones and tastants. This technique for assessing gastric emptying of liquid diet could be used to determine the effect of physiological, pharmacological and nutritional intervention on the motility of the gastrointestinal tract.

157 - Role of EGFR Tyrosine Kinase Activity in the Cytoprotective Mechanism and Intracellular Transport of L-Glutamine in Heat Stressed Intestinal Epithelial-6 Cells Stefanie Niederlechner1, Jelena Klawitter1, Uwe Christians1, Paul Wischmeyer1 1University of Colorado, Aurora, CO

Objective: L-Glutamine (GLN) can protect against critical illness and becomes conditionally essential for stressed enterocytes in the intestine. Therefore, GLN is known to be one of the key nutrients for the intestine and to have growth factor-like signaling functions, activating a number of genes involved in cell survival in the intestine. Epidermal growth factor receptors (EGFR) are also involved in cell proliferation, GLN transport, and inhibition of cell death. We hypothesize there may be a relationship between these pathways mediating GLN’s protection in intestinal epithelial-6 cells (IEC-6) after an injury, such as heat stress (HS). Therefore, we assessed if the EGFR tyrosine kinase activity is essential for intracellular GLN transport in IEC-6 cells by using the EGFR tyrosine kinase inhibitor AG1478. We also investigated whether its’ activity plays a role in GLN’s protective mechanism via p44/42MAPK (ERK1/2) and heat shock factor-1 (HSF-1) phosphorylation to prevent apoptosis in IEC-6 cells after HS. Methods: EGFR inhibitor AG1478 (20µM), or p44/42MAPK (ERK1/2) inhibitor PD98059 (50µM) were added to IEC-6 cells for 1h. Cells were then treated with or without GLN (0mM, 2mM, and 8mM), and heat stressed after 15min. Cell survival was measured via MTS assay 24h post-HS (44ºCx50min). All HS groups were normalized to their non-HS controls. Total ERK1/2, total HSF-1, [T(P)202/Y(P)204]ERK1/2, [S(P)303]HSF-1, Procaspase-3 and cleaved caspase-3 levels, were determined via Western blot after non-lethal HS (43ºCx45min). Liquid chromatography–mass spectrometry (LC-MS) was used to measure GLN-transport after non-lethal HS (43ºCx45min). Statistics were calculated via students t-test. Results: LC-MS results revealed, that the EGFR kinase activity inhibitor AG1478 neither affected GLN transport into IEC-6 cells in non-injured cells nor heat stressed cells (p<0.05; n=3). MTS assays showed, that all GLN doses increased cell survival in a range from 2 fold to 3 fold (p<0.05; n=3). However, AG1478 and PD98059 attenuated GLN-mediated protection after lethal HS (p<0.05; n=3). Western blots, probed for Procaspase-3 and cleaved caspase-3, confirmed these results (p<0.05; n=3). GLN increased Erk1/2 phosphorylation after HS, but AG1478 abolished GLN-mediated Erk1/2 activation (p<0.05; n=3). GLN

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activated HSF-1 by attenuating its’ phosphorylation of serine 303 after HS. However, the HS+0mM GLN group, the HS+GLN+AG1478 group, and the HS+GLN+PD98059 group repressed HSF-1 by its’ phosphorylation of serine 303 (p<0.05; n=3). Conclusion: EGFR kinase activity is not responsible for GLN transport into IEC-6 cells, however, EGFR kinase activity is involved in GLN’s protective mechanism via MAPK signaling in IEC-6 cells after HS. GLN gets transported into the cell, activates the EGFR, which phosphorylates ERK1/2. This phosphorylation activates HSF-1, by repressing HSF-1 phosphorylation of serine 303. Activated HSF-1 increases gene expression of survival factors that prevent apoptosis in an injury, such as HS.

Figure 1: Cell survival via MTS assay

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Figure 2: Working hypothesis

158- Citrulline-supplemented total parenteral nutrition in rats after massive intestinal resection Yuji Morishita1 1Nara Hospital, Kinki University School of Medicine, Ikoma, Japan

Purpose: Plasma levels of citrulline are known to decrease in patients with short bowel syndrome. Citrulline, synthesized from glutamine & arginine in the intestine, is one of the structural amino acids of the urea cycle contributing to ammonia detoxication. We investigated the metabolic effect of citrulline-supplemented total parenteral nutrition (TPN ) in rats after massive intestinal resection. Methods: Seven- to 8-week-old male S-D rats divided into 5 groups ; sham, SB, SB-Cit, SB-Arg and SB-Ala groups. The sham group had only simple transection of the intestine. Rats in the other groups underwent 80% small intestinal resection. The sham and SB groups received TPN TPN at 300 ml/kg/day (246 kcal/kg/day, & 9 g/kg/day of amino acids), whereas the SB-Cit, SB-Arg and SB-Ala groups received TPN supplemented with 1 g/kg/day of citrulline and alanine, respectively. All rats were sacrificed by exsanguination on the 7th day after the operation. Serum hepatic enxymes, plasma and hepatic concentrations of citrulline, ariginine, ornitine and alanine, and intestinal mucosal heights were evaluated. Results: Twelve out of 14 rats survived in the sham group, 12 out of 19 in the SB group, 12 out of 12 in the SB-Cit group, 12 out of 20 in the SB-Arg group, and 12 out of 15 in the SB-Ala group. There were no significant differences in survival rates, serum hepatic enzymes, or ammonium levels among the groups. The SB, SB-Arg and SB-Ala groups exhibited lower levels of plasma citrulline compared with the sham group. The SB-Cit group had a significantly higher level of plasma citrulline compared with the other 4 groups. The SB-Cit and SB-Arg groups had higher levels of plasma arginine compared with the other 3 groups, and higher levels of plasma ornithine compared with the SB group. The SB-Arg group had significantly higher plasma urea concentrations than the other 4 groups. Concentrations of citrulline, arginine, and ornithine in hepatic tissue significantly increased in the SB-Cit group than the sham, SB and SB-Ala groups. The SB-Cit groups maintained the intestinal mucosal height, while the SB. SB-Ala and SB-Arg groups revealed height loss. Conclusion: Citrulline supplementation increased plasma levels of citrulline, arginine, and ornithine, improved weight loss and maintained intestinal mucosa in rats after massive intestinal resection without nitrgen load that observed in arginine supplementation. These results suggest that citrulline

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homeostasis is impaired in short bowel syndrome, and that citrulline should be considered as an essential amino acid in total parenteral nutrition for short bowel syndrome patients.

159 - Associated factors for hypo and hypermetabolism in patients on the waiting list for liver transplantation Livia Ferreira1, Lucilene Anastacio1, Carolina Elisa da Cunha1, Aline Martins1, Agnaldo Lima1, Maria Isabel Correia1 1Universidade Federal de Minas Gerais, Belo Horizonte, Brazil

Introduction and Objective: The liver is the main metabolic organ, thus energy metabolism imbalance in cirrhotic patients could be associated with poor nutritional status and prognosis. Increased resting energy expenditure (REE) has been suggested for patients with liver disease. On the other hand, there have been reports that some of them may present with hypometabolism. The aim of this study was to assess the REE and to identify variables associated either with hypo and hypermetabolism in patients on the waiting list for liver transplantation. Methods: Patients on the waiting list for liver transplantation had their REE assessed between April 2010 and August 2011, by indirect calorimetry and this was compared with the REE predicted according to the Harris Benedict formula. If patients presented with excessive fluids, dry weight was used. Hypo and hypermetbolism were considered when the REE assessed was below 80% and above 120%, respectively. Demographic and socioeconomic data were assessed as well as severity and etiology of liver disease, associated complications, biochemical tests and medications related to liver disease, and nutritional status according to different methods. Logistic regression analysis (SPSS program version 16.0) was carried out to identify predictors (p<0.05) of hypo and hypermetabolism. The Hosmer Lemeshow test was used to check the fit of the model. Results: Sixty-five patients on the waiting list (50.0 ± 11 years old; 73.8% men) were assessed. Main indications for liver transplant were alcoholic disease (25), virus C cirrhosis (16) and cryptogenic cirrhosis (8). The median REE was 1,495 kcal/day (526-3,237kcal/day). The mean respiratory quotient was 0.69 ± 0.01. Energy metabolic disorders were seen in 31% of the patients: 10% were considered hypometabolic and 20% hypermetabolic. The predicting factors for hypometabolism were: female sex (OR: 12.02; IC: 1.03-16.6; 66.7% were women versus 33.3% men in the hypometabolic group); marital status (being married – OR: 0.06; IC: 0.03-0.88; 74.1% were married versus 25.9%, in the non hypometabolic group); and intracellular water (OR: 0.77; IC: 0.63-0.96; 18.1±6 L in the hypometabolic group versus 23.6 ± 4.4Ln). Predicting factors for hypermetabolism were: blood glucose (OR: 1.031; IC: 1.009-1.054; 149 ± 84mg/dL in the hypermetabolic group versus 89 ± 20 mg/dL in the non hypermetabolic group). Conclusion: Metabolic energy disorders are present in patients on the waiting list for liver transplantation, and are associated with different predicting factors.

160 - The preoperative carbohydrate loading reduces postoperative insulin resistance in gastric surgery. Kazuaki Tanabe1, Noriaki Tokumoto1, Takahisa Suzuki1, Hiroko Tabuchi1, Hideki Ohdan1 1Hiroshima University, Hiroshima, Japan

Background: In the past two decades, recovery after surgery (ERAS) protocol has been well investigated and established particular in the field of colorectal surgery. However, there are few studies about the usefulness of ERAS in gastric surgery. The aim of the present study was investigate the safety and effectiveness of ERAS protocol receiving gastrectomy. Specifically, in this study, we hypothesized that shortening the perioperative fasting period may feasible and improve the QOL, and that preoperative carbohydrate (CHO) loading may reduce postoperative insulin resistance. Method: Between May 2010 and July 2011, we designed a prospective study of consecutive 40 patients, undergoing gastrectomy comparing outcomes. The first consecutive 20 patients designed the control group and the next 20 patients the ERAS group. The ERAS group received 875ml of CHO until 2hr before operation, and start to drink on 1POD and to eat on 2POD. The outcome measures used were nutrition markers, length of postoperative stay, morbidity and QOL using SF-8 (24hr ver.). Postoperative insulin resistance was assessed by blood glucose and homeostasis model insulin resistance index (HOMA-R). Results: There were no statistical difference in patient characteristics, postoperative morbidity, and postoperative stay. HOMA-R in the ERAS group was significantly lower than the control group on 3POD (p=0.005)(Fig.1).

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The SF-8 mental component score (MCS) was statistically higher in the ERAS group on 2 and 7POD. (Fig.2). Conclusion: This present study indicates the preoperative CHO loading may reduce postoperative insulin resistance in gastric surgery. The ERAS protocol may feasible and improve the QOL.

161 - Probiotics and Diarrhoea Management Alma Mendoza1, Rozanne Kruger2, Tony Mutukumira2, Gil Hardy2 1University of Guanajuato, León, Mexico; 2Massey University, Auckland, New Zealand

The use of probiotics has become a promising therapeutic strategy for diarrhoea management. Diarrhoea is a common adverse effect of antibiotic treatments, defined as unexplained diarrhoea that is temporarily related to use of antibiotics. The incidence of Antibiotic-associated diarrhoea (AAD) occurs in approximately 5 - 25% of patients receiving antibiotics and Clostridium difficile-associated disease (CDAD) has emerged as the major enteropathogen of AAD. Clostridium difficile infection affects up to 35% hospitalised patients. Probiotics may contribute beneficially to health intestinal microbial flora. Currently not enough data exist to support the use of probiotics as a standard therapy strategy for these

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conditions. The objective was to conduct a literature review analyzing the main randomized clinical control trials and meta-analysis studies, in order to identify the role of probiotics in the management of AAD and CDAD. In this literature review we included the most significant controlled trials and meta-analyses involving the use of probiotics for the management of AAD and CDAD. Despite the diversity of probiotic strains and mixtures, there is consistent evidence that probiotics have benefit in the diarrhoea treatment. Studies testing single-agent strain have demonstrated significant effectiveness for the prevention of AAD, using Lactobacillus (RR = 0.35, 95%IC: 0.19-0.67, p<0.001) and Saccharomyces boulardii (RR=0.43, 95%IC: 0.23-0.78). Efficacy for the prevention of AAD with probiotic mixures has also been confirmed: Saccharomyces boulardii, Lactobacillus rhamnous GG (RR=0.43, 95%CI 0.31, 0.58, p<0.001) and Lactobacillus casei DN-114001, Streptococcus thermophilus and L bulgaricus (OR: 0.25, 95%CI 0.07 to 0.85). Only S. boulardii showed significant reduction in recurrence of CDAD. Probiotics did not have any impact on the hospital length of stay. The results suggest a strong benefit for the use of probiotics in Antibiotic-associated diarrhoea and Clostridium difficile-associated disease. Future research should verify and increase the assessment of newer probiotics strains and mixtures. Keywords: Probiotics, Antibiotic-associated diarrhoea, Clostridium difficile, antibiotic, diarrhoea, Saccharomyces boulardii and Lactobacillus

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162 - Influence of butyric acid supplemented parenteral nutrition on hepatic immunity Satoshi Murakoshi1, Kazuhiko Fukatsu2, Tomoyuki Moriya3, Jiro Omata3, Midori Noguchi1, Hiroshi Yasuhara2, Daizoh Saitoh1, Isamu Koyama4 1Division of Traumatology, National Defense Medical College Research Institute, Tokorozawa, Japan; 2Surgical Center, University of Tokyo, Tokyo,Japan; 3Department of Surgery, National Defense Medical College, Tokorozawa,Japan; 4Gastrointestinal Center, Saitama Medical University International Medical Center, Hidaka, Japan

Introduction: Our recent study clarified that butyric acid supplemented parenteral nutrition (Bu-PN) moderately restores PN-induced impairment of gut immunity. Because optimal functioning of the gut-liver axis depends on an intact intestine, recovery of gut immunity by Bu-PN may lead to preservation of hepatic immunity, which is also deteriorated by absence of enteral nutrition. Herein, we examined influence of Bu-PN on hepatic mononuclear cell (MNC) number and lipopolysaccharide (LPS) receptor expression on Kupffer cells in mice. Methods: Male ICR mice were randomized to standard PN (S-PN, n = 7), Bu-PN (n = 7), or Control (n = 8) group. After jugular vein catheter insertion, the S-PN and Bu-PN groups were advanced from 4.8 ml/day PN solution to a target rate of 9.6 ml/day by the third day of feeding (day 1, 0.2 ml/hr, day 2, 0.3 ml/ hr, days 3-5, 0.4 ml/hr). The Control group received normal saline infusion with free access to chow. The Bu-PN solution contained 47 mmol/L of butyric acid and 47 mmol/L of acetic acid, while the S-PN solution included 94 mmol/L of acetic acid. After five days of respective diet, hepatic MNCs were isolated and counted. The expression of LPS receptors (CD14 and TLR4/MD2) on Kupffer cells was analyzed by flow cytometry. Results: Hepatic MNC numbers and both CD14 and TLR-4/MD2 expressions were significantly higher in the Control than in the S- and Bu-PN groups, with no significant differences between the S- and Bu-PN groups (ANOVA). Conclusions: PN formula containing butyric acid is not capable of restoring PN-induced impairment of hepatic immunity despite its beneficial effects on gut immunity.

163 - NUTRITIONAL EFFECTS OF ONE YEAR OF ANTI-TNF a THERAPY IN MODERATE-SEVERE CROHN'S DISEASE PATIENTS Francesco William Guglielmi1, Silvia Mazzuoli1, Irene Addante1, Simona Fregnan1, Nunzia Regano1, Massimiliano Rizzi1, Giuseppina Leogrande1, Angela Di Molfetta1, Altomarino Guglielmi2 1Gastroenterology & Artificial Nutrition Dept, San Nicola Pellegrino Hospital, Trani, Italy; 2General Surgery Dept II University ‘F. Paccione’, Bari, Italy

Background: Malnutrition is variably reported in Crohn’s Disease (CD) patients with a prevalence raging up to 75%. The most important cause for impaired nutritional status in these patients is the severity of activity disease. In the last years the use of anti TNF α has been proven efficacious to induce clinical remission and healing of intestinal mucosa in a large percentage of patients. Aim of the study was to examine, in moderate-severe CD patients, the change of nutritional parameter induced by one year anti TNF α therapy. Methods: 29 patients (55.1% males; 44.2% females), aged 43±11, with moderate-severe CD and a history of resistance or dependence to steroid therapy were treated with infliximab 5mg/kg/bw i.v. or adalimumab 160/80 s.c. as a scheduled therapy. Crohn’s Disease Activity Index (CDAI) was used for the evaluation of activity disease. Body Mass Index (BMI), Malnutrition Universal Screening Tool

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(MUST), Nutritional Risk Screening 2002 (NRS), Weight Loss (WL), Non Dominant Handgrip Strength (HGS-nD) and Dominant Handgrip Strength (HGS-D) were registered in each patient at the hospital admission and every 8 weeks for one year. Student t-test was used to statistical evaluations. Results: CDAI changed significantly (p<0.005) from 285±107 to 183±85. In the table we report the data of nutritional assessment and percent of malnourished (Mal-M) patients, patients at risk of malnutrition (Risk) and wellnourished (Well-N) patients before and after one year of biological therapy. One year anti TNF α therapy in moderate-severe CD patients, significantly improves CDAI and nutritional status but does not avoid malnutrition in all patients. HGS-D and NRS2002 revealed the persistence of a high number of malnourished patients and patients at risk of malnutrition. Conclusion: In our opinion anti TNF α therapy in Crohn’s patients needs to be associated to nutritional treatment especially in undernourished subjects.

164 - Energy expenditure in long term liver transplantation recipients Helem Sena1, Lucilene Anastacio1, Livia Ferreira1, Agnaldo Lima1, Maria Isabel Correia1 1Universidade Federal de Minas Gerais, Belo Horizonte, Brazil

Rationale: The increase in survival of patients undergoing liver transplantation (LTx) has also been accompanied by the increase in metabolic complications. One of these complications is excessive weight, which may favor the onset of metabolic syndrome and its individual components. All of these are potential risk factors for developing cardiovascular disease and damage to the new graft. Decreased resting energy expenditure has been suggested for patients undergoing liver transplantation, as a risk factor for excessive weight, so the objective of this study was to assess the Resting Energy Expenditure (REE) and the development of a formula to predict REE in these patients. Methods: Patients who underwent LTx were transversally evaluated between April and August 2011. Demographic, lifestyle, clinical and anthropometric variables were collected. Excessive weight was defined by Body Mass Index (BMI) greater than 25 kg/m² and obesity BMI>30 kg/m². Body composition (fat free-mass and fat mass) was measured by a bioelectric impedance (Quantum X - RJL Systems®). REE was measured with an indirect calorimeter (Teem 100 - Aerosport Inc., Ann Arbor, Michigan, EUA) and predicted by the Harris-Benedict (HB) formula. Hypo metabolism was classified as a REE20% of HB. Statistics were assessed by univariate (Pearson correlation, t Student test) and multivariate linear regression analysis (SPSS version 17.0). Results: 23 patients were assessed, 48 ± 12.6 years old and 52.2 % male (n=12). Other characteristics are shown in Table 1. The most common indications for transplant were cryptogenic cirrhosis (26.1%, n=13), C virus cirrhosis (21.7%, n=5), ethanolic cirrhosis (13%, n=3) and autoimmune hepatitis (17.4%, n=4/ others: 30.4%, n=7). The average time since transplantation was 7 ± 3 years. The median BMI was 26.2 ± 4.6 kg/m², 54.2 % of the patients presented with excessive weight and 20.8% obesity. A significant correlation was found between measured REE by indirect calorimetry (1,460.3 ± 246.6 kcal) and the predicted by HB equation (1.470.5 ± 255.0; r=9.5; p<0.01). Only one patient was classified as hypo metabolic (-11% of HB) and no one with hyper metabolism. REE was associated with sex (p=0.03), weight (p<0.01) and BMI (p<0.01) by multivariate linear regression analysis. The final equation for predicting REE based on the results of calorimetry was: Y (kcal) = 714.04 - 78.08 x (1 for male sex and 0 for female sex) + 20.04 x weight (kg) – 23.711 x BMI. Conclusion: The HB formula and the formula developed in this study can be used to predict REE in patients who undergo liver transplantation. More than half of this population is overweight, but not hypo metabolic. These findings

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point to the potential contributing role of nutritional interventions and changes in lifestyle habits in order to prevent further metabolic complications.

165 - A New Fiber Blend Composed of a Large Fermentable Fiber (Acacia Gum) and Fructan-Type Fibers has Improved Fermentation Profile and Exhibits Prebiotic Benefits in vitro Abby Klosterbuer1, Jackie Noack1, Zamzam Roughead2, Claudia Roessle3, Florence Rochat3, Massimo Marzorati4, Sam Possemiers5, JoAnne Slavin1 1Department of Food Science and Nutrition, University of Minnesota, St. Paul, MN; 2Nestle R&D Center Minneapolis, Minnetonka, MN; 3Nestle Research Center, Lausanne, Switzerland; 4UGent, Fac. Bioscience Engineering, Gent,Belgium; 5ProDigest BVBA, Gent, Belgium

Introduction: Fructan-type fibers are recognized prebiotics commonly added to enteral nutrition formulas. These fibers have a number of potential health benefits including increased short chain fatty acid (SCFA) production and beneficial modulation of the gut microbiota. However, due to their small size and fast fermentation rate, they may cause intolerance. We hypothesized that partial substitution of fructans (i.e. fructooligosaccharides and inulin, Blend1) with a large, fermentable fiber (i.e. acacia gum, Blend1+) would cause more gradual fermentation, which may improve tolerance and extend benefits to the distal colon. Methods: The fermentation profile and prebiotic effects of Blend1 and the modified blend (Blend1+) were examined in a series of in vitro fermentation experiments: a batch fermentation system and a continuous simulator of the gastrointestinal tract (TWINSHIME®), which enables long term measurements in distinct colonic compartments. Results: Both blends were well fermented and produced similar amounts of total SCFA. Blend1+ had significantly lower gas volume at early time points (p<0.05), and took significantly longer to attain its maximum rate of gas production compared to Blend1 (11.1±0.9 hours vs. 4.7±0.1 hours, p<0.05). Partial replacement of fructans with acacia gum shifted the profile from boost fermentation in the proximal colon to gradual fermentation throughout the entire colon, as evidenced by gradual acidification of the colon in the TWINSHIME and significantly lower pH at 24 hours for Blend1+ in the batch fermentation (p<0.05). Gradual fermentation of Blend1+ was also confirmed by size exclusion chromatography: fructan fibers were quickly degraded in the proximal colon, while residual acacia gum was still present in the distal colon. Both blends were bifidogenic and increased total colonic biomass compared to control (p<0.05). Both blends increased colonic total biomass and had bifidogenic properties. Conclusions: Partial substitution of fructan-type fibers with acacia gum (Blend1+) improved the colonic fermentation pattern without compromising the prebiotic benefit of the fiber blend. The modified blend was fermented more gradually and yielded beneficial changes throughout the complete simulated colon. Use of this type of fiber blend may allow for more fiber to be added to enteral nutrition products with reduced risk of gastrointestinal intolerance.

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166 - The Effects of Enteral Nutrition on Intestinal Fu Tingliang1, Chen Qiangpu1 1Shandong Provincial Key Lab of Nutrition and Metabolism, Clinical Nutritional Support Center & Pediatric Surgery, Binzhou Medical University Hospital, Binzhou, China

Objective To investigate the immune defense and the effects of enteral nutrition on the impaired immune defense in an obstructive jaundice model of growing rats. Material and methods Forty growing male Wistar rats were randomly divided into four groups: control, sham operation, OJ,OJ+ Nutrison. The number of intestinal mucosal CD4+,CD8+ T lymphocytes were detected by flow cytometry technique. Results A significant decrease in numbers of intestinal mucosa CD4+ T lymphocytes was seen in OJ and OJ+N group, when compared with control and sham group, P<0.01, respectively. The ratio of CD4+/CD8+ T lymphocytes in OJ group increased in comparison with the other three groups, P<0.05, respectively. Conclusion The results showed that the number of intestinal mucosal CD4+ T lymphocytes did not recover to a normal level after administration of enteral nutrition, but the ratio of CD4+/CD8+ T lymphocytes was improved by enteral nutrition in growing rats with obstructive jaundice.

167- Results of an Intestinal Rehabilitation Program in the Treatment of Intestinal Failure Rosana Vagni1, Natalia Granados1, Carina Izquierdo1, Cecilia Diez1, Rodrigo Sanchez Claria1, Pablo Lobos1, Veronica Busoni1, Mateo Ferrero1, Maria Marchione1 1Hospitalitaliano de Buenos Aires, Ciudad Autonoma de Buenos Aires, Argentina

Objectives: To conduct a descriptive analysis of pediatric patients with intestinal failure evaluated in our Intestinal Reabilitation Program (CRIT) from December 2007 to August 2011. Methods: Descriptive, retrospective and transversal analysis of data obtained from electronic medical record. Were evaluated sex, age, diagnosis, remaining intestinal length, ileocecal valve and colon presence, thrombosis and hepatic complications , nutritional status in the first visit and currently, and need of enteral and parenteral support . Results: Were assessed a total of 32 patients referred to our program. The median age was 19,5 months, ranging from 14 days to 14 years old. 62.5% were male and 37,5% female. Diagnoses in order of frequency were intestinal atresia 31.25% (10 patients), necrotizing enterocolitis 15.6% (5 patients), intestinal volvulus 15.6% (5 patients), gastroschisis 15,6% (5 patients), intestinal pseudobstruction 6.25% (2 patients ), intussusception 6,25% (2 patients), Hirschsprung's disease 3,1% (1 patient), Prune Belly disease 3,1% (1 patient) and intractable diarrhea 3,1% (1 patient). The average intestinal length was 20 cm, with a range between 5 cm and 71 cm. 46,8% of patients have ileocecal valve (15 patients). 93,7% of patients (30 patients) had some or all of the colon. 56,25% (18 patients) had thrombotic complications and 18.7% (6patients) had liver disease associated with parenteral nutrition. At the time of initial assessment only 6,25% (2 patients) did not require parenteral nutrition. In the first visit 28,1% (9 patients) had mild to moderate malnutrition ( body mass index between -2 and -3 Z score- World health organization growth charts), and 25% (8 patients) had severe malnutrition ( body mass index of less than -3 z score). Of all patients, 12.5% (4 patients) visited our program once. Of the 28 patients who continued in follow-up, 93,7% (30 patients) improved their nutritional status. 37.5% (12 patients) weaned of parenteral nutrition , 25% (8 patients) were able to suspend both parenteral and enteral support. There were 2 patients who did not show improvement but in these cases the time of follow up was too short. Four patients received intestinal transplant. Conclusions: With an interdisciplinary team with experience, many patients with intestinal failure, improved their nutritional parameters with the ability to discontinue parenteral nutrition. It is worth mentioning that it is of vital importance the early referral of patients before developing parenteral nutrition associated complication.

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