Gastrointestinal Motility Problems in Critically Ill Patients

Urea-to-creatinine ratio as a biomarker for clinical outcome and response to nutritional support in non-critically ill patients: A secondary analysis of a randomized controlled trial

BACKGROUND

Assessing a patient's catabolism in clinical practice is challenging but could help guide nutritional interventions. The urea-to-creatinine ratio (UCR) reflects muscle breakdown and protein metabolism and has been associated with risk for overfeeding and adverse outcomes in the critical care setting. We validated this concept in a well-characterized population of medical ward patients from a previous nutritional trial.

METHODS

This secondary analysis of the Effect of Early Nutritional Support on Frailty, Functional Outcomes, and Recovery of Malnourished Medical Inpatients Trial (EFFORT) examined baseline UCR and changes during follow-up in medical inpatients at risk for malnutrition. A catabolic state was defined as a high baseline UCR or an increase in UCR over 7 days. The primary endpoint was mortality at 30 days.

RESULTS

We included 1595 of 2028 EFFORT patients with baseline UCR measurements and 870 who also had UCR measurements on day 7. A high baseline UCR, as well as an increase in UCR over 7 days, were associated with increased mortality (adjusted HR for 30-day mortality 2.05 (1.47-2.87) p < 0.001 and 2.02 (1.34-3.06) p = 0.001). There was no difference in treatment response when stratifying patients based on baseline or follow-up UCR.

CONCLUSION

Assessment of catabolism through UCR measurement at baseline and changes during follow-up was associated with increased mortality and adverse outcomes in medical inpatients at nutritional risk. However, this stratification was not associated with response to nutritional therapy in our sample. Further studies into the dynamic changes in UCR are needed to better understand the clinical implications for medical ward patients.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov as NCT02517476 (registered 7 August 2015).

Addressing Inflammaging and Disease-Related Malnutrition: Adequacy of Oral Nutritional Supplements in Clinical Care

BACKGROUND

Disease-related malnutrition, with or without inflammation, in older adults is currently emerging as a public health priority. The use of Foods for Special Medical Purposes, including Oral Nutritional Supplements, and supplements is crucial to support patients in achieving their nutritional needs. Therefore, this article aims to comprehensively provide an analysis of the adequacy of FSMPs in meeting the nutritional requirements of different age-related diseases and takes into account the emerging role of inflammation. Moreover, it provides an identikit of the ideal products, following the pathology-specific guidelines.

METHODS

Data on 132 products were gathered through face-to-face meetings with companies' consultants. Specifically, information on energy, macronutrient, and micronutrient contents were collected, as well as on texture and flavors, osmolarity, cost, and packaging.

RESULTS

Most FSMPs met the daily recommendations for energy and protein intake. Nonetheless, few products contained β-hydroxy-β-methylbutyrate, optimal Branched-Chain Amino Acids ratios, arginine, glutamine, and omega-3 fatty acids. Furthermore, a marked predominance of FSMPs with a high osmolarity (85.7%), sweet taste (72%), and only animal protein content (79.5%) was observed. Cost analysis of FSMPs revealed a mean cost of EUR 5.35/portion. Products were mostly adequate for cancer, neurodegenerative diseases, diabetes, inflammatory bowel disease, end-stage kidney disease, dysphagiam and chronic obstructive pulmonary disease. However, gaps have been found for sarcopenia and abdominal surgery.

CONCLUSION

In light of the current market landscape, there is a need for a comprehensive regulation that indicates the optimal composition of FSMPs and the production of such products to tackle disease-related malnutrition.

Inflammation and response to nutrition interventions

The complex interplay between nutrition and inflammation has become a major focus of research in recent years across different clinical settings and patient populations. Inflammation has been identified as a key driver for disease-related malnutrition promoting anorexia, reduced food intake, muscle loss, and on a cellular level, insulin resistance, which together stimulate catabolism. However, these effects may well be bidirectional, and there is strong evidence showing that nutrition influences inflammation. Several single nutrients and dietary patterns with either proinflammatory or anti-inflammatory properties have been studied, such as the long-chain ω-3 fatty acids eicosapentaenoic acid or docosahexaenoic acid. The Mediterranean diet combines several such nutrients and has been shown to improve medical outcomes in the outpatient setting. In addition, there is increasing evidence suggesting that inflammation affects the metabolism and modulates the response to nutrition support interventions. In fact, recent studies from the medical inpatient setting suggest that inflammation, mirrored by high levels of C-reactive protein, diminishes the positive effects of nutrition support. This may explain the lack of positive effects of some nutrition trials in severely ill patients, whereas similar approaches to nutritional support have shown positive results in less severely ill patients. The use of biomarkers, such as C-reactive protein, may help to identify patients with a lower response to nutrition, in whom other treatment options need to be used. There is need for additional research to understand how to best address the malnourished patient with inflammation by specifically lowering inflammation through anti-inflammatory medical treatments and/or nutrition interventions.

Adjunctive granisetron therapy in patients with sepsis or septic shock (GRANTISS): A single-center, single-blinded, randomized, controlled clinical trial

Background: In preclinical experiments, we demonstrated that the 5-HT3 receptor antagonist granisetron results in reduced inflammation and improved survival in septic mice. This randomized controlled trial was designed to assess the efficacy and safety of granisetron in patients with sepsis. Methods: Adult patients with sepsis and procalcitonin ≥ 2 ng/ml were randomized in a 1:1 ratio to receive intravenous granisetron (3 mg every 8 h) or normal saline at the same volume and frequency for 4 days or until intensive care unit discharge. The primary outcome was 28-day all-cause mortality. Secondary outcomes included the duration of supportive therapies for organ function, changes in sequential organ failure assessment scores over 96 h, procalcitonin reduction rate over 96 h, the incidence of new organ dysfunction, and changes in laboratory variable over 96 h. Adverse events were monitored as the safety outcome. Results: The modified intention-to-treat analysis included 150 septic patients. The 28-day all-cause mortalities in the granisetron and placebo groups were 34.7% and 35.6%, respectively (odds ratio, 0.96; 95% CI, 0.49-1.89). No differences were observed in secondary outcomes. In the subgroup analysis of patients without abdominal or digestive tract infections, the 28-day mortality in the granisetron group was 10.9% lower than mortality in the placebo group. Adverse events were not statistically different between the groups. Conclusion: Granisetron did not improve 28-day mortality in patients with sepsis. However, a further clinical trial targeted to septic patients without abdominal/digestive tract infections perhaps is worthy of consideration.

Safety, tolerability, pharmacokinetics and pharmacodynamics of parenterally administered dutogliptin: A prospective dose-escalating trial

Aims

Animal studies suggest that inhibition of dipeptidyl peptidase 4 (DPP‐IV) may improve heart function and survival after myocardial infarction by increasing cardiac myocytes’ regenerative capacity. Parenterally administered dutogliptin may provide continuous strong DPP‐IV inhibition to translate these results into humans. This trial investigated the safety and tolerability, as well as pharmacokinetics and pharmacodynamics, of parenterally administered dutogliptin after single and repeated doses.

Methods

In an open‐label trial, volunteers received dutogliptin at increasing doses of 30–120 mg subcutaneously or 30 mg intravenously in the single‐dose cohorts. Subjects in the multiple‐dose cohort received 60, 90 or 120 mg dutogliptin subcutaneously once daily on 7 consecutive days.

Results

Forty healthy males were included in the trial. No related serious adverse events occurred. Mild local injection site reactions with no requirement for intervention comprised 147 of 153 (96%) related adverse events. Subcutaneous bioavailability was approximately 100%. Multiple injections at daily intervals did not lead to the accumulation of the study drug. The accumulation ratios based on AUC_0‐24h range from 0.90 to 1.03, supporting this argument. All subjects receiving ≥60 mg dutogliptin yielded a maximum DPP‐IV inhibition >90%. The duration of DPP‐IV inhibition over time increased in a dose‐dependent manner and was highest in the 120‐mg multiple‐dosing cohort with a maximum AUEC_0‐24h of 342 h % (standard deviation: 73), translating into 86% DPP‐IV inhibition 24 hours after dosing.

Conclusion

Parenteral injection of dutogliptin was safe and subcutaneous bioavailability is excellent. DPP‐IV inhibition increased dose dependently to >86% over 24 hours after multiple doses of 120 mg dutogliptin.

A randomized controlled trial on the efficacy, safety, and pharmacokinetics of metformin in severe traumatic brain injury

OBJECTIVE

Traumatic brain injury (TBI) is a leading cause of morbidity and mortality worldwide. Metformin is reported to have pleiotropic neuroprotective effects through anti-inflammatory, antioxidative, and anti-ischemic activity, and improvements in vascular hemodynamics and endothelial function. The aim of this study is to examine the efficacy and safety of metformin therapy in severe TBI patients.

METHODS

This single-blind, parallel-group, randomized controlled trial enrolled adult TBI patients. Of 158 trauma patients assessed, 30 met the eligibility criteria and were randomly allocated in a one-to-one ratio to receive 1 g metformin every 12 h for five consecutive days (intervention group) or to usual management only (control group). For efficacy analysis, temporal profiles of serum levels of S100b, neutrophil to lymphocyte ratio (NLR), and glial fibrillary acidic protein (GFAP) were assessed. For pharmacokinetic analysis, serum concentrations of metformin were evaluated in the intervention group.

RESULTS

The two study groups were similar in terms of demographics, baseline clinical characteristics, and on-admission biomarkers' serum levels. Longitudinal analysis of S100b and NLR levels showed statistically significant declines in values toward normal levels in the intervention group (p values of < 0.001 and 0.030, respectively), different from the profiles of the control group (p values of 0.074 and 0.645, respectively). Pharmacokinetic analysis demonstrated that metformin absorption is delayed in TBI patients. No events of hypoglycemia and lactic acidosis occurred.

CONCLUSIONS

Metformin could potentially be an effective and safe therapeutic intervention in patients with severe TBI. Large-scale, multicentre studies are needed to confirm our encouraging results.