Obesity, inflammation, and the potential application of pharmaconutrition

Evaluating the risk of sepsis attributing to obesity: a two-sample Mendelian randomization study

BACKGROUND

Sepsis is a reaction to infection with high morbidity and mortality. It has been noted that patients with obesity were more likely to suffer from sepsis. However, the causality remains elucidating, as reverse causality and residual confounding could not be largely mitigated in conventional observational studies.

OBJECTIVE

To evaluate the risk of sepsis attributed to obesity phenotypes including body mass index (BMI), waist circumstance (WC), and WC adjusted for BMI (WCadjBMI) in a causal way.

METHODS

We conducted a two-sample Mendelian randomization (MR) study using large-scale genome-wide association study summary data with sample sizes ranging from 231 353 to 486 484. The inverse-weighted variance (IVW) was conducted as the primary approach. We also used the weighted median and MR-Egger for causal inference. A sensitivity analysis was conducted to evaluate the reliability of the MR estimates.

RESULTS

IVW detected that genetic liability for increased BMI [odds ratio (OR) = 1.40, 95% confidence interval (CI) = 1.20-1.63, P = 1.52 × 10-5] and WC (OR = 1.02, 95% CI = 1.01-1.03, P = 4.28 × 10-3) predicted a higher risk of sepsis. No evidence was observed for a causal effect of WCadjBMI on sepsis risk (OR = 1.01, 95% CI = 1.00-1.02, P = 0.08). Sensitivity analysis did not identify any bias in the MR results.

CONCLUSION

This MR study showed that obesity contributed to an increased risk of sepsis, indicating that obesity management might be beneficial for reducing sepsis risk. Key messages What is already known on this topic-Observational studies have reported the association between obesity and sepsis, but the causality has not been determined. What this study adds-This Mendelian randomization study demonstrated that obesity-related phenotypes, including body mass index and Waist circumstance, causally increased the risk of sepsis. How this study might affect research, practice, or policy-The findings of our study might have an implication for clinicians that obesity management might be a promised strategy for reducing the risk of sepsis.

Heparin-induced thrombocytopenia associated with low-molecular-weight heparin: clinical feature analysis of cases and pharmacovigilance assessment of the FAERS database

Background: Unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) are commonly used anticoagulants for the management of arterial and venous thromboses. However, it is crucial to be aware that LMWH can, in rare cases, lead to a dangerous complication known as heparin-induced thrombocytopenia (HIT). The objective of this study was to evaluate the pharmacovigilance and clinical features of HIT associated with LMWH, as well as identify treatment strategies and risk factors to facilitate prompt management. Methods: We extracted adverse event report data from the FDA Adverse Event Reporting System (FAERS) database for pharmacovigilance assessment. Case reports on LMWH-induced thrombocytopenia dated up to 20 March 2023 were collected for retrospective analysis. Results: Significantly elevated reporting rates of HIT were shown in adverse event (AE) data of LMWHs in the FAERS database, while tinzaparin had a higher proportional reporting ratio (PRR) and reporting odds ratio (ROR) than other LMWHs, indicating a greater likelihood of HIT. Case report analysis indicated that a total of 43 patients showed evidence of LMWH-induced thrombocytopenia with a median onset time of 8 days. Almost half of the events were caused by enoxaparin. LMWHs were mainly prescribed for the treatment of embolism and thromboprophylaxis of joint operation. Patients with a history of diabetes or surgery appeared to be more susceptible to HIT. Clinical symptoms were mostly presented as thrombus, skin lesion, and dyspnea. Almost 90% of the patients experienced a platelet reduction of more than 50% and had a Warkentin 4T score of more than 6, indicating a high likelihood of HIT. In all patients, LMWHs that were determined to be the cause were promptly withdrawn. Following the discontinuation of LMWHs, almost all patients were given alternative anticoagulants and eventually achieved recovery. Conclusion: LMWH-induced thrombocytopenia is rare but serious, with increased risk in patients with diabetes or a surgical history. Prompt recognition and management are crucial for the safe use of LMWHs.

Brown Fat and Nutrition: Implications for Nutritional Interventions

Brown and beige adipocytes are renowned for their unique ability to generate heat through a mechanism known as thermogenesis. This process can be induced by exposure to cold, hormonal signals, drugs, and dietary factors. The activation of these thermogenic adipocytes holds promise for improving glucose metabolism, reducing fat accumulation, and enhancing insulin sensitivity. However, the translation of preclinical findings into effective clinical therapies poses challenges, warranting further research to identify the molecular mechanisms underlying the differentiation and function of brown and beige adipocytes. Consequently, research has focused on the development of drugs, such as mirabegron, ephedrine, and thyroid hormone, that mimic the effects of cold exposure to activate brown fat activity. Additionally, nutritional interventions have been explored as an alternative approach to minimize potential side effects. Brown fat and beige fat have emerged as promising targets for addressing nutritional imbalances, with the potential to develop strategies for mitigating the impact of metabolic diseases. Understanding the influence of nutritional factors on brown fat activity can facilitate the development of strategies to promote its activation and mitigate metabolic disorders.

Evaluation of Parameters Affecting the Occurrence of Systemic Inflammatory Response Syndrome in Patients Operated on Due to Kidney Tumors

The application and prognostic nature of systemic inflammatory reaction syndrome (SIRS) is still being researched, as using SIRS parameters to predict patient status is cheap, efficient, fast, and easy. The study aimed to determine SIRS markers and postoperative complications occurrence in patients undergoing kidney tumor surgery, and to verify if SIRS occurrence depends on age, sex, BMI (body mass index), comorbidities, patients' general condition before the surgery, type of surgery, intraoperative blood loss, or intraoperative ischemia time. Body temperature, heart rate, respiratory rate, and leukocyte count were measured in patients (n = 285) operated on due to a kidney tumor on the first (T0) and third (T3) postoperative day. Univariable and multivariable logistic regression were used to analyze the factors affecting postoperative SIRS and complications occurrence. T0: SIRS developed in patients with higher BMI, >2 ASA points, and more substantial intraoperative blood loss. T3: SIRS developed in obese or overweight patients, with >2 ASA points, significantly higher relative HR change, lower relative body temperature change, respiratory rate, and leukocyte count. BMI values, preoperative general health status, and the amount of intraoperative blood loss in patients undergoing surgery due to a kidney tumor can contribute to SIRS occurrence. Patient's sex, age, tumor size, type of surgery, operated side, and time of intraoperative ischemia do not affect SIRS occurrence.

Effect of exogenus protease on performance, nutrient digestibility, intestinal histomorphometric, meat quality characteristics, carcass yield in broilers fed low protein diets

The objective of the present study was to evaluate the effects of increasing doses of protease on broilers from 1 to 42 days of age. A total of 1290 Ross AP broilers were used, distributed among five treatments: positive control diet, negative control diet (NC), NC + 50 ppm of protease, NC + 100 ppm of protease, and NC + 200 ppm of protease. Each treatment contained six replicates of 43 animals each. The inclusion of proteases in the diet had effects (P < 0.05) on body weight, feed intake, weight gain, and feed conversion in the 12 to 21 day period; body weight, weight gain, and feed intake in the 29 to 42 day period; nutrient digestibility (energy metabolizability coefficient and crude protein at 28 days); and intestinal parameters (crypt and muscle width of jejunum and ileum at 28 days and villus length, crypt length, and jejunum thickness muscle layer at 42 days). These results indicate that the inclusion of protease in broiler feed can improve production parameters when the amount of crude protein in the diet is reduced.

Effect of Carnitine Supplementation in Pediatric Patients with Left Ventricular Dysfunction

Carnitine is an essential amino acid involved in transporting fatty acids across the mitochondrial membrane. Fatty acids are a primary source of energy for the myocardium. Studies in adults demonstrated decreased carnitine levels in the ischemic myocardium, but subsequent exogenous carnitine supplementation showed improvement of myocardial metabolism and left ventricular function. However, only limited data regarding carnitine are available in pediatrics. A single-center retrospective, paired data study was conducted. Patients < 18 years, left ventricular ejection fraction (LVEF) < 55% by echocardiography, and had received at least 7 days of oral or intravenous carnitine supplementation between January 2018 and March 2021 are included in the study. Several endpoints and covariates were collected for each patient: before, one week after, one month after, and 6 months after carnitine supplementation. Univariate analysis consisted of an analysis of variance (ANOVA), followed by an analysis of covariance (ANCOVA) to model LVEF while adjusting for other variables. 44 patients included in the final analyses. LVEF significantly improved from 50.5 to 56.6% (p < 0.01). When LVEF was adjusted for other interventions (mechanical ventilation, afterload reduction, diuretic therapy, spironolactone), the estimated means demonstrated a significant increase from 45.7 to 58.0% (p < 0.01). Free carnitine level increased significantly (p = 0.03), and N-terminal-pro-brain natriuretic peptide (p = 0.03), creatinine (p < 0.01), and lactate (p < 0.01) all significantly decreased over the study period. Carnitine supplementation in pediatric patients with left ventricular systolic dysfunction may be associated with an increase in LVEF and improvement in laboratory markers of myocardial stress and cardiac output.

Effects of Dietary Supplementation of L-Carnitine and Mannan-Oligosaccharides on Growth Performance, Selected Carcass Traits, Content of Basic and Mineral Components in Liver and Muscle Tissues, and Bone Quality in Turkeys

The study aimed to determine the effect of L-carnitine and Bio-Mos administration on selected production performance, slaughter parameters, elemental and mineral content of liver, breast and thigh muscles, and physical, morphometric, strength and bone mineral composition parameters of turkeys. The experiment was conducted on 360 six-week-old Big-6 turkey females, randomly divided into three groups of 120 birds each (six replicates of 20 birds). The turkeys of the control group were fed standard feed without additives; group II was fed with drinking water, a preparation containing L-carnitine at a dose of 0.83 mL/L, while group III was provided mixed feed with 0.5% Bio-Mos. The addition of L-carnitine and Bio-Mos increased body weight at 16 weeks (p = 0.047) and reduced the proportion of fat in the breast muscle (p = 0.029) and liver (p = 0.027). It also modified the content of some minerals in breast muscle, thigh muscle, liver, and bone. Furthermore, the addition of L-carnitine and Bio-Mos increased bone mass and length and modified the value of selected morphometric and strength parameters. The results indicate a positive effect of the applied feed additives on selected rearing indices and carcass quality while improving the elasticity and fracture toughness of the femur. There is a need for further research to determine optimal doses of L-carnitine and Bio-Mos in poultry nutrition.

Mitigating effect of L-carnitine against atrazine-induced hepatotoxicity: histopathological and biochemical analyses in albino rats

Atrazine (ATR) is an extensively used herbicide that is often found in drinking water and waterways. After metabolization and excretion in the liver, ATR residues or its metabolites were found in tissues causing harmful effects mainly to the endocrine system and liver. This study aimed to elucidate the toxic impact of ATR on the liver and possible ameliorative effects of L-carnitine (LC). It utilized 30 adult male albino rats divided into three equal groups; the control group received 0.5 cc distilled water orally for 14 days, an ATR-treated group received ATR in a dose of 400 mg/kg BW dissolved in distilled water by oral gavage daily for 14 days, and a protected group (ATR + LC) received 400 mg/kg BW of ATR dissolved in distilled water, plus 100 mg/kg LC dissolved in distilled water by oral gavage daily for 14 days. At the end of the experiment, the liver tissue was prepared for histological and biochemical analyses and showed significant elevation of liver enzymes and oxidative parameters, altered expression of apoptotic and antiapoptotic genes, and hepatic degenerative changes in the ATR-treated group. In conclusion, atrazine induces oxidative stress, inflammation, and apoptosis in the liver of rats, and these toxic effects can be alleviated by L-carnitine.

l-carnitine: Nutrition, pathology, and health benefits

Carnitine is a medically needful nutrient that contributes in the production of energy and the metabolism of fatty acids. Bioavailability is higher in vegetarians than in people who eat meat. Deficits in carnitine transporters occur as a result of genetic mutations or in combination with other illnesses such like hepatic or renal disease. Carnitine deficit can arise in diseases such endocrine maladies, cardiomyopathy, diabetes, malnutrition, aging, sepsis, and cirrhosis due to abnormalities in carnitine regulation. The exogenously provided molecule is obviously useful in people with primary carnitine deficits, which can be life-threatening, and also some secondary deficiencies, including such organic acidurias: by eradicating hypotonia, muscle weakness, motor skills, and wasting are all improved l-carnitine (LC) have reported to improve myocardial functionality and metabolism in ischemic heart disease patients, as well as athletic performance in individuals with angina pectoris. Furthermore, although some intriguing data indicates that LC could be useful in a variety of conditions, including carnitine deficiency caused by long-term total parenteral supplementation or chronic hemodialysis, hyperlipidemias, and the prevention of anthracyclines and valproate-induced toxicity, such findings must be viewed with caution.

Biomedical role of L-carnitine in several organ systems, cellular tissues, and COVID-19

Carnitine is a conditionally necessary vitamin that aids in energy creation and fatty acid metabolism. Its bioavailability is higher in vegetarians than in meat-eaters. Deficits in carnitine transporters occur because of genetic mutations or in conjunction with other illnesses. Carnitine shortage can arise in health issues and diseases-including hypoglycaemia, heart disease, starvation, cirrhosis, and ageing-because of abnormalities in carnitine control. The physiologically active form of L-carnitine supports immunological function in diabetic patients. Carnitine has been demonstrated to be effective in the treatment of Alzheimer's disease, several painful neuropathies, and other conditions. It has been used as a dietary supplement for the treatment of heart disease, and it also aids in the treatment of obesity and reduces blood glucose levels. Therefore, L-carnitine shows the potential to eliminate the influences of fatigue in COVID-19, and its consumption is recommended in future clinical trials to estimate its efficacy and safety. This review focused on carnitine and its effect on tissues, covering the biosynthesis, metabolism, bioavailability, biological actions, and its effects on various body systems and COVID-19.

Exploring the Causality Between Body Mass Index and Sepsis: A Two-Sample Mendelian Randomization Study

Objective: Observational epidemiological studies have shown a link between obesity and sepsis, but any causal relationship is not clear. Our study aimed to explore the correlation and causal relationship between body mass index and sepsis by a two-sample Mendelian randomization (MR). Methods: In large sample genome-wide association studies, single-nucleotide polymorphisms related to body mass index were screened as instrumental variables. Three MR methods, MR-Egger regression, weighted median estimator, and inverse variance-weighted, were used to evaluate the causal relationship between body mass index and sepsis. Odds ratio (OR) and 95% confidence interval (CI) were used as the evaluation index of causality, and sensitivity analyses were conducted to assess pleiotropy and instrument validity. Results: By two-sample MR, the inverse variance weighting method results suggested that increased body mass index was associated with an increased risk of sepsis (odds ratio 1.32; 95% CI 1.21-1.44; p = 1.37 × 10^-9) and streptococcal septicemia (OR 1.46; 95% CI 1.11-1.91; p = 0.007), but there was no causal relationship with puerperal sepsis (OR, 1.06; 95% CI, 0.87-1.28; p = 0.577). Sensitivity analysis was consistent with the results, and there was no heterogeneity and level of pleiotropy. Conclusion: Our study supports a causal relationship between body mass index and sepsis. Proper control of body mass index may prevent sepsis.

A scoring system for the preoperative evaluation of prognosis in spinal infection: the MSI-20 score

BACKGROUND CONTEXT

Spinal infection (SI) is a life-threatening condition and its treatment remains challenging. Recent studies have supported early and aggressive surgery, but mortality still reaches 5% to 10% and it remains unclear, if an aggressive surgical strategy also applies for severely sick patients.

PURPOSE

The aim of this analysis was to generate an assessment score to predict mortality of SI in order to facilitate decision-making.

STUDY DESIGN

Retrospective risk factor analysis.

PATIENT SAMPLE

Two hundred fifty-two patients were retrospectively analyzed.

OUTCOME MEASURES

Physiologic measures, functional measures.

METHODS

Diagnosis was based on clinical presentation, imaging findings and inflammatory markers. Factors associated with mortality were identified by multivariate analysis, weighted according to their relative risk ratio (RR) and included in the novel assessment score.

RESULTS

Eight parameters were included: (1) BMI, (2) ASA score, (3) presence of sepsis, (4) age-adjusted Charlson Comorbidity Index, (5) presence and degree of renal failure, (6) presence of hepatopathy, (7) neurological deficits and (8) CRP levels at diagnosis. Each parameter was assigned a certain range of points, resulting in a maximum total score of 20. The mortality in spinal infection (MSI-20) score - indicating poorer status with higher values - was obtained for each patient and correlated with mortality.

CONCLUSION

An MSI-20 score of 11 or more points seems to identify the small group of patients being "too sick to undergo surgery," while early surgery can be recommended in the remainder (MSI-20 ≤10). Our results need to be confirmed in prospective studies, but may give guidance for indicating surgery even in rather sick and comorbid patients.

Network pharmacology combined with metabolomics and lipidomics to reveal the hypolipidemic mechanism of Alismatis rhizoma in hyperlipidemic mice

Alismatis rhizoma (AR), the dried rhizome of Alisma orientale (Sam) Juzep, is effective in treating hyperlipidemia, but the mechanisms involved require further exploration. This study evaluated the hypolipidemic properties of AR using an integrated strategy combining network pharmacology with metabolomics and lipidomics. Firstly, a hyperlipidemia mouse model induced by a high-fat diet was established to evaluate the therapeutic effects of AR. Secondly, plasma metabolomics and lipidomics were used to identify differential metabolites and lipids, and metabolic pathway analysis was performed using MetaboAnalyst. Thirdly, network pharmacology, based on the metabolic profile of AR in vivo, was used to discover potential therapeutic targets. Finally, key targets were obtained through a compound-target-metabolite network, which was verified by molecular docking and quantitative real-time PCR (qPCR). Biochemistry analysis and histological examinations showed that AR exerted hypolipidemic effects on hyperlipidemic mice. Seventy potential biomarkers for the AR treatment of hyperlipidemia were identified by metabolomics and lipidomics, which were mainly involved in lipid metabolism, energy metabolism and amino acid metabolism. Eighteen potentially active compounds were identified in the plasma of mice after oral administration of AR, which were associated with 83 potential therapeutic targets. The PPAR signaling pathway was considered a crucial signaling pathway of AR against hyperlipidemia by KEGG analysis. The joint analysis showed that 6 upstream key targets were regulated by AR, including ALB, TNF, IL1B, MMP9, PPARA and PPARG. Molecular docking showed that active compounds of AR had high binding affinity with these key targets. qPCR further demonstrated that AR could reverse the mRNA expression of these key targets in hyperlipidemic mice. This study integrates network pharmacology with metabolomics and lipidomics to reveal the regulatory effects of AR on endogenous metabolites and validates key therapeutic targets, and represents the most systematic and in-depth study on the hypolipidemic activity of AR.

Body mass index and risk of clostridioides difficile infection: a systematic review and meta-analysis

OBJECTIVE

To comprehensively investigate the association between obesity/high body mass index (BMI) and risk of Clostridioides difficile infection (CDI) using systematic review and meta-analysis.

METHODS

Potentially eligible studies were identified from Medline and EMBASE databases from inception to February 2021 using search strategy consisting of terms for "Body Mass Index" and "Clostridioides Difficile". We only included studies that consist of a group of individuals with CDI and another group without CDI. Then, the studies must report their BMI or history of obesity. Odds ratio (OR) and 95% CIs of the association between BMI status and CDI were retrieved from each study and combined using the generic inverse variance method. Funnel plot was used to assess publication bias.

RESULTS

A total of 4609 articles were identified. After two rounds of systematic review, 17 studies met the eligibility criteria and were included into the meta-analysis. Pooled analysis showed that individuals with high BMI had a significantly decreased odds of CDI with the pooled OR of 0.88 (95% CI 0.80-0.97). This meta-analysis had high statistical heterogeneity with I² of 74%. Funnel plot was symmetric, which was not suggestive of presence of publication bias.

CONCLUSION

This meta-analysis revealed a significant negative association between BMI and CDI.

Adequacy of prescribed caloric and protein intake and reduction of mortality in critically ill patients with body mass indices <30 kg/m2

OBJECTIVE

Although the provision of nutrition helps minimize adverse outcomes in most patients in intensive care units (ICUs), little is known about the relative effect of energy and protein delivered on mortality in ICU patients with different ranges of body mass index (BMI). The aim of this study was to examine the relationships between adequacy of dietary energy and protein intakes separately and simultaneously, and short-term mortality in medical ICU patients across four BMI categories.

METHODS

We enrolled 1693 patients admitted to a medical center ICU in Taiwan during the period of 2005 to 2011, subcategorizing them by BMI levels: <18.5(n = 418), 18.5-24.9 (n = 889), 25-29.9 (n = 289), and ≥30 kg/m² (n = 97). Dietary energy and protein intake (DEI and DPI) were defined by the percent of prescribed dosages that each patient actually received: highly adequate (>80%), moderately adequate (60-80%), and inadequate (<60%), during the first 10 d in the ICU.

RESULTS

Mean DEI was 1237 kcal/d and DPI 47 g protein/d. Analyzed separately in our multiple regression models, moderately and highly adequate DEI (P_trends = 0.003-0.026) and DPI (P_trends = 0.001-0.004) were both significantly correlated with reduced mortality in patients with BMI <18.5, 18.5-24.9, and 25-29.9 kg/m² but not in those with BMI levels ≥30 kg/m². With DEI and DPI analyzed simultaneously, only APACHE II scores and DPI levels remained significantly related to reduced mortality in patients with BMI <30 kg/m².

CONCLUSION

Although the adequacy of delivery of prescribed DEI or DPI dosages appeared to be important for reduced risks for mortality in ICU patients with BMI <30 kg/m² when analyzed separately, DPI had a stronger effect on decreases in ICU mortality when the two were analyzed simultaneously. Further investigation may be needed to study the role of increased protein in improving clinical outcomes.

Metabolomics-based understanding of the olanzapine-induced weight gain in female first-episode drug-naïve patients with schizophrenia

Previous studies have demonstrated that patients with schizophrenia (SZ) have greater rate of metabolic disorder as compared with the control population, which likely be the consequence of use of atypical antipsychotics. Olanzapine is a widely used antipsychotic, which increases the weight of SZ patients. However, the underlying mechanism remains poorly understood. Here we report the metabolomics-based understanding of the weight gain induced by olanzapine. 57 first-episode drug-naïve patients (FEDN) were recruited, of whom 27 patients completed a 4-week clinical trial. We then profiled the metabolomes of their plasma with the LC-MS-based nontargeted metabolomics approach at the baseline and after olanzapine monotherapy for 4 weeks. We observed that the plasma of the olanzapine-treated patient had significantly higher lysophosphatidylcholine (LysoPC), lysophosphatidylethanolamine (LysoPE) and lower carnitine as compared with that of the baseline plasma samples. Moreover, regression analyses indicated that the change of LysoPC(14:0) level was an independent contributor to the olanzapine-induced weight gain. Our study suggests that the metabolomics-based approach may facilitate the identification of biomarkers associated with the metabolic disorder causing by antipsychotic in schizophrenia patients.

A Synthetic Peptide Designed to Neutralize Lipopolysaccharides Attenuates Metaflammation and Diet-Induced Metabolic Derangements in Mice

Metabolic endotoxemia has been suggested to play a role in the pathophysiology of metaflammation, insulin-resistance and ultimately type-2 diabetes mellitus (T2DM). The role of endogenous antimicrobial peptides (AMPs), such as the cathelicidin LL-37, in T2DM is unknown. We report here for the first time that patients with T2DM compared to healthy volunteers have elevated plasma levels of LL-37. In a reverse-translational approach, we have investigated the effects of the AMP, peptide 19-2.5, in a murine model of high-fat diet (HFD)-induced insulin-resistance, steatohepatitis and T2DM. HFD-fed mice for 12 weeks caused obesity, an impairment in glycemic regulations, hypercholesterolemia, microalbuminuria and steatohepatitis, all of which were attenuated by Peptide 19-2.5. The liver steatosis caused by feeding mice a HFD resulted in the activation of nuclear factor kappa light chain enhancer of activated B cells (NF-ĸB) (phosphorylation of inhibitor of kappa beta kinase (IKK)α/β, IκBα, translocation of p65 to the nucleus), expression of NF-ĸB-dependent protein inducible nitric oxide synthase (iNOS) and activation of the NOD-, LRR- and pyrin domain-containing protein 3 (NLRP3) inflammasome, all of which were reduced by Peptide 19-2.5. Feeding mice, a HFD also resulted in an enhanced expression of the lipid scavenger receptor cluster of differentiation 36 (CD36) secondary to activation of extracellular signal-regulated kinases (ERK)1/2, both of which were abolished by Peptide 19-2.5. Taken together, these results demonstrate that the AMP, Peptide 19-2.5 reduces insulin-resistance, steatohepatitis and proteinuria. These effects are, at least in part, due to prevention of the expression of CD36 and may provide further evidence for a role of metabolic endotoxemia in the pathogenesis of metaflammation and ultimately T2DM. The observed increase in the levels of the endogenous AMP LL-37 in patients with T2DM may serve to limit the severity of the disease.

Sex-specific responses in placental fatty acid oxidation, esterification and transfer capacity to maternal obesity

Fatty acid metabolism and oxidation capacity in the placenta, which likely affects the rate and composition of lipid delivered to the fetus remains poorly understood. Long chain polyunsaturated fatty acids, such as docosahexaenoic acid (DHA), are critical for fetal growth and brain development. We determined the impact of maternal obesity on placental fatty acid oxidation, esterification and transport capacity by measuring PhosphatidylCholine (PC) and LysoPhosphatidylCholine (LPC) containing DHA by mass spectrometry in mother-placenta-baby triads as well as placental free carnitine and acylcarnitine metabolites in women with normal and obese pre-pregnancy BMI. Placental protein expression of enzymes involved in beta-oxidation and esterification pathways, MFSD2a (lysophosphatidylcholine transporter) and OCTN2 (carnitine transporter) expression in syncytiotrophoblast microvillous (MVM) and basal (BM) membranes were determined by Western Blot. Maternal obesity was associated with decreased umbilical cord plasma DHA in LPC and PC fractions in male, but not female, fetuses. Basal membrane MFSD2a protein expression was increased in placenta of males of obese mothers. In female placentas, despite an increased MVM OCTN2 expression, maternal obesity was associated with a reduced MUFA-carnitine levels and increased esterification enzymes. We speculate that lower DHA-PL in fetal circulation of male offspring of obese mothers, despite a significant increase in transporter expression for LPC-DHA, may lead to low DHA needed for brain development contributing to neurological consequences that are more prevalent in male children. Female placentas likely have reduced beta-oxidation capacity and appear to store FA through greater placental esterification, suggesting impaired placenta function and lipid transfer in female placentas of obese mothers.

How Differences in the Disease Process of the COVID-19 Pandemic Pose Challenges to the Delivery of Critical Care Nutrition

PURPOSE OF REVIEW

The COVID-19 pandemic is a unique disease process that has caused unprecedented challenges for intensive care specialists. The hyperinflammatory hypermetabolic nature of the disease and the complexity of its management create barriers to the delivery of nutritional therapy. This review identifies the key differences which characterize this pandemic from other disease processes in critical illness and discusses alternative strategies to enhance success of nutritional support.

RECENT FINDINGS

Prolonged hyperinflammation, unlike any previously described pattern of response to injury, causes metabolic perturbations and deterioration of nutritional status. High ventilatory demands, hypercoagulation with the risk of bowel ischemia, and threat of aspiration in patients with little or no pulmonary reserve, thwart initial efforts to provide early enteral nutrition (EN). The obesity paradox is invalidated, tolerance of EN is limited, intensivists are reluctant to add supplemental parenteral nutrition (PN), and efforts to give sufficient nutritional therapy remain a low priority. The nature of the disease and difficulties providing traditional critical care nutrition lead to dramatic deterioration of nutritional status. Institutions should not rely on insufficient gastric feeding alone but focus instead on redoubling efforts to provide postpyloric deep duodenal/jejunal EN or re-examine the role of supplemental PN in this population of patients with such severe critical illness.

L-carnitine improves metabolic disorders and regulates apelin and apelin receptor genes expression in adipose tissue in diabetic rats

Apelin is a new adipocytokine that acts as an endogenous hormone in various tissues through its receptor (APJ). This study aimed to investigate the effects of oral administration of L-carnitine (LC) on the expression of Apelin and APJ in adipose tissue of experimentally induced insulin-resistant and type 2 diabetic rats. In this experimental study, 60 male rats fed with high fat/high carbohydrate (HF/HC) diet. After 50 mg/kg intraperitoneally injection of streptozotocin (STZ) and confirmation of diabetes (FBS higher than 126 mg/dl), the animals were daily treated with 300 mg/kg LC for 28 days. At days 7, 14, and 28 of posttreatment, the expression of apelin and APJ in adipose tissue were determined using qPCR in diabetic, diabetic + LC treated, control, and control + LC treated groups. Apelin, insulin, TNF-α, and IL1-β were measured by the ELISA method. Results demonstrated that the rats fed with the HF/HC diet for 5 weeks were hyperinsulinemic and normoglycemic, while after STZ injection, they showed hyperinsulinemia and hyperglycemia with higher levels of HOMA-IR. Apelin serum level, APJ and apelin gene expression in adipose tissue increased significantly with the development of diabetes compared to the control group. Treatment with LC for 14 days caused a reduction in apelin and APJ expressions in adipose tissue of diabetic rats. TNF-α and IL1-β levels were reduced in diabetic rats 14 days after their treatment with LC. The study results show that L-carnitine could act as a new regulator in apelin gene expression in adipose tissue, improving the metabolic disorders in diabetic patients.

Protein Requirements during Hypocaloric Nutrition for the Older Patient With Critical Illness and Obesity: An Approach to Clinical Practice

Current guidelines recommend a hypocaloric, high protein nutrition regimen for patients with obesity and critical illness. The impact of advancing age presents with unique challenges in which a greater protein intake is required to overcome the anabolic resistance associated with aging in the face of presumed decreased renal function. The primary objective of this review is to provide an overview of the impact of obesity and advancing age on protein requirements for patients with critical illness and review the scientific evidence supporting the rationale for hypocaloric, high protein nutrition for this subpopulation, as well as provide some practical suggestions for their clinical management.

Effects of carnitine supplementation on liver aminotransferase enzymes: A systematic review and meta-analysis of randomized controlled clinical trials

BACKGROUND AND AIMS

This meta-analysis of the randomized controlled trials was performed to assess effects of carnitine supplementation on serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels.

METHODS

A comprehensive literature search of PubMed, Cochrane's library, Web of Science, Scopus, and Embase was performed up to May 2018. From a total of 2012 articles identified initially, only 17 articles were included in the final meta-analysis to evaluate the effects of carnitine supplementation on serum levels of ALT and AST enzymes.

RESULTS

Random effects model meta-analysis showed that carnitine supplementation led to reduction in serum ALT (weighted mean difference [WMD] - 10.25 IU/L; 95% CI = - 15.73, - 4.77; p < 0.001) and AST levels (WMD - 7.85 IU/L; 95% CI = - 11.85, - 3.86; p < 0.001). The results of subgroup analysis showed that carnitine could reduce serum AST levels at dosages equal to 2000 mg/day (p = 0.014) or more than 2000 mg/day (p < 0.001). However, carnitine supplementation at dosages of ≤ 1000 mg/day (p = 0.035) or equal to 2000 mg/day (p = 0.013) resulted in significant reduction in ALT level, while doses more than 2000 mg/day did not change ALT significantly. Carnitine exerts its reducing effect on serum ALT and AST levels only when these aminotransferases are raised or when the duration of supplementation lasts at least 3 months.

CONCLUSION

Results of the current meta-analysis showed that carnitine supplementation can decrease serum AST and ALT levels significantly, especially when supplementation lasts 3 months or more in patients with elevated serum aminotransferase levels.

The effects of supplementation with L-carnitine on apolipoproteins: A systematic review and meta-analysis of randomized trials

Randomized controlled trials (RCTs) have reported that L-carnitin may change serum apolipoproteins. However, the results of RCTs are contradictory. Our objective was to conduct a systematic review and meta-analysis to summarize earlier RCTs on the effects of L-carnitine supplementation on apolipoproteins B100 and AI. ISI web of science, Ovid, PubMed/Medline, Scopus, and Google Scholar were searched from inception to January 2019 using relevant keywords. Treatment effects were considered as weighted mean difference (MD) and the corresponding 95% confidence interval in concentrations of serum apolipoproteins. Random-effects model (Dersimonian-Liard) was used to estimate the overall summary effect. This meta-analysis was performed on fourteen trials. Our results indicated that L-carnitine supplementation has a non-significant effect on Apo B100 (mean difference (MD): 1.820 mg/dl; 95% CI: -3.367 to 7.006, p = 0.492) and Apo AI (MD: -0.119 mg/dl; 95% CI: -4.425 to 4.186, p = 0.957). We also found body mass index, L-carnitine dosage; health condition and intervention duration could change the results. We conclude that L-carnitine does not change Apo B100 and Apo AI concentration. Further trials with sufficient sample size are needed to confirm these findings.

Effects of Dietary Supplementation of L-Carnitine and Excess Lysine-Methionine on Growth Performance, Carcass Characteristics, and Immunity Markers of Broiler Chicken

L-carnitine as well as lysine and methionine are amino acids of important nutritional and nutraceutical interest and are used in nutritional strategies as diet supplements to improve feed quality characteristics in animals and broiler chicken in particular. This study investigated the effect of different levels of L-carnitine and extra levels of lysine-methionine on growth performance, carcass characteristics, and some immune system markers. Two hundred seventy male Ross 308 broilers were a fed control diet (C) and eight different diets supplemented with an excess of amino acids. In the experimental diets, identified as D1, D2, D3, D4, D5, D6, D7, and D8, extra L-carnitine, lysine, and methionine were added in excess with respect to the American National Research Council (NRC) recommendations: L-carnitine equal to NRC (D1); control diet supplemented with lysine at 30% in excess of NRC, methionine at 30% in excess of NRC, and L-carnitine equal to NRC (D2); control diet supplemented with lysine equal to NRC, methionine equal to NRC, and L-carnitine at 15% in excess of NRC (D3); control diet supplemented control diet supplemented with lysine at 15% in excess of NRC, methionine at 15% in excess of NRC, and L-carnitine at 15% in excess of NRC (D4); control diet supplemented lysine at 30% in excess of NRC, methionine at 30% in excess of NRC, and L-carnitine at 15% in excess of NRC (D5); control diet supplemented with lysine equal to NRC recommendations, methionine equal to NRC recommendations, and L-carnitine at 75% in excess of NRC (D6); control diet supplemented with lysine at 15% in excess of NRC, methionine at 15% in excess of NRC, and L-carnitine at 75% in excess of NRC (D7); and control diet supplemented with lysine at 30% in excess of NRC, methionine at 30% in excess of NRC, and L-carnitine at 75% in excess of NRC (D8). During the starter and growth phases, feed intake was not affected by dietary treatment (p > 0.05). By contrast, body weight and FCR were both affected (p < 0.001) during the starter period. During the finisher phase, feed consumption was affected (p < 0.05) by dietary treatment. Feed intake of broilers fed on C, D3, D6, and D7 were statistically similar (p > 0.05) (1851.90, 1862.00, 1945.10, and 1872.80 g/pen/day, respectively) and were higher (p < 0.05) than 1564.40 g/pen/day (D5). With the exception of drumsticks, neck, back thoracic vertebrae, and proventriculus weights, economical carcass segments were not affected (p > 0.05) by the dietary supplementation of amino acids. Duodenum and ileum weights and lengths decreased with amino acid supplementation (p < 0.05). IgT and IgG titers against Sheep Red Blood Cells (SRBC) for both primary and secondary responses were not affected by dietary treatments (p > 0.05). Dietary amino acids supplementation did not affect IgM titer after the secondary challenge (p > 0.05) and had a significant effect (p < 0.05) on serum antibody titers in broilers vaccinated against Newcastle disease (NCD) and Gumboro ‘s disease at the 27th and 30th days, respectively.

A comparison of L-carnitine and several cardiovascular-related biomarkers between healthy vegetarians and omnivores

OBJECTIVE

A plant-based diet has been associated with a reduced risk of cardiovascular (CV) diseases. This study aimed to determine the levels and correlations of CV-related biomarkers and the beneficial role of dietary habits.

METHODS

A total of 63 healthy vegetarians (n = 32) and omnivores (n = 31) were recruited. The baseline characteristics were recorded and measured (including lipid profiles, blood glucose, etc.). Liquid chromatography-mass spectrometry method was developed for the simultaneous determination of seven circulating CV-related biomarkers.

RESULTS

L-carnitine (L-Car), L-methionine, and ascorbic acid (AA) were significantly higher in vegetarians than in omnivores. In the vegetarians, L-Car had a negative correlation with triacylglycerols (P = 0.042) and blood glucose (P = 0.048) and a positive correlation with high-density lipoprotein cholesterol (P = 0.049). L-Car was also positively correlated with L-lysine (P = 0.009), L-methionine (P = 0.006), and AA (P = 0.035). The vegetarians' AA also had a negative correlation with L-homocysteine (P = 0.028). In the omnivores, L-Car was negatively correlated with total cholesterol (P = 0.008), low-density lipoprotein cholesterol (P = 0.004), and high-density lipoprotein cholesterol (P = 0.038). Omnivores' body mass index was positively correlated with L-homocysteine (P = 0.033), and age was positively correlated with trimethylamine N-oxide (P < 0.001) and blood glucose (P = 0.007), but not in vegetarians.

CONCLUSIONS

Our results suggest that vegetarians have an elevated level of L-Car, which might be associated with endogenous biosynthesis and diet composition. Circulating L-Car might play an important role in CV protection, especially in vegetarians.

Energy balance in obese, mechanically ventilated intensive care unit patients

OBJECTIVES

The aims of this study were, first, to compare the predicted (calculated) energy requirements based on standard equations with target energy requirement based on indirect calorimetry (IC) in critically ill, obese mechanically ventilated patients; and second, to compare actual energy intake to target energy requirements.

METHODS

We conducted a prospective cohort study of mechanically ventilated critically ill patients with body mass index ≥30.0 kg/m² for whom enteral feeding was planned. Clinical and demographic data were prospectively collected. Resting energy expenditure was measured by open-circuit IC. American Society of Parenteral and Enteral Nutrition (APSPEN)/Society of Critical Care Medicine (SCCM) 2016 equations were used to determine predicted (calculated) energy requirements. Target energy requirements were set at 65% to 70% of measured resting energy expenditure as recommended by ASPEN/SCCM. Nitrogen balance was determined via simultaneous measurement of 24-h urinary nitrogen concentration and protein intake.

RESULTS

Twenty-five patients (mean age: 64.5 ± 11.8 y, mean body mass index: 35.2 ± 3.6 kg/m²) underwent IC. The mean predicted energy requirement was 1227 kcal/d compared with mean measured target energy requirement of 1691 kcal/d. Predicted (calculated) energy requirements derived from ASPEN/SCCM equations were less than the target energy requirements in most cases. Actual energy intake from enteral nutrition met 57% of target energy requirements. Protein intake met 25% of target protein requirement and the mean nitrogen balance was -2.3 ± 5.1 g/d.

CONCLUSIONS

Predictive equations underestimated target energy needs in this population. Further, we found that feeding to goal was often delayed resulting in failure to meet both protein and energy intake goals.

Are low birth weight children predisposed to renal loss of carnitine?

Aim: The plasma homeostasis of both free and esterified carnitines is mostly regulated by renal tubular reabsorption, which may be disturbed in low birth weight children. The aim of study was to check whether disturbances in excretion of l-carnitine (LC) and its main ester, acetyl-carnitine (ALC), may be the result of renal dysfunction in low birth weight children (LBW).Methods: This study included 59 LBW children (2165 g [1490-2440]) and 22 children with normal birth weight as a reference group (3500 g [3275-3650]). Subjects were divided into three groups: 0-3 months, 4-12 months and over 1 year at the time of testing. Urinary levels of carnitine were measured spectrophotometrically.Results: The urine excretion of Free LC, Free LC/cr, Total LC and Total LC/cr. Were significantly higher in 0-3 and 4-12-month old LBW infants study groups when compared to the reference groups. We found statistically significant higher urine excretion of ALC and ALC/cr. in all age groups of LBW infants compared to the reference group. There was a negative correlation between birth weight and free LC/cr. (r= -0.3, p < .05), Total LC/cr. (r= -0.34, p < .05), and ALC/cr. (r= -39, p < .05), and in the children >12-month-old strong negative correlation between eGFR and free LC/cr. (r= -0.6, p < .05), Total LC/cr. (r= -0.61, p < .05), ALC/cr. (r= -0.61, p < .05.)Conclusion: Higher urine excretion of both LC and ALC and its negative correlation with birth weight and eGFR may reflect some degree of renal dysfunction in LBW infants.

Carnitine deficiency in epileptic children treated with a diversity of anti-epileptic regimens

Background

Carnitine deficiency is relatively common in epileptic patients. The risk factors reported include the combination of valproic acid with other antiepileptic drugs (AEDs), young age, multiple neurologic disabilities, non-ambulatory status, and being underweight.

Objectives

To study the level of carnitine deficiency and its associated risk factors among a group of children with idiopathic epilepsy treated with different AEDs.

Patients and methods

Fifty children with idiopathic epilepsy and 40 age-matched controls were enrolled. For all, serum carnitine level was measured by enzyme-linked immune sorbent assay (ELISA).

Results

The mean carnitine level was lower in cases compared to controls (p = 0.04). Patients receiving monotherapy treatment had a high percentage of carnitine deficiency compared to controls (p = 0.04). Patients receiving valproate with other AEDs had a lower level of carnitine compared to controls (p = 0.03). The age of the patients, the duration of treatment, and the doses of different AEDs were not risk factors for carnitine deficiency.

Conclusions

Carnitine deficiency is common in our population, and the use of valproate with other AEDs is considered the most important risk factor for it in epileptic children.

High-Fat Diet, Betaine, and Polydextrose Induce Changes in Adipose Tissue Inflammation and Metabolism in C57BL/6J Mice

SCOPE

High-fat diets are a likely cause of low-grade inflammation and obesity-related pathologies. This study measures the effects of a high-fat diet, in combination with two dietary supplements-betaine and polydextrose-on metabolism and inflammation in the adipose tissue of diet-induced obese mice.

METHODS AND RESULTS

Forty male C57BL/6J mice are fed a high-fat diet for 8 weeks and compared with low-fat-diet-fed control animals (n = 10). For the last 4 weeks, the high-fat-diet-fed animals are supplemented with 1% betaine, 3.33% polydextrose, their combination, or plain water. Fat depots from subcutaneous and visceral adipose tissue are analyzed for inflammatory markers and nontargeted metabolomics by quantitative PCR and LC-QTOF-MS. The high-fat diet significantly increases adipose tissue inflammation in both fat depots. By metabolic profiling, clear differences are noted between low-fat-diet and high-fat-diet groups with regard to the levels of several metabolite species-primarily carnitines, lipids, and amino acids. Dietary betaine mitigates the high-fat-diet-induced IL-6 expression and significantly increases betaine and butyrobetaine levels in adipose tissue.

CONCLUSIONS

The high-fat diet induces patent changes in carnitine and lipid metabolism in adipose tissue. Betaine supplementation elevates the levels of betaine and its derivatives and certain carnitine species, as reported in muscle and liver, and moderately reduces inflammation.

The use of fermented buckwheat to produce L-carnitine enriched oyster mushroom

l-Carnitine is an essential compound that shuttles long chain fatty acids into mitochondria. The objective of this study was to produce l-carnitine enriched oyster mushroom (Pleurotus ostreatus) using common buckwheat fermented by Rhizopus oligosporus. Mushroom grown on common buckwheat medium contained 9.9–23.9% higher l-carnitine (186.3 mg/kg) than those grown on basal medium without any buckwheat addition. Those grown on fermented common buckwheat medium contained the highest l-carnitine content (201.2 mg/kg). Size index and lightness of mushroom pileus (L*) were also the highest (100.7 and 50.6, respectively) for those grown in medium added with fermented common buckwheat (20%, w/w). Antioxidant activities of both mushroom extracts (1.5 mg/mL) showed the same level as 38.7% for mushroom grown in media added with common buckwheat or fermented common buckwheat. At the treatment concentration of 300 μg/mL, viabilities of murine macrophage cell line Raw 264.7 cells treated with ethanol extract of oyster mushroom grown on buckwheat medium ranged from 58.9 to 67.8%. The oyster mushroom grown on buckwheat and fermented buckwheat medium can be used as one of the substitutes for meat based diets.

Effect of L-Carnitine Supplementation on Apelin and Apelin Receptor (Apj) Expression in Cardiac Muscle of Obese Diabetic Rats

Objective

L-carnitine (LC) has been shown to protect cardiac metabolism in diabetes patients with cardiovascular diseases (CVDs). Apelin, a newly discovered adipocytokines, is an important regulator of cardiac muscle function; however, the role of the level of expression of Apelin axis in improvement of cardiac function by LC in diabetic patients, is not clear. In the present study, obese insulin-resistant rats were used to determine the effect of LC, when given orally with a high-calorie diet, on Apelin and Apelin receptor (Apj) expression in cardiac muscle.

Materials and Methods

In this experimental study, rats were fed with high-fat/high-carbohydrate diet for five weeks and subsequently were injected with streptozotocin 30 mg/kg for induction of obesity and insulin resistance. After confirming the induction of diabetes (serum glucose above 7.5 mmol/L), the animals received LC 300 mg/kg in drinking water for 28 days. On days 0, 14 and 28 after treatment, cardiac Apelin and Apj gene expression was evaluated by real time polymerase chain reaction (PCR) analysis. Serum levels of insulin, Apelin, glucose, tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β) and the homeostasis model assessment of insulin resistance (HOMA-IR) were also measured using commercial kits.

Results

Cardiac Apelin and Apj expression and serum Apelin were increased in obese rats, while LC supplementation decreased the serum levels of Apelin and down-regulated Apelin and Apj expression in cardiac muscle. These changes were associated with reduced insulin resistance markers and serum inflammatory factors and improved lipid profile.

Conclusion

We concluded that LC supplementation could attenuate the over-expression of Apelin axis in heart of diabetic rats, a novel mechanism by which LC improves cardiovascular complications in diabetic patients.

Obesity, Inflammation, Toll-Like Receptor 4 and Fatty Acids

Obesity leads to an inflammatory condition that is directly involved in the etiology of cardiovascular diseases, type 2 diabetes mellitus, and certain types of cancer. The classic inflammatory response is an acute reaction to infections or to tissue injuries, and it tends to move towards resolution and homeostasis. However, the inflammatory process that was observed in individuals affected by obesity and metabolic syndrome differs from the classical inflammatory response in certain respects. This inflammatory process manifests itself systemically and it is characterized by a chronic low-intensity reaction. The toll-like receptor 4 (TLR4) signaling pathway is acknowledged as one of the main triggers of the obesity-induced inflammatory response. The aim of the present review is to describe the role that is played by the TLR4 signaling pathway in the inflammatory response and its modulation by saturated and omega-3 polyunsaturated fatty acids. Studies indicate that saturated fatty acids can induce inflammation by activating the TLR4 signaling pathway. Conversely, omega-3 polyunsaturated fatty acids, such as eicosapentaenoic acid and docosahexaenoic acid, exert anti-inflammatory actions through the attenuation of the activation of the TLR4 signaling pathway by either lipopolysaccharides or saturated fatty acids.

Insulin Regimens to Treat Hyperglycemia in Hospitalized Patients on Nutritional Support: Systematic Review and Meta-Analyses

BACKGROUND

The best insulin regimen to treat hyperglycemia in hospitalized patients on nutritional support (NS) is unclear.

METHODS

We searched electronic databases to identify cohort studies or randomized clinical trials in order to evaluate the efficacy of different insulin regimens used to treat hyperglycemia in hospitalized patients on NS on diverse outcomes: mean blood glucose (MBG), hypoglycemia, length of stay in hospital, and mortality.

RESULTS

Seventeen studies from a total of 5,030 were included. Enteral Group included 8 studies; 1,203 patients using rapid, glargine, NPH, or Premix insulin; MBG 108-225 mg/dL; hypoglycemia 0-13%. In indirect meta-analyses, NPH insulin ranked best for glucose control (MD 95% CI -2.50 mg/dL [2.65 to -2.35]). Parenteral Group included 4 studies; 228 patients using regular and glargine or NPH insulin; MBG 137-202 mg/dL; hypoglycemia 0-40%. In meta-analyses comparing regular insulin added to parenteral nutrition bag with glargine, MBG (MD 95% CI -3.78 mg/dL [-11.93 to 4.37]; I2 = 0%) or hypoglycemia frequency (RR 95% CI 1.37 [0.43-4.32]; I2 = 70.7%) did not differ. The description related to hospital length of stay and mortality was inconsistent between groups.

CONCLUSIONS

The best insulin regimen to treat hyperglycemia in hospitalized patients on NS has not been established; best results using insulin regimens with NPH in enteral nutrition do not seem to be clinically relevant.

Body Mass Index and Intensive Care Unit Outcomes in African American Patients

PURPOSE

We sought to determine whether body mass index (BMI) is associated with worse intensive care unit (ICU) outcomes among Black patients.

METHODS

Patients admitted to the medical ICU during 2012 were categorized into six BMI groups based on the World Health Organization criteria. ICU mortality, ICU and hospital length of stay (LOS), need for and duration of mechanical ventilation and organ failure rate were assessed.

RESULTS

A total of 605 patients with mean age 58.9 ± 16.0 years were studied. Compared with those with normal BMI, obese patients had significant higher rates of hypertension, diabetes mellitus and obstructive sleep apnea diagnoses (P<.001 for all). A total of 100 (16.5%) patients died during their ICU stay. Obesity was not associated with increased odds of ICU mortality (OR=.58; 95% CI, .16-2.20). Moreover, improved survival was observed for class II obese patients (OR, .031; 95% CI, .001-.863). There were no differences in the need for and duration of mechanical ventilation between the BMI groups. However, ICU and hospital LOS were significantly longer in patients with obesity.

CONCLUSION

Obesity was not associated with increased ICU mortality; however, obesity was associated with increased comorbid illness and with significant longer ICU and hospital length of stay.

Nutrition and metabolism in burn patients

Severe burn causes significant metabolic derangements that make nutritional support uniquely important and challenging for burned patients. Burn injury causes a persistent and prolonged hypermetabolic state and increased catabolism that results in increased muscle wasting and cachexia. Metabolic rates of burn patients can surpass twice normal, and failure to fulfill these energy requirements causes impaired wound healing, organ dysfunction, and susceptibility to infection. Adequate assessment and provision of nutritional needs is imperative to care for these patients. There is no consensus regarding the optimal timing, route, amount, and composition of nutritional support for burn patients, but most clinicians advocate for early enteral nutrition with high-carbohydrate formulas.

Nutritional support must be individualized, monitored, and adjusted throughout recovery. Further investigation is needed regarding optimal nutritional support and accurate nutritional endpoints and goals.

Risk of Acute Stroke After Hospitalization for Sepsis: A Case-Crossover Study

BACKGROUND AND PURPOSE

Infections have been found to increase the risk of stroke over the short term. We hypothesized that stroke risk would be highest shortly after a sepsis hospitalization, but that the risk would decrease, yet remain up to 1 year after sepsis.

METHODS

This case-crossover analysis utilized data obtained from the California State Inpatient Database of the Healthcare Cost and Utilization Project. All stroke admissions were included. Exposure was defined as hospitalization for sepsis or septicemia 180, 90, 30, or 15 days before stroke (risk period) or similar time intervals exactly 1 or 2 years before stroke (control period). Conditional logistic regression was used to calculate the odds ratio (OR) and 95% confidence interval (95% CI) for the association between sepsis/septicemia and ischemic or hemorrhagic stroke.

RESULTS

Ischemic (n=37 377) and hemorrhagic (n=12 817) strokes that occurred in 2009 were extracted where 3188 (8.5%) ischemic and 1101 (8.6%) hemorrhagic stroke patients had sepsis. Sepsis within 15 days before the stroke placed patients at the highest risk of ischemic (OR, 28.36; 95% CI, 20.02-40.10) and hemorrhagic stroke (OR, 12.10; 95% CI, 7.54-19.42); however, although the risk decreased, it remained elevated 181 to 365 days after sepsis for ischemic (OR, 2.59; 95% CI, 2.20-3.06) and hemorrhagic (OR, 3.92; 95% CI 3.29-4.69) strokes. There was an interaction with age (P=0.0006); risk of developing an ischemic stroke within 180 days of hospitalization for sepsis increased 18% with each 10-year decrease in age.

CONCLUSIONS

Risk of stroke is high after sepsis, and this risk persists for up to a year. Younger sepsis patients have a particularly increased risk of stroke after sepsis.

Bofutsushosan ameliorates obesity in mice through modulating PGC-1α expression in brown adipose tissues and inhibiting inflammation in white adipose tissues

The inducible co-activator PGC-1α plays a crucial role in adaptive thermogenesis and increases energy expenditure in brown adipose tissue (BAT). Meanwhile, chronic inflammation caused by infiltrated-macrophage in the white adipose tissue (WAT) is a target for the treatment of obesity. Bofutsushosan (BF), a traditional Chinese medicine composed of 17 crude drugs, has been widely used to treat obesity in China, Japan, and other Asia countries. However, the mechanism underlying anti-obesity remains to be elucidated. In the present study, we demonstrated that BF oral administration reduced the body weight of obese mice induced by high-fat diet (HFD) and alleviated the level of biochemical markers (P < 0.05), including blood glucose (Glu), total cholesterol (TC), triglyceride (TG), low density lipoprotein (LDL-C) and insulin. Our further results also indicated that oral BF administration increased the expression of PGC-1α and UCP1 in BAT. Moreover, BF also reduced the expression of inflammatory cytokines in WAT, such as tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6). These findings suggested that the mechanism of BF against obesity was at least partially through increasing gene expression of PGC-1α and UCP1 for energy consumption in BAT and inhibiting inflammation in WAT.

PROTECTIVE ROLE OF CARNITINE SYNERGIZED WITH VITAMIN E AGAINST ISOPROTERENOL INDUCED CARDIAC INFARCTION IN RATS

Background:

The current study aimed to evaluate the role of carnitine in combination with vitamin E in protection against myocardial infarction induced by isoproterenol (ISO) in rats.

Materials and Methods:

Rats were grouped into 5 (each 10 rats): Group I. Control fed a standard diet. Group III: Rats were injected with vitamin E (100 IU/kg bw, i.p) daily. Group IV: Rats were given carnitine (20 mg/kg bw, i.p) daily. Group V: Rats were injected with both vitamin E (100 IU/kg bw, i.p) and carnitine (20 mg/kg bw, i.p) daily. On 7^th, 8^th, and 9^th day, rats in groups (II-V) were injection i.p with ISO (55mg/kg b.w for successive three days). The treatment with carnitine and vitamin E were continuous for 21 days.

Results:

Canirine combined with vitamin E significantly increased coronary flow (CF) (P<0.001) in rats injected with ISO. The recovery of rate pressure product (RPP) and left ventricular developed pressure (LVDP) were significantly improved in treated rats in comparison to untreated. The rats administrated with ISO resulted in a significant elevation of serum enzymes (CK-MB and LDH) compared with control group (p<0.001). However, it returned to about normal. ISO administration resulted in a significant elevation in the levels of malondialdehyde (MDA) and nitric oxide (NO) as compared with control (p<0.001) and a significant reduction in the activities of GSPxase and GSRase (p<0.001) compared with control group. The levels of cardiac inflammatory markers interleukine-6 (IL-6) and tumor necrosis factor (TNF-α) were markedly elevated in rats injected with ISO compared with control group. Vitamin E combined with carnitine reversed these effects. However, pretreatment with vitamin E or carnitine or combined together showed a significant reduction in MDA and NO (p<0.001) and a significant elevation in the activities of GSPxase and GSRase (p<0.001) as compared to ISO injected group. The combined effect was more significant than individual ones.

Conclusion:

Vitamin E combined with carnitine exerts potential protective effect against MI through suppression of inflammatory mediators and enhancement of antioxidant activity.

Nutrition and metabolism in burn patients

Severe burn causes significant metabolic derangements that make nutritional support uniquely important and challenging for burned patients. Burn injury causes a persistent and prolonged hypermetabolic state and increased catabolism that results in increased muscle wasting and cachexia. Metabolic rates of burn patients can surpass twice normal, and failure to fulfill these energy requirements causes impaired wound healing, organ dysfunction, and susceptibility to infection. Adequate assessment and provision of nutritional needs is imperative to care for these patients. There is no consensus regarding the optimal timing, route, amount, and composition of nutritional support for burn patients, but most clinicians advocate for early enteral nutrition with high-carbohydrate formulas. Nutritional support must be individualized, monitored, and adjusted throughout recovery. Further investigation is needed regarding optimal nutritional support and accurate nutritional endpoints and goals.

Nutritional management of hyperapoB

Plasma apoB is a more accurate marker of the risk of CVD and type 2 diabetes (T2D) than LDL-cholesterol; however, nutritional reviews targeting apoB are scarce. Here we reviewed eighty-seven nutritional studies and present conclusions in order of strength of evidence. Plasma apoB was reduced in all studies that induced weight loss of 6–12 % using hypoenergetic diets (seven studies; 5440–7110 kJ/d; 1300–1700 kcal/d; 34–50 % carbohydrates; 27–39 % fat; 18–24 % protein). When macronutrients were compared in isoenergetic diets (eleven studies including eight randomised controlled trials (RCT); n 1189), the diets that reduced plasma apoB were composed of 26–51 % carbohydrates, 26–46 % fat, 11–32 % protein, 10–27 % MUFA, 5–14 % PUFA and 7–13 % SFA. Replacement of carbohydrate by MUFA, not SFA, decreased plasma apoB. Moreover, dietary enriching with n-3 fatty acids (FA) (from fish: 1·1–1·7 g/d or supplementation: 3·2–3·4 g/d EPA/DHA or 4 g/d EPA), psyllium (about 8–20 g/d), phytosterols (about 2–4 g/d) or nuts (30–75 g/d) also decreased plasma apoB, mostly in hyperlipidaemic subjects. While high intake of trans-FA (4·3–9·1 %) increased plasma apoB, it is unlikely that these amounts represent usual consumption. Inconsistent data existed on the effect of soya proteins (25–30 g/d), while the positive association of alcohol consumption with low plasma apoB was reported in cross-sectional studies only. Five isoenergetic studies using Mediterranean diets (including two RCT; 823 subjects) reported a decrease of plasma apoB, while weaker evidence existed for Dietary Approaches to Stop Hypertension (DASH), vegetarian, Nordic and Palaeolithic diets. We recommend using a Mediterranean dietary pattern, which also encompasses the dietary components reported to reduce plasma apoB, to target hyperapoB and reduce the risks of CVD and T2D.

Effect of L-Carnitine in Patients With Liver Cirrhosis on Energy Metabolism Using Indirect Calorimetry: A Pilot Study

Background

L-carnitine supplementation has been suggested to show several favorable effects on patients with liver cirrhosis (LC). However, there have been no reports regarding the effect of L-carnitine on energy metabolism in patients with LC using indirect calorimetry which is a well-established method for assessing the degree of liver malnutrition. We examined the effect of L-carnitine in patients with LC on energy metabolism using indirect calorimetry.

Methods

A total of 13 LC patients who are scheduled to be treated with L-carnitine (1,800 mg/day) were analyzed in this study. None of the patients previously received L-carnitine. An evaluation of the nutritional status was performed at the initiation of L-carnitine therapy and after 4 weeks of L-carnitine therapy. We evaluated the effect of L-carnitine on the nutritional status and energy metabolism by comparing various clinical variables at these two time points. In addition, the changes in the nutritional status of the patients were also evaluated using indirect calorimetry.

Results

After 4 weeks of L-carnitine treatment, for all cases, the mean substrate oxidation rates of carbohydrate (%C) increased from 37.6% to 48.2%, the mean substrate oxidation rates of fat (%F) decreased from 40.2% to 31.9% and the mean substrate oxidation rates of protein (%P) decreased from 22.2% to 19.9%. In a subgroup analysis of patients with baseline non-protein respiratory quotient (npRQ) < 0.85, the mean %C increased from 15.3% to 34.2%, the mean %F decreased from 59.9% to 45.1%, and the mean %P decreased from 24.8% to 20.6%. After 4 weeks of L-carnitine treatment, for all cases (n = 13), the mean value of npRQ increased in comparison with the baseline levels, although the difference was not significant (0.868 ± 0.060 vs. 0.838 ± 0.097, P = 0.19). Conversely, in patients with baseline npRQ < 0.85, the npRQ value significantly increased after 4 weeks treatment of L-carnitine compared with the baseline levels (0.827 ± 0.030 vs. 0.760 ± 0.043, P = 0.016).

Conclusion

L-carnitine supplementation can be useful for improving energy metabolism, especially in patients who have an advanced LC status and lower baseline npRQ values.

Common Medications Which Lead to Unintended Alterations in Weight Gain or Organ Lipotoxicity

Obesity is one of the most common chronic conditions in the world. Its management is difficult, partly due to the multiple associated comorbidities including fatty liver, diabetes, hypertension, and hyperlipidemia. As a result, the choice of prescription medications in overweight and obese patients has important implications as some of them can actually worsen the fat accumulation and its associated metabolic complications. Several prescription medications are associated with weight gain with mechanisms that are often poorly understood and under-recognized. Even less data are available on the distribution of fat and lipotoxicity (the organ damage related to fat accumulation). The present review will discuss the drugs associated with weight gain, their mechanism of action, and the magnitude and timing of their effect.

Effects of Oral L-Carnitine on Liver Functions after Transarterial Chemoembolization in Intermediate-Stage HCC Patients

Transarterial chemoembolization (TACE) is usually followed by hepatic dysfunction. We evaluated the effects of L-carnitine on post-TACE impaired liver functions. Methods. 53 cirrhotic hepatocellular carcinoma patients at Osaka Medical College were enrolled in this study and assigned into either L-carnitine group receiving 600 mg oral L-carnitine daily or control group. Liver functions were evaluated at pre-TACE and 1, 4, and 12 weeks after TACE. Results. The L-carnitine group maintained Child-Pugh (CP) score at 1 week after TACE and exhibited significant improvement at 4 weeks after TACE (P < 0.01). Conversely, the control group reported a significant CP score deterioration at 1 week (P < 0.05) and 12 weeks after TACE (P < 0.05). L-carnitine suppressed serum albumin deterioration at 1 week after TACE. There were significant differences between L-carnitine and control groups regarding mean serum albumin changes from baseline to 1 week (P < 0.05) and 4 weeks after TACE (P < 0.05). L-carnitine caused prothrombin time improvement from baseline to 1, 4 (P < 0.05), and 12 weeks after TACE. Total bilirubin mean changes from baseline to 1 week after TACE exhibited significant differences between L-carnitine and control groups (P < 0.05). The hepatoprotective effects of L-carnitine were enhanced by branched chain amino acids combination. Conclusion. L-carnitine maintained and improved liver functions after TACE.

Heparin-induced thrombocytopenia in a non-heparin-naive patient: a case report

Introduction

Administration of low molecular weight heparin (LMWH) is recommended for prophylaxis of venous thromboembolism in patients undergoing hip surgery. In this context, heparin-induced thrombocytopenia (HIT) type II is a complication of rare incidence but sometimes fatal outcome.

Case description

A 52-year old obese patient undergoing antithrombotic therapy with Enoxaparin after hip surgery presented with a painful, swollen leg and thrombocytopenia on day eight after surgery. Medical history showed previous administration of Enoxaparin without complications 2 years ago. Further diagnostic investigation supplied evidence of multiple thromboembolic events and concomitant compartment syndrome. Administration of Enoxaparin was stopped immediately and treatment with Argatroban was initiated. Diagnosis of HIT was confirmed according to current guidelines. Despite interventional thrombectomy and fasciotomy, amputation of both lower limbs had to be performed due to ongoing necroses. After a 30-days-stay at the intensive care unit because of sepsis, respiratory and renal failure, clinical condition improved and the patient could be transferred for rehabilitation.

Discussion and evaluation

HIT II is known as complication of administration of LMWH in the perioperative setting. Diagnosis results from clinical findings and platelet count. Argatroban is recommended as an alternative therapeutic anticoagulant in HIT II. Inflammation and surgical trauma are discussed as priming factors to increase risk of HIT II.

Conclusions

Administration of LMWH may result in HIT II despite prior uneventful drug exposure. Except for immediate diagnosis, only consequent anticoagulation can stop the course of disease. Hence, interdisciplinary awareness is inevitable for early diagnosis and accurate therapy to prevent from a catastrophic clinical course.