Searching the Literature by Design

Current nursing knowledge has been generated by studies whose designs range from exploratory to experimental. Searching the literature for a study illustrating a particular design can be a perplexing process. This article explains strategies that are useful in identifying research studies according to the designs used in their methods. The suggested search strategies assist in identifying the most relevant search results and can save time. Outcomes of such a search can be instructional about the implementation of a design in its classic form or some variation. They can provide practical illustrations of the advantages and limitations of a design when applied in a particular area of interest.

Comparing community and specialty provider-based recruitment in a randomized clinical trial: clinical trial in fecal incontinence

Recruitment of participants to clinical trials remains a significant challenge, especially for research addressing topics of a sensitive nature such as fecal incontinence (FI). In the Fiber Study, a randomized controlled trial on symptom management for FI, we successfully enrolled 189 community-living adults through collaborations with specialty-based and community-based settings, each employing methods tailored to the organizational characteristics of their site. Results show that using the two settings increased racial and ethnic diversity of the sample and inclusion of informal caregivers. There were no differential effects on enrollment, final eligibility, or completion of protocol by site. Strategic collaborations with complementary sites can achieve sample recruitment goals for clinical trials on topics that are sensitive or known to be underreported.

Management of fecal incontinence in adults

This article summarises the findings from the Conservative Management of Faecal Incontinence in Adults Committee of the International Consultation on Incontinence. We conducted comprehensive literature searches using the following keywords combined with the relevant intervention: "anal, anorectal, bowel, faecal, fecal, rectal, stool" and "continent$ or incontinent$," Prevalence etimates for faecal or anal incontinence vary widely, from 2.2% to 2.5%. Expert opinion supports the use of general health education, patient teaching about bowel function and advice on lifestyle modification, but the evidence base is small. Unlike urinary incontinence, few "lifestyle" associations have been identified with FI and little is known about whether interventions designed to reduce potential risk factors might improve FI. The article summarises the evidence and recommendations from the committee for clinical practice and future research.

Re-examination of risk factors for non-Clostridium difficile-associated diarrhoea in hospitalized patients

AIM

This paper is a report of a study to determine the incidence of non-Clostridium difficile-associated diarrhoea in hospitalized patients and to re-evaluate clinical characteristics and other risk factors related to non-C. difficile-associated diarrhoea.

BACKGROUND

Numerous factors are thought to be responsible for diarrhoea in hospitalized patients. Reports about the diarrhoeal effects of some medications administered concomitantly with tube feeding have stimulated reappraisal of the influence of tube feeding as a potential cause.

METHOD

This study was a secondary analysis of data of 154 hospitalized patients collected during a prospective epidemiological study from 1992 to 1993. The secondary analysis was completed in 2006 in order to investigate unanswered questions of current importance.

FINDINGS

The sample was predominantly male and middle aged; approximately 50% were tube fed, and 25% were in an intensive care unit. The incidence of diarrhoea was 35%. Increased severity of illness as well as the combination of sorbitol-containing medication administration and tube feeding were found to be statistically significant factors in the development of diarrhoea.

CONCLUSION

As diarrhoea in hospitalized patients appears to be multifactorial, use of an algorithm to systematically evaluate and manage related factors is recommended.

Incontinence-associated skin damage in nursing home residents: a secondary analysis of a prospective, multicenter study

More than half of the nursing home population is incontinent of urine or feces, presenting challenges to perineal skin health. To determine the occurrence and severity of skin damage in nursing home residents with incontinence, a secondary analysis of data collected from a multisite, open-label, quasi-experimental study of cost and efficacy of four regimens for preventing incontinence-associated dermatitis in nursing home residents was performed. Sixteen randomly selected nursing homes from across the US were included in the study. Participating nursing home residents were incontinent of urine and/or feces and free of skin damage. Of the 1,918 persons screened, 51% (n = 981) qualified for prospective surveillance. Perineal skin was assessed over a 6-week period; frequency, type, and severity of skin damage were observed. Skin damage developed after a median of 13 (range 6 to 42) days in 45 out of 981 residents (4.6%), of which 3.4% was determined to be incontinence-associated dermatitis. Some residents (14 out of 45, 31%) had incontinence-associated dermatitis of other skin damage in more than one area. This study is one of the first to report the characteristics of incontinence-associated dermatitis in a large sample of nursing home residents. The sample size and random selection of nursing homes impart generalizability to the findings. Incontinence-associated dermatitis is a risk in nursing home residents, especially those with fecal incontinence. These findings suggest that the rate and severity of incontinence-associated dermatitis are low with close monitoring and use of a defined skin care regimen that includes a pH-balanced cleanser and moisture barrier.

Prevalence and Correlates of Perineal Dermatitis in Nursing Home Residents

BACKGROUND

Perineal dermatitis is an adverse outcome of incontinence, which is common in older nursing home residents; yet knowledge about perineal dermatitis in this population is sorely lacking.

OBJECTIVES

To determine the prevalence and significant correlates of perineal dermatitis in older nursing home residents.

METHODS

Assessment data from 59,558 records in the Minimum Data Set (MDS) were linked with 2,883,049 orders in the medical record which enabled definition of variables related to perineal dermatitis, identification of cases, and determination of the prevalence of perineal dermatitis. Data from two subsamples, each with the records of 10,215 older nursing home residents, were analyzed using logistic regression to identify the significant correlates of perineal dermatitis.

RESULTS

Perineal dermatitis was found in 5.7% (n = 3,405) of residents and 73% of these were incontinent. Having perineal dermatitis was significantly associated with (a) impairments in tissue tolerance (i.e., more health problems, presence of a fever, requiring nutrition support, and having more problems of diminished perfusion or oxygenation); (b)problems of the perineal environment (i.e., having fecal incontinence only, double incontinence, and more items associated with mechanical chafing); and (c) altered toileting ability from daily use of restraints.

DISCUSSION

Several correlates of perineal dermatitis (mechanical chafing, fecal and double incontinence, and use of restraints) appear modifiable through nursing intervention. Clinical interventions should consider the complex health status of this population.

Community-based recruitment and enrollment for a clinical trial on the sensitive issue of fecal incontinence: the Fiber study

The recruitment of community-living participants for clinical trials of sensitive topics, when the population is largely hidden and reluctant to self-identify, and the study protocols and procedures intensive, creates significant challenges to researchers. The Fiber Study is an ongoing randomized controlled clinical trial conducted to compare the effectiveness of three dietary fibers with different levels of fermentability for symptom management in community-living adults with fecal incontinence. The researchers developed a staged approach to recruitment using three primary recruitment methods and a three-phase approach to the enrollment process. We have been successful in reaching, recruiting, and enrolling participants in a clinical trial, as well as in effectively managing study resources and staff time.

Diet Strategies Used by Women to Manage Fecal Incontinence

Fecal incontinence occurs in community-living women who are elderly, as well as younger women, particularly after vaginal childbirth. Little is known about how women manage fecal incontinence in their everyday lives. Ten women who had fecal incontinence for at least 1 year participated in an audio-taped interview in a phenomenological study. Diet modification was identified as a key strategy for managing fecal incontinence. Various food types were avoided, restricted, or used as remedies. The meanings that the women applied to the diet strategies for managing fecal incontinence had 4 themes: restricting diet and eating patterns, eating and dealing with the consequences, treating fecal incontinence with foods and fluids, and lacking therapeutic guidance regarding diet modifications for fecal incontinence. The results of this study suggest that the continence nurse specialist recognize the important role and meaning of diet as a self-care strategy for women with fecal incontinence and address diet in their assessment and management recommendations.

Preparing a Grant Proposal—Part 5

Translating a research idea into a well-written grant proposal takes planning and commitment. This Spotlight is the fifth in a series by the members of the Center for Clinical Investigation (CCI) of the Wound, Ostomy and Continence Nurses (WOCN) Society. The aim of this series is to facilitate high-quality grant writing and encourage submissions to WOCN's grants program. This article provides guidance on the development of a grant proposal and the revisions necessary to result in a polished final product.

Managing Fecal Incontinence: SELF-CARE PRACTICES OF OLDER ADULTS

Little is known about the ways in which community-dwelling elderly individuals manage fecal incontinence (FI) in their daily lives. In this study, community-dwelling elderly individuals were surveyed at clinics of a health maintenance organization (HMO) to describe the self-care practices used to manage FI and to examine factors that influenced the number of self-care practices used and the reporting of FI to a health care practitioner. Responses of 242 elderly individuals who reported that they had FI several times per year were analyzed. The self-care practices used most commonly were changing diet, wearing a sanitary pad/brief, and reducing activity or exercise. Elderly women and those with a greater severity of FI and more chronic health problems engaged in more self-care practices. Factors associated with reporting FI to a clinician were considering FI to be a problem, uncertainty about the cause of FI, and changing diet to avoid FI. There is a need to promote effective management strategies for FI to older individuals living in the community.

Dietary fiber in conservative management of chronic renal failure

Conservative management of chronic renal failure has included a variety of dietary manipulations. Supplementation of dietary fiber to reduce adverse symptoms is a novel approach, but whether it can make an effective clinical impact is yet undetermined. This commentary accompanies a brief report of improved well-being during fiber supplementation. It explains some of the background thinking and early trials of fiber supplementation in chronic renal failure patients.

Severity of fecal incontinence in community-living elderly in a health maintenance organization

An anonymous survey containing questions about the severity of fecal incontinence (FI)--frequency, amount, and type--and its correlates was distributed to community-living elderly at four managed-care clinics. Completed surveys were received from 1,352 respondents whose mean (+/-standard deviation) age was 75 +/- 6 years and 60% of whom were female. Approximately 19% reported having FI one or more times within the past year. Incontinence that soiled underwear or was of loose or liquid consistency was most common. More frequent FI and a greater amount of FI were significantly associated with loose or liquid stool consistency, defecation urgency, bowel surgery, and chronic health conditions. Therapies aimed at normalizing stool consistency or reducing urgency may be beneficial in lessening FI severity.

Development of evidence-based protocols for evaluation and management of dysfunctional vascular access devices in interventional radiology

Assessment and treatment of dysfunctional vascular access devices (VADs) is a mutual responsibility of nurses who use these devices and the interventional radiology (IR) team. Understanding causes of dysfunction, implementing assessment and treatment protocols, and communication between referral areas and the IR team are beneficial to both areas and to the patient. This study describes development of evidence-based protocols, combining research utilization and a quality improvement educational process.

Tool to classify stool consistency: content validity and use by persons of diverse cultures

Developing and testing the quality of a research instrument, including its ability to be used by culturally diverse persons, is an important methodological objective. The present study determined the content validity and feasibility of culturally diverse persons to use an instrument to classify stool consistency that has been employed in research on fecal incontinence. Five multidisciplinary clinicians experienced in assessing stool consistency determined the tool to possess content validity. Twenty-four foreign nationals of diverse cultures who spoke English as a second language (ESL) classified the consistency of nine stools using word only or word plus diagram descriptions. The agreement of the ratings of the participants were compared with the those of an experienced investigator. There was no significant difference between the ratings of participants using either type of description. There was good agreement between the classifications of the participants and those of the investigator. The findings of this study contribute to the quality of our instrument and support its use by culturally diverse persons.

Supplementation with dietary fiber improves fecal incontinence

BACKGROUND

Human studies have shown that dietary fiber affects stool composition and consistency. Because fecal incontinence has been shown to be exacerbated by liquid stools or diarrhea, management strategies that make stool consistency less loose or liquid may be useful.

OBJECTIVE

To compare the effects of a fiber supplement containing psyllium, gum arabic, or a placebo in community-living adults who were incontinent of loose or liquid stools. Mechanisms underlying these effects (e.g., fermentation of the fibers and water-holding capacity of stools) were examined.

METHODS

Thirty-nine persons with fecal incontinence of loose or liquid stools prospectively recorded diet intake and stool characteristics and collected their stools for 8 days prior to and at the end of a 31-day fiber supplementation period. During the fiber supplementation period, they ingested psyllium, gum arabic, or a placebo by random assignment.

RESULTS

In the baseline period, the groups were comparable on all variables measured. In the fiber supplementation period, (a) the proportion of incontinent stools of the groups ingesting the fiber supplements was less than half that of the group ingesting the placebo, (b) the placebo group had the greatest percentage of stools that were loose/unformed or liquid, and (c) the psyllium group had the highest water-holding capacity of water-insoluble solids and total water-holding capacity. The supplements of dietary fiber appeared to be completely fermented by the subjects as indicated by nonsignificant differences in total fiber, short chain fatty acids and pH in stools among the groups in the baseline or fiber supplementation periods.

CONCLUSIONS

Supplementation with dietary fiber from psyllium or gum arabic was associated with a decrease in the percentage of incontinent stools and an improvement of stool consistency. Improvements in fecal incontinence or stool consistency did not appear to be related to unfermented dietary fiber.

Survey of nutritional status in newly hospitalized patients with stage III or stage IV pressure ulcers

OBJECTIVE

To examine the nutritional status of newly hospitalized patients with Stage III or Stage IV pressure ulcers.

DESIGN

Descriptive survey.

STUDY PARTICIPANTS

405 newly admitted hospitalized non-ICU patients were eligible for inclusion in the study. Patients included in the study had Stage III or Stage IV pressure ulcers on their trunk, had weight indices available, and had prealbumin levels measured. One hundred and twenty patients were included in the analysis.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Measurements of weight, prealbumin and albumin levels, nutritional intake, type of diet, gender, age, type of pressure ulcer, and type of residence prior to admission.

RESULTS

Analysis of the data revealed that a majority of the patients were elderly, had a Stage III sacral ulcer, were below their usual body weight, had a low prealbumin level, and were not taking in enough nutrition to meet their needs.

CONCLUSION

The results of this study suggest that a majority of newly hospitalized patients with severe pressure ulcers are malnourished and aggressive nutritional therapy may be warranted.

Fecal incontinence in hospitalized patients who are acutely ill

BACKGROUND

Information about fecal incontinence experienced by patients in acute-care settings is lacking. The relationship of fecal incontinence to several well-known nosocomial or iatrogenic causes of diarrhea has not been determined.

OBJECTIVES

To determine the cumulative incidence of fecal incontinence in hospitalized patients who are acutely ill, and to ascertain the relationship between fecal incontinence and stool consistency, and between diarrhea and two well-known nosocomial or iatrogenic etiologies of diarrhea: Clostridium difficile and tube feeding. The relationship of fecal incontinence and risk factors for diarrhea associated with C. difficile and tube feeding in hospitalized patients was examined.

METHODS

Fecal incontinence, stool frequency and consistency, administration of tube feeding and medications, severity of illness, and nutritional data were prospectively recorded in 152 patients on acute or critical care units of a university-affiliated Veterans' Affairs Medical Center. Rectal swabs and stool specimens from patients were obtained weekly for C. difficile culture. C. difficile culture and cytotoxin assay were performed on diarrheal stools. HindIII restriction endonuclease analysis (REA) was used for typing of C. difficile isolates.

RESULTS

In this study, 33% (50/152) of the patients had fecal incontinence. The proportion of total surveillance days with fecal incontinence in these patients was 0.50 +/- 0.06. A greater percentage of patients with diarrhea had fecal incontinence than patients without diarrhea (23/53 [43%] vs. 27/99 [27%]; p = 0.04). Incontinence was more frequent in patients with loose/liquid stool consistency than in patients with hard/soft stool consistency (48/50 [96%] vs. 71/100 [71%]; p < 0.001). The proportion of surveillance days with fecal incontinence was related to the proportion of surveillance days with diarrhea (r = 0.69; p < 0.001) and the proportion of surveillance days with loose/liquid stools (r = 0.64; p < 0.001). Multivariate risk factors for fecal incontinence were unformed/loose or liquid consistency of stool (RR = 11.1; 95% confidence interval [CI] = 2.2, 56.7), severity of illness (RR = 5.7; CI = 2.6, 12.3), and age (RR = 1.1; CI = 1, 1.1).

CONCLUSIONS

Fecal incontinence is common in hospitalized patients who are acutely ill, but the condition was not associated with any specific cause of diarrhea. Because loose or liquid stool consistency is a risk factor for fecal incontinence, use of treatments that result in a more formed stool may be beneficial in managing fecal incontinence. However, treatments that slow intestinal transit should be avoided in patients with C. difficile-associated diarrhea.

Comparison of the nutritional composition of diets of persons with fecal incontinence and that of age- and gender-matched controls

PURPOSE

In our clinical and research experience, persons with fecal incontinence anecdotally report altered diet intake to avoid incontinence. The purpose of this study was to compare the dietary intake of 39 persons with fecal incontinence living in the community with that of age- and gender-matched control subjects who had normal bowel function. The diets of both groups were compared with recommended dietary allowances (RDAs) for their constituent nutrients.

METHODS

Subjects prospectively recorded the type, amount, and method of preparing all foods and beverages ingested for 8 consecutive days. Diet records were analyzed using the Nutritionist IV software program.

MAIN OUTCOME MEASURES

The main outcome measures were the amounts and percentage of the RDAs of macronutrients and micronutrients in the subjects' diets.

RESULTS

There were no significant differences in the intake of total kilocalories, protein, fat, dietary fiber, caffeine, or lactose by the fecal incontinence and control groups. The fecal incontinence group had a greater intake of carbohydrates, manganese, and vitamin B(1) compared with the control group. Diets of both groups exceeded 100% of the RDA for protein, phosphorus, iron, sodium, potassium, Vitamins B(1), B(2), B(3), B(12), and C and folate. Diets of both groups had less than 50% of the RDA for biotin, chromium, copper, and manganese but did not differ significantly. The percentages of the RDA for calcium and vitamin D were 84% +/- 6% and 56% +/- 8% for the fecal incontinence group and 90 +/- 8 (P =.6) and 69 +/- 11 for the control group (P =.4).

CONCLUSIONS

The diets of persons with fecal incontinence were similar to those of control subjects with normal bowel function. Both the fecal incontinence and control groups may improve their nutritional patterns by lowering sodium and protein intake and increasing dietary fiber and monounsaturated fat intake. Calcium and vitamin D supplementation may improve dietary deficiencies and lower disease risks. Including a nutritional assessment and consultation in the care of persons with fecal incontinence to improve their general health and prevent disease is recommended, but consideration must be given to altered diet patterns perceived by the patient to prevent fecal incontinence.

Tube feeding: immune-boosting formulas

This first of two articles on enteral nutrition focuses on the formulas that contain special nutrients to enhance immune system function and digestion. We'll review the specific nutrients in enhanced formulas, what researchers have found about their effects on the critically ill, and whether they're worth using.

Tube feeding: administration tips

This second of two articles on enteral nutrition discusses the basics of tube feedings, including the types of tubes that are used, when to start a feeding, and some common complications that develop in patients--aspiration and diarrhea chief among them.

Comparison of subjective classification of stool consistency and stool water content

OBJECTIVE

The purpose of this study was to compare the stool consistency categorizations made by 39 adults with fecal incontinence and the percentage of water in their stools determined by lyophilization.

METHODS

Subjects collected all stools daily for 8 days during a baseline period and at the end of a fiber treatment period. Stool consistency was recorded as hard and formed, soft but formed, loose and unformed, or liquid. Aliquots of the stools were lyophilized to constant weight.

MAIN OUTCOME MEASURES

The main outcome measures were the percentage of stool water among stools in each consistency category and the correlation between subjects' stool consistency categorizations and the percentage of stool water.

RESULTS

The subjects were 8 men and 21 women, ranging in age from 30 to 89 years, who were participating in a study of the effectiveness of dietary fiber for treating fecal incontinence. A total of 1023 stool samples were analyzed. Significant differences in the mean percentage of water were found among the 4 stool consistency categories (hard and formed = 68% +/- 0.9%, soft but formed = 74% +/- 0.3%, loose and unformed = 80% +/- 0.4%, and liquid = 85% +/- 0.3%; P < .001). Ninety-six percent of the stools had a percentage of water within 2 SDs of the mean percentage of water of other stools in their consistency category.

CONCLUSION

This classification system of stool consistency is a valid and practical measure for clinical studies. It may be useful for clinicians and patients to evaluate outcomes of treatments directed at improving stool consistency.

Acquisition of Clostridium difficile and Clostridium difficile-associated diarrhea in hospitalized patients receiving tube feeding

BACKGROUND

Clostridium difficile is the most common infectious cause of nosocomial diarrhea, but its role in diarrhea associated with tube feeding has not been rigorously investigated.

OBJECTIVE

To determine the incidence of C. difficile acquisition and C. difficile-associated diarrhea in tube-fed and non-tube-fed patients.

DESIGN

Prospective cohort study.

SETTING

A university-affiliated Veterans Affairs Medical Center.

PATIENTS

76 consecutive hospitalized, tube-fed patients and 76 hospitalized, non-tube-fed patients. The two cohorts were matched for age, unit location, duration of hospitalization before surveillance, and severity of illness.

MEASUREMENTS

Incidence of C. difficile acquisition, incidence of C. difficile-associated diarrhea, and C. difficile restriction endonuclease analysis typing results.

RESULTS

More tube-fed patients than non-tube-fed patients acquired C. difficile (15 of 76 patients [20%] compared with 6 of 76 patients [8%]; P=0.03) and developed C. difficile-associated diarrhea (7 of 76 patients [9%] compared with 1 of 76 patients [1%]; P=0.03). The mean proportion (+/-SD) of surveillance days with diarrhea was greater for tube-fed patients after the development of C. difficile-associated diarrhea than for tube-fed patients without this diarrhea (0.68+/-0.4 compared with 0.22+/-0.2 [95% CI for the mean difference, 0.08 to 0.84]). Postpyloric tube feeding (odds ratio, 3.14 [CI, 1.008 to 9.77]) and duration of surveillance (odds ratio, 1.08 [CI, 1.0009 to 1.16]) were risk factors for the acquisition of C. difficile. Nineteen restriction endonuclease analysis types of C. difficile were identified from 20 patients.

CONCLUSIONS

Hospitalized, tube-fed patients, especially those receiving postpyloric tube feeding, are at greater risk for the acquisition of C. difficile and the development of C. difficile-associated diarrhea than are hospitalized, non-tube-fed patients. Clinicians should test for C. difficile in tube-fed patients with diarrhea.

Primary symptomless colonisation by Clostridium difficile and decreased risk of subsequent diarrhoea

BACKGROUND

Little is known about whether patients who develop Clostridium-difficile-associated diarrhoea (CDAD) are culture-positive or culture-negative before illness. The most important risk factor is antibiotic exposure. We aimed to find out whether patients identified as primary symptom-free C difficile carriers are at higher risk of developing CDAD than patients who are culture-negative.

METHOD

We reviewed four longitudinal studies in which 810 patients admitted to hospital were followed up by prospective rectal-swab culture. At least two consecutive weekly cultures were obtained. We calculated the difference in risk of CDAD between colonised and non-colonised patients in each study and combined the results of the four studies in a random-effects model.

FINDINGS

Of 618 non-colonised patients (mean follow-up 1.7 weeks [SD 1.3]), 22 (3.6%) developed CDAD, whereas only two (1.0%) of 192 primary symptom-free carriers (1.5 [1.5]) developed CDAD (pooled risk difference -2.3% [95% CI 0.3-4.3], p=0.021). Of patients who received antibiotics, the risk difference was increased: 22 (4.5%) of 491 non-colonised patients compared with two (1.1%) of 176 colonised patients developed CDAD (-3.2% [0.4-6.0], p=0.024). Of the primary symptom-free C difficile carriers, 95 were colonised with toxigenic strains, 76 with non-toxigenic strains, 12 with both toxigenic and non-toxigenic strains (non-concurrently), and nine with strains of undetermined toxigenicity. Nine of the 12 toxogenic strains of C difficile isolates that cause CDAD were also recovered from stools of symptom-free patients.

INTERPRETATION

Primary symptomless C difficile colonisation is associated with a decreased risk of CDAD. Although the mechanism is unknown, risk reduction is found in colonisation with non-toxigenic and toxigenic strains.

Comparison of cycloserine-cefoxitin-fructose agar (CCFA) and taurocholate-CCFA for recovery of Clostridium difficile during surveillance of hospitalized patients

The effectiveness of cycloserine-cefoxitin-fructose agar (CCFA) and taurocholate-CCFA (TCCFA) in isolating Clostridium difficile from swabs of the rectum or stools from 184 hospitalized patients who were monitored weekly and when they had diarrhea was compared. The number of surveillance time points ranged from two to eight per patient over a period of 4 to 34 days per patient, totalling 621 comparisons of the media. C. difficile was isolated more frequently by TCCFA than CCFA at seven of eight surveillance points, a significant trend (O'Brien test, p = 0.002). This difference reached statistical significance at the second surveillance time point when the prevalence of C. difficile was sufficiently high. At the second surveillance point, C. difficle was isolated only by TCCFA in 7 of 184 comparisons of the media, only by CCFA in none of the comparisons, and by both media in 19 comparisons (p = 0.016). C. difficle was first isolated at an earlier surveillance time point on TCCFA in 11 of 36 patients and on CCFA first only once (p = 0.005). Use of TCCFA media increased the rapidity and sensitivity of culture for C. difficle when doing patient surveillance but did not increase sensitivity when diagnosing patients with diarrhea.

Supplementation with gum arabic fiber increases fecal nitrogen excretion and lowers serum urea nitrogen concentration in chronic renal failure patients consuming a low-protein diet

In chronic renal failure (CRF), plasma concentrations of the products of protein metabolism are increased. Current dietary management is to prescribe a decrease in protein intake. The use of dietary fiber to increase fecal excretion of retained metabolites in CRF may be a beneficial adjunct to a low-protein diet (LPD). Colonic bacteria ferment dietary fiber, providing them with energy for growth and nitrogen incorporation, in turn, increasing nitrogen excretion in feces. Sixteen CRF patients consuming an LPD were randomly assigned to receive a supplement of a highly fermentable fiber, gum arabic (50 g/d), or a placebo (1 g pectin/d) in a prospective, single-blind, crossover design. Fecal bacterial mass and fecal nitrogen content were significantly increased during supplementation with gum arabic compared with the baseline LPD or supplementation with pectin. Serum urea nitrogen was significantly decreased during supplementation with gum arabic compared with the baseline LPD or supplementation with pectin. Nitrogen balance did not change significantly.

Defining and reporting diarrhea in tube-fed patients--what a mess!

The frequency and consistency of stools of all patients at a VA Medical Center who were tube-fed during a 3-mo period were recorded prospectively and analyzed in terms of eight definitions of diarrhea derived from the literature. The extent of diarrhea, reported as incidence and as percentage of days with diarrhea, was used to determine differences among the definitions. The relationship between extent of diarrhea and duration of monitoring patients was also determined. Results of 29 patients monitored for 13.0 d (6.5 d) [median (interquartile range)] indicated that the definition of diarrhea significantly influenced the reported incidence of and percentage of days with diarrhea. Duration of monitoring showed a significant, positive relationship to the incidence of diarrhea (ie, the longer the duration, the more likely that diarrhea was observed). When diarrhea was reported as the percentage of days with diarrhea, the influence of monitoring duration virtually disappeared.

Parenteral nutrition supplemented with short-chain fatty acids: effect on the small-bowel mucosa in normal rats

When enteral nutrition is excluded from animals maintained solely with total parenteral nutrition (TPN), atrophy of the intestinal mucosa is observed. Short-chain fatty acids (SCFAs) are produced in the colon by the fermentation of dietary carbohydrates and fiber polysaccharides and have been shown to stimulate mucosal-cell mitotic activity in the intestine. This study compared the effects of an intravenous and an intracecal infusion of SCFAs on the small-bowel mucosa. Rats received standard TPN, TPN with SCFAs (sodium acetate, propionate, and butyrate), TPN with an intracecal infusion of SCFAs, or rat food. After 7 d jejunal and ileal mucosal weights, DNA, RNA, and protein were determined. Standard TPN produced significant atrophy of the jejunal and ileal mucosa. Both the intracecal and intravenous infusion of SCFAs significantly reduced the mucosal atrophy associated with TPN. The intravenous and intracolonic infusion of SCFAs were equally effective in inhibiting small-bowel mucosal atrophy.