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Critical Care (London, England) Jul 2023Personalization of ICU nutrition is essential to future of critical care. Recommendations from American/European guidelines and practice suggestions incorporating recent... (Review)
Review
Personalization of ICU nutrition is essential to future of critical care. Recommendations from American/European guidelines and practice suggestions incorporating recent literature are presented. Low-dose enteral nutrition (EN) or parenteral nutrition (PN) can be started within 48 h of admission. While EN is preferred route of delivery, new data highlight PN can be given safely without increased risk; thus, when early EN is not feasible, provision of isocaloric PN is effective and results in similar outcomes. Indirect calorimetry (IC) measurement of energy expenditure (EE) is recommended by both European/American guidelines after stabilization post-ICU admission. Below-measured EE (~ 70%) targets should be used during early phase and increased to match EE later in stay. Low-dose protein delivery can be used early (~ D1-2) (< 0.8 g/kg/d) and progressed to ≥ 1.2 g/kg/d as patients stabilize, with consideration of avoiding higher protein in unstable patients and in acute kidney injury not on CRRT. Intermittent-feeding schedules hold promise for further research. Clinicians must be aware of delivered energy/protein and what percentage of targets delivered nutrition represents. Computerized nutrition monitoring systems/platforms have become widely available. In patients at risk of micronutrient/vitamin losses (i.e., CRRT), evaluation of micronutrient levels should be considered post-ICU days 5-7 with repletion of deficiencies where indicated. In future, we hope use of muscle monitors such as ultrasound, CT scan, and/or BIA will be utilized to assess nutrition risk and monitor response to nutrition. Use of specialized anabolic nutrients such as HMB, creatine, and leucine to improve strength/muscle mass is promising in other populations and deserves future study. In post-ICU setting, continued use of IC measurement and other muscle measures should be considered to guide nutrition. Research on using rehabilitation interventions such as cardiopulmonary exercise testing (CPET) to guide post-ICU exercise/rehabilitation prescription and using anabolic agents such as testosterone/oxandrolone to promote post-ICU recovery is needed.
Topics: Humans; Intensive Care Units; Nutritional Support; Critical Care; Nutritional Status; Enteral Nutrition; Critical Illness
PubMed: 37403125
DOI: 10.1186/s13054-023-04539-x -
American Journal of Physiology. Cell... Jul 2021Critical illnesses, including sepsis, cancer cachexia, and burn injury, invoke a milieu of systemic metabolic and inflammatory derangements that ultimately results in... (Review)
Review
Critical illnesses, including sepsis, cancer cachexia, and burn injury, invoke a milieu of systemic metabolic and inflammatory derangements that ultimately results in increased energy expenditure leading to fat and lean mass catabolism. Burn injuries present a unique clinical challenge given the magnitude and duration of the hypermetabolic response compared with other forms of critical illness, which drastically increase the risk of morbidity and mortality. Skeletal muscle metabolism is particularly altered as a consequence of burn-induced hypermetabolism, as it primarily provides a main source of fuel in support of wound healing. Interestingly, muscle catabolism is sustained long after the wound has healed, indicating that additional mechanisms beyond wound healing are involved. In this review, we discuss the distinctive pathophysiological response to burn injury with a focus on skeletal muscle function and metabolism. We first examine the diverse consequences on skeletal muscle dysfunction between thermal, electrical, and chemical burns. We then provide a comprehensive overview of the known mechanisms underlying skeletal muscle dysfunction that may be attributed to hypermetabolism. Finally, we review the most promising current treatment options to mitigate muscle catabolism, and by extension improve morbidity and mortality, and end with future directions that have the potential to significantly improve patient care.
Topics: Burns; Cachexia; Epigenesis, Genetic; Exercise; Human Growth Hormone; Humans; Insulin; Metformin; Muscle Proteins; Muscle, Skeletal; Muscular Atrophy; Oxandrolone; Propranolol; Protein Biosynthesis; Proteolysis; Sepsis; Signal Transduction; Wound Healing
PubMed: 33909503
DOI: 10.1152/ajpcell.00106.2021 -
Current Urology Reports Oct 2016There has recently been renewed interest in novel clinical applications of the anabolic-androgenic steroid (AAS) testosterone and its synthetic derivatives, particularly... (Review)
Review
There has recently been renewed interest in novel clinical applications of the anabolic-androgenic steroid (AAS) testosterone and its synthetic derivatives, particularly given with the rising popularity of testosterone supplementation therapy (TST) for the treatment of male hypogonadism. In this manuscript, we provide a brief review of the history of AAS and discuss clinical applications of two of the more well-known AAS: nandrolone and oxandrolone. Both agents exhibit favorable myotrophic/androgenic ratios and have been investigated for effectiveness in numerous disease states. We also provide a brief synopsis of selective androgen receptor modulators (SARMs) and postulate how these orally active, non-aromatizing, tissue-selective agents might be used in contemporary andrology. Currently, the applications of testosterone alternatives in hypogonadism are limited. However, it is tempting to speculate that these agents may one day become accepted as alternatives, or adjuncts, to the treatment of male hypogonadism.
Topics: Anabolic Agents; Androgen Antagonists; Humans; Male; Men's Health; Nandrolone; Oxandrolone
PubMed: 27535042
DOI: 10.1007/s11934-016-0629-8 -
The Surgical Clinics of North America Jun 2023Hypermetabolism is a hallmark of larger burn injuries. The hypermetabolic response is characterized by marked and sustained increases in catecholamines, glucocorticoids,... (Review)
Review
Hypermetabolism is a hallmark of larger burn injuries. The hypermetabolic response is characterized by marked and sustained increases in catecholamines, glucocorticoids, and glucagon. There is an increasing body of literature for nutrition and metabolic treatment and supplementation to counter the hypermetabolic and catabolic response secondary to burn injury. Early and adequate nutrition is key in addition to adjunctive therapies, such as oxandrolone, insulin, metformin, and propranolol. The duration of administration of anabolic agents should be at minimum for the duration of hospitalization, and possibly up to 2 to 3 years postburn.
Topics: Humans; Anabolic Agents; Oxandrolone; Insulin; Nutritional Support; Burns
PubMed: 37149383
DOI: 10.1016/j.suc.2023.01.009 -
The Journal of Pharmacy Technology :... Aug 2022Burn injuries remain among the most severe traumatic injuries globally. With the discovery of cortisol, the use of steroids has become an essential therapy for the... (Review)
Review
Burn injuries remain among the most severe traumatic injuries globally. With the discovery of cortisol, the use of steroids has become an essential therapy for the management of inflammatory and metabolic conditions. Several studies have shown the steroid oxandrolone improves burn injuries through stimulating anabolic and reducing catabolic processes. In this review, we examine the efficacy and applications of oxandrolone with regard to burn management and treatment. A literature search was performed using the PubMed database from January 1990 to May 2020 to identify articles on oxandrolone and burn management. A total of 18 studies were included in our review. The keywords used in our search strategy for PubMed included "oxandrolone" and "burns." The main benefit of oxandrolone is the improved long-term lean body, protein, and bone mineral mass of burn patients. In addition, 3 separate meta-analyses showed oxandrolone shortened length of hospital stay, donor-site healing time, reduced weight loss, and net protein loss. However, oxandrolone therapy did not affect mortality, infection, or liver function. Oxandrolone remains an effective therapy for reducing the hypermetabolic response and comorbidities from burn injuries. Future clinical trials are needed using larger sample sizes and long-term follow-up to determine whether oxandrolone in the context of rehabilitation programs can reduce mortality, lower treatment costs, and improve function outcomes among burn patients.
PubMed: 35832568
DOI: 10.1177/87551225221091115 -
Seminars in Plastic Surgery May 2024Nutrition and modulation of the hypermetabolic response to acute burns are reviewed in this article. Methods to determine caloric requirements are evaluated, including... (Review)
Review
Nutrition and modulation of the hypermetabolic response to acute burns are reviewed in this article. Methods to determine caloric requirements are evaluated, including indirect calorimetry and predictive equations. Individual nutritional components of carbohydrates, fat, protein, vitamins, and trace elements are discussed specifically in relation to acute burn care. Selection of formula and route of administration are outlined, with an enteral high-carbohydrate, low-fat diet being preferable. Awareness and recognition of the signs and symptoms of malnutrition is critical in the management of variable caloric needs throughout hospitalization. Lastly, the catabolic state of acute burns is addressed through early excision and grafting and implementation of various pharmacologic agents, including growth hormone, insulin-like growth factor-1, insulin-like growth factor-binding protein-3, insulin, propranolol, and oxandrolone. Through a multipronged approach to nutrition, pediatric burn patients are provided the substrates for successful recovery and rehabilitation.
PubMed: 38746694
DOI: 10.1055/s-0044-1782648 -
Critical Care Clinics Apr 2019Low-dose hydrocortisone reduces the dose of vasopressors and hospital length of stay; it may also decrease the rate of hospital-acquired pneumonia and time on... (Meta-Analysis)
Meta-Analysis Review
Low-dose hydrocortisone reduces the dose of vasopressors and hospital length of stay; it may also decrease the rate of hospital-acquired pneumonia and time on ventilator. No major side effect was reported, but glycemia and natremia should be monitored. Progesterone did not enhance outcome of trauma patients. A meta-analysis suggested that oxandrolone was associated with shorter length of stay and reduced weight loss. Erythropoietin did not enhance neurologic outcome of traumatic brain-injured patients; such treatment, however, could reduce the mortality in subgroups of patients. This review focuses mainly on glucocorticoids, which are the most extensively investigated treatments in hormone therapy.
Topics: Erythropoietin; Female; Hormones; Humans; Hydrocortisone; Length of Stay; Male; Oxandrolone; Progesterone; Wounds and Injuries
PubMed: 30784604
DOI: 10.1016/j.ccc.2018.11.009 -
Current Opinion in Endocrinology,... Feb 2019Klinefelter syndrome is the most common sex chromosome abnormality in men. Hypogonadism and testicular degeneration are almost universal. Truncal adiposity, metabolic... (Review)
Review
PURPOSE OF REVIEW
Klinefelter syndrome is the most common sex chromosome abnormality in men. Hypogonadism and testicular degeneration are almost universal. Truncal adiposity, metabolic syndrome and low bone mass occur frequently. This review summarizes the most recent advances in the pathogenesis and management of the endocrine abnormalities in Klinefelter syndrome. It is expected that optimal endocrine management will improve outcomes and quality of life in Klinefelter syndrome.
RECENT FINDINGS
In Klinefelter syndrome, testosterone replacement is routinely prescribed despite lack of evidence on the optimal dose and time for initiation of therapy. Cross-sectional studies have linked hypogonadism to the development of metabolic abnormalities and low bone mass. Testosterone therapy, however, is not consistently associated with improved metabolic and bone outcomes. Increased truncal adiposity and high rates of metabolic syndrome are present in prepubertal children. A randomized trial of oxandrolone in prepubertal boys showed improvement in visual-motor function, socialization and cardiometabolic health. Testicular sperm extraction (TESE) has success rates similar to other causes of nonobstructive azoospermia when performed between 16 and 35 years of age.
SUMMARY
Endocrine care in Klinefelter syndrome should start in childhood and include evaluation of metabolic risk factors and bone health. Further research to guide evidence-based endocrine care is very much needed.
Topics: Adolescent; Adult; Child; Cross-Sectional Studies; Endocrine System; Hormones; Humans; Hypogonadism; Klinefelter Syndrome; Male; Metabolic Syndrome; Quality of Life; Risk Factors; Young Adult
PubMed: 30507702
DOI: 10.1097/MED.0000000000000454 -
Molecules (Basel, Switzerland) Jan 2021Oxandrolone, a synthetic testosterone analog, is used for the treatment of several diseases associated with weight loss. Unfortunately, oxandrolone is abused by many...
Oxandrolone, a synthetic testosterone analog, is used for the treatment of several diseases associated with weight loss. Unfortunately, oxandrolone is abused by many athletes and bodybuilders due to its strong anabolic effect. We have developed and validated a highly sensitive and rapid on-line SPE-UHPLC-MS/MS method for the determination of oxandrolone and simultaneous identification of its major metabolite 17-epi-oxandrolone in urine matrices. Enrichment of the analytes via an integrated solid-phase extraction was achieved using an Acquity UPLC BEH C18 Column. Subsequently, the chromatographic separation of the on-line preconcentrated sample fraction was achieved using an Acquity HSS T3 C18 Column. For the structural identification of these analytes, a high-resolution mass spectrometer Synapt-G2Si coupled to the Acquity M-class nano-LC system with ionKey source was used. A highly sensitive determination of oxandrolone was achieved using a tandem quadrupole mass spectrometer XEVO TQD. The method was successfully validated in the linear range of oxandrolone from 81.63 pg·mL (limit of quantification, LOQ) to 5000 pg·mL in the human urine matrix. It was applied to the analysis of real urine samples obtained from a healthy volunteer after the oral administration of one dose (10 mg) of oxandrolone. Concentration vs. time dependence was tested in the time interval of 4 h-12 days (after oral administration) to demonstrate the ability of the method to detect the renal elimination of oxandrolone from the human body. Favorable performance parameters along with successful application indicate the usefulness of the proposed method for its routine use in antidoping control labs.
Topics: Chromatography, High Pressure Liquid; Humans; Oxandrolone; Solid Phase Extraction; Tandem Mass Spectrometry; Urinalysis
PubMed: 33477515
DOI: 10.3390/molecules26020480 -
Current Opinion in Critical Care Aug 2016After major progress in the 1980s of burn resuscitation resulting, the last years' research has focused on modulation of metabolic response and optimization of substrate... (Review)
Review
PURPOSE OF REVIEW
After major progress in the 1980s of burn resuscitation resulting, the last years' research has focused on modulation of metabolic response and optimization of substrate utilization. The persisting variability of clinical practice is confirmed and results in difficult comparisons between burn centers.
RECENT FINDINGS
Recent research explores intracellular mechanisms of the massive metabolic turmoil observed after burns: very early alterations at the mitochondrial level largely explain the hypermetabolic response, with a diminished coupling of oxygen consumption and ATP production. The metabolic alterations (elevated protein and glucose turnover) have been shown to be long lasting. Modulating this response by pharmacological tools (insulin, propranolol, and oxandrolone) results in significant clinical benefits. A moderate glucose control proves to be safe in adult burns; data in children remain uncertain as the risk of hypoglycemia seems to be higher. The enteral feeding route is confirmed as an optimal route: some difficulties are now clearly identified, such as the risk of not delivering sufficient energy by this route.
SUMMARY
Major burn patients differ from other critically ill patients by the magnitude and duration of their inflammatory and metabolic responses, their energy and substrate requirements. Pieces of the metabolic puzzle finally seem to fit together.
Topics: Burns; Enteral Nutrition; Humans; Nutritional Requirements; Nutritional Status; Oxygen Consumption; Resuscitation
PubMed: 27314258
DOI: 10.1097/MCC.0000000000000323