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1.  A Modern Twist on the Beaumont and St. Martin Case: Encouraging Analysis and Discussion in the Bioethics Classroom with Reflective Writing and Concept Mapping† 
Historical ethical dilemmas are a valuable tool in bioethics courses. However, garnering student interest in reading and discussing the assigned cases in the classroom can be challenging. In an effort to actively engage undergraduate and graduate students in an Ethical Issues in Biotechnology course, an activity was developed to encourage reflection on a classical ethical dilemma between a patient, St. Martin, and his employer/caretaker, Beaumont. Two different texts were used to analyze the ethical ramifications of this relationship: a chapter in a popular press book and a short perspective in a medical journal. Participants read the book chapter for homework and discussed it in class. This easy read highlights the fundamental ethical issues in the relationship between two men. Students were then provided with a second text focusing on the scientific accomplishments achieved through Beaumont’s experimentation on St. Martin. A structured worksheet prompted participants to reflect on their feelings after reading each text and create a concept map depicting the dilemma. Student-generated concept maps and written reflections indicate participants were able to list the ethical issues, analyze the situation, and evaluate the information provided. This activity not only encouraged higher-level thinking and reflection, it also mirrored the course’s structured approach of using concept mapping and reflection to dissect ethical dilemmas.
doi:10.1128/jmbe.v15i2.771
PMCID: PMC4278484  PMID: 25574285
2.  The effect of exogenous glucagon-like peptide-1 on the glycaemic response to small intestinal nutrient in the critically ill: a randomised double-blind placebo-controlled cross over study 
Critical Care  2009;13(3):R67.
Introduction
Hyperglycaemia occurs frequently in the critically ill, affects outcome adversely, and is exacerbated by enteral feeding. Furthermore, treatment with insulin in this group is frequently complicated by hypoglycaemia. In healthy patients and those with type 2 diabetes, exogenous glucagon-like peptide-1 (GLP-1) decreases blood glucose by suppressing glucagon, stimulating insulin and slowing gastric emptying. Because the former effects are glucose-dependent, the use of GLP-1 is not associated with hypoglycaemia. The objective of this study was to establish if exogenous GLP-1 attenuates the glycaemic response to enteral nutrition in patients with critical illness induced hyperglycaemia.
Methods
Seven mechanically ventilated critically ill patients, not previously known to have diabetes, received two intravenous infusions of GLP-1 (1.2 pmol/kg/min) and placebo (4% albumin) over 270 minutes. Infusions were administered on consecutive days in a randomised, double-blind fashion. On both days a mixed nutrient liquid was infused, via a post-pyloric feeding catheter, at a rate of 1.5 kcal/min between 30 and 270 minutes. Blood glucose and plasma GLP-1, insulin and glucagon concentrations were measured.
Results
In all patients, exogenous GLP-1 infusion reduced the overall glycaemic response during enteral nutrient stimulation (AUC30–270 min GLP-1 (2077 ± 144 mmol/l min) vs placebo (2568 ± 208 mmol/l min); P = 0.02) and the peak blood glucose (GLP-1 (10.1 ± 0.7 mmol/l) vs placebo (12.7 ± 1.0 mmol/l); P < 0.01). The insulin/glucose ratio at 270 minutes was increased with GLP-1 infusion (GLP-1 (9.1 ± 2.7) vs. placebo (5.8 ± 1.8); P = 0.02) but there was no difference in absolute insulin concentrations. There was a transient, non-sustained, reduction in plasma glucagon concentrations during GLP-1 infusion (t = 30 minutes GLP-1 (90 ± 12 pmol/ml) vs. placebo (104 ± 10 pmol/ml); P < 0.01).
Conclusions
Acute, exogenous GLP-1 infusion markedly attenuates the glycaemic response to enteral nutrition in the critically ill. These observations suggest that GLP-1 and/or its analogues have the potential to manage hyperglycaemia in the critically ill.
Trial Registration
Australian New Zealand Clinical Trials Registry number: ACTRN12609000093280.
doi:10.1186/cc7874
PMCID: PMC2717426  PMID: 19439067
4.  Evaluation of the Role of Enteral Nutrition in Managing Patients with Diabetes: A Systematic Review 
Nutrients  2014;6(11):5142-5152.
The aim of this systematic review is to evaluate the role of enteral nutrition in managing patients with diabetes on enteral feed. The prevalence of diabetes is on the increase in the UK and globally partly due to lack of physical activities, poor dietary regimes and genetic susceptibility. The development of diabetes often leads to complications such as stroke, which may require enteral nutritional support. The provision of enteral feeds comes with its complications including hyperglycaemia which if not managed can have profound consequences for the patients in terms of clinical outcomes. Therefore, it is essential to develop strategies for managing patients with diabetes on enteral feed with respect to the type and composition of the feed. This is a systematic review of published peer reviewed articles. EBSCOhost Research, PubMed and SwetsWise databases were searched. Reference lists of identified articles were reviewed. Randomised controlled trials comparing enteral nutrition diabetes specific formulas with standard formulas were included. The studies which compared diabetes specific formulas (DSF) with standard formulas showed that DSF was more effective in controlling glucose profiles including postprandial glucose, HbA1c and insulinemic response. The use of DSF appears to be effective in managing patients with diabetes on enteral feed compared with standard feed.
doi:10.3390/nu6115142
PMCID: PMC4245584  PMID: 25412151
enteral nutrition; diabetes; diabetes specific formula; standard formula; hyperglycaemia; glycaemic index
5.  Complications and Monitoring – Guidelines on Parenteral Nutrition, Chapter 11 
Compared to enteral or hypocaloric oral nutrition, the use of PN (parenteral nutrition) is not associated with increased mortality, overall frequency of complications, or longer length of hospital stay (LOS). The risk of PN complications (e.g. refeeding-syndrome, hyperglycaemia, bone demineralisation, catheter infections) can be minimised by carefully monitoring patients and the use of nutrition support teams particularly during long-term PN. Occuring complications are e.g. the refeeding-syndrome in patients suffering from severe malnutrition with the initiation of refeeding or metabolic, hypertriglyceridemia, hyperglycaemia, osteomalacia and osteoporosis, and hepatic complications including fatty liver, non-alcoholic fatty liver disease, cholestasis, cholecystitis, and cholelithiasis. Efficient monitoring in all types of PN can result in reduced PN-associated complications and reduced costs. Water and electrolyte balance, blood sugar, and cardiovascular function should regularly be monitored during PN. Regular checks of serum electrolytes and triglycerides as well as additional monitoring measures are necessary in patients with altered renal function, electrolyte-free substrate intake, lipid infusions, and in intensive care patients. The metabolic monitoring of patients under long-term PN should be carried out according to standardised procedures. Monitoring metabolic determinants of bone metabolism is particularly important in patients receiving long-term PN. Markers of intermediary, electrolyte and trace element metabolism require regular checks.
doi:10.3205/000076
PMCID: PMC2795374  PMID: 20049074
refeeding syndrome; hyperglycaemia; hypertriglyceridemia; liver disease; catheter infection
6.  Stress hyperglycaemia 
Lancet  2009;373(9677):1798-1807.
Results of randomised controlled trials of tight glycaemic control in hospital inpatients might vary with population and disease state. Individualised therapy for different hospital inpatient populations and identification of patients at risk of hyperglycaemia might be needed. One risk factor that has received much attention is the presence of pre-existing diabetes. So-called stress hyperglycaemia is usually defined as hyperglycaemia resolving spontaneously after dissipation of acute illness. The term generally refers to patients without known diabetes, although patients with diabetes might also develop stress hyperglycaemia—a fact overlooked in many studies comparing hospital inpatients with or without diabetes. Investigators of several studies have suggested that patients with stress hyperglycaemia are at higher risk of adverse consequences than are those with pre-existing diabetes. We describe classification of stress hyperglycaemia, mechanisms of harm, and management strategies.
doi:10.1016/S0140-6736(09)60553-5
PMCID: PMC3144755  PMID: 19465235
7.  Glucose and lipid assessment in patients with acute stroke 
Background
Stroke is a major health issue in Nigeria and it is also a common cause of emergency admissions. Stroke often results in increased morbidity, mortality and reduced quality of life in people thus affected. The risk factors for stroke include metabolic abnormalities such as dyslipidaemia and diabetes mellitus (DM). The stress of an acute stroke may present with hyperglycaemia and in persons without a prior history of DM, may be a pointer to stress hyperglycaemia or undiagnosed DM.
Methodology
This was a cross sectional study carried out over a period of one year in a teaching hospital in Lagos, Nigeria. Patients with acute stroke admitted to the hospital within three days of the episode of stroke and who met other inclusion criteria for the Study were consecutively recruited. Clinically relevant data was documented and biochemical assessments were carried out within three days of hospitalization. Tests for lipid profile, glycosylated haemoglobin(HbA1c), and blood glucose at presentation were carried out. The presence of past history of DM, undiagnosed DM, stress hyperglycaemia and abnormal lipid profile were noted. Students t test and Chi square were the statistical tests employed.
Results
A total of 137 persons with stroke were recruited of which 107 (76%) met the defining criteria for ischaemic stroke. The mean age and age range of the Study subjects were 62.2 (11.7) and 26–89 years respectively. The Study subjects were classified according to their glycaemic status into the following categories viz; stress hyperglycaemia, euglycaemia, DM and previously undiagnosed DM. Stress hyperglycaemia occurred commonly in the fifth decade of life and its incidence was comparable between those with cerebral and haemorrhagic stroke. The commonly occurring lipid abnormalities were elevated LDL-C and low HDL.
Conclusions
The detection of abnormal metabolic milieu is a window of opportunity for aggressive management in persons with stroke as this will improve outcome. Routine screening for hyperglycaemia in persons with stroke using glycosylated haemoglobin tests and blood glucose may uncover previously undiagnosed DM.
doi:10.1186/1755-7682-7-45
PMCID: PMC4221686  PMID: 25379056
8.  Enteral nutrition after bone marrow transplantation 
Archives of Disease in Childhood  1997;77(2):131-136.
Accepted 16 April 1997

Nutritional insult after bone marrow transplantation (BMT) is complex and its nutritional management challenging. Enteral nutrition is cheaper and easier to provide than parenteral nutrition, but its tolerance and effectiveness in reversing nutritional depletion after BMT is poorly defined. Nutritional status, wellbeing, and nutritional biochemistry were prospectively assessed in 21 children (mean age 7.5 years; 14 boys) who received nasogastric feeding after BMT (mean duration 17 days) and in eight children (mean age 8 years, four boys) who refused enteral nutrition and who received dietetic advice only.
 Enteral nutrition was stopped prematurely in eight patients. Greater changes in weight and mid upper arm circumference were observed in the enteral nutrition group, while positive correlations were found between the duration of feeds and increase in weight and in mid upper arm circumference. Vomiting and diarrhoea had a similar incidence in the two groups, while fever and positive blood cultures occurred more frequently in the dietetic advice group. Diarrhoea occurring during enteral nutrition was not associated with fat malabsorption, while carbohydrate malabsorption was associated with rotavirus infection only. Enteral feeding did not, however, affect bone marrow recovery, hospital stay, general wellbeing, or serum albumin concentrations. Hypomagnesaemia, hypophosphataemia, zinc and selenium deficiency were common in both groups. In conclusion, enteral nutrition, when tolerated, is effective in limiting nutritional insult after BMT. With existing regimens nutritional biochemistry should be closely monitored in order to provide supplements when required.


PMCID: PMC1717280  PMID: 9301351
9.  Enteral nutritional therapy in septic patients in the intensive care unit: compliance with nutritional guidelines for critically ill patients 
Objective
Evaluate the compliance of septic patients' nutritional management with enteral nutrition guidelines for critically ill patients.
Methods
Prospective cohort study with 92 septic patients, age ≥18 years, hospitalized in an intensive care unit, under enteral nutrition, evaluated according to enteral nutrition guidelines for critically ill patients, compliance with caloric and protein goals, and reasons for not starting enteral nutrition early or for discontinuing it. Prognostic scores, length of intensive care unit stay, clinical progression, and nutritional status were also analyzed.
Results
The patients had a mean age of 63.4±15.1 years, were predominantly male, were diagnosed predominantly with septic shock (56.5%), had a mean intensive care unit stay of 11 (7.2 to 18.0) days, had 8.2±4.2 SOFA and 24.1±9.6 APACHE II scores, and had 39.1% mortality. Enteral nutrition was initiated early in 63% of patients. Approximately 50% met the caloric and protein goals on the third day of intensive care unit stay, a percentage that decreased to 30% at day 7. Reasons for the late start of enteral nutrition included gastrointestinal tract complications (35.3%) and hemodynamic instability (32.3%). Clinical procedures were the most frequent reason to discontinue enteral nutrition (44.1%). There was no association between compliance with the guidelines and nutritional status, length of intensive care unit stay, severity, or progression.
Conclusion
Although the number of septic patients under early enteral nutrition was significant, caloric and protein goals at day 3 of intensive care unit stay were met by only half of them, a percentage that decreased at day 7.
doi:10.1590/S0103-507X2013000100005
PMCID: PMC4031857  PMID: 23887755
Sepsis; Intensive care units; Intensive care; Nutrition therapy; Guidelines as topic; Enteral nutrition
12.  An audit of referral patterns for glioblastoma patients in Beaumont hospital 
BMC Proceedings  2012;6(Suppl 4):O48.
doi:10.1186/1753-6561-6-S4-O48
PMCID: PMC3426012
23.  Mr. W. M. BEAUMONT 
PMCID: PMC512081
24.  Beaumont's Medicine 
British Medical Journal  1962;1(5294):1741.
PMCID: PMC1959039
25.  John Morton Beaumont 
British Medical Journal  1877;2(882):745-746.
PMCID: PMC2221563

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