***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    ***EXAMPLES*** 
    Input: Objective To evaluate the potential clinical , metabolic , and economic advantages of enteral nutrition over total parenteral nutrition . Design Prospect i ve , r and omized clinical trial . Setting Department of surgery in a university hospital . Patients Two hundred and fifty-seven patients with cancer of the stomach ( n = 121 ) , pancreas ( n = 110 ) , or esophagus ( n = 26 ) were r and omized to receive postoperative total parenteral nutrition ( TPN group , n = 131 ) or early enteral nutrition ( EEN group , n = 126 ) . The nutritional goal was 25 kcal/kg/day . The two nutritional formulas were isocaloric and isonitrogenous , and they were continued until oral intake was at least 800 kcal/day . Measurements Morbidity , mortality , length of hospital stay , and treatment costs were evaluated in all patients . In 40 consecutive patients , selected nutritional , immunologic and inflammatory variables were studied . Moreover , intestinal oxygen tension was evaluated by micropolarographic implantable probes . Main Results The nutritional goal was reached in 100/126 ( 79.3 % ) patients in the EEN group and in 128/131 ( 97.7 % ) patients in the TPN group ( p < .001 ) . In the EEN group , hyperglycemia ( serum glucose , > 200 mg/dL ) was observed in 4.7 % of the patients vs. 9.1 % in the TPN group ( p = NS ) . Alteration of serum electrolyte levels was 3.9 % in the EEN group vs. 13.7 % in the TPN group ( p < .01 ) . No significant difference was found in nutritional , immunologic , and inflammatory variables between the two groups . The overall complication rate was similar ( 40.4 % for TPN vs. 35.7 % , for EEN;p = .52 ) . No difference was detected for either infectious or noninfectious complications , length of hospital stay , and mortality . From postoperative day 5 , intestinal oxygen tension recovered faster in the EEN group than in the TPN group ( 43 ± 5 mm Hg vs. 31 ± 4 mm Hg at day 7;p < .001 ) . EEN was four-fold less expensive than TPN ( $ 25 vs. $ 90.60/day , respectively ) . Conclusion EEN represents a rational alternative to TPN in patients who undergo upper gastrointestinal tract surgery for cancer and who clinical ly require postoperative artificial nutrition BACKGROUND AND AIMS To determine whether the inclusion of 20 g free glutamine as part of the nitrogen source of parenteral feeds reduces length of hospital stay or mortality . METHODS In a r and omised , double blind , controlled trial in 168 patients clinical ly accepted for parenteral nutrition , st and ard feeds were compared with feeds in which 3.8 g of the total nitrogen was replaced with the equivalent 20 g glutamine . A minimum of 11 g nitrogen/day was used in all patients . Daily intakes of energy and nitrogen were determined using a vali date d computer protocol and were similar for the two groups . All feeds included trace elements , vitamins , electrolytes , and minerals . RESULTS A total of 85 patients received a median of eight ( interquartile range 5–13 ) daily feeds containing glutamine while 83 received a median of eight ( 5–15 ) st and ard feeds . No difference between groups was detected for infective complications .  Twenty control patients and 14 who had received glutamine  died during their hospital stay ( NS ) . Median length of stay was 32 ( 23–52 ) days on glutamine , which was not significantly different from the control value of 35 ( 25–55 ) days . Glutamine was associated with a significant ( p<0.03 ) reduction in length of stay in surgical patients ( 45 days ( range 29–81 ) versus 30 days ( range 19–54 ) ) . CONCLUSION The benefit from glutamine supplementation of parenteral feeds as used in this trial has not been proved . Supplementation may have advantages in surgical patients and in haematological malignancy . Further trials are required Gut malnutrition in patients with persistent hypermetabolism is hypothesized to be an important factor in postseptic multiple organ failure syndrome ( MOFS ) . The hypothesis was made that enteral nutrition ( EN ) started at the onset of hypermetabolism could reduce the incidence of MOFS . Sixty-six patients with persistent hypermetabolism 4 to 6 days after onset of sepsis were prospect ively r and omized to receive either parenteral nutrition ( PN ) or enteral nutrition ( EN ) at 1.5 gm protein/kg/day and 30 nonprotein calories/kg/day ; the EN and TPN were of the same composition . There was no reduction in either the incidence of MOFS or mortality attributable to the route of nutrition administration . The PN group tended to have better visceral protein support ; the EN group had more gut complications . When analyzed , the type of formula given did have an effect on the nutritional outcome but not on the mortality rate . A formula with a nonprotein-calorie-to-nitrogen ratio of 100:1 was associated with more nitrogen retention , higher levels of visceral proteins , and better gut tolerance . The route of nutrition administration does not seem to affect the incidence of postseptic MOFS or mortality when hypermetabolism is already present and when commercially available nutritional formulas are used . The relationships among the route of nutrition , the type of enteral formula , and the disease process of hypermetabolism and MOFS appear to be complex and require much more investigation before the role of the gut and enteral nutrition can be defined Objective To determine whether the frequency rate of hyperglycemia and infectious complications can be reduced by an underfeeding strategy in patients requiring total parenteral nutrition ( TPN )  , without deleterious effects on nitrogen balance . Design Prospect i ve , r and omized , controlled nonblinded trial . Setting A university-affiliated teaching hospital with a dedicated TPN service . Patients  TPN was initiated in 40 adult patients and continued for ≥5 days . InterventionTwo different TPN feeding strategies were compared : hypocaloric feeding ( 1 L containing 70 g protein and 1000 kcal ) and st and ard weight-based regimen , begun in similar amounts initially , but advanced in increments toward 25 kcal and 1.5 g protein/kg dry ( or adjusted ideal ) weight . Measurements and Main Results We evaluated the frequency rate of hyperglycemia , average blood glucose , numbers and types of infections while receiving nutritional support , and nitrogen balance after 5 days of TPN . There were significant differences between the quantities of calories , dextrose , fat , and protein provided to the two groups . However , average blood glucose , frequency rate of hyperglycemia , and infection rates ( from intravenous catheter , pneumonia , and wound/abdominal collection ) were similar in each group . The control group showed a trend toward a higher insulin requirement . Nitrogen balance , only available as a subset , was significantly more negative in the hypocaloric group . Conclusions Provision of TPN to a goal of 25 kcal/kg was not associated with more hyperglycemia or infections than a deliberate underfeeding strategy . A regimen of 1.5 g/kg protein in conjunction with 25 kcal/kg did , however , provide significant nutritional benefit in terms of nitrogen balance in comparison with hypocaloric TPN Objective To determine the effect of intravenous glutamine supplementation vs. an isonitrogenous control on infectious morbidity in severely burned patients . Previous clinical studies in seriously ill patients suggest a beneficial effect of glutamine on infectious morbidity , but no trials have examined possible clinical benefits in severely burned patients . Design Prospect i ve , double-blind , r and omized trial . Setting Burn intensive care unit of a university hospital . Patients Twenty-six severe burn patients with total burn surface area of 25 % to 90 % and presence of full-thickness burns . Patients were evaluated for occurrence of bacteremia and antibiotic use during the first 30 days of their burn unit admission . Nutritional status and overall inflammation were also measured . Intervention Either intravenous glutamine or an isonitrogenous control amino acid solution was administered as a continuous infusion during burn intensive care unit stay . Measurements and Main Results The incidence of Gram-negative bacteremia was significantly reduced in the glutamine-supplemented group ( 8 % ) vs. control ( 43%;p < .04 ) . No difference was seen in the incidence of Gram-positive bacteremia or fungemia . Average number of positive blood cultures , antibiotic usage , and mortality rates also were reduced but did not reach statistical significance . Significant improvements in serum transferrin and prealbumin were observed in glutamine-supplemented patients at 14 days after burn injury ( p < .01 and .04 , respectively ) . C-reactive protein was also significantly reduced at 14 days after burn injury in the glutamine group ( p < .01 ) . Conclusions Significantly fewer bacteremic episodes with Gram-negative organisms occurred in the glutamine-supplemented patients . Glutamine supplementation improved measures of nutrition and decreased measures of overall inflammation . In addition , a trend toward lower mortality rate , decreased overall bacteremia incidence , and antibiotic usage in the glutamine group was observed . Glutamine ’s beneficial effects may be a result of improved gut integrity or immune function , but the precise mechanism of glutamine ’s protection is unknown We measured energy expenditure ( MREE ) and nitrogen excretion ( UUN ) in patients with severe head injury r and omized to early parenteral ( TPN , n = 21 ) or jejunal ( ENT , n = 27 ) feeding  with identical formulations . The MREE rose to 2400 + /- 531 kcal/day in both groups and remained at 135 % + /- 26 % to 146 % + /- 42 % of predicted energy expenditure over 4 weeks . Nitrogen excretion peaked the second week at 33.4 + /- 10 ( TPN ) and 31.2 + /- 7.5 ( ENT ) g N/day . Both routes were equally effective at meeting nutritional goals ( 1.2 x MREE , 2.5 g protein/kg/day intake , stabilized albumin and transferrin levels ) . Infections were equally frequent : 1.86 episodes/TPN patient versus 1.89 episodes/ENT patient . While patient charges were much greater for TPN , the hospital costs were similar for TPN and ENT support regimens . These findings show that patients with head injuries are hypermetabolic for weeks , that only 27 % are capable of spontaneously eating nutritional requirements by discharge , and that either TPN or ENT support is equally effective when prescribed according to individual measurements of MREE and nitrogen excretion To investigate the importance of route of nutrient administration on  septic complications after blunt and penetrating trauma , 98 patients with an abdominal trauma index of at least 15 were r and omized to either enteral or parenteral feeding within 24 hours of injury .  Septic morbidity was defined as pneumonia , intra-abdominal abscess , empyema , line sepsis , or fasciitis with wound dehiscence . Patients were fed formulas with almost identical amounts of fat , carbohydrate , and protein .  Two patients died  early in the study . The enteral group sustained significantly fewer pneumonias ( 11.8 % versus total parenteral nutrition 31.% , p less than 0.02 ) , intra-abdominal abscess ( 1.9 % versus total parenteral nutrition 13.3 % , p less than 0.04 ) , and line sepsis ( 1.9 % versus total parenteral nutrition 13.3 % , p less than 0.04 ) , and sustained significantly fewer infections per patient ( p less than 0.03 ) , as well as significantly fewer infections per infected patient ( p less than 0.05 ) . Although there were no differences in infection rates in patients with injury severity score less than 20 or abdominal trauma index less than or equal to 24 , there were significantly fewer infections in patients with an injury severity score greater than 20 ( p less than 0.002 ) and abdominal trauma index greater than 24 ( p less than 0.005 ) . Enteral feeding produced significantly fewer infections in the penetrating group ( p less than 0.05 ) and barely missed the statistical significance in the blunt-injured patients ( p = 0.08 ) . In the sub population of patients requiring more than 20 units of blood , sustaining an abdominal trauma index greater than 40 or requiring reoperation within 72 hours , there were significantly fewer infections per patient ( p = 0.03 ) and significantly fewer infections per infected patient ( p less than 0.01 ) . There is a significantly lower incidence of septic morbidity in patients fed enterally after blunt and penetrating trauma , with most of the significant changes occurring in the more severely injured patients . The authors recommend that the surgeon obtain enteral access at the time of initial celiotomy to assure an opportunity for enteral delivery of nutrients , particularly in the most severely injured patients 59 elderly patients ( mean age 82 ) with femoral neck fractures were r and omised into two groups . 27 patients received daily an oral nutrition supplement ( 250 ml , 20 g protein , 254 kcal ) for a mean of 
    Output:
    
PN was associated with a higher incidence of hyperglycemia .
CONCLUSION The use of EN as opposed to PN results in an important decrease in the incidence of infectious complications in the critically ill and may be less costly .