Answers to Self-Assessment Questions - ACCP

Answers to 

Self-Assessment 

Questions 

Nutrition I 

Metabolic and Nutrition Issues 

in Patients Receiving Continuous 

Renal Replacement Therapy 

1. Answer: B 

The most likely reason B.A. required CRRT was 

acute renal failure (ARF)-related hyperkalemia (Answer 

B). Because potassium is excreted by the kidneys and 

the resulting hyperkalemia can cause life-threatening 

cardiac arrhythmias, hyperkalemia is a well-established 

indication for CRRT. Phosphorus and magnesium are 

also excreted by the kidneys; therefore, in patients with 

ARF, both hyperphosphatemia and hypermagnesemia 

can occur. However, neither hyperphosphatemia (Answer 

C) nor hypermagnesemia (Answer D) is an indication for 

dialysis; therefore, Answer C and Answer D are incorrect. 

Hypernatremia secondary to cardiogenic shock (Answer 

A) is not the best answer; in the setting of fluid overload, 

which occurs in patients with ARF because of a reduced 

renal water excretion, hyponatremia is more likely to occur 

because of dilution of serum sodium. B.A.’s chronic heart 

failure also likely contributed to his fluid overload. 

1. Wooley JA, Btaiche IF, Good KL. Metabolic and nutritional 

aspects of acute renal failure in critically ill patients requiring 

continuous renal replacement therapy. Nutr Clin Pract 

2005;20:176–91. 

2. Liu KD, Stralovich-Romani A, Chertow GM. Nutrition support 

for adult patients with acute renal failure. In: Merritt R, ed. The 

A.S.P.E.N. Nutrition Support Practice Manual, 2nd ed. Silver 

Spring, MD: American Society for Parenteral and Enteral 

Nutrition, 2005:281–6. 

2. Answer: B 

B.A.’s usual weight is 82 kg. On admission he weighed 

90 kg (an indication of fluid overload), and 6 months ago 

he weighed 70 kg (significantly lower than his usual body 

weight). He has experienced a 17% weight loss over the 

past 6 months; therefore he is at risk of nutrition-related 

complications, and Answer B (he experienced a weight loss 

of more than 10% in the past 6 months so he is at risk of 

nutrition-related complications) is correct. An involuntary 

weight loss/gain of 10% or more within 6 months or 5% 

or more within 1 month is considered a risk factor for 

malnutrition. B.A.’s body mass index (BMI) is within the 

range of 22 kg/m 2 to 28.5 kg/m 2 , depending on which weight 

you use for the calculation. Despite the BMI indicating 

that he is normal to slightly overweight, his recent weight 

loss places him at risk of nutrition-related complications, 

therefore Answer A (his BMI is within normal limits so he is 

not at risk of nutrition-related complications) and Answer D 

(his BMI is increased so he is not at risk of nutrition-related 

complications) are incorrect. B.A.’s current weight is 90 kg, 

which is 23% above his ideal body weight (IBW). A body 

weight 20% or more above or below the IBW is a risk factor 

for nutrition-related complications. However, B.A.’s usual 

weight is 82 kg, and his most recent weight at his last office 

visit was 70 kg, which are both less than 20% above his IBW 

and a more accurate representation of his nutrition status. 

His current weight of 90 kg most likely represents fluid 

retention; thus this weight should not indicate an increased 

risk of nutrition-related complications, making Answer C 

(his current weight is more than 20% above his IBW, so he 

is at risk of nutrition-related complications) incorrect. 




2005;20:176–91. 

2. Marin A, Hardy G. Practical implications of nutritional support 

during continuous renal replacement therapy. Curr Opin Clin 

Nutr Metab Care 2001;4:219–25. 





Nutrition, 2005:281–6. 

3. Answer: D 

B.A. is being started on parenteral nutrition (PN). Of 

the trace elements listed, zinc (Answer D) is the one least 

likely to require supplementation during PN. Zinc is filtered 

only minimally by CRRT. In fact, elevated serum zinc 

concentrations have been observed in patients receiving 

CRRT because of the zinc content of replacement solutions; 

therefore, Answer D is correct. Serum copper (Answer 

Pharmacotherapy Self-Assessment Program, 6th Edition 35 Gastroenterology and Nutrition Answers

A), chromium (Answer B), and selenium (Answer C) 

concentrations have been reported to be decreased in patients 

receiving CRRT; therefore, these trace elements should be 

supplemented in patients receiving CRRT, making Answers 

A, B, and C incorrect. 

1. Klein CJ, Moser-Veillon PB, Schweitzer A, Douglass LW, 

Reynolds HN, Patterson KY, et al. Magnesium, calcium, 

zinc, and nitrogen loss in trauma patients during continuous 

renal replacement therapy. JPEN J Parenter Enteral Nutr 

2002;26:77–92. 

2. Berger MM, Shenkin A, Revelly JP, Roberts E, Cayeux MC, 

Baines M, et al. Copper, selenium, zinc, and thiamine balances 

during continuous venovenous hemodiafiltration in critically 

ill patients. Am J Clin Nutr 2004;80:410–6. 

3. Story DA, Ronco C, Bellomo R. Trace element and vitamin 

concentrations and losses in critically ill patients treated 

with continuous venovenous hemofiltration. Crit Care Med 

1999;27:220–3. 

4. Answer: C 

Because of fluid overload, A.B.’s usual weight (82 kg) 

or his most recent preadmission weight (70 kg) should be 

used to calculate his caloric requirements. B.A.’s estimated 

caloric requirement is 25–35 kcal/kg/day. Answer C (2460 

kcal/day) provides 30 kcal/kg/day based on B.A.’s usual 

body weight (82 kg) or 35 kcal/kg/day based on his most 

recent preadmission weight, and is therefore the best answer. 

Answer A (1230 kcal/kg/day) and Answer B (1640 kcal/ 

kg/day) provide fewer than 25 kcal/kg/day; these amounts 

are less than recommended for patients like B.A. Answer 

D (3280 kcal/kg/day) provides more than 35 kcal/kg/day, 

which would be an excessive daily caloric intake for B.A. 

leading to complications associated with overfeeding. 





Nutrition, 2005:281–6. 

2. A.S.P.E.N. Board of Directors and The Clinical Guidelines 

Task Force. Guidelines for the use of parenteral and enteral 

nutrition in adult and pediatric patients. JPEN J Parenter 

Enteral Nutr 2002;26S:1SA–6SA. 

5. Answer: C 

B.A. is receiving CRRT with citrate anticoagulation 

and has developed metabolic alkalosis. In this situation, 

bicarbonate administration should be decreased (Answer C); 

thus Answer C is the correct answer. Citrate is converted by 

the liver to bicarbonate and may precipitate alkalosis if the 

patient is not monitored closely or if intake of other buffer 

solutions (bicarbonate, lactate, and acetate) is not reduced. 

Answer A (lactate solutions should be used to correct B.A.’s 

alkalosis) is incorrect because lactate-containing solutions 

have been shown to have a negative effect on cardiac 

function and mean arterial pressure. These effects would be 

undesirable in B.A., who has chronic heart failure and shock. 

Additionally, lactate is converted to bicarbonate in the liver, 

which would exacerbate B.A.’s alkalosis. Bicarbonatebased 

solutions (Answer B) are not indicated because of the 

potential for worsening B.A.’s alkalosis; thus Answer B is 

incorrect. Acetate solutions (Answer D) should not be used 

routinely in patients in the intensive care unit (ICU) because 

Gastroenterology and Nutrition Answers 

36 

vasodilation and reduced myocardial contractility have 

been observed. These effects along with the conversion of 

acetate by the liver to bicarbonate may worsen the alkalosis. 

Therefore, Answer D is incorrect. 

1. Gabutti L, Marine C, Colucci G, Duchini F, Schönholzer 

C. Citrate anticoagulation in continuous venovenous 

hemodiafiltration: a metabolic challenge. Intensive Care Med 

2002;28:1419–25. 

2. Druml W. Metabolic aspects of continuous renal replacement 

therapies. Kidney Int Suppl 1999;72:S56–S61. 

6. Answer: B 

J.G.’s traumatic injury (Answer B) will increase her 

energy requirements compared with a healthy woman 

of her age and weight because hypermetabolism that 

occurs with trauma increases energy needs; thus Answer 

B is correct. The presence of ARF (Answer A) does not 

increase a patient’s basal metabolic expenditure, making 

Answer A is incorrect. In general, women have lower 

energy requirements compared with men, making Answer 

C (female sex) incorrect. Answer D (hypothermia from 

the absence of a blood warmer for the CRRT replacement 

solutions) is incorrect because hypothermia would induce a 

hypometabolic response, reducing energy needs. 




2. A.S.P.E.N. Board of Directors and the Clinical Guidelines 




3. Uehara M, Plank LD, Hill GL. Components of energy 

expenditure in patients with severe sepsis and major trauma: a 

basis for clinical care. Crit Care Med 1999;27:1295–302. 

7. Answer: A 

J.G. is receiving CVVHD using a dialysis solution 

containing dextrose 2% at a rate of 1 L/hour, which will 

supply 480 g of dextrose per day. Because an estimated 

35% to 45% of dextrose in the CRRT dialysate is absorbed, 

168–216 g of dextrose per day would be absorbed from J.G.’s 

dialysate. This dextrose delivery should be accounted for 

in J.G.’s nutrition regimen, necessitating a decrease in the 

amount of dextrose administered through modalities other 

than CRRT. Decreasing the dextrose in the PN formulation 

by about 200 g/day (Answer A) is therefore the best option. 

Decreasing the dextrose in the PN by 480 g/day (Answer 

B) is incorrect because it represents 100% absorption of the 

dextrose being supplied through CRRT when only 35% to 

45% is actually absorbed. Therefore, decreasing the dextrose 

delivery by 480 g/day would result in a caloric deficit. 

Answer C (increase dextrose by 200 g/day) and Answer 

D (increase dextrose by 480 g/day) are incorrect because 

dextrose in the PN formulation should be decreased, not 

increased, to avoid overfeeding and its inherent risks. 

1. Bellomo R, Martin H, Parkin G, Love J, Kearley Y, Boyce N. 

Continuous arteriovenous haemodiafiltration in the critically 

ill: influence on major nutrient balances. Intensive Care Med 

1991;17:399–402. 




Pharmacotherapy Self-Assessment Program, 6th Edition

8. Answer: A 

J.G. is receiving propofol at 11 mL/hour, which provides 

1.1 kcal/mL through its vehicle (10% fat emulsion). This 

amount of propofol will provide 290 kcal/day and 29 g of fat 

per day. The amount of fat emulsion in J.G.’s PN formulation 

must be reduced to avoid overfeeding. Decreasing the lipid 

emulsion by 29 g/day (Answer A) will reduce the fat intake by 

about the same amount of fat being provided by the propofol 

drip; making Answer A the best answer. Decreasing lipid 

emulsion by 53 g/day (Answer C) would decrease the lipid 

delivery by an amount that exceeds that being provided by 

the propofol drip, making Answer C is incorrect. Answer 

B (increase lipid emulsion by 29 g/day) and Answer D 

(increase lipid emulsion by 53 g/day) are incorrect because 

the lipid content should be reduced to avoid overfeeding. 

Once the propofol drip is discontinued, readjustment of the 

PN formulation will be required. 

1. Lowrey TS, Dunlap AW, Brown RO, Dickerson RN, Kudsk 

KA. Pharmacologic influence on nutrition support therapy: 

use of propofol in a patient receiving combined enteral and 

parenteral nutrition support. Nutr Clin Pract 1996;11:147–9. 

2. Mateu-de Antonio J, Barrachina F. Propofol infusion and 

nutrition support. Am J Health Syst Pharm 1997;52:2515–6. 

9. Answer: C 

Thiamine (Answer C) should be supplemented in 

J.G.’s PN formulation because it is lost in significant 

amounts during CRRT, making Answer C the correct 

answer. Thiamine is important in dextrose metabolism, 

and supplementation of 50–100 mg/day is recommended 

for patients receiving CRRT. Vitamin A (Answer A) and 

vitamin D (Answer B) are fat-soluble and are not removed 

to any appreciable degree during CRRT, so Answer A and 

Answer B are incorrect. Although vitamin C (Answer D) is 

lost in the CRRT filtrate, the clinical significance of this loss 

is unknown, and vitamin C supplementation is not currently 

recommended; thus Answer D is incorrect. 








1999;27:220–3. 

10. Answer: D 

In patients like J.G. (weight 60 kg) receiving CRRT, 

protein intakes of 2.5 g/kg/day have been shown to 

optimize nitrogen balance; thus Answer D (150 g/day) is 

correct. Protein intakes less than 2.5 g/kg/day have been 

associated with serum amino acid concentrations below the 

reference range, whereas protein intakes of 2.5 g/kg/day 

are associated with a normalization of serum amino acid 

concentrations and a higher prevalence of positive nitrogen 

balance. Answer A (60 g/day), Answer B (90 g/day), and 

Answer C (120 g/day) provide only 1 g/kg/day, 1.5 g/kg/day, 

and 2 g/kg/day of protein, respectively; therefore, Answer 

A, Answer B, and Answer C are incorrect because the 

protein intake is insufficient to meet J.G.’s needs. 

1. Scheinkestel CD, Adams F, Mahony L, Bailey M, Davies 

AR, Nyulasi I, et al. Impact of increasing parenteral protein 

loads on amino acid levels and balance in critically ill anuric 

patients on continuous renal replacement therapy. Nutrition 

2003;19:733–40. 

2. Scheinkestel CD, Kar L, Marshall K, Bailey M, Davies A, 

Nyulasi I, et al. Prospective randomized trial to assess caloric 

and protein needs of critically ill, anuric, ventilated patients 

requiring continuous renal replacement therapy. Nutrition 

2003;19:909–16. 

11. Answer: C 

In patients like J.G. with ARF, there are derangements 

of serum amino acids. Studies have demonstrated that 

patients with ARF should receive an essential–nonessential 

amino acid combination when PN is required; thus, Answer 

C (essential plus nonessential amino acid combination 

formulation) is the correct option for J.G.’s PN formulation. 

Essential amino acid–only formulations (Answer A) are 

more costly than standard amino acid formulations and have 

not been shown to produce a clinical benefit; thus Answer 

A is incorrect. A nonessential amino acid formulation 

(Answer B) would put J.G. at risk of amino acid deficiencies 

if essential amino acids were not provided, so Answer B is 

incorrect. Modular protein formulations (Answer D) are not 

available for administration in PN formulations but are used 

in enteral nutrition (EN) to supplement oral intake or tube 

feeds; therefore, Answer D is incorrect. 





2. Mirtallo JM, Schneider PJ, Mavko K, Ruberg RL, Fabri PJ. 

A comparison of essential and general amino acid infusions 

in the nutritional support of patients with compromised renal 

function. JPEN J Parenter Enteral Nutr 1982;6:109–13. 

3. Feinstein EI, Blumenkrantz MJ, Healy M, Koffler A, Silberman 

H, Massry SG, et al. Clinical and metabolic responses to 

parenteral nutrition in acute renal failure: a controlled doubleblind 

study. Medicine 1981;60:124–37. 

12. Answer: B 

J.G. has ARF and is receiving CVVHD with citrate 

anticoagulation. Her condition and therapies put her at risk of 

both calcium and phosphorus imbalance. Close monitoring 

of serum ionized calcium and phosphorus concentrations 

is vital; therefore, Answer B (calcium balance should be 

frequently assessed by monitoring J.G.’s serum ionized 

calcium and serum phosphorus concentrations) is correct. 

The serum ionized calcium is more reliable in patients with 

hypoalbuminemia, which is common in ARF. Answer A 

(citrate anticoagulation will likely induce hypercalcemia, 

thus requiring a reduction in the amount of J.G.’s calcium 

intake) is incorrect because citrate anticoagulation would 

likely induce hypocalcemia because of calcium chelation by 

citrate. Because calcium is filtered by CRRT, hypocalcemia 

may develop, and the need for calcium supplementation is 

common in patients receiving CRRT; therefore, Answer 

C (hypocalcemia is rare in patients such as J.G. with ARF 

receiving CRRT, and calcium supplementation will not 

be required) is incorrect. Hyperphosphatemia is unlikely 

because phosphorus is removed by CRRT; however, this 

would not preclude correction of hypocalcemia, if necessary. 

Therefore, Answer D (calcium supplementation in J.G. 


should only occur if her serum phosphorus concentration is 

within the reference range) is incorrect. 




2005;20:176–91. 

2. Cubattoli L, Teruzzi M, Cormio M, Lampati L, Pesenti A. 

Citrate anticoagulation during CVVH in high risk bleeding 

patients. Int J Artif Organs 2007;30:244–52. 

13. Answer: D 

M.T.’s current metabolism is likely to be unchanged 

(Answer D) compared with her normal metabolic state 

because isolated ARF caused by nephrotoxic injury does 

not increase energy needs, making Answer D correct. 

If ARF is accompanied by critical illness, then resting 

energy expenditure will increase. M.T. is not critically ill; 

therefore, Answer A (resting energy expenditure is greatly 

increased) is incorrect. The presence of ARF is associated 

with increased gluconeogenesis and increased protein 

catabolism; therefore, Answer B (gluconeogenesis is 

decreased) and Answer C (protein catabolism is decreased) 

are incorrect. 

1. Druml W. Metabolic aspects of continuous renal replacement 

therapies. Kidney Int Suppl 1999;72:S56–S61. 

2. A.S.P.E.N. Board of Directors and the Clinical Guidelines Task 

Force. Guidelines for the use of parenteral and enteral nutrition 

in adult and pediatric patients. JPEN J Parenter Enteral Nutr 

2002;26S:1SA–6SA. 

14. Answer: A 

M.T. is not receiving dialysis; therefore, a low-electrolyte 

renal disease–specific enteral product (Answer A) would be 

the best choice for her tube feedings. If dialysis is required in 

the future, a high-nitrogen product (Answer D) would be an 

appropriate choice, but at this time, it is not the best option. 

An immune-enhancing product (Answer B) would not be 

the best choice because current evidence does not support 

its use in patients with ARF, and these formulations are 

much more expensive than standard renal disease-specific 

products. A calorie-dense product (Answer C) could be an 

option if fluid restriction is needed; however, these products 

are associated with gastroparesis, making other alternatives 

more desirable when initiating feedings. 




2005;20:176–91. 

2. Kapadia FN, Bhojani K, Shah B. Special issues in the patient 

with renal failure. Crit Care Clin 2003;19:233–51. 

15. Answer: A 

M.T.’s prealbumin and albumin concentrations must be 

interpreted carefully. Prealbumin is renally eliminated; 

thus in patients like M.T. with ARF, serum prealbumin 

concentrations will be falsely elevated, making Answer A 

(her serum prealbumin concentration is falsely elevated) 

the correct answer. A reasonable goal for M.T.’s serum 

prealbumin concentration is 30 mg/dL or higher. M.T. 

could be malnourished despite a normal serum prealbumin 

concentration because of the false elevation in serum 

prealbumin concentrations described previously. Therefore, 


38 

Answer B (she is not malnourished because her serum 

prealbumin concentration is within the reference range) 

is incorrect. Albumin is a negative acute-phase protein 

that decreases in response to stress and is therefore not a 

good indicator of malnutrition in the acute care setting. In 

addition, M.T.’s serum albumin concentration is not within 

the reference range. For these reasons, Answer C (she is 

malnourished because her serum albumin concentration 

is decreased) and Answer D (her serum albumin 

concentration is within the reference range; therefore, she is 

not malnourished) are incorrect. 





Nutrition, 2005:281–6. 





16. Answer: A 

M.T. has developed metabolic acidosis (Answer A) 

as evidenced by the low serum pH and bicarbonate 

concentration; thus Answer A is correct. Metabolic acidosis 

is common in patients with ARF because of the kidney’s 

decreased ability to synthesize and reabsorb bicarbonate 

and its impaired ability to excrete hydrogen ions. For this 

reason, metabolic alkalosis (Answer B) is uncommon, 

unless iatrogenic. Neither respiratory acidosis (Answer C) 

nor respiratory alkalosis (Answer D) is evident by the blood 

gas results (pCO 2 

35 mm Hg). 




2005;20:176–91. 

2. Leblanc M. Acid-base balance in acute renal failure and 

renal replacement therapy. Best Pract Res Clin Anaesthesiol 

2004;18:113–27. 

17. Answer: A 

W.G.’s renal replacement therapy has been changed 

from intermittent hemodialysis to CRRT. With this change, 

one consideration for W.G. is that while phosphorus is 

not removed by intermittent hemodialysis, it is removed 

by CRRT modalities. Therefore, W.G.’s oral phosphate 

binder should be discontinued (Answer A) to prevent 

hypophosphatemia, making Answer A the best answer. 

Renal vitamin formulations, which contain water-soluble 

vitamins, should be continued because these vitamins are 

removed during CRRT. Thus, Answer B (oral renal vitamin 

formulation should be discontinued) is incorrect. If PN 

becomes necessary, neither selenium (Answer C) nor zinc 

(Answer D) should be removed from the PN formulation. 

Selenium supplementation should be continued because, 

although selenium will accumulate in ARF, it is removed 

by CRRT. Although zinc concentrations have been reported 

to be elevated in patients with CRRT, the reported increases 

have been mild, and the clinical impact is unknown at this 

time. Therefore Answer C and Answer D are incorrect. 









1999;27:220–3. 

18. Answer: D 

W.G.’s serum glucose concentration has been consistently 

elevated. The best approach for managing his hyperglycemia 

would be to start regular insulin by continuous intravenous 

infusion (Answer D); thus Answer D is correct. Using a 

sliding scale regimen of insulin aspart (Answer B) would 

be a reactive approach to hyperglycemia as opposed to 

a proactive approach with the insulin infusion. Sliding 

scale insulin regimens are no longer widely used in ICUs. 

Although adding regular insulin to the PN formulation 

(Answer C) is more convenient for the nursing staff, it is 

not ideal for a patient like W.G. who is receiving CRRT. 

If insulin is in the PN formulation and CRRT is stopped 

for any reason (e.g., because of filter clotting), the glucose 

delivery from the dialysis and replacement solutions will 

abruptly stop, creating the potential for hypoglycemia unless 

the PN formulation is also stopped. Similarly, administering 

insulin glargine subcutaneously every night (Answer A) 

would place the patient at risk of hypoglycemia in the event 

that any glucose source is discontinued. 




2005;20:176–91. 

2. Scheinkestel CD, Adams F, Mahony L, Bailey M, Davies 

AR, Nyulasi I, et al. Impact of increasing parenteral protein 

loads on amino acid levels and balance in critically ill anuric 

patients on continuous renal replacement therapy. Nutrition 

2003;19:733–40. 

19. Answer: B 

Various formulas are available for calculating nitrogen 

balance. Standard formulas have been revised to be used 

in patients receiving CRRT. W.G.’s nitrogen balance is 

negative 6.5 (-6.5) g of nitrogen (Answer B). This value can 

be calculated using the following equation: 

Nitrogen balance (g/day) = nitrogen intake (g/day) − 

nitrogen loss (g/day). In patients receiving CRRT, nitrogen 

loss (g/day) = effluent urea nitrogen loss (g/day) + amino 

acid losses across CRRT membrane (g/day) + urine urea 

nitrogen [UUN] (g/day) + insensible losses (2–4 g/day). 

W.G. is receiving 175 g of protein per day through his 

enteral formulation and additional protein supplementation. 

This intake provides 28 g of nitrogen per day (175 g of 

protein/6.25 g of protein per gram of nitrogen). The effluent 

urea nitrogen loss (grams per day) = total volume of 

replacement fluid (liters) + dialysate fluid (liters) + volume 

(liters) of parenteral volume removed from the patient over 

24 hours × the average urea nitrogen from the effluent 

sample (51 mg/dL). Convert 51 mg/dL to grams per liter 

by multiplying by 0.01 = 0.51 g of nitrogen per liter. Total 

replacement fluid plus dialysate fluid plus parenteral volume 

removed = 36,000 mL + 12,000 mL + 8,000 mL = 56,000 

mL = 56 L. Therefore, 56 L × 0.51 g of N per liter = 28.5 

g of nitrogen is lost as dialysate urea nitrogen. Dialysate 

plus replacement fluids are infusing at 2 L/hour; therefore, 

amino acid losses across the CRRT membrane = 2 g of N 

per day. Because W.G. is anuric, the UUN is omitted from 

the calculation. Adding 4 g of nitrogen for insensible losses 

gives a total of 34.5 g of nitrogen out. Nitrogen balance = 28 

g of nitrogen in – 34.5 g of nitrogen out = − 6.5 g of nitrogen. 

Answer A [negative 9 (−9) g of N], Answer C [negative 1.5 

(−1.5) g of N], and Answer D [positive 1 (+1) g of N] are 

incorrect based on the above calculations. 





Nutrition, 2005:281–6. 

2. Manning EM, Shenkin A. Nutritional assessment in the 

critically ill. Crit Care Clin 1995;11:603–34. 

20. Answer: D 

W.G. has been converted from intermittent hemodialysis 

to CRRT. A high-nitrogen feeding formulation (Answer 

D) should be initiated because it will meet the high protein 

needs of this patient receiving CRRT. Also, additional 

protein supplementation will be needed. A low-electrolyte, 

renal disease–specific enteral formulation (Answer A) is not 

needed at this time because the low-electrolyte composition 

of these products is not needed during CRRT. Immuneenhancing 

feeding formulations (Answer B) may have a 

role, but currently neither clinical nor literature support is 

available to justify the use of these expensive formulations 

in patients receiving CRRT. Calorie-dense feeding 

formulations (Answer C) often lead to gastroparesis, which 

is common in patients such as W.G. who have diabetes 

mellitus and are receiving CRRT; thus Answer C is not the 

best answer. 




2005;20:176–91. 

2. Kapadia FN, Bhojani K, Shah B. Special issues in the 

patient with renal failure. Crit Care Clin 2003;19:233–5 

Home Parenteral Nutrition 

21. Answer: D 

A 70-year-old man was hospitalized with pancreatitis 

associated with biliary tract disease. Fifteen days after 

admission, after undergoing cholecystectomy, he is unable 

to tolerate oral nutrition. Two pancreatic pseudocysts were 

identified by ultrasound examination. The best nutrition 

support regimen for home nutrition support for this patient 

is Answer D (enteral feeding with the tip of the feeding 

tube located past the ligament of Treitz). There are several 

studies demonstrating that a nasojejunal feeding tube 

with the tip past the ligament of Treitz provides effective 

nutrition without pancreatic stimulation, which is the cause 

of the pain when oral feedings are attempted. Although 

difficult, this type of feeding can be done at home and, if 

it is tolerated, saves the high cost and complication rate of 

home PN. Answer A (PN though a central venous access 

device [CVAD]) is incorrect because PN is not indicated 


unless the patient does not tolerate a trial of nasojejunal 

feedings. Answer B (nasogastric feedings) is incorrect 

because nasogastric feedings empty into the duodenum and 

thus stimulate the pancreas, resulting in pain. Answer C (PN 

through a peripheral venous catheter) is incorrect for two 

reasons. First, the patient has not had a trial of nasojejunal 

feedings, and secondly, peripheral PN is impractical at 

home because peripheral venous catheters often need to be 

replaced every 1–2 days, resulting in significant nursing 

effort and decreasing quality of life for the patient. 

1. McClave SA. Nutrition support in acute pancreatitis. 

Gastroenterol Clin North Am 2007;36:65–74. 

2. McClave SA, Chang WK, Dhaliwal R, Heyland DK. Nutrition 

support in acute pancreatitis: a systematic review of the 

literature. JPEN J Parenter Enteral Nutr 2006;30:143–56. 

3. ASPEN Board of Directors and the Clinical Guidelines Task 


in adult and pediatric patients. JPEN 2002;26(1 Suppl):1SA– 

138SA. 

22. Answer: B 

R.C. is a 40-year-old who underwent bowel resection 

secondary to mesenteric artery thrombosis, leaving him 

with short bowel syndrome (SBS). He will require home 

PN probably for the rest of his life. The most appropriate 

access for R.C. is Answer B (a tunneled CVAD with the 

tip in the superior vena cava). Either an implanted line, a 

percutaneously inserted central catheter (PICC), or an 

implanted port with the tip in the superior vena cava is 

appropriate for all patients receiving home PN. A patient 

receiving home PN also needs a CVAD that is reasonably 

resistant to accidental dislodgement. These CVADs are 

placed under the skin, and some have a cuff that makes them 

more resistant to dislodgement. Answer A (a percutaneous 

subclavian CVAD) is incorrect because these catheters are 

prone to being dislodged, which may result in significant 

bleeding. Answer C (a femoral CVAD with the tip located 

distal to the bifurcation of the iliac veins) is incorrect 

because femoral catheters increase the risk of infection, and 

most intravenous CVADs are too short to reach the superior 

vena cava from a femoral approach. Answer D (a peripheral 

venous catheter) is incorrect because these catheters are 

intended for short-term use only, and R.C. will need an 

intravenous catheter for the rest of his life. 




138SA. 

2. Siepler J. Principles and strategies for monitoring home 

parenteral nutrition. Nutr Clin Pract 2007;22:340–50. 

23. Answer: C 

A 45-year-old woman required a massive bowel resection 

and duodenocolostomy after a motor vehicle accident. The 

first step in the process of discharging a patient home on PN 

is to discuss the need for home PN with a discharge planner 

(Answer C); thus Answer C is correct. Finding a physician 

willing to manage the patient’s PN at home (Answer A) 

is incorrect. Although finding a physician experienced in 

home PN is desirable, if funding has not been ensured, it 

is unlikely that she will be able to pay for her PN. Answer 

B (find a home care provider to make the PN) will need to 


40 

be accomplished before discharge; however, this answer is 

incorrect because it is not the first step in the process. The 

home PN provider will need funding information before 

accepting the patient. Training the patient and her family in 

CVAD care and PN administration (Answer D) is another 

important step in the process, but it is not the first step, 

making Answer D incorrect. 

1. Messing B, Joly F. Guidelines for management of home 

parenteral support in adult chronic intestinal failure patients. 

Gastroenterology 2006:130:S43–S51. 



3. Howard L. Home parenteral nutrition: survival, cost, and 

quality of life. Gastroenterology 2006;130:S52–S59. 

24. Answer: D 

Reimbursement for home PN by most insurance plans 

is provided based on the patient meeting certain criteria. 

Answer D (the patient is unable to maintain body mass 

because of intestinal failure) is the condition that most 

correctly identifies a patient for whom home PN will be 

reimbursed. Answer A (the patient is unable to maintain 

body mass because of malabsorption of oral nutrients) is 

incorrect because a trial of tube feedings with a predigested 

enteral formulation has not been attempted. Inability to 

eat or refusal to have tube feedings (Answer B) is not an 

indication for home PN that would be reimbursed by most 

insurance companies, making Answer B incorrect. Answer 

C (inability to eat because of a terminal illness with a life 

expectancy of 1 month) is incorrect because a patient with 

a terminal illness and 1-month life expectancy is generally 

not considered an acceptable candidate for home PN. 

However, controversy does exist because some data suggest 

that patients in this condition may have an improved quality 

of life with nutrition support. Most experts in the field of 

nutrition support, however, feel that the risk of complications 

with home PN, including increased infections, may actually 

decrease quality of life and hasten a patient’s death. 


parenteral nutrition. Nutr Clin Prac 2007;22:340–50. 

2. Kovacevich DS, Frederick A, Kelly D, Nishikawa RA, Young 

L. Standards for specialized nutrition support: home care 

patients. Nutr Clin Prac 2005;20:579–90. 




25. Answer: C 

Before a patient can be discharged to receive PN in the 

home, electricity, a refrigerator, and a telephone (Answer C) 

must be in the home. The PN solutions will be delivered for 

a 7–14 day period. These solutions must be refrigerated until 

use. A telephone is necessary to be able to communicate 

with the medical provider, home health nurses, and the home 

PN provider. Thus, Answer C is the correct answer. Answer 

B (transportation to a laboratory for weekly blood draws) 

is incorrect because laboratory samples can be drawn in 

the home by the home care nurse. Daily nursing care in the 

home to initiate and discontinue the PN infusion (Answer 

A) is impractical and not supported by third-party payers. 

The patient or a caregiver must be trained to administer 


the PN solution daily. Having a caregiver, other than the 

patient, to care for the CVAD and manage the PN infusion 

(Answer D) would be helpful for all patients, but it is not 

necessary before discharge because most patients can do 

these functions; thus Answer D is not the best answer. 



2. Kovacevich DS, Frederick A, Kelly D, Nishikawa RA, Young 

L. Standards for specialized nutrition support: home care 

patients. Nutr Clin Pract. 2005;20:579–9. 

26. Answer: B 

A patient with Crohn’s disease and SBS has a tunneled 

CVAD for home PN. She has a temperature of 104°F (40°C) 

for several days. The most likely cause of her fever is a 

CVAD-associated infection (Answer B); thus, Answer B 

is the correct answer. Answer A (Crohn’s disease–related 

hyperthermia) is possible, but in a patient receiving home 

PN through a CVAD, infection is more likely to explain her 

fever; thus, Answer A is incorrect. Answer C (a systemic 

viral infection) is also possible, but a CVAD-associated 

infection is more likely with the high fever. Answer D 

(hypersensitivity reaction to the fat emulsion in the PN) is 

incorrect because the patient has been receiving home PN 

for several years. 



2. Yildizeli B, Lacin T, Batirel HF, Yuksel M. Complications and 

management of long-term central venous access CVADs and 

ports. J Vasc Access 2004;5:174–8. 

27. Answer: D 

A 45-year-old man (weight 75 kg, height 165 cm ) with 

SBS (150 cm small bowel and the entire colon remaining) 

is receiving 2200 calories only 2 days/week. Answer D 

(his PN infusion should be weaned to 1 day/week) is the 

correct answer. He has had stable weight gain for 3 years, 

is well hydrated, and does not need additional hydration 

on the days that he does not receive a PN infusion. Thus, 

a trial of weaning his PN to 1 day/week is appropriate. 

Both Answer A (referral to an intestinal rehabilitation 

program) and Answer B (referral to an intestinal transplant 

program) are incorrect because it appears that he will be 

able to wean off PN without additional assistance; his bowel 

length is long enough, and he has been able to wean to only 

two PN infusions weekly. It would be desirable to attempt 

to wean him off PN first before referral to a rehabilitation 

or transplantation program. Answer C (his PN should be 

changed to a daily infusion of 630 kcal) is incorrect because 

he is doing well with hydration using his current twice 

weekly regimen, so there is no need to go back to a daily 

infusion. 






3. Jeppesen PB, Mortensen PB. Intestinal failure defined by 

measurements of intestinal energy and wet weight absorption. 

Gut 2000;46:701–6. 

28. Answer: C 

A 34-year-old with Crohn’s disease and SBS (25 

cm residual small bowel) had a dual-energy x-ray 

absorptiometry (DEXA) scan with T scores reported as 

lumbosacral spine −3.2 and right femoral neck −3.0. This 

patient has osteoporosis with a significant risk of fracture; 

thus the best treatment for her is to start pamidronate 60 

mg intravenously every month (Answer C). Answer A (start 

alendronate oral solution 7.5 mg daily) is not the best answer 

because alendronate in either the tablet or liquid dosage form 

is likely to be inadequately absorbed in this patient with 

severe SBS. Answer B (discontinue methylprednisolone) is 

incorrect because rapidly discontinuing her corticosteroid 

treatment is not advisable as it may result in a flare of her 

Crohn’s disease. Answer D (do nothing) is not the best 

course of action because she will require PN for her lifetime, 

and her osteoporosis likely will continue to worsen without 

treatment. 

1. Buchman AL, Moukarzel A. Metabolic bone disease associated 

with total parenteral nutrition. Clin Nutr 2000;19:217–31. 

2. Hurley DL, McMahon M. Long term parenteral nutrition and 

metabolic bone disease. Endocrinol Metab Clin North Am 

1990;19:113–31. 

29. Answer: A 

A patient receiving home PN is having difficulty aspirating 

blood from her CVAD for routine laboratory testing. The 

CVAD flushes easily, and she reports no problems with 

the PN infusion. This difficulty in withdrawing blood 

from the CVAD likely is caused by a thrombus “flap” that 

allows infusion of fluid through the CVAD but obstructs 

the CVAD lumen when negative pressure is applied in the 

process of aspirating blood. Answer A (instill alteplase in 

the CVAD to attempt to clear the obstruction) is the correct 

answer. Answer B (do nothing) is incorrect because this 

withdrawal occlusion can progress to complete occlusion 

and should be addressed at this time. Answer C (instill 

ethanol 70% to dissolve the probable lipid occlusion) is 

incorrect because the most likely problem is a thrombus 

occlusion, not a lipid occlusion, because the catheter 

still flushes well. A lipid plug usually causes a complete 

occlusion, not just withdrawal occlusion. Answer D 

(have the CVAD removed) is incorrect because alteplase 

will likely correct the problem, avoiding CVAD removal. 

1. Gould JR, Carlos HW, Skinner WL. Groshong CVAD associated 

subclavian CVAD thrombosis. Am J Med 1993;95:419–23. 

2. Bern MM, Lokich JJ, Wallach SR, Bothe A Jr, Benotti PN, Arkin 

CF, et al. Very low doses of warfarin can prevent thrombosis in 

central venous CVADs. A randomized prospective trial. Ann 

Int Med 1990;112:4213–28. 

30. Answer: D 

The most likely cause of W.H.’s weight loss is 

dehydration, probably from an increase in his stool output. 

Before any changes in his therapy are made, he should be 

questioned to determine if his stool output has increased 

during the past week. Answer A (increase the protein and 

carbohydrate in his PN formulation to stimulate weight 

gain) and Answer B (increase the intravenous fat component 

of his PN formulation to stimulate weight gain) assume 

that his weight loss is caused by suboptimal calorie intake. 


However, a 10-kg weight loss in a 1-week period is unlikely 

to result from inadequate calorie intake; thus, Answer A and 

Answer B are incorrect. Answer C (obtain a resting energy 

expenditure study to determine his caloric needs) is also 

incorrect because it again assumes that the weight loss is 

caused by inadequate calorie intake. The initial intervention 

for W.H., given the most likely reason for the weight loss, is 

to provide additional intravenous fluid either by increasing 

his PN volume or by adding additional intravenous fluids 

(Answer D); thus Answer D is the correct answer. W.H.’ s 

weight and stool output should be followed daily, and the 

additional fluid reduced to the previous volume once W.H.’s 

weight has returned to his usual weight and his stool output 

has decreased to the usual volume. 






3. Jeppesen PB, Mortensen PB. Intestinal failure defined by 

measurements of intestinal energy and wet weight absorption. 

Gut 2000;46:701–6. 

31. Answer: B 

W.H.’s wife tells you that he has developed a tremor and 

is having hallucinations. These symptoms are not normally 

seen in patients receiving home PN; thus Answer A (do 

nothing, but reassure W.H.’s wife that these symptoms 

are normal) is incorrect. Hypermagnesemia can occur in 

patients receiving long-term home PN when receiving a 

trace element cocktail daily. Manganese is deposited in 

the basal ganglia, so hypermagnesemia results in various 

neurological symptoms including those being experienced 

by W.H. However, other nutrient imbalances may also lead 

to similar symptoms. Therefore, Answer B (have the home 

health nurse draw a basic metabolic panel, complete blood 

count, and serum manganese concentration) is the best 

intervention at this time, making Answer B the correct 

answer. Answer C (have the nurse draw a serum manganese 

concentration) is one of the appropriate interventions, but 

Answer C is not the best answer because other laboratory 

tests should also be checked. Answer D (remove the 

trace element preparation from W.H.’s PN formulation) is 

incorrect. It would be premature to remove the trace elements 

from the PN formulation at this time. If hypermagnesemia 

is determined to be the cause of W.H.’s new neurological 

symptoms, then the trace element preparation would have to 

be removed, but zinc and perhaps chromium would need to 

be added to the PN formulation to prevent a deficiency state. 

1. Dickerson RN. Manganese intoxication and parenteral 

nutrition. Nutrition 2001;17:689–93. 

2. Bertinet DB, Tinivella M, Balzola FA, de Francesco A, Davini 

O, Rizzo L, et al. Brain manganese deposition and blood levels 

in patients undergoing home parenteral nutrition. JPEN J 

Parenter Enteral Nutr 2000;24:223–7. 

3. Clark SF. Vitamins and trace elements. In: Gottschlick MM, 

DeLegge MH, Mattox T, Mueller C, Worthington P, eds. The 

A.S.P.E.N. Nutrition Support Core Curriculum: A Case-based 

Approach – The Adult Patient. Silver Spring, MD: American 

Society for Parenteral and Enteral Nutrition, 2007, 129–59. 

32. Answer: A 

A 25-year-old woman (weight 42 kg, height 163 cm) 

with chronic intestinal pseudo-obstruction is admitted to 

the hospital because of continued weight loss over the last 

2 years (maximum weight 60 kg). Eating causes abdominal 

pain, as did continuous jejunal feedings during her last 

hospitalization. Her symptoms are typical of patients with 

chronic intestinal pseudo-obstruction. Some patients have 

severe small intestinal dysmotility with propulsion upward 

towards the stomach instead of downwards toward the colon. 

The best plan for this patient is to plan for discharge home 

on PN therapy (Answer A), making Answer A the correct 

answer. Answer B (start high-calorie oral supplements) is 

incorrect because any type of oral feedings will produce 

the same symptoms and will not be tolerated. Placing a 

transpyloric feeding tube and starting an elemental feeding 

formulation (Answer D) is incorrect because this therapy has 

already been tried and was not successful. Discharging her 

home with no nutrition support and waiting for her weight 

to decrease further (Answer C) is incorrect as she is already 

12 kg below her ideal weight. Further weight loss will likely 

occur and result in another hospitalization to initiate PN. 




2. Kelly DA. Intestinal failure-associated liver disease: what do 

we know today? Gastroenterology 2006;S70–S77. 

33. Answer: C 

A 25-year-old man (weight 50 kg, height173 cm) has been 

receiving home PN for 2 years after being injured in a motor 

vehicle accident. He has SBS with 20 cm of residual small 

intestine and 50% of his colon. His medical history includes 

intravenous drug abuse. His recent laboratory results include 

a 4-fold increase in his alkaline phosphatase (ALK), alanine 

aminotransferase (ALT), aspartate aminotransferase (AST), 

and total bilirubin concentrations. The most appropriate 

response to the elevation in this man’s liver function 

tests (LFTs) is to obtain hepatitis serology and conduct a 

detailed drug history looking for drug-induced causes of 

his laboratory abnormalities (Answer C), making Answer 

C the correct answer. Answer A (reduce the intravenous fat 

emulsion in his PN formulation), Answer B (reduce both 

the intravenous fat emulsion and dextrose components of 

the PN formulation), and Answer D (discontinue his home 

PN therapy immediately) are incorrect because the cause 

of the elevated the LFTs must be determined before the 

correct therapy can be determined. This patient has risk 

factors for hepatitis as well as PN-induced steatosis and 

cholestasis. Additionally, with this patient’s degree of SBS, 

discontinuing his PN is not a practical option. 

1. Kelly DA. Intestinal failure-associated liver disease: what do 

we know today? Gastroenterology 2006;S70–S77. 



3. OKeefe SJ. Bacterial overgrowth and liver complications 

in short bowel intestinal failure patients. Gastroenterology 

2006;130:S67–S69. 


42 


34. Answer: D 

T.O. is obese (i.e., 300% of IBW) and is continuing to 

gain weight with her current PN formulation, which provides 

29 kcal/kg/day based on her actual weight and 58 kcal/kg/ 

day based on an adjusted body weight for obesity. Thus, 

Answer A (continue the current PN formulation and follow 

up in 1 month) is not a good option for T.O. and is incorrect. 

Reducing the calories delivered by the PN formulation to 

2500 kcal/day with 150 grams of protein per day (Answer 

C) is an appropriate intervention, but Answer D (decreasing 

the PN to 2500 kcal/day, maintaining 150 grams of protein 

per day, and attempting slow enteral feedings, is the best 

answer because T.O. should be given another trial of enteral 

feeding. Therefore, Answer C is incorrect and Answer D is 

the best answer. Stopping the PN and initiating either tube 

or oral feedings (Answer B) is not an appropriate option for 

T.O.; it will fail because she does not have adequate bowel 

length to have sufficient nutrient absorption to discontinue 

the PN. 






138SA. 

3. Seres DS. Surrogate nutrition markers, malnutrition, and 

adequacy of nutrition support. Nutr Clin Prac 2005;20:308–13. 

35. Answer: C 

T.O. has had an increase in stool output for the past 

2 days. The stool is foul-smelling, and she has crampy 

abdominal pain but is afebrile. She is concerned that the 

diarrhea will soon lead to dehydration without intervention. 

The best therapeutic intervention for T.O. is to start 

metronidazole 500 mg intravenously three times/day and 

order intravenous replacement fluids for her stool losses 

(Answer C), making Answer C the correct answer. Simply 

reassuring her that her PN formulation provides adequate 

volume for increased stool losses and having her call back in 

2–3 days (Answer A), is incorrect because her PN provides 

only 3 L/day, which will not be adequate if the stool volume 

has increased significantly. Answer B (start metronidazole 

500 mg intravenously three times/day and order intravenous 

replacement fluids) is not the best answer because with the 

severity of her SBS and the increased stool output, the transit 

time for metronidazole taken orally will likely be too fast to 

allow for efficacy. Admitting T.O. to the hospital for broadspectrum 

intravenous antibiotics (Answer D) is incorrect 

because T.O.’s symptoms suggest bacterial overgrowth, 

which can be treated with metronidazole alone. Unless 

dehydration develops, bacterial overgrowth can usually be 

managed without hospital admission. 

1. Di Stefano M, Miceli E, Missanelli A, Corazza GR. Treatment 

of small intestine bacterial overgrowth. Eur Rev Med 

Pharmacol Sci 2005;9:217–22. 

2. Van Citters GW, Lin HC. Management of small intestinal 

bacterial overgrowth. Curr Gastroenterol Rep 2005;7:317–20. 

3. Parrish CR, Krenitsky J, Willcutts K, Radigan AE. 

Gastrointestinal disease. In: Gottschlick MM, DeLegge MH, 

Mattox T, Mueller C, Worthington P, eds. The A.S.P.E.N. 

Nutrition Support Core Curriculum: A Case-based Approach 

– The Adult Patient. Silver Spring, MD: American Society for 

Parenteral and Enteral Nutrition, 2007, 508–39. 

36. Answer: B 

A 70-year-old woman is admitted to the hospital because 

of weight loss of unknown etiology. She has diabetes 

mellitus and gastroparesis (diagnosed 10 years ago) and is 

receiving nasojejunal feedings with a polymeric formula. 

After 2 weeks, she is gaining weight and her prealbumin 

concentration has increased. She is ready for discharge but 

is refusing to go home on tube feedings and would rather go 

home on PN. She has Medicare with no secondary provider. 

Because she is tolerating and responding to EN, Medicare 

will not cover the cost of PN therapy. Therefore, Answer 

A (place a tunneled CVAD, initiate PN, plan for discharge 

on home PN) and Answer C (discharge the patient to home 

on peripheral PN) are not good options for this patient who 

likely would not be able to pay for the cost of PN therapy. 

Additionally, peripheral PN is not a good option for use 

in the home because of the need to frequently replace the 

peripheral infusion site. Because she came into the hospital 

with unexplained weight loss, sending her back home on 

a oral diet with intravenous hydration is not optimal. She 

likely will not continue to gain weight on this regimen, and 

the cost of intravenous hydration will not be reimbursed by 

Medicare. The best option for this patient is to discuss the 

complications of long-term PN with her and the fact that 

Medicare will not cover the cost of PN therapy, and try to 

convince her to go home with jejunostomy tube feedings 

(Answer B), making Answer B the correct answer. 




2. Howard L. Home parenteral nutrition: survival, cost, and 

quality of life. Gastroenterology 2006;130:S52–S59. 

37. Answer: D 

R.C.’s laboratory reports indicate that he is dehydrated. 

Therefore, doing nothing (Answer A), is not an appropriate 

response. The best response to R.C.’s current situation is 

to continue the PN formulation and give lactated Ringer’s 

2 L followed by lactated Ringer’s replacement for his 

jejunostomy losses (Answer D). Increasing the PN volume 

to 4.5 L may help correct the existing dehydration, but it 

may not be adequate depending on the jejunostomy output; 

therefore Answer B is not the best option. Correcting the 

dehydration first, then replacing the losses proactively 

is the best approach to prevent dehydration in the future. 

Answer C (increase the sodium acetate in the current PN 

formulation to150 mEq/day) would help to acutely correct 

R.C.’s metabolic acidosis, but it would not correct the 

dehydration; thus Answer C is not the best response. 







2. Buchman AL, Scolapio J, Fryer J. AGA technical review 

on short bowel syndrome and intestinal transplantation. 

Gastroenterology 2003;124:1111–34. 


3. Sundaram A, Koukia P, Apovian CM. Nutritional management 

of short bowel syndrome in adults. J Clin Gastroenterol 

2002;34:207–20. 

38. Answer: A 

R.C. is at high risk of developing a zinc deficiency 

(Answer A) because of the fact that zinc will be lost in high 

concentrations from the high-output jejunostomy; thus 

Answer A is correct. Zinc concentrations in small bowel 

output can be as high as 12 mg/L; thus, R.C. may be losing 

as much as 18 mg of zinc per day in the jejunostomy fluid. 

Vitamin B 12 

(Answer B), folic acid (Answer C), and copper 

(Answer D) are not substantially eliminated in the stool; thus 

R.C.’s risk of zinc deficiency is substantially higher than 

the risk of vitamin B 12 

, folic acid, or copper deficiencies, 

making Answer B, Answer C, and Answer D incorrect. 







2. Buchman AL, Scolapio J, Fryer J. AGA technical review 

on short bowel syndrome and intestinal transplantation. 

Gastroenterology 2003;124:1111–34. 

3. Sundaram A, Koukia P, Apovian CM. Nutritional management 

of short bowel syndrome in adults. J Clin Gastroenterol 

2002;34:207–20. 

39. Answer: C 

T.C. has developed hypoglycemia (blood glucose 

concentration less than 60 mg/dL. The most appropriate 

response to hypoglycemia after discontinuing the PN when 

cycling in a young infant is to increase the ramp-down 

time; therefore, Answer C (continue to ramp up over 1 

hour; increase the ramp-down time to 2 hours) is the correct 

answer. Answer A (do nothing) is not correct. A blood 

glucose concentration less than 60 mg/dL can be associated 

with complications, including changes in neurodevelopment; 

therefore, allowing T.C.’s blood glucose concentration to 

fall to 45 mg/dL after discontinuing PN is not appropriate. 

Answer B (increase the ramp-up time to 2 hours; continue 

to ramp down over 1 hour) is incorrect because the serum 

glucose concentration at the maximum PN infusion rate is 

acceptable (90 mg/dL), so no change in the ramp-up time is 

needed; also, this option does not address the low glucose 

after discontinuing the PN. Answer D (increase both the 

ramp-up and ramp-down times to 2 hours) could be done; 

however, it is not the best answer because the ramp-up time 

does not need to be changed. 

1. Kumpf VJ, Gervasio J. Complications of parenteral nutrition. 

In: Gottschlick MM, DeLegge MH, Mattox T, Mueller C, 

Worthington P, eds. The A.S.P.E.N. Nutrition Support Core 

Curriculum: A Case-based Approach – The Adult Patient. 

Silver Spring, MD: American Society for Parenteral and 

Enteral Nutrition, 2007, 323–39. 

2. Bendorf K, Friesen CA, Roberts CC. Glucose response to 

discontinuation of parenteral nutrition in patients less than 3 

years of age. JPEN: J Parenteral Enteral Nutr 1996;20:120–2. 

40. Answer: C 

T.C. has been receiving a standard multivitamin 

preparation in her PN formulation, but only zinc and 

chromium, because the standard trace element preparation 

was removed from her PN when her direct bilirubin was 

elevated to 4 mg/dL. She is receiving about 40% of her 

nutrition by the enteral route. Her direct bilirubin in clinic 

today is 2.1 mg/dL, and she has a microcytic anemia. The 

most appropriate response would be to draw a serum iron 

panel and ferritin and copper concentrations (Answer C). 

Deficiency of both iron and copper can cause microcytic 

anemia. T.C. is receiving neither iron nor copper in her 

PN formulation; thus she is at risk for deficiency of both. 

Therefore, Answer C is correct. Answer A (add standard 

pediatric trace elements to the PN formulation daily) is 

incorrect because T.C.’s direct bilirubin is still elevated, 

indicating cholestasis; thus, copper and manganese excretion 

may be compromised. The trace element preparation 

should not be added unless a deficiency of both copper 

and manganese is documented. Answer B (draw a serum 

iron panel and ferritin, vitamin B 12 

, folate, and copper 

concentrations) is incorrect because T.C. has been receiving 

both vitamin B 12 

and folate daily in her PN formulation, and 

these nutrients are associated with macrocytic anemia, not 

microcytic anemia. Answer D (start ferrous sulfate drops 

orally) is not appropriate at this time because the cause of 

the microcytic anemia has not been determined. 

1. Chessman KH, Kumpf VJ. Assessment of nutrition status and 

nutrition requirements. In: Dipiro JT, Talber RL, Yee GC, 

Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A 

Pathophysiologic Approach, 7 th edition. New York: McGraw 

Hill Medical, 2008, 2349–66. 

2. Btaiche IF, Khalidi N. Parenteral nutrition-associated liver 

complications in children. Pharmacotherapy 2002;22:188–211. 

3. Btaiche IF, Khalidi N. Metabolic complications of parenteral 

nutrition in adults, part 2. Am J Health Syst Pharm 

2004;61:2050–9. 

Immunonutrition 

41. Answer: D 

The best EN intervention for J.B. immediately upon 

admission is actually no enteral feeding (Answer D) because 

J.B. is hemodynamically unstable and has been incompletely 

resuscitated; thus Answer D is correct. However, 

hemodynamic instability is a relative contraindication 

to EN, and some institutions might begin EN in a patient 

such as J.B. The immune-enhancing EN formulation with 

omega-3 polyunsaturated fatty acids (PUFAs) 8.6 g/L and 

antioxidants (Answer B) would be the best response only 

if J.B. was hemodynamically stable so that feedings could 

be initiated safely, so Answer B is incorrect. Answer A 

(immune-enhancing EN formulation with arginine 10 g/L 

and omega-3 PUFAs 3.6 g/L) and Answer C (immuneenhancing 

EN formulation with arginine 16.3 g/L, glutamine 

15 g/L, nucleotides 1.6 g/L, and omega-3 PUFAs 1.7 g/L) are 

not correct choices because each contains arginine, which 

has been associated with potential harm in patients with 

sepsis. 


44 


1. Consensus recommendations from the U.S. Summit on 

immune-enhancing enteral therapy. JPEN J Parenter Enteral 

Nutr 2001;25:S61–S63. 

2. Kudsk KA. Immunonutrition in surgery and critical care. 

Annu Rev Nutr 2006;26:463–79. 

42. Answer: B 

In patients like J.B. with ARDS and acute lung injury 

(ALI), immune-enhancing EN formulations supplemented 

with the omega-3 PUFAs (eicosapentaenoic acid [EPA] 

and g-linolenic acid [GLA]) and antioxidants have been 

associated with decreased mortality and improved 

oxygenation. The immune-enhancing EN formulation 

with omega-3 PUFAs 8.6 g/L and antioxidants (Answer 

B) contains these nutrients and is therefore the best choice. 

The standard EN formulation with enteral glutamine 

supplementation (Answer C) is not the best option because 

it does not contain omega-3 PUFAs or antioxidants. Neither 

Answer A (immune-enhancing EN formulation with 

arginine, nucleotides, and omega-3 PUFAs) nor Answer 

D (immune-enhancing EN formulation with arginine and 

omega-3 PUFAs) is best for J.B. at this time because each 

contains arginine, which has been associated with potential 

harm in patients with sepsis. 

1. Pontes-Arruda A, Aragao AM, Albuquerque JD. Effects of 

enteral feeding with eicosapentaenoic acid, gamma-linolenic 

acid, and antioxidants in mechanically ventilated patients with 

severe sepsis and septic shock. Crit Care Med 2006;34:2325– 

33. 

2. Kreymann KG, Berger MM, Deutz NE, Hiesmayr M, Jolliet 

P, Kazandjiev G, et al. ESPEN guidelines on enteral nutrition: 

intensive care. Clin Nutr 2006;25:210–23. 

43. Answer: C 

Once J.B. is started on an immune-enhancing EN 

formulation, the duration of therapy will have to be decided. 

Clinical studies indicate that the greatest benefit from these 

formulations in patients with ARDS is obtained when therapy 

is continued until the patient has been extubated (Answer 

C); thus, Answer C is the best answer. Patients are unlikely 

to benefit from any immunonutrition therapy administered 

for only 2 days (Answer A) or 4 days (Answer B), and there 

is no clinical evidence that patients with ARDS derive any 

further improvement in outcome if immune-enhancing 

diets are used after they have recovered sufficiently to be 

extubated. Because hospital discharge will generally occur 

days to weeks after extubation, discontinuing the product on 

discharge (Answer D) is not appropriate for the duration of 

J.B.’s immunonutrition therapy. 

1. Pontes-Arruda A, Aragao AM, Albuquerque JD. Effects of 

enteral feeding with eicosapentaenoic acid, gamma-linolenic 

acid, and antioxidants in mechanically ventilated patients with 

severe sepsis and septic shock. Crit Care Med 2006;34:2325– 

33. 



Nutr 2001;25:S61–S63. 

44. Answer: C 

If a patient with ARDS receiving an immune-enhancing 

EN formulation was evaluated for immunologic and 

inflammatory markers, the result likely would reflect the 

increased use of omega-3 PUFAs, which is associated 

with a decrease in inflammatory mediators and markers. 

Thus, the concentrations of prostaglandin E 2 

(Answer D) 

and interleukin 6 (IL-6) (Answer B) would be expected 

to decrease, not increase, making Answer B and Answer 

D incorrect. Tumor necrosis factor alpha concentrations 

(Answer C) decrease with the addition of PUFAs to the 

diet; thus, Answer C is correct. Although these immuneenhancing 

EN formulations may alter T lymphocyte 

function, total lymphocyte count would not be expected to 

decrease (Answer A); thus Answer A is incorrect. 

1. Suchner U, Kuhn KS, Furst P. The scientific basis of 

immunonutrition. Proc Nutr Soc 2000;59:553–63. 

2. Pacht ER, DeMichele SJ, Nelson JL, Hart J, Wennberg AK, 

Gadek JE. Enteral nutrition with eicosapentaenoic acid, gammalinolenic 

acid, and antioxidants reduces alveolar inflammatory 

mediators and protein influx in patients with acute respiratory 

distress syndrome. Crit Care Med 2003;31:491–500. 

45. Answer: D 

The use of immune-enhancing EN formulations 

containing arginine, omega-3 PUFAs, and nucleotides has 

been shown to improve outcomes in patients after trauma. 

The potential benefit is greatest in patients with an injury 

severity score (ISS) greater than 20 or an abdominal 

trauma index (ATI) greater than 25. The 47-year-old 

woman injured in a fall with an ISS of 22 (Answer D) is 

the patient most likely to derive additional benefit from 

the use of immunonutrition. The 32-year-old man with an 

ISS of 12 (Answer A), the 29-year-old woman injured in an 

industrial accident with a ATI of 22 (Answer C), and the 

55-year-old woman injured in an automobile accident with 

an ATI score of 11 (Answer B) do not have markers of injury 

severity in the range where a benefit of immunonutrition 

has been shown; thus Answer A, Answer B, and Answer C 

are incorrect. However, use of these products would not be 

expected to increase complications. 

1. Kudsk KA, Minard G, Croce MA, Brown RO, Lowrey TS, 

Pritchard FE, et al. A randomized trial of isonitrogenous 

enteral diets after severe trauma. An immune-enhancing diet 

reduces septic complications. Ann Surg 1996;224:531–40; 

discussion 540–3. 



Nutr 2001;25:S61–S63. 

46. Answer: B 

Improved outcomes have been demonstrated when 

patients with burn injuries like R.R. are given a standard 

EN formulation and enteral glutamine supplementation, so 

Answer B (begin feeding with a standard EN formulation 

with enteral glutamine supplementation) is the correct 

answer. Withholding enteral feeding for the first 48 hours 

after a thermal injury (Answer D) decreases the likelihood 

that EN will be tolerated once started; thus, Answer D is 

incorrect. Feeding should begin as soon as the patient is 

hemodynamically stable after thermal injury. Immuneenhancing 

EN formulations supplemented with arginine 

12.5, omega-3 PUFAs, and nucleotides (Answer A) or 

arginine (Answer C) are not associated with harm in patients 

with burns, but they are not recommended for routine use 


in this patient population because there is no evidence that 

they improve outcomes. 

1. Garrel D, Patenaude J, Nedelec B, Samson L, Dorais J, 

Champoux J, et al. Decreased mortality and infectious 

morbidity in adult burn patients given enteral glutamine 

supplements: a prospective, controlled, randomized clinical 

trial. Crit Care Med 2003;31:2444–9. 

2. Prelack K, Dylewski M, Sheridan RL. Practical guidelines for 

nutritional management of burn injury and recovery. Burns 

2007;33:14–24. 

47. Answer: D 

The medical resident would like to discuss changing 

R.R. to an immune-enhancing EN formulation with 

omega-3 PUFAs and antioxidants. The correct response to 

this suggestion would highlight that immune-enhancing 

EN formulations shown to be beneficial in a specific 

patient population may not be associated with the same 

improvements in outcomes in other patient populations. 

The correct response is that the suggested change should 

not be made because an immune-enhancing EN formulation 

with omega-3 PUFAs 8.6 g/L and antioxidants is associated 

with increased survival in patients with sepsis and ARDS 

but has not been evaluated in patients with burns (Answer 

D). An immune-enhancing EN formulation with omega-3 

PUFAs 8.6 g/L and antioxidants has not been shown to 

alter oxygenation in patients with burns (Answer B) or 

to increase survival in a nonseptic mixed medical ICU 

population (Answer C). Because an immune-enhancing EN 

formulation has not been evaluated in patients with burns, 

switching to an immune-enhancing product (Answer A) is 

incorrect. 








2007;33:14–24. 

48. Answer: D 

The length of time that RR receives immunonutrition 

should be evidence-based. In one study that evaluated 

immunonutrition in patients with burns and demonstrated 

improved patient survival with enteral glutamine 

supplementation, immunonutrition was continued until 

complete wound healing was achieved (Answer D), making 

Answer D the correct answer. The other durations, until 

extubation (Answer C), 96 hours (Answer B), or 48 hours 

(Answer A), have been used as minimum therapy goals in 

other trials of immune-enhancing nutrients. However, in 

patients with burns, extending the duration of therapy until 

complete would healing occurs is more likely to result in 

additional benefit. 








2007;33:14–24. 

49. Answer: C 

Clinicians should be aware that harm might result from 

the use of immune-enhancing EN formulations in certain 

patient populations. Some evidence indicates that argininecontaining 

immune-enhancing diets may be harmful in 

critically ill patients with severe sepsis. Therefore, the 

62-year-old man with severe sepsis and an APACHE II score 

of 26 (Answer C) may be harmed by an arginine-containing 

immune-enhancing EN formulation, making Answer C the 

best answer. The 32-year-old patient with a urinary tract 

infection after severe trauma (Answer A) is likely to benefit 

from an arginine-containing immune-enhancing diet, as is 

the 59-year-old man with gastrointestinal (GI) cancer after 

colonic resection (Answer B); thus Answer A and Answer 

B are incorrect. The 48-year-old man in the medical ICU 

with an APACHE II score of 12 (Answer D) is less likely 

to benefit from an immune-enhancing diet, but he is not 

in a patient population in which additional harm has been 

suggested. 

1. Bertolini G, Iapichino G, Radrizzani D, Facchini R, Simini 

B, Bruzzone P, et al. Early enteral immunonutrition in 

patients with severe sepsis: results of an interim analysis of 

a randomized multicentre clinical trial. Intensive Care Med 

2003;29:834–40. 

2. Kreymann KG, Berger MM, Deutz NE, Hiesmayr M, Jolliet 

P, Kazandjiev G, et al. ESPEN guidelines on enteral nutrition: 

intensive care. Clin Nutr 2006;25:210–23. 

50. Answer: C 

Glutamine is a major energy source for enterocytes and is 

associated with enhanced luminal barrier function (Answer 

A), but this effect is not a potential advantage of parenteral 

glutamine compared with enteral glutamine because this 

effect should occur regardless of the route of administration, 

so Answer A is incorrect. Arginine, not glutamine, increases 

the production of inducible nitric oxide (NO) (Answer B); 

thus, neither route of glutamine administration would be 

expected to produce this effect, and Answer B is incorrect. 

Increasing the production of heat shock proteins (Answer 

C) is an advantage of parenteral compared with enteral 

glutamine administration because this effect has been 

more strongly associated with parenteral supplementation 

than enteral supplementation, making Answer C correct. 

Glutamine by either route would be expected to increase 

T-helper lymphocytes, rather than decrease them as stated 

in Answer D; thus, Answer D is incorrect. 

1. Tjader I, Berg A, Wernerman J. Exogenous glutamine— 

compensating a shortage? Crit Care Med 2007;35(suppl):S553– 

S556. 



51. Answer: D 

The use of PN is often necessary because of GI 

intolerance or other complications of EN or because of the 

presence of a contraindication to EN. The use of immuneenhancing 

EN is often limited by the ability of the patient to 

tolerate an adequate volume enterally, so feeding intolerance 


46 


(Answer D) occurs more often in patients receiving 

immunonutrition than those receiving PN, making Answer 

D the correct answer. Hyperglycemia (Answer A) and 

hypertriglyceridemia (Answer B) are both more common in 

patients receiving PN than in those receiving any form of 

EN, making Answer A and Answer B incorrect. Because of 

interruptions in the delivery of EN caused by GI intolerance, 

the ability to deliver enough calories to overfeed a patient 

(Answer C) is also more likely in patients fed parenterally 

than enterally, making Answer C incorrect. 

1. Adam S, Batson S. A study of problems associated with the 

delivery of enteral feed in critically ill patients in five ICUs in 

the UK. Intensive Care Med 1997;23:261–6. 

2. Radrizzani D, Bertolini G, Facchini R, Simini B, Bruzzone P, 

Zanforlin G, et al. Early enteral immunonutrition vs. parenteral 

nutrition in critically ill patients without severe sepsis: a 

randomized clinical trial. Intensive Care Med 2006;32:1191–8. 

52. Answer: B 

The EN formulation suggested by the physician contains 

arginine 2 g/L, omega-3 PUFAs 5 g/L, and antioxidants 

but does not supplement nucleotides; therefore, it is not the 

best choice for P.K.’s EN formulation, and Answer A (begin 

the physician’s suggested formula by nasojejunal tube) is 

incorrect. The best option for P.K. is an immune-enhancing 

EN formulation with a higher concentration of arginine and 

nucleotides (Answer B) because this formulation is most 

similar to formulations that have been shown to improve 

outcomes in patients with traumatic injuries; thus Answer B 

is correct. The use of immune-enhancing diets is appropriate 

in trauma patients, and those with severe injuries like P.K. 

(ISS 22) are more likely to benefit; thus, suggesting a 

standard EN formulation (Answer C) for P.K. is not the best 

choice, and Answer C is incorrect. No evidence exists that 

assesses outcomes with the use of immune-enhancing EN 

formulations supplemented only with omega-3 PUFAs and 

antioxidants in trauma patients, so Answer D (suggest an 

immune-enhancing EN formulation with no arginine but 

more omega-3 PUFAs) is also incorrect. 



Nutr 2001;25:S61–S63. 






53. Answer: D 

P.K. is receiving an immune-enhancing EN formulation 

containing arginine 18.7 g/L, nucleotides 1.8 g/L, and 

omega-3 PUFAs 2.6 g/L. Clinically significant GI 

hemorrhage is generally viewed as a complication that can 

compromise GI perfusion, requiring at least temporary 

discontinuation of EN, including immune-enhancing diets. 

Therefore, Answer D (discontinue his immune-enhancing 

formulation) is the correct action and will decrease the 

likelihood of further GI-related complications. There is no 

evidence that indicates P.K.’s outcome will be improved by 

continuing his current immune-enhancing EN formulation 

(Answer C), providing enteral glutamine supplementation 

(Answer B), or switching to a standard EN formulation 

(Answer A); thus Answer A, Answer B, and Answer C are 

incorrect. 



Nutr 2001;25:S61–S63. 

2. ASPEN Board of Directors. Guidelines for the use of parenteral 

and enteral nutrition in adult and pediatric patients. JPEN J 

Parenter Enteral Nutr 2002;26:1SA–138SA. 

54. Answer: A 

Clinical studies of the use of immune-enhancing EN 

formulations containing arginine 12.5 g/L, nucleotides 1.2 

g/L, and omega-3 PUFAs 1.7 g/L in patients after trauma 

show decreased infectious complications (Answer A), 

making Answer A the best response to a physician asking 

for justification of the use of the more expensive immuneenhancing 

EN formulation. There is no evidence, however, 

indicating that this immune-enhancing EN formulation 

results in improved survival (Answer B) or better rates of 

functional recovery (Answer C), making Answer B and 

Answer C incorrect. Immune-enhancing EN formulations 

have not been associated with a decreased incidence of 

hyperglycemia (Answer D) compared with standard EN 

formulations; thus, Answer D is also incorrect. 






2. Jacobs DG, Jacobs DO, Kudsk KA, Moore FA, Oswanski MF, 

Poole GV, et al; EAST Practice Management Guidelines Work 

Group. Practice management guidelines for nutritional support 

of the trauma patient. J Trauma 2004;57:660–78; discussion 

679. 

55. Answer: D 

The use of immune-enhancing diets in surgical patients 

appears to have the greatest impact in preoperative patients 

with preexisting malnutrition. The 58-year-old man with a 

12% weight loss in the past 6 months (Answer D) best meets 

these criteria, making Answer D correct. The 56-year-old 

man with a BMI of 28 kg/m 2 (Answer A) does not appear to 

be malnourished. The 36-year-old woman with a 4% weight 

loss in the past 6 months (Answer B) has lost weight but 

not enough to be considered at risk of malnutrition-related 

adverse outcomes. The 52-year-old woman with a normal 

serum albumin concentration (Answer C) does not have 

evidence of significant malnutrition. Therefore, the patients 

in Answer A, Answer B, and Answer C are less likely to 

benefit from an immune-enhancing diet, and these answers 

are incorrect. 

1. Weimann A, Braga M, Harsanyi L, Laviano A, Ljungqvist O, 

Soeters P, et al. ESPEN guidelines on enteral nutrition: surgery 

including organ transplantation. Clin Nutr 2006;25:224–44. 

2. Gianotti L, Braga M, Nespoli L, Radaelli G, Beneduce A, 

Di Carlo V. A randomized controlled trial of preoperative 

oral supplementation with a specialized diet in patients with 

gastrointestinal cancer. Gastroenterology 2002;122:1763–70. 


56. Answer: B 

The immune-enhancing EN formulation containing 

arginine 12.5 g/L, nucleotides 1.2 g/L, and omega-3 PUFAs 

1.7 g/L (Answer B) is the best choice for preoperative 

nutrition for H.H. because the evidence indicates improved 

outcomes in surgical patients with diets supplemented with 

arginine, omega-3 PUFAs, and nucleotides. The immuneenhancing 

formulation containing just arginine 8 g/L 

(Answer A) does not contain enough arginine and does 

not supplement omega-3 PUFAs or nucleotides; thus, it is 

not the best choice for H.H and Answer A is incorrect. The 

immune-enhancing EN formulation containing omega-3 

PUFAs 8.6 g/L and antioxidants (Answer C) does not 

contain supplemental arginine or nucleotides, making it a 

poor choice; thus Answer C is also incorrect. The immuneenhancing 

EN formulation containing arginine 5.5 g/L and 

omega-3 PUFAs 3.29 g/L (Answer D) contains less arginine 

and does not supplement nucleotides, making it a poor 

choice for H.H; thus Answer D is also incorrect. 








57. Answer: A 

Patients like H.H. undergoing head and neck surgeries 

for cancer, with a low serum albumin concentration, should 

receive preoperative immune-enhancing EN. Clinical 

studies indicate improvement in clinical outcomes when 

immunonutrition therapy is initiated 5 days before surgery 

(Answer A is correct). Neither starting 1 day before surgery 

(Answer B) nor 1 day after surgery (Answer C) is optimal 

based on current guidelines; thus Answer B and Answer 

C are incorrect. Waiting 5 days after surgery to begin an 

immune-enhancing diet (Answer D) would be waiting 

longer than in any of the studies that have demonstrated 

clinical improvement with immunonutrition, and 5 days is 

probably too long to wait to expect the immune-enhancing 

EN formulation to confer any benefit in decreasing 

postoperative complications. Therefore, Answer D is also 

incorrect. 




2. Braga M, Gianotti L, Nespoli L, Radaelli G, Di Carlo V. 

Nutritional approach in malnourished surgical patients: a 

prospective randomized study. Arch Surg 2002;137:174–80. 

58. Answer: C 

When considering the duration of immunonutrition 

therapy in patients like H.H. undergoing GI surgery, both 

the physiologic stress of the procedure and the preoperative 

nutritional state are important considerations. Head 

and neck cancer surgery is considered very stressful, 

and preoperatively H.H. had a mildly decreased serum 

albumin concentration. Evidence suggests that continuing 

his preoperative feeding perioperatively would be best, so 

discontinuing 1 day before surgery (Answer A) is not an 

appropriate intervention and Answe A is incorrect. It is also 


48 

unlikely that the postoperative benefit would be maximized 

if immunonutrition therapy was stopped 1 day after surgery 

(Answer B is incorrect), but there is no evidence addressing 

the effect of continuing immunonutrition therapy for 14 days 

after surgery (Answer D is incorrect). Available evidence 

suggests that immunonutrition should be continued for 5 to 

7 days after surgery (Answer C) to optimize its benefits on 

postoperative complications; thus Answer C is the correct 

answer. 







59. Answer: B 

H.H. and his wife seek more information regarding the 

benefits of using an immune-enhancing EN formulation. 

They should be informed that the primary benefit of 

immunonutrition in patients like H.H. undergoing surgery is 

decreased postoperative infectious complications, including 

postoperative pneumonia and surgical site infections 

(Answer B) and length of hospital stay; thus Answer B is 

correct. There is no evidence that this nutrition intervention 

improves the probability of survival (Answer A) or 

oxygenation parameters allowing more rapid removal from 

mechanical ventilation (Answer C); thus Answer A and 

Answer C are incorrect. Although an immune-enhancing 

diet is used to meet a patient’s caloric needs, its use should 

not be associated with a significantly greater weight gain 

perioperatively (Answer D) than the use of a standard EN 

formulation; thus Answer D is incorrect. 








60. Answer: A 

The mechanism by which arginine is associated with worse 

outcomes in patients with sepsis and refractory hypotension 

is most likely the increase in NO production (Answer A) 

associated with arginine supplementation; thus Answer A is 

the correct answer. Immune-enhancing nutrients improve, 

rather than interfere with, gut barrier function (Answer 

B), are generally associated with decreases rather than 

increases in inflammatory mediator production (Answer 

C), and are not associated with significant decreases in total 

lymphocyte counts (Answer D); thus, Answer B, Answer C, 

and Answer D are incorrect. 



2. Zhou M, Martindale RG. Arginine in the critical care setting. J 

Nutr 2007;137:1687S–1692S. 


Dietary Supplements 

61. Answer: B 

Information regarding the safety and efficacy of dietary 

supplements must be communicated to the consumer by 

pharmacists. Although the Federal Trade Commission 

(FTC) rather than the FDA regulates advertising of dietary 

supplements (Answer A), this fact is not helpful to the 

consumer making decisions regarding whether use of such a 

supplement is safe and efficacious, and Answer A is incorrect. 

Although structure and function claims on the labels of 

dietary supplements must be followed by a disclaimer that 

the claim has not been evaluated by the FDA (Answer C), 

this information mainly addresses efficacy (or lack thereof) 

of dietary supplements rather than safety, and Answer C is 

incorrect. Although it is now mandated that manufacturers 

follow Good Manufacturing Practices (GMPs) as indicated 

in Answer D, these address only whether the product 

ingredients are consistent with the labeling and ensure that 

the product is free of contaminants; GMPs do not address 

the efficacy of dietary supplements, making Answer D 

incorrect. Informing the consumer that dietary supplements 

are regulated more like foods than conventional drugs and 

that they do not require premarketing approval by the FDA 

(Answer B) should alert them that safety and efficacy could 

both be issues with use of the product, making Answer B 

correct. 

1. Dietary Supplement Current Good Manufacturing Practices 

(CGMPs) and Interim Final Rule (IFR) Facts. U.S. Food and 

Drug Administration Center for Food Safety and Applied 

Nutrition. June 22, 2007. Available at www.cfsan.fda.gov/~dms/ 

dscgmps6.html. Accessed April 10, 2009. 

2. Overview of Dietary Supplements. U.S. Food and Drug 

Administration Center for Food Safety and Applied Nutrition. 

January 3, 2001. Available at www.cfsan.fda.gov/~dms/dsoview.html#regulate. 

Accessed April 10, 2009. 

62. Answer: A 

The Dietary Supplement Health and Education Act 

(DSHEA) of 1994 defined dietary supplements to include 

vitamins, minerals, herbs or other botanicals, amino acids, 

and other dietary substances that supplement the diet by 

increasing total dietary intake. In this case, the patient’s 

supplements all fall into one of these categories (folic acid 

and ascorbic acid [vitamin C] are vitamins, glucosamine 

falls under “other dietary substances,” and ginkgo and green 

tea extracts are herbs), making Answer A correct. Answer B 

does not include green tea and therefore implies that green 

tea extract is not regulated by DSHEA, something that would 

be correct if the patient were consuming commercially 

available green tea rather than the extract; thus, Answer B is 

incorrect. Answer C does not include glucosamine, implying 

that it is not regulated by DSHEA; this is incorrect, and 

Answer C is not the best answer. Even though glucosamine 

is not derived from an herbal source, it is a natural product 

that falls in the “other dietary substances” category. Folic 

acid in dosages greater than 0.8 mg/day was regulated as 

a prescription drug before DSHEA. However, since 1994, 

folic acid dosages greater than 0.8 mg/day are considered 

dietary supplements and may be sold without a prescription. 

Therefore, Answer D, which indicates that folic acid 1 mg is 

not regulated by the DSHEA, is incorrect. 

1. Overview of dietary supplements. U.S. Food and Drug 




2. FDA/CDER Drug Info. Personal communication. May 9, 2008. 

Mailed to/from: DRUGINFO@fda.hhs.gov. Accessed October 

31, 2008. 

63. Answer: C 

Ephedra was finally removed from the market as a 

weight loss drug by the FDA because it was shown to 

cause a significant risk of injury (Answer C); thus, Answer 

C is correct. Although the FTC can levy fines for false 

advertising, it cannot require that a product be removed from 

the market (Answer A); thus Answer A is incorrect. Under 

DSHEA, dietary supplements do not have to be shown to 

be effective either before or after marketing, thus Answer 

B (the FDA removed ephedra from the market because of 

ineffectiveness) is incorrect. Ephedra can no longer be sold 

as a dietary supplement in the United States; thus Answer D 

(ephedra may still be sold as a dietary supplement but not as 

a nonprescription drug) is incorrect. 





2. Federal Trade Commission. Dietary claims: an advertising 

guide for industry. Available at www.ftc.gov/bcp/conline/pubs/ 

buspubs/dietsupp.shtm. Accessed April 10, 2009. 

64. Answer: D 

The GMPs apply to both domestic and foreign 

manufactured dietary supplements. These long-awaited rules 

help ensure the identity, purity, strength, and composition of 

dietary supplements and thus will help prevent adulterated 

products from reaching the market, making Answer D 

correct. Although the GMPs should help promote the safety 

of these products, the rules do not require safety testing in 

animals or humans (Answer A is incorrect). Similarly, the 

GMPs do not address efficacy, so Answer B is incorrect. 

No tariffs are levied on foreign products related to the GMP 

(Answer C is incorrect); however, implementation of these 

new rules will be costly, especially for small companies, and 

this may drive up prices of some supplements. 

1. U.S. Food and Drug Administration. Dietary supplement 

current good manufacturing practices (CGMPs) and interim 

final rule (IFR) facts (fact sheet). June 22, 2007. Available at 

www.cfsan.fda.gov/~dms/dscgmps6.html. Accessed April 10, 

2009. 

2. Current good manufacturing practice in manufacturing, 

packaging, labeling, or holding operations for dietary 

supplements, final rule (21 CFR part 111). Federal Register. 

June 25, 2007;72:34751. Available at www.cfsan.fda.gov/~lrd/ 

fr07625a.html. Accessed April 10, 2009. 

65. Answer: B 

J.H., a 35-year-old obese woman with mild osteoarthritis, 

would like advice on using green tea for weight loss. 

Some clinical studies of green tea have demonstrated 

benefit in promoting weight loss and weight maintenance, 

whereas others have not. Because of the benign nature of 

the therapy, especially in patients without hypertension 


or cardiovascular disease, drinking green tea or taking a 

reliable, standardized green tea extract may be worth a try. 

Therefore, Answer B (taking an extract may be worth a try) 

is correct. Answer A (risks of adverse events with green tea 

outweigh the benefits) is incorrect because it indicates there 

are substantial adverse events with this approach, which is 

not the case. It appears that both the catechin and caffeine 

components of green tea may be important for any weight 

loss or maintenance benefit. Green tea generally contains an 

amount of caffeine considered sufficient for the beneficial 

effect on weight, making Answer C (she will need to both 

drink green tea and take an extract) incorrect. Although 

patients with hypertension or cardiovascular disease may be 

at increased risk of adverse events with green tea because 

of its sympathetic activity, there is no reason to believe that 

green tea extract would exacerbate osteoarthritis, making 

Answer D incorrect. 

1. Westerterp-Plantenga MS, Lejeune MP, Kovacs EM. Body 

weight loss and weight maintenance in relation to habitual 

caffeine intake and green tea supplementation. Obes Res 

2005;17:1195–204. 

2. Diepvens K, Westerterp KR, Westerterp-Plantenga MS. 

Obesity and thermogenesis related to the consumption of 

caffeine, ephedrine, capsaicin, and green tea. Am J Physiol 

Regul Integr Comp Physiol 2007;292:R77–85. 

3. Seeram NP, Henning SM, Niu Y, Lee R, Scheuller HS, Heber D. 

Catechin and caffeine content of green tea dietary supplements 

and correlation with antioxidant capacity. J Agric Food Chem 

2006;54:1599–603. 

66. Answer: D 

According to DSHEA, a dietary supplement 

manufacturer may make a structure or function claim on 

the label as long as “This statement has not been evaluated 

by the FDA. This product is not intended to diagnose, treat, 

cure, or prevent any disease” also appears on the label. The 

claim that cranberry helps promote urinary tract health is 

clearly a function claim and is thus allowed as long as the 

disclaimer is present (Answer D is correct). Sometimes the 

distinction between structure or function claims and disease 

prevention or treatment claims is very difficult to determine. 

However, in this case, the claim would not be construed as 

a disease prevention claim (e.g., “helps prevent urinary tract 

infections”); therefore, Answer A (prevents bacteria from 

invading and proliferating in the urinary tract) is incorrect. 

If a claim is deemed to be a disease prevention or treatment 

claim, the product would be considered a drug and thus 

misbranded as a dietary supplement. Again, because this 

is a function claim, the cranberry would not in this case 

be considered a drug, making Answer B (decreases the 

duration of urinary tract infections) incorrect. According 

to the FDA, such a claim can only be made for drugs, not 

dietary supplements. Structure or function claims can be 

made based on a single ingredient within a multi-ingredient 

product; therefore, Answer C (decreases the severity of 

urinary tract infection symptoms) is incorrect. This claim 

can be made if the product contains only cranberry or other 

substances promoting urinary health; if it contains other 

ingredients, it would be considered misbranded. 





2. U.S. Food and Drug Administration. Structure/function 

claims. Available at www.cfsan.fda.gov/~dms/labstruc.html. 


67. Answer: C 

U.W., a 45-year-old woman who takes Saint John’s 

wort for depression, has been admitted to the hospital for 

complications related to her diabetes. In its Statement on 

the Use of Dietary Supplements, the American Society 

of Health-System Pharmacists (ASHP) discourages selfadministration 

of the patient’s own supply of dietary 

supplements during hospitalization because of lack of 

information regarding safety and efficacy, as well as 

inadequate standards for product quality. Therefore, Answer 

A (she may be allowed to self-administer her own supply if 

ordered by her physician) and Answer B (she may be allowed 

to self-administer her own supply after the pharmacist has 

verified the identity and checked for drug interactions), 

both of which concern self-administration of the patient’s 

own supply of drug, are not consistent with the ASHP 

recommendations and are incorrect. It is recommended that 

hospitals have a general policy in place regarding inpatient 

use of dietary supplements, but Answer D is not the best 

response because Saint John’s wort is not actually on the 

formulary but rather must be obtained for use in this patient. 

Answer C best follows recommendations; the pharmacy 

could supply the dietary supplement if Saint John’s wort 

is on the formulary, the physician specifically prescribes 

it, and the pharmacist checks the patient profile for drug 

interactions; thus Answer C is correct. 

1. American Society of Health-System Pharmacists Council on 

Professional Affairs. ASHP statement on the use of dietary 

supplements. Am J Health Syst Pharm 2004;61:1707–11. 

2. Bizzie KL, Witmer DR, Pinto B, Bush C, Clark J, Deffenbaugh 

J Jr. National survey of dietary supplement policies in acute 

care facilities. Am J Health Syst Pharm 2006;63:65–70. 

3. Cohen MH, Hrbek A, Davis RB, Schachter SC, Kemper KJ, 

Boyer EW, et al. Emerging credentialing practices, malpractice 

liability policies, and guidelines governing complementary 

and alternative medical practices and dietary supplement 

recommendations: a descriptive study of 19 integrative 

health care centers in the United States. Arch Intern Med 

2005;165:289–95. 

68. Answer: B 

The question relates to the design of a demographic 

survey of dietary supplement use and what aspects of the 

design could lead to overstating the prevalence of use. 

Recent surveys of the use of dietary supplements in the 

United States have reported a broad array of percentages of 

the population using these supplements, largely because of 

the population studied, the definition of dietary supplement, 

and the definition of recent use. Dietary supplements are 

used more commonly among women than men. Older 

people use them more commonly than younger people, 

making Answer C (excluding people older than 65 from the 

survey) incorrect. Answer D (oversampling of minorities 

with lower socioeconomic status) is also incorrect because 

dietary supplement use in the United States is more common 

in those of higher socioeconomic status and education 


50 


level. Exclusion of conventional vitamins and minerals 

from the definition of dietary supplements (Answer A) 

would make supplement use appear to be less common 

than more common, making Answer A incorrect. Because 

more people will have used dietary supplements within the 

past month than within the past week, querying about use 

of supplements within the past month rather than the past 

week (Answer B) would appear to make supplement use 

more common; therefore, Answer B is correct. 

1. Kelly JP, Kaufman DW, Kelley K, Rosenberg L, Anderson TE, 

Mitchell AA. Recent trends in use of herbal and other natural 

products. Arch Intern Med 2005;165:281–6. 

2. Kennedy J. Herb and supplement use in the U.S. adult 

population. Clin Ther 2005;27:1847–58. 

69. Answer: A 

D.L. has heard that black cohosh may alleviate some of 

her menopause-related symptoms but is concerned about 

the risk of developing breast cancer. Although the evidence 

demonstrating efficacy of black cohosh in relieving vasomotor 

symptoms associated with menopause is inconsistent, it 

appears to be safe and may be of benefit for some women 

experiencing mild symptoms. The dosages most commonly 

used in clinical trials were black cohosh extract standardized 

to the 1-mg equivalent of 27-deoxyacetein twice daily 

(Remifemin 20–40 mg or equivalent product twice daily). 

Most studies were of short duration, typically lasting a 

maximum of 6 months. Based on this evidence, Answer A 

(a cautious trial using 20–40 mg of Remifemin or equivalent 

twice daily for up to 6 months is unlikely to do harm) is 

the best response and the correct answer. A few cases have 

been published reporting hepatotoxicity associated with the 

consumption of black cohosh; however, more than 2000 

subjects have been enrolled in clinical trials with black 

cohosh extract, and no reports of hepatotoxicity have been 

published. In addition, there is currently no known plausible 

biologic mechanism for hepatotoxic activity of black 

cohosh. The recommendation of the National Center for 

Complementary and Alternative Medicine and the National 

Institutes of Health Office of Dietary Supplements is on the 

side of caution, recommending monitoring liver function in 

patients consuming black cohosh. Based on this information, 

Answer B (the risk of hepatotoxicity with black cohosh is 

well established and its use should be avoided) is incorrect. 

Current evidence does not support the mechanistic view of 

black cohosh possessing estrogenic effects. Instead, research 

suggests that black cohosh inhibits binding of serotonin 

5-hydroxytryptamine- 1A 

and 5-hydroxytryptamine 7 

, both 

of which are associated with the hypothalamus. Current 

information is inconclusive regarding black cohosh and the 

risk of breast cancer. It appears to be safe in women with no 

increased risk of breast cancer; however, current evidence is 

insufficient to recommend its use in women with increased 

risk. Therefore, Answer C (recent trials have demonstrated 

an estrogenic effect of black cohosh on breast tissue) is 

incorrect. Insufficient evidence exists to support an effect of 

black cohosh on cardiovascular health; therefore, Answer D 

(black cohosh can be recommended for primary prevention 

of cardiovascular disease) is also incorrect. 

1. National Center for Complementary and Alternative Medicine, 

National Institutes of Health Office of Dietary Supplements. 

Workshop on the safety of black cohosh in clinical studies. 

National Institutes of Health, Bethesda, MD. November 

11, 2004. Available at nccam.nih.gov/news/pastmeetings/ 

blackcohosh_mtngsumm.htm. Accessed October 31, 2008. 

2. Huntley A, Ernst E. A systematic review of the safety of black 

cohosh. Menopause 2003;10:58–64. 

3. Osmers R, Friede M, Liske E, Schnitker J, Freudenstein 

J, Henneicke-von Zepelin HH. Efficacy and safety of 

isopropanolic black cohosh extract for climacteric symptoms. 

Obstet Gynecol 2005;105:1074–83. 

70. Answer: A 

D.L. decides to try black cohosh. She wants your 

recommendation for the most efficacious product. 

Remifemin black cohosh extract is the most widely studied 

product showing possible efficacy among products available 

in the United States (Answer A); therefore, Answer A is 

correct. Answer C (studies reporting efficacy and safety of 

Remifemin black cohosh extract support use of the extract 

for periods extending up to 1 year) is incorrect because most 

studies have only lasted 6 months or less. The manufacturer 

of Remifemin has switched between isopropanolic and 

ethanolic preparations and between fluid extracts and dried 

fluid extracts, and the package labeling has changed at least 

twice. These changes make it difficult to compare the results 

of the various trials using Remifemin; therefore, Answer B 

(Remifemin black cohosh extracts used in clinical studies 

has been consistently manufactured) is incorrect. No 

black cohosh product has been consistently demonstrated 

to increase bone density; therefore, Answer D (because 

Remifemin has been demonstrated to increase bone density, 

it should be the black cohosh product of choice) is incorrect. 

1. Newton KM, Reed SD, LaCroix AZ, Grothaus LC, Ehrlich K, 

Guiltinan J. Treatment of vasomotor symptoms of menopause 

with black cohosh, multibotanicals, soy, hormone therapy, or 

placebo: a randomized trial. Ann Intern Med 2006;145:869–79. 

2. Jellin JM, Gregory PJ, Batz F, eds. Pharmacist’s Letter/ 

Prescriber’s Letter Natural Medicines Comprehensive 

Database, 9th ed. Stockton, CA: Therapeutic Research Faculty, 

2007. 

3. DerMarderrosian A, ed. The Review of Natural Products. St. 

Louis, MO: Elsevier Inc., 2005. 

71. Answer: C 

L.B., a 62-year-old man with hypertension, hyperlipidemia, 

and coronary artery disease, wants to take ginkgo to prevent 

Alzheimer’s disease. Although some studies have shown 

ginkgo extract to be efficacious in slowing progression and 

ameliorating symptoms of Alzheimer’s dementia, the overall 

combined evidence of benefit in patients with cognitive 

impairment or dementia fails to demonstrate consistent 

efficacy for these disorders. Therefore, Answer B (ginkgo 

extract appears to be efficacious, but adverse effects and 

drug interactions preclude its use) and Answer D (terpene 

ginkgolide B is a potent inducer of cytochrome [CYP] P450 

3A4 and has the potential to interact with drugs metabolized 

by this isozyme) are both incorrect. Ginkgo is relatively 

safe, and adverse effects are usually mild. Ginkgolide B 

is a potent inhibitor of platelet-activating factor, and there 

is an increased risk of bleeding if the extract is taken 

concomitantly with antiplatelet agents, such as aspirin. 

Therefore, Answer C (ginkgo is generally well tolerated, but 


there is insufficient evidence to support efficacy and drug 

interactions are a concern for L.B.) is the correct response, 

and Answer A (ginkgo is free of drug interactions with 

L.B.’s drugs) is incorrect. 

1. Carlson JJ, Farquhar JW, DiNucci E, Ausserer L, Zehnder 

J, Miller M, et al. Safety and efficacy of a Ginkgo biloba– 

containing dietary supplement on cognitive function, quality 

of life, and platelet function in healthy, cognitively intact older 

adults. J Am Diet Assoc 2007;107:422–32. 

2. Schneider LS, DeKosky ST, Farlow MR, Tariot PN, Hoerr R, 

Kieser M. A randomized, double-blind, placebo-controlled 

trial of two doses of Ginkgo biloba extract in dementia of the 

Alzheimer’s type. Curr Alzheimer Res 2005;2:541–51. 

72. Answer: C 

Most published studies examining the effects of ginkgo in 

tinnitus lack sufficient methodology to interpret their results 

accurately and there is insufficient evidence that ginkgo is 

effective for tinnitus. Therefore, Answer A (several strong 

studies indicate effectiveness, but adverse effects preclude 

it use) and Answer D (it is well tolerated, and evidence 

suggests it is effective) are both incorrect. Although the first 

half of Answer B pertaining to efficacy is correct, ginkgo is 

generally well tolerated; therefore, Answer B (evidence fails 

to support efficacy, and adverse effects preclude its use) is 

incorrect. By the time a patient presents with distressing 

tinnitus, there is a significant psychological component 

present as well, which creates a strong placebo effect. This 

placebo effect makes it difficult to interpret results from 

clinical trials; therefore, Answer C (because of the strong 

placebo effect noted in tinnitus management, trials using 

ginkgo for tinnitus are difficult to interpret) is correct. 

1. DerMarderrosian A, ed. The Review of Natural Products. St. 

Louis, MO: Elsevier Inc., 2007. 

2. Hilton M, Stuart E. Ginkgo biloba for tinnitus. Cochrane 

Database Syst Rev 2004;2:CD003852. 

73. Answer: A 

B.L. is a 66-year-old moderately obese woman with 

chronic, bilateral knee pain caused by moderately severe 

osteoarthritis. She takes acetaminophen for the pain but 

is interested in learning more about glucosamine. The 

overall response rate in the Glucosamine/chondroitin 

Arthritis Intervention Trial (GAIT) in participants receiving 

glucosamine, chondroitin, and the combined treatment 

was similar to that achieved with placebo. However, in a 

subgroup analysis of patients with moderate to severe pain 

at baseline, a significantly higher response rate was reported 

with combined therapy than with placebo. Based on this 

information, Answer A (patients with moderate to severe 

knee pain are more likely to benefit from glucosamine 

combined with chondroitin than patients with milder pain) 

is correct. The GAIT study used glucosamine hydrochloride 

and chondroitin sulfate, and the study was conducted under 

an Investigational New Drug Application filed with the FDA; 

therefore, the products used in this study were subject to more 

stringent regulations compared with other over-the-counter 

products. The Glucosamine Unum In Die Efficacy (GUIDE) 

trial used a prescription glucosamine sulfate product 

manufactured by the European pharmaceutical company, 

Rottapharm, and this product is not currently available in 

the United States. Because of a lack of standardization of 


52 

glucosamine products in the United States, together with 

highly variable amounts of glucosamine contained in these 

products, extrapolation of the results from either GAIT or 

GUIDE cannot be recommended. Therefore, Answer B 

(products used in GAIT and GUIDE are similar to those 

available in the United States) is incorrect. The Western 

Ontario and McMaster University (WOMAC) and Lequesne 

indices were used to measure the primary outcomes in this 

study. The importance of addressing the implications of 

using differing measures of primary outcomes in clinical 

trials when evaluating response rates is understood. The 

WOMAC index appears to be more sensitive than the 

Lequesne index. Therefore, Answer C (they demonstrate 

comparable validity, reliability, and responsiveness to 

glucosamine) is incorrect. Although most of the published 

trials examining the use of glucosamine in patients with 

osteoarthritis indicate it is generally well tolerated with a 

safety profile significantly superior to nonsteroidal antiinflammatory 

drugs (NSAIDs), most of these trials have 

been short, lasting 6 months or less. Long-term safety 

information beyond 6 months cannot be ascertained at this 

time, making Answer D (the long-term safety profile is 

superior to NSAIDs) incorrect. 

1. Gentell-Bonnassies S, Le Claire P, Mezieres M, Ayral X, 

Dougados M. Comparison of the responsiveness of symptomatic 

outcome measures in knee osteoarthritis. Arthritis Care Res 

2000;13:280–5. 

2. Clegg DO, Reda DJ, Harris CL, Klein MA, O’Dell JR, Hooper 

MM, et al. Glucosamine, chondroitin sulfate, and the two in 

combination for painful knee osteoarthritis. N Engl J Med 

2006;354:795–808. 

3. Herrero-Beaumont G, Ivorra JA, Del Carmen Trabado M, 

Blanco FJ, Benito P, Martin-Mola E, et al. Glucosamine sulfate 

in the treatment of knee osteoarthritis symptoms: a randomized, 

double-blind, placebo-controlled study using acetaminophen 

as a side comparator. Arthritis Rheum 2007;56:555–67. 

74. Answer: B 

The Glucosamine/chondroitin Arthritis Intervention 

Trial used a robust study design (a randomized, doubleblind, 

placebo- and celecoxib-controlled multicenter 

design); however, the study design cannot correct for a 

higher-than-expected placebo response and lower-thanexpected 

celecoxib response. In addition, inclusion of 

patients with mild symptoms may have resulted in less 

sensitivity to the outcome measures. Therefore, Answer 

A (they are of minimal concern in this trial because of 

the robustness of the study design) is incorrect. The high 

placebo response rate, together with the lower-than-expected 

celecoxib response rate, may limit the ability to detect true 

treatment benefits, thus increasing the risk of mistakenly 

failing to reject the null hypothesis when the alternative 

hypothesis is true (a type II error); therefore, Answer B 

(may mask true response rates to glucosamine, increasing 

the risk of a type II error) is correct. Type I errors (Answer 

C) occur when a true null hypothesis is rejected; therefore, 

Answer C is incorrect. Although the authors did perform 

a power analysis, readers should realize that statistical 

power depends on the statistically significant criterion (a 

= 0.017 for comparisons of glucosamine, chondroitin, and 

combined-treatment group with placebo, with an overall a 

= 0.05), the effect size, and the sensitivity of the data. The 


claimed effect size in GAIT was an absolute increase of 

15% in the response rate compared with placebo, assuming 

a 35% response rate in the placebo group. The much larger 

placebo response reported in GAIT would make it more 

difficult to detect the effect size. Therefore, Answer D (there 

is minimal concern in this trial because of the successful 

use of a power analysis) is incorrect. 

1. Towheed TE, Maxwell L, Anastassiades TP, Shea B, Houpt 

J. Robinson V, et al. Glucosamine therapy for treating 

osteoarthritis. Cochrane Database Syst Rev 2005;2:CD002946. 

2. Guller U, DeLong E. Interpreting statistics in medical literature: 

a vade mecum for surgeons. J Am Coll Surg 2004;198:441–58. 

75. Answer: C 

T.G. is a 49-year-old man with hypercholesterolemia 

being treated with atorvastatin. He is interested in obtaining 

information regarding the use of policosanol. Although early 

studies of Cuban sugar cane policosanol showed promising 

results in lipid-lowering effects, recent studies have not 

substantiated these results. In a double-blind, placebocontrolled 

trial, adding policosanol to atorvastatin (Answer 

A) showed no better lipid-lowering effect than atorvastatin 

alone. Other recent studies of policosanol have demonstrated 

that results with its use are no better than placebo in reducing 

low-density lipoprotein cholesterol (LDL-C). Therefore, 

Answer B (replacement of atorvastatin with policosanol 

would result in similar lowering of LDL-C) is incorrect. 

The advice that policosanol should not be expected to lower 

LDL-C is based on its lack of efficacy (Answer C), making 

Answer C the correct response. Policosanol is relatively 

free of adverse events such as elevated liver function 

tests or elevated creatine phosphokinase, making Answer 

D (it has the potential to elevate creatine phosphokinase 

concentrations) incorrect. 

1. Cubeddu LX, Cubeddu RJ, Heimowitz T, Restrepo B, 

Lamas GA, Weinberg GB. Comparative lipid-lowering 

effects of policosanol and atorvastatin: a randomized, 

parallel, double-blind, placebo-controlled trial. Am Heart J 

2006;152:982.e1–5. 

2. Berthold HK, Unverdorben S, Degenhardt R, Bulitta 

M, Gouni-Berhold I. Effect of policosanol on lipid values 

among patients with hypercholesterolemia or combined 

hyperlipidemia: a randomized controlled trial. JAMA 

2006;295:2262–9. 

76. Answer: D 

C.D. is a 32-year-old moderately obese woman who is 

seeking advice on the use of Saint John’s wort for postpartum 

depression. Although recent literature does not indicate 

a significant interaction between hypericum and oral 

contraceptives, the potential for such an interaction cannot 

be excluded; therefore, Answer A (current evidence fails 

to substantiate significant drug interactions between Saint 

John’s wort and oral contraceptives) is incorrect. Lovastatin 

undergoes similar metabolism compared with simvastatin, 

with CYP P450 3A4 playing a major part in its metabolism, 

as well as being a potential substrate for P-glycoprotein. 

Therefore, a significant interaction with hypericum is likely, 

which may result in significantly reduced bioavailability of 

lovastatin. Therefore, Answer B (significant interactions 

with Saint John’s wort and lovastatin are unlikely) is 

incorrect. Because C.D. is described to be suffering from 

major depression (i.e., postpartum depression), Answer C 

(recent evidence suggests benefit of hypericum extracts in 

patients with mild to moderate depression and is therefore a 

viable option for C.D.) is incorrect. Although older studies 

have suggested a benefit of hypericum compared with 

placebo for the treatment of major depression, more recent, 

methodologically robust studies fail to support these results. 

Although the consensus continues to indicate its efficacy in 

the treatment of symptoms associated with mild to moderate 

depression, more studies are needed to further ascertain 

its role in the treatment of major depression. Therefore, 

Answer D (recent data suggest Saint John’s wort is no 

more efficacious than placebo for the treatment of major 

depression such as C.D. is experiencing) is correct because 

C.D. appears to meet criteria for major depression. 

1. Madabushi R, Frank B, Drewelow B, Derendorf H, Butterweck 

V. Hyperforin in St. John’s wort drug interactions. Eur J Clin 

Pharmacol 2006;62:225–33. 

2. Whitten DL, Myers P, Hawrelak A, Wolhmuth H. The effect 

of St. John’s wort extracts on CYP3A: a systematic review of 

prospective clinical trials. Br J Clin Pharmacol 2006;62:512– 

26. 

3. Hypericum Depression Trial Study Group. Effect of Hypericum 

perforatum (St. John’s wort) in major depressive disorder: a 

randomized controlled trial. JAMA 2002;287:1807–14. 

4. Fava M, Alpert J, Nierenberg AA, Mischoulon D, Otto MW, 

Zajecka J, et al. A double-blind, randomized trial of St. John’s 

wort, fluoxetine, and placebo in major depressive disorder. J 

Clin Psychopharmacol 2005;25:441–7. 

77. Answer: D 

Equol is an isoflavone formed by bacterial intestinal 

metabolism of the soy isoflavone daidzein. Equol has 

greater affinity for the estrogen receptor than daidzein, and 

activity at the estrogen receptor is believed to be important 

for the activity of soy in cardioprevention and for relief of 

menopausal symptoms. Only about one-third of non-Asian 

people can form equol from daidzein, so it is plausible 

that these populations may derive less benefit from soy 

isoflavones compared with Asian populations in which a 

higher percentage of the constituency are equol formers. 

Thus, Answer A (most Americans are equol formers) is 

incorrect. Although soy food supplementation has resulted 

in blood pressure lowering in hypertensive patients in some 

studies, this result has not been consistent across studies. 

Thus Answer B (blood pressure reduction is expected with 

soy isoflavones) is incorrect. The lipid-lowering effects of 

soy have been found to be more modest in recent studies 

compared with older studies. These recent effects of a 3% 

to 5% reduction in LDL-C are lower than those typically 

seen with statin agents, making Answer C (the effects are 

similar) an incorrect answer. The most compelling reason 

for incorporating more soy into the animal protein–rich 

American diet is that this will tend to decrease dietary 

saturated fat and cholesterol (Answer D); thus Answer D is 

the correct answer. 

1. Reynolds K, Chin A, Lees KA, Nguyen A, Bujnowski D, He J. 

A meta-analysis of the effect of soy protein supplementation on 

serum lipids. Am J Cardiol 2006;98:633–40. 

2. Nettleton JA, Greany KA, Thomas W, Wangen KE, Adlercreutz 

H, Kurzer MS. The effect of soy consumption on the urinary 


2:16-hydroxyestrone ratio in postmenopausal women depends 

on equol production status but is not influenced by probiotic 

consumption. J Nutr 2005;135:603–8. 

78. Answer: C 

A patient who has been taking green tea extract for weight 

loss is complaining that the product is not working for her. 

The weight loss effects of green tea and green tea extract 

are believed to be related to their caffeine and catechin 

content. Therefore, Answer A (the product contains too 

much catechin relative to the caffeine content) is incorrect. 

Guarana or mate could be found in combination with green 

tea extract in some weight loss products. Although these 

combinations might be expected to increase the adverse 

effect potential of the product, natural sources of caffeine, 

guarana, and mate would be expected to potentiate the 

effects of green tea extract on weight loss rather counteract 

them (Answer B); thus Answer B is incorrect. Habitually 

high consumption of caffeine can accentuate weight loss 

during green tea therapy, whereas habitually high caffeine 

consumption is a risk factor for weight regain after weight 

loss. Thus, Answer C (habitually low caffeine consumption 

may attenuate the effect of the green tea extract) is correct. 

The antiangiogenic effect of green tea extracts may attenuate 

the growth of new adipose tissue (Answer D); however, this 

effect would not explain why the patient is not losing weight 

while taking the extract, making Answer D incorrect. 

1. Cooper R, Morre J, Morre DM. Medicinal benefits of green 

tea. Part I. Review of noncancer health benefits. J Altern Comp 

Med 2005:11:521–8. 

2. Westerterp-Plantenga MS, Lejeune MP, Kovacs EM. Body 

weight loss and weight maintenance in relation to habitual 

caffeine intake and green tea supplementation. Obes Res 

2005;13:1195–204. 

79. Answer: A 

T.K. is a 52-year-old, overweight, postmenopausal 

woman seeking advice regarding incorporating more soy 

into her diet. In T.K., who consumes a high animal protein/ 

high-fat diet, the incorporation of several servings of soyderived 

foods daily (taken in place of animal-derived foods) 

likely would result in a diet more in line with the saturated fat 

and cholesterol content suggested in the Dietary Guidelines 

for Americans. Such a diet could thus help reduce her 

LDL-C. Although not all studies of soy show benefit in 

LDL-C lowering or alleviation of vasomotor symptoms 

of menopause, some studies do show benefit. Therefore, 

Answer A (incorporating several servings of soy per day 

could modestly help her vasomotor symptoms and lower 

LDL-C) is the correct answer. Answer B (consumption 

of three to five servings of soy-derived foods per week) 

would not supply the 30 g of soy protein per day necessary 

to contribute to enough weight loss to improve the blood 

lipid profile or alleviate vasomotor symptoms. Therefore, 

Answer B is incorrect. Answer C, which states erroneously 

that several servings per day are unlikely to result in any 

health benefit but may increase her risk of endometrial 

cancer, is incorrect. Answer D (risks of several servings per 

week include a greater chance of developing endometrial 

hyperplasia or breast cancer and would outweigh any benefit) 

postulates a connection between a modest consumption of 

soy and detrimental effects on endometrial and breast tissue 

that is highly unlikely; therefore, Answer D is incorrect. 

1. Lethaby AE, Brown J, Marjoribanks J, Kronenberg F, 

Roberts H, Eden J. Phytoestrogens for vasomotor menopausal 

symptoms. Cochrane Database of Systematic Reviews 

2007;4:CD001395. 

2. St-Onge MP, Claps N, Wolper C, Heymsfield SB. 

Supplementation with soy-protein–rich foods does not enhance 

weight loss. J Am Diet Assoc 2007;107:500–5. 

3. Reynolds K, Chin A, Lees KA, Nguyen A, Bujnowski D, He J. 

A meta-analysis of the effect of soy protein supplementation on 

serum lipids. Am J Cardiol 2006;98:633–40. 

4. Taku K, Umegaki K, Sato Y, Taki Y, Endoh K, Watanabe S. 

Soy isoflavones lower serum total and LDL cholesterol in 

humans: a meta-analysis of 11 randomized controlled trials. 

Am J Clin Nutr 2007;85:1148–56. 

80. Answer: C 

A meta-analysis included five studies that evaluated the 

effect of soy isoflavone on LDL-C concentrations. Data 

from the studies are summarized in the following table: 

LDL-C 

Concentrations 

(mmol/L) with High 

Isoflavone Intake 

LDL-C 

Concentrations 

(mmol/L) with Low 

Isoflavone Intake 

Weighted Mean 

Difference 

(95% confidence 

interval) 

3.83 3.85 −0.02 (−0.32, 0.28) 

3.83 3.80 0.03 (−0.29, 0.35) 

2.14 2.31 −0.17 (−0.31, −0.03) 

2.86 2.87 −0.01 (−0.29, 0.27) 

3.01 3.22 −0.21 (−0.35, −0.07) 

Total 

−0.14 (−0.23, −0.06) 

With these types of data, a 95% confidence interval that 

crosses on both sides of 0 means that there is no statistical 

difference between treatment groups. Because the 

aggregated weighted mean difference for all of the studies 

in this meta-analysis was –0.23 to –0.06, it did not cross 0, 

indicating a benefit for one of the therapies over the other. 

Thus, Answer D (has no statistically significant effect on 

LDL-C) is incorrect. Answer A (raises the effect of soy 

isoflavone intake on LDL-C in a statistically significant 

fashion) is incorrect. Results from four of the five studies 

showed lower LDL-C concentrations with high isoflavone 

intake compared with low isoflavone intake; therefore, the 

aggregated value represents a benefit for high isoflavone 

intake (Answer C, lowers LDL-C in a statistically significant 

fashion) rather than a detrimental effect (Answer B, raises 

LDL-C in a non-statistically significant fashion), making 

Answer C correct and Answer B incorrect. 

1. Zhuo XG, Melby MK, Watanabe S. Soy isoflavone intake 

lowers serum LDL cholesterol: a meta-analysis of 8 randomized 

controlled trials in humans. J Nutr 2004;134:2395–400. 

2. Guller U, DeLong E. Interpreting statistics in medical literature: 

a vade mecum for surgeons. J Am Coll Surg 2003;198:441–58. 


54

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