Efectividad y seguridad de las emulsiones de pescado en la colestasis asociada a nutrición parenteral en neonatos

El daño hepático asociado a Nutrición Parenteral es una complicación letal en pacientes con nutrición parenteral prolongada. Su etiología no es clara aún, y se cree que las emulsiones lipídicas tradicionales con en base aceite de soya pueden contribuir a su génesis. Recientemente la modificación del contenido de ácidos grasos de las emulsiones lipídicas tradicionalmente de ácidos grasos omega-6 a ricas en omega-3 se postula como terapia prometedora en niños con PNALD. Se realizó una búsqueda sistemática de la literatura en Cochrane y Pubmed, se seleccionaron ensayos clínicos controlados y estudios de cohorte prospectiva. Se utilizó le metodología SIGN para la calificación de los estudios y evaluación del grado de recomendación basada en la evidencia. El meta-análisis que se llevó a cabo incluyó dos artículos de cohorte prospectiva del grupo de Boston para la variable principal de desenlace considerada: tiempo de reverso de la colestasis. Los pacientes que recibieron emulsiones de lípidos de pescado experimentaron regresión de la colestasis significativamente más rápido que los que recibieron emulsiones de soya (HR=10.3, IC 95%:3.7,29,0, efectos fijos), menor mortalidad y menor necesidad de trasplante hepático. Su utilización no se asocia con deficiencia de ácidos grasos, hipertrigliceridemia, coagulopatía o retraso en el crecimiento. Se evidencio una correlación entre la disminución de los niveles de triglicéridos y aumento de los niveles de albúmina, sugiriendo un beneficio nutricional en los pacientes bajo infusiones de lípidos de pescado.

Sugammadex versus neostigmina en la reversión de la relajación neuromuscular en neurocirugía. Experimento clínico. Reporte preliminar

Existen grupos quirúrgicos específicos donde es mandatorio el uso de relajantes neuromusculares no despolarizantes, como es el caso de los pacientes llevados a procedimiento de neurocirugía; debido a sus características particulares el rocuronio es una buena alternativa para este tipo de procedimientos, ya sea en bolos o en infusión. Sin embargo la relajación residual y los efectos adversos de los medicamentos para revertir la relajación neuromuscular deben tenerse en cuenta en este grupo de pacientes en particular. El presente trabajo busca comparar la reversión de la relajación de infusiones de rocuronio, con Neostigmina mas Atropina vs la reversión con Sugammadex en pacientes llevados a manejo quirúrgico de lesiones supratentoriales por parte del servicio de neurocirugía de la Fundación Cardioinfantil, evaluando complicaciones durante la administración de los medicamentos y 24 horas posoperatorias, así como los tiempos para extubación y salida de salas de cirugía. Estudio con características de experimento prospectivo, aleatorizado, ciego, controlado. En este documento se realiza un reporte preliminar descriptivo de 14 pacientes reclutados hasta la actualidad.

Comparación entre analgesia epidural continua vs bloqueo nervio periférico en niños llevados a cirugía múltiple de miembros inferiores

Las cirugías reconstructivas múltiples de miembros inferiores son intervenciones quirúrgicas que implican un difícil manejo analgésico en el postoperatorio, actualmente la técnica analgésica usada es la analgesia peridural; sin embargo los efectos adversos asociados a esta no la hacen una técnica ideal para manejo de dolor. Los bloqueos de nervio periférico han aparecido como una alternativa para el manejo del dolor; pero no se ha difundido ampliamente su uso. Se pretende evaluar la disminución de efectos adversos con el uso de bloqueos de nervio periférico sobre la analgesia epidural. Este estudio piloto inicial se realizo para verificar efectividad técnicas a usar y problemas que se pudieran presentar. Se aplico el protocolo en 23 pacientes que fueron llevados a cirugía de miembros inferiores, se dividieron en 2 grupos 11 recibieron bloqueos de nervio periférico y 12 analgesia epidural. Se les realizo seguimiento por 48 horas y se evaluó el control del dolor, consumo de opioides y efectos adversos. El tiempo de colocación del bloqueo fue similar en ambos grupos, el grupo de bloqueos presento menos episodios de dolor y menos episodios de dolor severo. No se presento retención urinaria en ningún paciente pero en el grupo de epidural se presento mayor incidencia de nausea y vomito (60% vs 45%). Se encontró que los bloqueos de nervio periférico son una adecuada opción para el manejo del dolor en este tipo de cirugías; y al parecer disminuye la incidencia de eventos adversos asociados a la analgesia epidural.

Experiencia del uso de ácido valproico intravenoso en estatus epiléptico en la fundación Cardio Infantil – I.C. de Bogotá

El Acido Valproico (AV) es un antiepiléptico de primera línea bien efectivo en una gama amplia de crisis. Hay varias condiciones bajo las cuales una preparación parenteral es necesaria, ya sea porque el paciente es incapaz de tomar la medicación oral o porque se requiere una carga rápida, por ejemplo en el estatus epiléptico (EE).1 Al lado de las benzodiazepinas de corta acción, sólo la fenitoina y el fenobarbital están en uso como una preparación intravenosa (I.V.). Desgraciadamente, éstos tienen una ventana terapéutica estrecha y un amplio rango de complicaciones y efectos colaterales que limitan su administración. Hay una opción terapéutica actualmente disponible en nuestro país, como lo es el Acido Valproico en la presentación de ampolla para administración intravenosa y en el momento no se cuenta con ningún reporte en Colombia ni Latinoamérica donde se describa el uso del AV I.V. para EE. Los reportes internacionales muestran una efectividad del AV I.V. desde 63 hasta 85%2-3, con pocos efectos adversos y resultados prometedores. Por consiguiente, pensamos que es importante reportar nuestra experiencia con el uso del AV I.V. en el tratamiento del EE, como una opción terapéutica y con lo cual se derivaran estudios aleatorizados, ramdomizados y controlados.

Ingestão de água e relação com o conteúdo em água da dieta numa população saudável

Os vários estudos sobre a importância da água na fisiologia humana têm demonstrado que a quantidade de água presente nos alimentos e a produzida por via metabólica, não são suficientes para suprir as necessidades diárias deste nutriente. A água ingerida em função do reflexo da sede ou por vontade do próprio varia entre os indivíduos e, ao contrário de outros nutrientes fundamentais, não existe para a água uma definição clara sobre as necessidades diárias. Este facto pode ser parcialmente explicado pelo conjunto altamente sensível de adaptações neurofisiológicas que se fazem sentir com vista a manter a osmolaridade e a hidratação do organismo. Afim de avaliar a quantidade total de água consumida, os voluntários foram questionados sobre a quantidade de água/infusões/chás que consumiam diariamente. Com base num inquérito de frequência alimentar foi possível calcular o valor de 2,5l/dia consumo/conteúdo total de água da dieta da população em estudo. Os dados revelados pelo presente estudo, estão de acordo, com a literatura publicada, justificando o interesse no aprofundamento do tema, de modo a contribuir para o conhecimento sobre a importância da água no contexto dos nossos hábitos alimentares, na fisiologia normal.

Abomasal infusion of casein, starch and soybean oil differentially affect plasma concentrations of gut peptides and feed intake in lactating dairy cows

The effects of specific nutrients on secretion and plasma concentrations of gut peptides (glucagon-like peptide-1((7-36)) amide (GLP-1), glucose-dependent insulinotropic polypeptide (GIP), and cholecystokinin-8 (CCK)) differ across species, but are not reported for cattle. Our objective was to determine acute (hours) and chronic (1 week) effects of increased abomasal supply of protein, carbohydrate, or fat to the small intestine on dry matter intake (DMI) and plasma concentrations of GLP-1, GIP, CCK, and insulin. Four mid-lactation Holstein cows were used in a 4 x 4 Latin square design experiment. Treatments were 7-day abomasal infusions of water, soybean oil (500 g/d), corn starch (1100 g/d), or casein (800 g/d). Jugular vein plasma was obtained over 7 h at the end of the first and last day of infusions. Oil infusion decreased DMI on day 7, but total metabolizable energy (ME) supply (diet plus infusate) did not differ from water infusion. Casein and starch infusion had no effect on feed DMI; thus, ME supply increased. Decreased DMI on day 7 of oil infusion was accompanied by increased plasma GLP-1 concentration, but decreased plasma CCK concentration. Increased plasma GIP concentration was associated with increased ME supply on day 7 of casein and starch infusion. Casein infusion tended to increase plasma CCK concentration on both days of sampling, and increased plasma GLP-1 and insulin concentration on day 1 of infusion. The present data indicate a sustained elevation of plasma concentration of GLP-1, but not CCK, may contribute to the reduced DMI observed in dairy cows provided supplemental fat. (C) 2008 Elsevier Inc. All rights reserved.

Production and metabolic effects of site of starch digestion in lactating dairy cattle

Milk solids yield in modern dairy cows has increased linearly over the last 50 years, stressing the need for maximal dietary energy intake to allow genetic potential for milk energy yield to be realized with minimal negative effects on health and reproduction. Feeding supplemental starch is a common approach for increasing the energy density of the ration and supplying carbon for meeting the substantial glucose requirement of the higher yielding cow. In this regard, it is a long held belief that feeding starch in forms that increase digestion in the small intestine and glucose absorption will benefit the cow in terms of energetic efficiency and production response, but data supporting this dogma are equivocal. This review will consider the impact of supplemental starch and site of starch digestion on metabolic and production responses of lactating dairy cows, including effects on feed intake, milk yield and composition, nutrient partitioning, the capacity of the small intestine for starch digestion, and nutrient absorption and metabolism by the splanchnic tissues (the portal-drained viscera and liver). Whilst there appears to be considerable capacity for starch digestion and glucose absorption in the lactating dairy cow, numerous strategic studies implementing postruminal starch or glucose infusions have observed increases in milk yield, but decreased milk fat concentration such that there is little effect on milk energy yield, even in early lactation. Measurements of energy balance confirm that the majority of the supplemental energy arising from postruminal starch digestion is used with high efficiency to support body adipose and protein retention, even in early lactation. These responses may be mediated by changes in insulin status, and be beneficial to the cow in terms of reproductive success and well-being. However, shifting starch digestion from the rumen impacts the nitrogen economy of the cow as well by shifting the microbial protein gained from starch digestion from potentially absorbable protein to endogenous faecal loss.

Effect of prolonged intravenous glucose and essential amino acid infusion on nitrogen balance, muscle protein degradation and ubiquitin-conjugating enzyme gene expression in calves

Background: Intravenous infusions of glucose and amino acids increase both nitrogen balance and muscle accretion. We hypothesised that co-infusion of glucose ( to stimulate insulin) and essential amino acids (EAA) would act additively to improve nitrogen balance by decreasing muscle protein degradation in association with alterations in muscle expression of components of the ubiquitin-proteasome proteolytic pathway. Methods: We examined the effect of a 5 day intravenous infusions of saline, glucose, EAA and glucose + EAA, on urinary nitrogen excretion and muscle protein degradation. We carried out the study in 6 restrained calves since ruminants offer the advantage that muscle protein degradation can be assessed by excretion of 3 methyl-histidine and multiple muscle biopsies can be taken from the same animal. On the final day of infusion blood samples were taken for hormone and metabolite measurement and muscle biopsies for expression of ubiquitin, the 14-kDa E2 ubiquitin conjugating enzyme, and proteasome sub-units C2 and C8. Results: On day 5 of glucose infusion, plasma glucose, insulin and IGF-1 concentrations were increased while urea nitrogen excretion and myofibrillar protein degradation was decreased. Co-infusion of glucose + EAA prevented the loss of urinary nitrogen observed with EAA infusions alone and enhanced the increase in plasma IGF-1 concentration but there was no synergistic effect of glucose + EAA on the decrease in myofibrillar protein degradation. Muscle mRNA expression of the ubiquitin conjugating enzyme, 14-kDa E2 and proteasome sub-unit C2 were significantly decreased, after glucose but not amino acid infusions, and there was no further response to the combined infusions of glucose + EAA. Conclusion: Prolonged glucose infusion decreases myofibrillar protein degradation, prevents the excretion of infused EAA, and acts additively with EAA to increase plasma IGF-1 and improve net nitrogen balance. There was no evidence of synergistic effects between glucose + EAA infusion on muscle protein degradation or expression of components of the ubiquitin-proteasome proteolytic pathway.

Effect of plasma insulin and branched-chain amino acids on skeletal muscle protein synthesis in fasted lambs

The increase in fractional rate of protein synthesis (K-s) in the skeletal muscle of growing rats during the transition from fasted to fed state has been explained by the synergistic action of a rise in plasma insulin and branched-chain amino acids (BCAA). Since growing lambs Also exhibit an increase in K-s with level of feed intake, the objective of the present study was to determine if this synergistic relationship between insulin and BCAA also occurs in ruminant animals. Six 30 kg fasted (72 h) lambs (8 months of age) received each of four treatments, which were based on continuous infusion into the jugular vein for 6 h of: (1) saline (155 mmol NaCl/l); (2) a mixture of BCAA (0.778 mumol leucine, 0.640 mumol isoleucine and 0.693 mumol valine/min.kg); (3) 18.7 mumol glucose/min.kg (to induce endogenous insulin secretion): (4) co-infusion of BCAA and glucose. Within each period all animals received the same isotope of phenylalanine, (Phe) as follows: (1) L-[1-C-13]Phe; (2) L-phenyl-[ring H-2(5)]-alanine; (3) L-[N-15]Phe; (4) L-[ring 2,6-H-3]Phe. Blood was sampled serially during infusions to measure plasma concentrations of insulin, glucose and amino acids, and plasma free Phe isotopic activity; biopsies were taken 6 h after the beginning of infusions to determine K-s in in. longissimus dorsi and vastus muscle. Compared with control (saline-infused) lambs, K-s was increased by an average of 40% at the end of glucose infusion, but this effect was not statistically significant in either of the muscles sampled. BCAA infusion, alone or in combination with glucose, also had no significant effect on K-s compared with control sheep. K-s was approximately 60% greater for vastus muscle than for m. longissimus dorsi (P<0.01), regardless of treatment. It is concluded that there are signals other than insulin and BCAA that are responsible for the feed-induced increase in K-s in muscle of growing ruminant animals.

Effect of feeding fat or intrajugular infusion of glucagon-like peptide-1 and cholecystokinin on dry matter intake, digestibility, and digesta rate of passage in growing wethers

A cause and effect relationship between glucagon-like peptide 1 (7, 36) amide (GLP-1) and cholecystokinin (CCK) and DMI regulation has not been established in ruminants. Three randomized complete block experiments were conducted to determine the effect of feeding fat or infusing GLP-1 or CCK intravenously on DMI, nutrient digestibility, and Cr rate of passage (using Cr(2)O(3) as a marker) in wethers. A total of 18 Targhee × Hampshire wethers (36.5 ± 2.5 kg of BW) were used, and each experiment consisted of four 21-d periods (14 d for adaptation and 7 d for infusion and sampling). Wethers allotted to the control treatments served as the controls for all 3 experiments; experiments were performed simultaneously. The basal diet was 60% concentrate and 40% forage. In Exp. 1, treatments were the control (0% added fat) and addition of 4 or 6% Ca salts of palm oil fatty acids (DM basis). Treatments in Exp. 2 and 3 were the control and 3 jugular vein infusion dosages of GLP-1 (0.052, 0.103, or 0.155 µg•kg of BW(-1)•d(-1)) or CCK (0.069, 0.138, or 0.207 µg•kg of BW(-1)•d(-1)), respectively. Increases in plasma GLP-1 and CCK concentrations during hormone infusions were comparable with increases observed when increasing amounts of fat were fed. Feeding fat and infusion of GLP-1 tended (linear, P = 0.12; quadratic, P = 0.13) to decrease DMI. Infusion of CCK did not affect (P > 0.21) DMI. Retention time of Cr in the total gastrointestinal tract decreased (linear, P < 0.01) when fat was fed, but was not affected by GLP-1 or CCK infusion. In conclusion, jugular vein infusion produced similar plasma CCK and GLP-1 concentrations as observed when fat was fed. The effects of feeding fat on DMI may be partially regulated by plasma concentration of GLP-1, but are not likely due solely to changes in a single hormone concentration.

Evaluation of phenolic compounds in mate (Ilex paraguariensis) processed by gamma radiation

The radiation food processing has been demonstrating great effectiveness in the attack of pathogenic agents, while little compromising nutritional value and sensorial properties of foods. The mate (Ilex paraguariensis), widely consumed product in South America, generally in the form of infusions with hot or cold water, calls of chimarrao or terere, it is cited in literature as one of the best sources phenolic compounds. The antioxidants action of these constituent has been related to the protection of the organism against the free radicals, generated in alive, currently responsible for the sprouting of some degenerative illness as cancer, arteriosclerosis, rheumatic arthritis and cardiovascular clutters among others. The objective of that work was to evaluate the action of the processing for gamma radiation in phenolic compounds of terere beverage in the doses of 0, 3, 5, 7 and 10 kGy. The observed results do not demonstrate significant alterations in phenolic compounds of terere beverage processed by gamma radiation. Crown Copyright (C) 2009 Published by Elsevier Ltd. All rights reserved.

End-of-life practices in seven Brazilian pediatric intensive care units

Objective: To evaluate the incidence of life support limitation and medical practices in the last 48 hrs of life of children in seven Brazilian pediatric intensive care units (PICUs). Design. Cross-sectional multicenter retrospective study based on medical chart review. Setting: Seven PICUs belonging to university and tertiary hospitals located in three Brazilian regions: two in Porto Alegre (southern region), two in Sao Paulo (southeastern region), and three in Salvador (northeastern region). Patients. Medical records of all children who died in seven PICUs from January 2003 to December 2004. Deaths in the first 24 hrs of admission to the PICU and brain death were excluded. Interventions: Two pediatric intensive care residents from each PICU were trained to fill out a standard protocol (K = 0.9) to record demographic data and all medical management provided in the last 48 hrs of life (inotropes, sedatives, mechanical ventilation, full resuscitation maneuvers or not). Student`s t-test, analysis of variance, chi-square test, and relative risk were used for comparison of data. Measurements and Main Results. Five hundred and sixty-one deaths were identified; 97 records were excluded (61 because of brain death and 36 due to <24 hrs in the PICU). Thirty-six medical charts could not be found. Cardiopulmonary resuscitation was performed in 242 children (57%) with a significant difference between the southeastern and northeastern regions (p =.0003). Older age (p = .025) and longer PICU stay (p = .001) were associated with do-not-resuscitate orders. In just 52.5% of the patients with life support limitation, the decision was clearly recorded in the medical chart. No ventilatory support was provided in 14 cases. Inotropic drug infusions were maintained or increased in 66% of patients with do-not-resuscitate orders. Conclusions. The incidence of life support limitation has increased among Brazilian PICUs but with significant regional differences. Do-not-resuscitate orders are still the most common practice, with scarce initiatives for withdrawing or withholding life support measures.

Liver glycogen metabolism during short-term insulin-induced hypoglycemia in fed rats

The activities of glycogen phosphorylase and synthase during infusions of glucagon, isoproterenol, or cyanide in isolated liver of fed rats submitted to short-term insulin-induced hypoglycemia (IIH) was investigated. A condition of hyperinsulinemia/hypoglycemia was obtained with an intraperitoneal injection of regular insulin (1.0 U kg(-1)). The control group received ip saline. The experiments were carried out 60 min after insulin (IIH group) or saline (COG group) injection. The rats were anesthetized and after laparotomy, blood was collected from the vena cava for glucose and insulin measurements. The liver was their infused with glucagon (1 nM), isoproterenot (2 mu M), or cyanide (0.5 mM) during 20 min and a sample of the organ was collected for determination of the activities of glycogen phosphorylase and synthase 5 min after starting and 10 min after stopping the infusions. The infusions of cyanide, glucagons, and isoproterenol did not change the activities of glycogen synthase and glycogen phosphorylase. However, glycogen catabolism was decreased during the infusions of glucagon and isoproterenol in IIH rats, being more intense with isoproterenol (p < 0.05), than glucagon. It was concluded that short-term IIH promoted changes in the liver responsiveness of glycogen degradation induced by glucagon and isoproterenol without a change in the activities of glycogen phosphorylase and synthase. Copyright (c) 2008 John Wiley & Sons, Ltd.

Nutrient Selection in the Absence of Taste Receptor Signaling

When allowed to choose between different macronutrients, most animals display a strong attraction toward carbohydrates compared with proteins. It remains uncertain, however, whether this food selection pattern depends primarily on the sensory properties intrinsic to each nutrient or, alternatively, metabolic signals can act independently of the hedonic value of sweetness to stimulate elevated sugar intake. Here we show that Trpm5(-/-) mice, which lack the cellular mechanisms required for sweet and several forms of L-amino acid taste transduction, develop a robust preference for D-glucose compared with isocaloric L-serine independently of the perception of sweetness. Moreover, a close relationship was found between glucose oxidation and taste-independent nutrient intake levels, with animals increasing intake as a function of glucose oxidation rates. Furthermore, microdialysis measurements revealed nutrient-specific dopaminergic responses in accumbens and dorsal striatum during intragastric infusions of glucose or serine. Specifically, intragastric infusions of glucose induced significantly higher levels of dopamine release compared with isocaloric serine in both ventral and dorsal striatum. Intragastric stimulation of dopamine release seemed to depend on glucose utilization, because administration of an anti-metabolic glucose analog resulted in lower dopamine levels in striatum, an effect that was reversed by intravenous glucose infusions. Together, our findings suggest that carbohydrate-specific preferences can develop independently of taste quality or caloric load, an effect associated with the ability of a given nutrient to regulate glucose metabolism and stimulate brain dopamine centers.

Role of glutamate NMDA receptors and nitric oxide located within the periaqueductal gray on defensive behaviors in mice confronted by predator

The midbrain periaqueductal gray (PAG) is part of the brain system involved in active defense reactions to threatening stimuli. Glutamate N-methyl-d-aspartate (NMDA) receptor activation within the dorsal column of the PAG (dPAG) leads to autonomic and behavioral responses characterized as the fear reaction. Nitric oxide (NO) has been proposed to be a mediator of the aversive action of glutamate, since the activation of NMDA receptors in the brain increases NO synthesis. We investigated the effects of intra-dPAG infusions of NMDA on defensive behaviors in mice pretreated with a neuronal nitric oxide synthase (nNOS) inhibitor [N omega-propyl-l-arginine (NPLA)], in the same midbrain site, during a confrontation with a predator in the rat exposure test (RET). Male Swiss mice received intra-dPAG injections of NPLA (0.1 or 0.4 nmol/0.1 mu l), and 10 min later, they were infused with NMDA (0.04 nmol/0.1 mu l) into the dPAG. After 10 min, each mouse was placed in the RET. NMDA treatment enhanced avoidance behavior from the predator and markedly increased freezing behavior. These proaversive effects of NMDA were prevented by prior injection of NPLA. Furthermore, defensive behaviors (e.g., avoidance, risk assessment, freezing) were consistently reduced by the highest dose of NPLA alone, suggesting an intrinsic effect of nitric oxide on defensive behavior in mice exposed to the RET. These findings suggest a potential role of glutamate NMDA receptors and NO in the dPAG in the regulation of defensive behaviors in mice during a confrontation with a predator in the RET.