The role of energy and nutritional support in the intensive care unit.

Malnutrition is common in critically ill, hospitalized patients and so represents a major problem for intensive care. Nutritional support can be beneficial in such cases and may help preserve vital organ and immune function. Energy requirements, route of delivery and potential complications of nutritional support are discussed in this paper.

The cost-effectiveness and public health benefit of nalmefene added to psychosocial support for the reduction of alcohol consumption in alcohol-dependent patients with high/very high drinking risk levels: a Markov model.

OBJECTIVES: To determine whether nalmefene combined with psychosocial support is cost-effective compared with psychosocial support alone for reducing alcohol consumption in alcohol-dependent patients with high/very high drinking risk levels (DRLs) as defined by the WHO, and to evaluate the public health benefit of reducing harmful alcohol-attributable diseases, injuries and deaths. DESIGN: Decision modelling using Markov chains compared costs and effects over 5 years. SETTING: The analysis was from the perspective of the National Health Service (NHS) in England and Wales. PARTICIPANTS: The model considered the licensed population for nalmefene, specifically adults with both alcohol dependence and high/very high DRLs, who do not require immediate detoxification and who continue to have high/very high DRLs after initial assessment. DATA SOURCES: We modelled treatment effect using data from three clinical trials for nalmefene (ESENSE 1 (NCT00811720), ESENSE 2 (NCT00812461) and SENSE (NCT00811941)). Baseline characteristics of the model population, treatment resource utilisation and utilities were from these trials. We estimated the number of alcohol-attributable events occurring at different levels of alcohol consumption based on published epidemiological risk-relation studies. Health-related costs were from UK sources. MAIN OUTCOME MEASURES: We measured incremental cost per quality-adjusted life year (QALY) gained and number of alcohol-attributable harmful events avoided. RESULTS: Nalmefene in combination with psychosocial support had an incremental cost-effectiveness ratio (ICER) of £5204 per QALY gained, and was therefore cost-effective at the £20,000 per QALY gained decision threshold. Sensitivity analyses showed that the conclusion was robust. Nalmefene plus psychosocial support led to the avoidance of 7179 alcohol-attributable diseases/injuries and 309 deaths per 100,000 patients compared to psychosocial support alone over the course of 5 years. CONCLUSIONS: Nalmefene can be seen as a cost-effective treatment for alcohol dependence, with substantial public health benefits. TRIAL REGISTRATION NUMBERS: This cost-effectiveness analysis was developed based on data from three randomised clinical trials: ESENSE 1 (NCT00811720), ESENSE 2 (NCT00812461) and SENSE (NCT00811941).

Effects of social support on the clinical course of Crohn's disease.

BACKGROUND: Social support has been found to be protective from adverse health effects of psychological stress. We hypothesized that higher social support would predict a more favorable course of Crohn's disease (CD) directly (main effect hypothesis) and via moderating other prognostic factors (buffer hypothesis). METHODS: Within a multicenter cohort study we observed 597 adults with CD for 18 months. We assessed social support using the ENRICHD Social Support Inventory. Flares, nonresponse to therapy, complications, and extraintestinal manifestations were recorded as a combined endpoint indicating disease deterioration. We controlled for several demographic, psychosocial, and clinical variables of potential prognostic importance. We used multivariate binary logistic regression to estimate the overall effect of social support on the odds of disease deterioration and to explore main and moderator effects of social support by probing interactions with other predictors. RESULTS: The odds of disease deterioration decreased by 1.5 times (95% confidence interval [CI]: 1.2-1.9) for an increase of one standard deviation (SD) of social support. In case of low body mass index (BMI) (i.e., 1 SD below the mean or <19 kg/m(2)), the odds decreased by 1.8 times for an increase of 1 SD of social support. In case of low social support, the odds increased by 2.1 times for a decrease of 1 SD of BMI. Low BMI was not predictive under high social support. CONCLUSIONS: The findings suggest that elevated social support may favorably affect the clinical course of CD, particularly in patients with low BMI. (Inflamm Bowel Dis 2010;).

The death domain-containing protein Unc5CL is a novel MyD88-independent activator of the pro-inflammatory IRAK signaling cascade.

The family of death domain (DD)-containing proteins are involved in many cellular processes, including apoptosis, inflammation and development. One of these molecules, the adapter protein MyD88, is a key factor in innate and adaptive immunity that integrates signals from the Toll-like receptor/interleukin (IL)-1 receptor (TLR/IL-1R) superfamily by providing an activation platform for IL-1R-associated kinases (IRAKs). Here we show that the DD-containing protein Unc5CL (also known as ZUD) is involved in a novel MyD88-independent mode of IRAK signaling that culminates in the activation of the transcription factor nuclear factor kappa B (NF-κB) and c-Jun N-terminal kinase. Unc5CL required IRAK1, IRAK4 and TNF receptor-associated factor 6 but not MyD88 for its ability to activate these pathways. Interestingly, the protein is constitutively autoproteolytically processed, and is anchored by its N-terminus specifically to the apical face of mucosal epithelial cells. Transcriptional profiling identified mainly chemokines, including IL-8, CXCL1 and CCL20 as Unc5CL target genes. Its prominent expression in mucosal tissues, as well as its ability to induce a pro-inflammatory program in cells, suggests that Unc5CL is a factor in epithelial inflammation and immunity as well as a candidate gene involved in mucosal diseases such as inflammatory bowel disease.

Experimental support for the make-up hypothesis in nestling tawny owls (Strix aluco)

Body condition can affect coloration of traits used in sexual selection and parent-offspring communication by inducing rapid internal changes in pigment concentration or aggregation, thickness of collagen arrays, or blood flux. The recent "makeup hypothesis" proposes an alternative honesty-reinforcing mechanism, with behaviorally mediated deposition of substances on body surfaces ("cosmetics") generating covariation between body condition and coloration. In birds, the uropygial gland wax is actively spread on feathers using the bill and changes in its deposition rate may cause rapid changes in bill and plumage coloration. Using tawny owl nestlings, we tested 3 predictions of the makeup hypothesis, namely that 1) quantity of preen wax deposited accounts for variation in bill coloration, 2) an immune stimulation (induced by injection of a lipopolysaccharide [LPS]) impairs uropygial gland wax production, and 3) different intensities of immune stimulations (strong vs. weak stimulations induced by injections of either LPS or phytohemagglutinin [PHA], respectively) and high versus low food availabilities result in different bill colorations. We found that 1) preen wax reduced bill brightness, 2) a challenge with LPS impaired uropygial gland development, and 3) nestlings challenged with LPS had a brighter bill than PHA-injected nestlings, whereas diet manipulation had no significant effect. Altogether, these results suggest that a strong immune challenge may decrease preen wax deposition rate on the bill of nestling birds, at least by impairing gland wax production, which causes a change in bill coloration. Our study therefore highlights that cosmetic colors might signal short-term variation in immunological status.

Le Soutien psychiatrique Intensif dans le Milieu (SIM) à Lausanne: un projet pilote [Intensive Psychiatric Support at the Setting in Lausanne: a pilot project]

While the hospital remains an important element of the psychiatric health-care system, the fact that it is always the best place to treat acute psychotic episodes is still debated. After a brief review of the literature relative to the main existing community care models, the authors describe the development in the Department Universitaire de Psychiatrie Adulte (DUPA), of an alternative to hospitalisation for patient going through a severe acute psychiatric episode. They present three clinical situations and the aims of the research project, which will follow this pilot phase.