Glutamine and antioxidants in the critically ill patient: a post hoc analysis of a large-scale randomized trial.

BACKGROUND: The recent large randomized controlled trial of glutamine and antioxidant supplementation suggested that high-dose glutamine is associated with increased mortality in critically ill patients with multiorgan failure. The objectives of the present analyses were to reevaluate the effect of supplementation after controlling for baseline covariates and to identify potentially important subgroup effects. MATERIALS AND METHODS: This study was a post hoc analysis of a prospective factorial 2 × 2 randomized trial conducted in 40 intensive care units in North America and Europe. In total, 1223 mechanically ventilated adult patients with multiorgan failure were randomized to receive glutamine, antioxidants, both glutamine and antioxidants, or placebo administered separate from artificial nutrition. We compared each of the 3 active treatment arms (glutamine alone, antioxidants alone, and glutamine + antioxidants) with placebo on 28-day mortality. Post hoc, treatment effects were examined within subgroups defined by baseline patient characteristics. Logistic regression was used to estimate treatment effects within subgroups after adjustment for baseline covariates and to identify treatment-by-subgroup interactions (effect modification). RESULTS: The 28-day mortality rates in the placebo, glutamine, antioxidant, and combination arms were 25%, 32%, 29%, and 33%, respectively. After adjusting for prespecified baseline covariates, the adjusted odds ratio of 28-day mortality vs placebo was 1.5 (95% confidence interval, 1.0-2.1, P = .05), 1.2 (0.8-1.8, P = .40), and 1.4 (0.9-2.0, P = .09) for glutamine, antioxidant, and glutamine plus antioxidant arms, respectively. In the post hoc subgroup analysis, both glutamine and antioxidants appeared most harmful in patients with baseline renal dysfunction. No subgroups suggested reduced mortality with supplements. CONCLUSIONS: After adjustment for baseline covariates, early provision of high-dose glutamine administered separately from artificial nutrition was not beneficial and may be associated with increased mortality in critically ill patients with multiorgan failure. For both glutamine and antioxidants, the greatest potential for harm was observed in patients with multiorgan failure that included renal dysfunction upon study enrollment.

Moderate glycemic control safe in critically ill adult burn patients: A 15 year cohort study.

INTRODUCTION: Hyperglycemia is a metabolic alteration in major burn patients associated with complications. The study aimed at evaluating the safety of general ICU glucose control protocols applied in major burns receiving prolonged ICU treatment. METHODS: 15year retrospective analysis of consecutive, adult burn patients admitted to a single specialized centre. EXCLUSION CRITERIA: death or length of stay <10 days, age <16years. VARIABLES: demographic variables, burned surface (TBSA), severity scores, infections, ICU stay, outcome. Metabolic variables: total energy, carbohydrate and insulin delivery/24h, arterial blood glucose and CRP values. Analysis of 4 periods: 1, before protocol; 2, tight doctor driven; 3, tight nurse driven; 4, moderate nurse driven. RESULTS: 229 patients, aged 45±20 years (mean±SD), burned 32±20% TBSA were analyzed. SAPSII was 35±13. TBSA, Ryan and ABSI remained stable. Inhalation injury increased. A total of 28,690 blood glucose samples were analyzed: the median value remained unchanged with a narrower distribution over time. After the protocol initiation, the normoglycemic values increased from 34.7% to 65.9%, with a reduction of hypoglycaemic events (no extreme hypoglycemia in period 4). Severe hyperglycemia persisted throughout with a decrease in period 4 (9.25% in period 4). Energy and glucose deliveries decreased in periods 3 and 4 (p<0.0001). Infectious complications increased during the last 2 periods (p=0.01). CONCLUSION: A standardized ICU glucose control protocol improved the glycemic control in adult burn patients, reducing glucose variability. Moderate glycemic control in burns was safe specifically related to hypoglycemia, reducing the incidence of hypoglycaemic events compared to the period before. Hyperglycemia persisted at a lower level.

DAI-DEPUR: an integrated and distributed architecture for wastewater treatment plants supervision

The activated sludge process - the main biological technology usually applied towastewater treatment plants (WWTP) - directly depends on live beings (microorganisms), and therefore on unforeseen changes produced by them. It could be possible to get a good plant operation if the supervisory control system is able to react to the changes and deviations in the system and can take thenecessary actions to restore the system’s performance. These decisions are oftenbased both on physical, chemical, microbiological principles (suitable to bemodelled by conventional control algorithms) and on some knowledge (suitable to be modelled by knowledge-based systems). But one of the key problems in knowledge-based control systems design is the development of an architecture able to manage efficiently the different elements of the process (integrated architecture), to learn from previous cases (spec@c experimental knowledge) and to acquire the domain knowledge (general expert knowledge). These problems increase when the process belongs to an ill-structured domain and is composed of several complex operational units. Therefore, an integrated and distributed AIarchitecture seems to be a good choice. This paper proposes an integrated and distributed supervisory multi-level architecture for the supervision of WWTP, that overcomes some of the main troubles of classical control techniques and those of knowledge-based systems applied to real world systems

The self-management approach of health education in the treatment of chronic illnesses

Health education is essential to the successful treatment of individuals with chronic illnesses. Self-management is a philosophical model of health education that has been shown to be effective in teaching individuals with chronic arthritis to manage their illness as part of their daily lives. Despite the proven results of arthritis self-management programs, some limitations of this form of health education were apparent in the literature. The present study attempted to address the problems of the self-management approach of health education such as reasons for lack of participation in programs and poor course outcomes. In addition, the study served to investigate the relationship between course outcomes and participation in programs with the theory upon which arthritis self-management programs are based, known as self-efficacy theory. Through a combination of qualitative and quantitative methodologies, data collection, and analysis, a deeper understanding of the self-management phenomenon in the treatment of chronic arthritic conditions was established. Findings of the study confirm findings of previous studies that suggest that arthritis self-management programs result in enhanced levels of self-efficacy and are effective in teaching individuals with arthritis to self-manage their health and health care. Findings of the study suggest that there are many factors that determine the choice of participants to participate in programs and the outcomes for the individuals who do choose to participate in programs. Some of the major determinants of enrollment and outcomes of programs include: the participant's personality, beliefs, attitudes and abilities, and the degree of emotional acceptance of the illness. Other determinants of course enrollment and outcomes included class size and length of time, timing of participation, and ongoing support after the program. The results of the study are consistent with the self-management literature and confirm the relationship between the underlying philosophies of adult education and Freire's model of education and self-management.

DAI-DEPUR: an integrated and distributed architecture for wastewater treatment plants supervision

The activated sludge process - the main biological technology usually applied to wastewater treatment plants (WWTP) - directly depends on live beings (microorganisms), and therefore on unforeseen changes produced by them. It could be possible to get a good plant operation if the supervisory control system is able to react to the changes and deviations in the system and can take the necessary actions to restore the system’s performance. These decisions are often based both on physical, chemical, microbiological principles (suitable to be modelled by conventional control algorithms) and on some knowledge (suitable to be modelled by knowledge-based systems). But one of the key problems in knowledge-based control systems design is the development of an architecture able to manage efficiently the different elements of the process (integrated architecture), to learn from previous cases (spec@c experimental knowledge) and to acquire the domain knowledge (general expert knowledge). These problems increase when the process belongs to an ill-structured domain and is composed of several complex operational units. Therefore, an integrated and distributed AI architecture seems to be a good choice. This paper proposes an integrated and distributed supervisory multi-level architecture for the supervision of WWTP, that overcomes some of the main troubles of classical control techniques and those of knowledge-based systems applied to real world systems

Supervisory systems in waste water treatment plants: sistematise their implementation

La implantació de Sistemes de Suport a la presa de Decisions (SSD) en Estacions Depuradores d'Aigües Residuals Urbanes (EDAR) facilita l'aplicació de tècniques més eficients basades en el coneixement per a la gestió del procés, assegurant la qualitat de l'aigua de sortida tot minimitzant el cost ambiental de la seva explotació. Els sistemes basats en el coneixement es caracteritzen per la seva capacitat de treballar amb dominis molt poc estructurats, i gran part de la informació rellevant de tipus qualitatiu i/o incerta. Precisament aquests són els trets característics que es poden trobar en els sistemes biològics de depuració, i en conseqüència en una EDAR. No obstant, l'elevada complexitat dels SSD fa molt costós el seu disseny, desenvolupament i aplicació en planta real, pel que resulta determinant la generació d'un protocol que faciliti la seva exportació a EDARs de tecnologia similar. L'objectiu del present treball de Tesi és precisament el desenvolupament d'un protocol que faciliti l'exportació sistemàtica de SSD i l'aprofitament del coneixement del procés prèviament adquirit. El treball es desenvolupa en base al cas d'estudi resultant de l'exportació a l'EDAR Montornès del prototipus original de SSD implementat a l'EDAR Granollers. Aquest SSD integra dos tipus de sistemes basats en el coneixement, concretament els sistemes basats en regles (els quals són programes informàtics que emulen el raonament humà i la seva capacitat de solucionar problemes utilitzant les mateixes fonts d'informació) i els sistemes de raonament basats en casos (els quals són programes informàtics basats en el coneixement que volen solucionar les situacions anormals que pateix la planta en el moment actual mitjançant el record de l'acció efectuada en una situació passada similar). El treball està estructurat en diferents capítols, en el primer dels quals, el lector s'introdueix en el món dels sistemes de suport a la decisió i en el domini de la depuració d'aigües. Seguidament es fixen els objectius i es descriuen els materials i mètodes utilitzats. A continuació es presenta el prototipus de SSD desenvolupat per la EDAR Granollers. Una vegada el prototipus ha estat presentat es descriu el primer protocol plantejat pel mateix autor de la Tesi en el seu Treball de Recerca. A continuació es presenten els resultats obtinguts en l'aplicació pràctica del protocol per generar un nou SSD, per una planta depuradora diferent, partint del prototipus. L'aplicació pràctica del protocol permet l'evolució del mateix cap a un millor pla d'exportació. Finalment, es pot concloure que el nou protocol redueix el temps necessari per realitzar el procés d'exportació, tot i que el nombre de passos necessaris ha augmentat, la qual cosa significa que el nou protocol és més sistemàtic.

Threat interpretation in anxious children and their mothers: comparison with nonclinical children and the effects of treatment

Interpretation biases towards threat play a prominent role in cognitive theories of anxiety, and have been identified amongst highly anxious adults and children. Little is known, however, about the development of these cognitive biases although family processes have been implicated. The current study investigated the nature of threat interpretation of anxious children and their mothers through (i) comparison of a clinic and non-clinic population, (ii) analysis of individual differences; and (ill) pre- and post-treatment comparisons. Participants were 27 children with a primary anxiety disorder and 33 children from a non-clinic population and their mothers. Children and mothers completed self-report measures of anxiety and indicated their most likely interpretation of ambiguous scenarios. Clinic and non-clinical groups differed significantly on measures of threat interpretation. Furthermore, mothers' and children's threat interpretation correlated significantly. Following treatment for child anxiety, both children and their mothers reported a reduction in threat interpretation. (c) 2005 Elsevier Ltd. All rights reserved.

Clinical and parasitological evaluation of dogs naturally infected by Leishmania (Leishmania) chagasi submitted to treatment with meglumine antimoniate

Aiming to evaluate the efficacy of the treatment of canine visceral leishmaniasis, to verify the occurrence of a possible disease relapse, and to search for the presence of the parasites after the end of the treatment, seven dogs naturally infected by Leishmania (Leishmania) chagasi were used. The dogs were subjected to a treatment with 75 mg/kg meglumine antimoniate subcutaneously every 12 h for 21 days, and followed-up for a period of 6 months. During the whole experimental period the animals wore deltamethrin collars and were kept in a screened kennel to avoid reinfection. Lymph node and bone marrow aspiration biopsy was carried out to search for the parasite at seven moments: before the treatment, 30, 60, 90, 120 150 and 180 days after the start of the treatment. After the end of the experiment all dogs were humanely euthanized. Then, spleen and liver imprints and ill vitro cultures were carried out to search for amastigote forms of the parasite. During the treatment all animals presented remission of symptoms. However, two dogs were observed to present new symptoms in the course of the experiment. At the end of the experiment, the presence of amastigote forms of the parasite was evidenced in five of the seven dogs. This enabled us to conclude that the treatment promoted clinical cure but did not eliminate the parasites completely. (c) 2006 Elsevier B.V. All rights reserved.

The use of glucan as immunostimulant in the treatment of paracoccidioidomycosis

A group of 10 patients, nine of them seriously infected with Paracoccidioides brasiliensis (G1), received glucan (beta-1,3 polyglucose) as an immunostimulant intravenously once a week for one month, followed by monthly doses (10 mg) over an ii-month period, together with a specific anti-fungal agent as an immunostimulant. A second group of eight moderately infected patients (G2) was treated with only the anti-fungal agent. Among the patients in G1, there was only one case of relapse compared with five in G2. Values for the erythrocyte sedimentation rate (ESR) showed a significant difference (P < 0.01) post-treatment in G1 patients, when compared with the pretreatment levels. There was also a significant reduction (P < 0.001) in the level of serum antibodies to P. brasiliensis in the G1 patients in post-treatment examinations. The phytohemagglutinin (PHA) skin test showed a positive reaction among the patients in G1 (P < 0.01) post-treatment and there was a tendency towards an increase in the number of CD4+ T lymphocytes in both groups after treatment. The serum level of tumor necrosis factor (TNF) proved to be significantly higher (P < 0.02) in the G1 patients during treatment. In the G1 patients, the correlation between ESR and TNF tended to be negative whereas that between ESR and serum antibodies was positive. The present results indicate that the patients who received glucan, in spite of being more seriously ill, had a stronger and more favorable response to therapy.

Evaluation of sample treatment for the simultaneous flow injection hydride generation and determination of As, Bi, Sb and Se by GRAS

A new method was developed for the simultaneous determination of As, Bi, Sb, and Se by flow injection hydride generation graphite furnace atomic absorption spectrometry. An alternative two-step sample treatment procedure was used. The sample was heated (80degreesC) for 10 min in 6 M HCl to reduce Se(VI) to Se(IV), followed by the addition of 1% (m/v) thiourea solution to reduce arsenic and antimony from the pentavalent to the trivalent states.With this procedure, all analytes were converted to their most favorable and sensitive oxidation states to generate the corresponding hydrides. The pre-treated sample solution was then processed in the flow system for in situ trapping and atomization in a graphite tube coated with iridium. The impermanent modifier remained stable up to 300 firings and new coating out significant were possible wit changes in the analytical performance.The accuracy was checked for As, Bi, Sb, and Se determination in water standard reference materials NIST 1640 and 1643d and the results were in agreement with the certified values at a 95% confidence level. Good recoveries (94-104%.) of spiked mineral waters and synthetic As(V), Sb(Ill), mixtures of As(Ill), Sb(V), Se(VI), and Se(IV) were also found. Calculated characteristic masses were 32 mug As, 79 mug Bi, 35 mug Sb, and 130 pg Se, and the corresponding limits of detection were 0.06, 0.16, 0.19, and 0.59 mug L-1, respectively. The repeatability for a typical solution containing 5 mug L-1 As, Bi, Sb, and Se was in the 1-3% range.

Cultivo do cajueiro anão (Anacardium occidentale L.) nas regionais de Andradina e Jales do estado de São Paulo: tratos culturais, custos e mercados

Pós-graduação em Agronomia - FEIS

Does videothoracoscopy improve clinical outcomes when implemented as part of a pleural empyema treatment algorithm?

OBJECTIVE: We aimed to evaluate whether the inclusion of videothoracoscopy in a pleural empyema treatment algorithm would change the clinical outcome of such patients. METHODS: This study performed quality-improvement research. We conducted a retrospective review of patients who underwent pleural decortication for pleural empyema at our institution from 2002 to 2008. With the old algorithm (January 2002 to September 2005), open decortication was the procedure of choice, and videothoracoscopy was only performed in certain sporadic mid-stage cases. With the new algorithm (October 2005 to December 2008), videothoracoscopy became the first-line treatment option, whereas open decortication was only performed in patients with a thick pleural peel (>2 cm) observed by chest scan. The patients were divided into an old algorithm (n = 93) and new algorithm (n = 113) group and compared. The main outcome variables assessed included treatment failure (pleural space reintervention or death up to 60 days after medical discharge) and the occurrence of complications. RESULTS: Videothoracoscopy and open decortication were performed in 13 and 80 patients from the old algorithm group and in 81 and 32 patients from the new algorithm group, respectively (p < 0.01). The patients in the new algorithm group were older (41 +/- 1 vs. 46.3 +/- 16.7 years, p=0.014) and had higher Charlson Comorbidity Index scores [0(0-3) vs. 2(0-4), p = 0.032]. The occurrence of treatment failure was similar in both groups (19.35% vs. 24.77%, p= 0.35), although the complication rate was lower in the new algorithm group (48.3% vs. 33.6%, p = 0.04). CONCLUSIONS: The wider use of videothoracoscopy in pleural empyema treatment was associated with fewer complications and unaltered rates of mortality and reoperation even though more severely ill patients were subjected to videothoracoscopic surgery.

Flagellin:allergen fusion proteins as novel vaccines for the treatment of severe type I allergies

Over the last decades the prevalence of food allergies has continually increased on a world wide scale. While there are effective treatments available for bee and wasp venom allergic patients, there is currently no established therapy for the treatment of severe food allergies. Aim of the project was to genetically fuse different food allergens with the immune modulating Toll-like receptor 5 (TLR5)-ligand flagellin and to test these constructs for their immune modulatory capacities both in vitro and in vivo. Chicken ovalbumin (Ova) as model antigen, Pru p 3, and Ara h 2 the respective major allergens from peach and peanut were used as allergens. The potential vaccine candidates were characterized by protein biochemical methods (purity, folding, endotoxin contaminations). Moreover, their immune modulating effects on cell culture lines (TLR5-receptor activation) and primary mouse immune cells (myeloid and plasmacytoid dendritic cells) were investigated. Additionally, the prophylactic and therapeutic use of the flagellin Ova fusion protein (rflaA:Ova) were investigated in a mouse model of intestinal allergy. In myeloid dendritic cells (mDC) stimulation with the fusion proteins led to a strong cell activation and cytokine secretion. Here, the fusion proteins proved to be a much stronger stimulus than the equimolar amount of both proteins provided alone or as a mixture. Noteworthy, stimulation with rflaA:Ova induced the secretion of the anti-inflammatory cytokine IL-10 from mDC. In co-culture experiments this IL-10 secretion suppressed the Ova-induced secretion of Th1 and Th2 cytokines from Ova-specific CD4 T cells. Using MyD88-deficient mDC this repression of cytokine secretion was shown to be TLR-dependent. Finally, the potency of the rflaA:Ova construct was investigated in a mouse model of Ova-induced intestinal allergy. In a prophylactic vaccination approach rflaA:Ova was shown to prevent the establishment of the intestinal allergy and all associated symptoms (weight loss, temperature drop, soft faeces). This fusion protein-mediated protection was accompanied by a reduced T cell activation, and reduced Th2 cytokines in intestinal homogenates. These effects were paralleled by a strong induction of Ova-specific IgG2a antibodies in rflaA:Ova-vaccinated sera, while Ova-specific IgE antibody production was significantly reduced. Therapeutic vaccination with rflaA:Ova reduced allergic symptoms and T cell activation but did not influence weight loss and antibody production. In all in vivo experiments vaccination with both proteins either provided alone or as a mixture did not have comparable effects. Future experiments aim at elucidating the mechanism and further optimization of the therapeutic vaccination approach. The results presented in this thesis demonstrate, that fusion proteins containing flagellin have strong immune modulatory capacities both in vitro and in vivo. Therefore, such constructs are promising vaccine candidates for the therapy of type I allergies.

Bone and cartilage wedge technique in posttraumatic enophthalmos treatment

To evaluate a new surgical method, using calvarial bone graft combined with a wedge of irradiated homologous costal cartilage, for the revision repair of posttraumatic enophthalmos.

Clinical and Histological Evaluation of a Granular Bovine Bone Biomaterial Used as an Adjunct to Guided Tissue Regeneration With a Bioresorbable Bovine Pericardium Collagen Membrane in the Treatment of Intrabony Periodontal Defects

The aim of the present study is to evaluate the clinical and histologic healing of deep intrabony defects treated with guided tissue regeneration (GTR) with a collagen membrane from bovine pericardium and implantation of granular bovine bone biomaterial.