Monitoring the clinical introduction of a glutamine and antioxidant solution in critically ill trauma and burn patients

OBJECTIVE: Enteral glutamine supplementation and antioxidants have been shown to be beneficial in some categories of critically ill patients. This study investigated the impact on organ function and clinical outcome of an enteral solution enriched with glutamine and antioxidant micronutrients in patients with trauma and with burns. METHODS: This was a prospective study of a historical control group including critically ill, burned and major trauma patients (n = 86, 40 patients with burns and 46 with trauma, 43 in each group) on admission to an intensive care unit in a university hospital (matching for severity, age, and sex). The intervention aimed to deliver a 500-mL enteral solution containing 30 g of glutamine per day, selenium, zinc, and vitamin E (Gln-AOX) for a maximum of 10 d, in addition to control treatment consisting of enteral nutrition in all patients and intravenous trace elements in all burn patients. RESULTS: Patients were comparable at baseline, except for more inhalation injuries in the burn-Gln-AOX group (P = 0.10) and greater neurologic impairment in the trauma-Gln-AOX group (P = 0.022). Intestinal tolerance was good. The full 500-mL dose was rarely delivered, resulting in a low mean glutamine daily dose (22 g for burn patients and 16 g for trauma patients). In burn patients intravenous trace element delivery was superior to the enteral dose. The evolution of the Sequential Organ Failure Assessment score and other outcome variables did not differ significantly between groups. C-reactive protein decreased faster in the Gln-AOX group. CONCLUSION: The Gln-AOX supplement was well tolerated in critically ill, injured patients, but did not improve outcome significantly. The delivery of glutamine below the 0.5-g/kg recommended dose in association with high intravenous trace element substitution doses in burn patients are likely to have blunted the impact by not reaching an efficient treatment dose. Further trials testing higher doses of Gln are required.

Traumatologie de la personne âgée : une urgence nutritionnelle ? [Elderly orthopedic patients: Is nutritional support needed?]

La fracture de hanche chez la personne âgée reste un problème de santé publique. Elle est la conséquence d'une chute neuf fois sur dix et survient chez des personnes fragilisées par une ostéoporose, une sarcopénie, une dénutrition. Dans un service de traumatologie, la dénutrition protéino-énergétique est fréquente. Présente dès l'admission chez environ un patient sur deux, elle va souvent s'aggraver pendant le séjour hospitalier et favoriser la survenue de complications. Une prise en charge nutritionnelle doit impliquer une équipe multidisciplinaire qu'il faut coordonner. Elle doit être envisagée précocement pendant le séjour hospitalier et privilégier la voie orale. L'assistance nutritionnelle sous forme de CNO a prouvé son efficacité dans la réduction de la morbidité postopératoire. Son impact sur la mortalité, sur le pronostic fonctionnel et social reste discuté. Il faudra attendre l'étude de nouvelles cohortes dans lesquelles la compliance au traitement est nettement améliorée avant de conclure de manière définitive.

Percutaneous endoscopic gastrostomy in head and neck cancer patients: indications, techniques, complications and results.

The aim of this study was to review our experience in percutaneous endoscopic gastrostomy (PEG) performed in patients with cancer of the upper aerodigestive tract. Descriptive retrospective study of 142 patients (115 males, 27 females), mean age 62.4 years (25-84 years), with head and neck or esophageal cancer, who underwent PEG tube insertion between January 2006 and December 2008. The studied parameters were indications, success rate, rate and type of complications, and their management. Percutaneous endoscopic gastrostomy was inserted before chemoradiation therapy in 80% and during or after cancer treatment in 20% of the patients. PEG placement was possible in 137 patients (96%). Major complications were observed in 9 (7%) and minor complications in 22 (17%) of the 137 patients. Seven of the 9 patients with a major complication needed revision surgery. The mortality directly related to the procedure was 0.7%. Percutaneous endoscopic gastrostomy tube insertion has a high success rate. In patients with upper aerodigestive tract cancer, PEG should be the first choice for enteral nutrition when sufficient oral intake is not possible. Although apparently easy, the procedure may occasionally lead to severe complications. Therefore, a strict technique and knowledge of clinical signs of possible complications are mandatory.

Nutrition préopératoire en chirurgie viscérale: recommandations et réalité [Preoperative nutrition in abdominal surgery: recommendations and reality].

Malnutrition concerns up to 50% at in-hospital admission. Its diagnosis and treatment are fundamental parts of the surgical approach because nutritional status directly influences the clinical outcome. The Nutritional Risk Score (NRS-2002) represents the recommended screening tool by the European Society of Parenteral and Enteral Nutrition (ESPEN). Patients with a score > or = 3 and aged > 70 years old, should receive a nutritional support during 7-14 day before surgery. Depending on patient's clinical conditions, the enteral route of administration should be preferred. Despite strong evidence in favor of nutritional supplementation, much effort must be done to implement these supportive strategies in the everyday clinical practice.

Características agronômicas e tecnológicas de genótipos de feijão do grupo comercial Carioca

A busca por cultivares produtivas, adaptadas ao local de cultivo e com características tecnológicas desejáveis é uma constante. O objetivo deste trabalho foi avaliar o comportamento de genótipos de feijão, do grupo comercial Carioca, quanto a características agronômicas e tecnológicas. Vinte e nove genótipos foram cultivados na época das águas, nos anos de 2001 e 2002, e distribuídos em blocos casualizados, com quatro repetições. Sobressaíram-se os genótipos IAC-Carioca, FT-Bonito, Rudá, Porto Real, CNFC 8008, CNFC 8011, CNFC 8012, CNFC 8013 e CNFC 8156 com produtividade de grãos acima da média obtida. Destacaram-se com produtividade média de grãos acima de 3.000 kg ha-1 e tempo de cozimento médio em torno de 20 minutos, os genótipos IAC-Carioca, CNFC 8012 e CNFC 8156.

Ethical issues in nutrition support of severely disabled elderly persons: a guide for health professionals.

Providing or withholding nutrition in severely disabled elderly persons is a challenging dilemma for families, health professionals, and institutions. Despite limited evidence that nutrition support improves functional status in vulnerable older persons, especially those suffering from dementia, the issue of nutrition support in this population is strongly debated. Nutrition might be considered a basic need that not only sustains life but provides comfort as well by patients and their families. Consequently, the decision to provide or withhold nutrition support during medical care is often complex and involves clinical, legal, and ethical considerations. This article proposes a guide for health professionals to appraise ethical issues related to nutrition support in severely disabled older persons. This guide is based on an 8-step process to identify the components of a situation, analyze conflicting values that result in the ethical dilemma, and eventually reach a consensus for the most relevant plan of care to implement in a specific clinical situation. A vignette is presented to illustrate the use of this guide when analyzing a clinical situation.

The burden of hospital malnutrition in Spain: methods and development of the PREDyCES® study

It is well known that hospital malnutrition is a highly prevalent condition associated to increase morbidity and mortality as well as related healthcare costs. Although previous studies have already measured the prevalence and/or costs of hospital nutrition in our country, their local focus (at regional or even hospital level) make that the true prevalence and economic impact of hospital malnutrition for the National Health System remain unknown in Spain. The PREDyCES® (Prevalence of hospital malnutrition and associated costs in Spain) study was aimed to assess the prevalence of hospital malnutrition in Spain and to estimate related costs. Some aspects made this study unique: a) It was the first study in a representative sample of hospitals of Spain; b) different measures to assess hospital malnutrition (NRS2002, MNA as well as anthropometric and biochemical markers) where used both at admission and discharge and, c) the economic consequences of malnutrition where estimated using the perspective of the Spanish National Health System.

Produtividade e característica tecnológica de grãos em feijoeiro adubado com nitrogênio e molibdênio

O objetivo deste trabalho foi avaliar o efeito da adubação com nitrogênio e molibdênio, na produtividade e nas características tecnológicas dos grãos de feijão. O delineamento utilizado foi o de blocos ao acaso, em esquema fatorial 4x2, constituído por doses de nitrogênio em cobertura (0, 30, 60 e 120 kg ha-1), aliado à aplicação ou não de molibdênio por via foliar (0 e 80 g ha-1), com quatro repetições. A semeadura do feijão, cultivar Pérola, foi realizada em condições de sequeiro e no sistema de plantio direto. A adubação nitrogenada em cobertura e a molíbdica via foliar não influenciam a produtividade, mas interferem na característica tecnológica dos grãos de feijão. O teor de proteína bruta, o tempo de cozimento e o tempo para a máxima hidratação dos grãos aumentam com as doses de nitrogênio em cobertura. O tempo de cozimento é maior, à medida que há incremento de nitrogênio aplicado em cobertura, com uso de molibdênio via foliar. O uso de molibdênio via foliar proporciona o menor tempo para a máxima hidratação de grãos.

Contribuição de solutos orgânicos e inorgânicos no ajustamento osmótico de pinhão-manso submetido à salinidade

O objetivo deste trabalho foi avaliar a acumulação de solutos orgânicos e inorgânicos e suas contribuições para o ajustamento osmótico de folhas de pinhão-manso (Jatropha curcas L.) submetido à salinidade. O experimento foi conduzido em delineamento experimental inteiramente casualizado, com cinco tratamentos (0, 25, 50, 75 e 100 mmol L-1 de NaCl) e quatro repetições. As plantas foram cultivadas hidroponicamente em casa de vegetação, em condições controladas de fotoperíodo (12 horas), temperatura (média de 28ºC) e umidade relativa do ar (média de 65%), com radiação fotossinteticamente ativa máxima média de 700 µmol m-1 s-1. O potencial osmótico das folhas decresceu progressivamente e variou de -0,84 a -2,05 MPa, enquanto o conteúdo relativo de água aumentou nos tratamentos com 75 e 100 mmol L-1. Os íons Na+ e Cl- foram os mais importantes, em termos quantitativos, e contribuíram com cerca de 52 e 20%, respectivamente, para o ajustamento osmótico das folhas de plantas tratadas com NaCl. A contribuição do K+ decresceu de modo acentuado e foi de 17 e 5% nos tratamentos com 25 e 100 mmol L-1 de NaCl. A contribuição média dos solutos orgânicos, açúcares, aminoácidos, glicina betaína e prolina, foi de 5,5, 6, 4 e 0,03%, respectivamente. As folhas de pinhão-manso ajustam-se osmoticamente em presença de salinidade, e mantêm bom nível de hidratação, principalmente por meio da acumulação de Na+ e Cl-. A glicina betaína tem papel quantitativo mais importante do que a prolina no ajustamento osmótico, tanto em presença quanto em ausência de salinidade.

Malignant gastroduodenal obstruction: palliation with self-expanding metallic stents.

PURPOSE: To evaluate the feasibility, efficacy, and tolerance of self-expanding metallic stent insertion under fluoroscopic guidance for palliation of symptoms related to malignant gastroduodenal obstruction. MATERIALS AND METHODS: Seventy-two patients (38 men, 34 women) aged 25-98 years (mean, 62 years) with duodenal (n = 43), antropyloric (n = 13), surgical gastrojejunostomy (n = 10), or pyloroduodenal (n = 6) malignant obstruction were referred for insertion of self-expanding metallic stents over a 6-year period. Stent insertion was performed with use of a peroral or transgastric approach when necessary (n = 11). RESULTS: Stents were successfully inserted in 70 of the 72 patients (97%) and provided symptom relief in 65 patients (90%). Inserted stents were mainly uncovered vascular (n = 55) or enteral (n = 10) Wallstents. One hundred eight stents were initially inserted: one, two, three, or four stents were indicated in 43, 17, nine, and one patient, respectively. Mean follow-up was 119 days (range, 4-513 days). Mean stent patency was 113 days (range, 4-513 days). Mean survival of patients was 120 days. During follow-up, stent obstruction occurred in seven patients as a result of tumoral overgrowth (n = 5) or ingrowth (n = 2). Complications occurred in 12 of the 72 patients (17%), including stent migration (n = 8), stent fracture (n = 1), duodenal perforation (n = 1), and death related to general anesthesia (n = 1). CONCLUSION: Despite a significant complication rate, self-expanding metallic stent insertion under fluoroscopic guidance appears to be a feasible and useful technique in the palliative management of malignant gastroduodenal obstruction.

Umidade e congelamento de grãos de amaranto e sua capacidade de expansão térmica

O objetivo deste trabalho foi avaliar a influência do teor de umidade, da temperatura de armazenamento e do momento da hidratação de grãos de amaranto (Amaranthus cruentus L. ) sobre sua capacidade de expansão térmica, bem como comparar as composições químicas de grãos crus e pipocados. Os atributos diâmetro médio ponderado, volume de expansão, densidade, rendimento, quantidade descartada e tempo de residência de grãos da variedade BRS Alegria foram avaliados de acordo com três teores de umidade (9,5, 11,5 e 13,5%), duas formas de armazenamento, temperatura ambiente de ±28ºC e congelado a -18ºC, e dois momentos de hidratação, antes e após congelamento. Utilizou-se chapa metálica aquecida a 215ºC para pipocar os grãos. Grãos congelados com umidade de 13,5% tiveram maior diâmetro médio ponderado e volume de expansão, e menor densidade e tempo de residência. A umidade de 13,5% proporcionou os maiores rendimentos e expansão dos grãos. O armazenamento a -18ºC produziu pipocas maiores e mais leves do que em condições ambientais. As pipocas apresentaram redução nos teores de proteínas e fibras insolúveis e aumento nos de lipídeos e fibras solúveis, em relação ao grão cru. O congelamento dos grãos a -18ºC e sua hidratação a 13,5% de umidade favorecem o pipocamento de grãos de amaranto, com produção de pipocas de melhor qualidade.

Prospective study of the barriers to nutritional support in a paediatric intensive care unit : P16

Introduction and aim: Children hospitalised in a paediatric intensive care unit (PICU) are mainly fed by nutritional support (NS) which may often be interrupted. The aims of the study were to verify the relationship between prescribed (PEI) and actual energy intake (AEI) and to identify the reasons for NS interruption. Methods: Prospective study in a PICU. PEI and AEI from day 1 to 15, type of NS (enteral, parenteral, mixed), position of the feeding tube, interruptions in NS and reasons for these were noted. Inter - ruptions were classified in categories of barriers and their frequency and duration were analysed. Results: Fifteen children (24 ± 25.2 months) were studied for 84 days. The NS was exclusively enteral (69%) or mixed (31%). PEI were significantly higher than AEI (54.7 ± 32.9 vs 49.2 ± 33.6 kcal/kg, p = 0.0011). AEI represented 93% of the PEI. Ninety-eight interruptions were noted and lasted 189 h, i.e. 9.4% of the evaluated time. The most frequent barriers were nursing procedures, respiratory physiotherapy and unavailability of intravenous access. The longest were caused by the necessity to stop NS for surgery or diagnostic studies, to treat burns or to carry out medical procedures. Conclusion: AEI in PICU were inferior by 7% to PEI, considerably lower than in adult studies. Making these results available to medical staff for greater anticipation and compensation could reduce NS interruptions. Starving protocols should be reconsidered.

Produção de celulases por Aspergillus niger por fermentação em estado sólido

O objetivo deste trabalho foi avaliar a produção enzimática de celulases pelo fungo filamentoso Aspergillus niger por fermentação em estado sólido de diferentes substratos. Foram avaliados os substratos sólidos bagaço de cana-de-açúcar, farelo de soja, farelo de trigo e misturas entre os substratos. Em substrato com 90% de bagaço e 10% de farelo de soja, avaliaram-se os efeitos do conteúdo de umidade (60, 70 e 80%, base úmida) e da suplementação com os meios indutores da atividade enzimática: sacarose, Mandels & Weber básico, Mandels & Weber modificado, com acréscimo de carboximetilcelulose, e Czapeck Dox. As maiores atividades de celulase total e endoglucanase, em farelo de trigo, foram obtidas após 72 horas de cultivo: 0,4 e 21,0 UI g-1, respectivamente. Observou-se expressivo aumento nas atividades enzimáticas na medida em que se aumentou a proporção de farelos no substrato, em comparação à fermentação com bagaço de cana apenas. O conteúdo de umidade de 50% foi insuficiente para conseguir completa hidratação do bagaço de cana, e a umidade ideal varia de acordo com o meio utilizado para suplementação e encontra-se entre 70 e 80%. O meio de Mandels & Weber modificado apresenta o melhor resultado como indutor da atividade enzimática.

Energy deficit and length of hospital stay can be reduced by a two-step quality improvement of nutrition therapy: the intensive care unit dietitian can make the difference.

OBJECTIVE: Critically ill patients are at high risk of malnutrition. Insufficient nutritional support still remains a widespread problem despite guidelines. The aim of this study was to measure the clinical impact of a two-step interdisciplinary quality nutrition program. DESIGN: Prospective interventional study over three periods (A, baseline; B and C, intervention periods). SETTING: Mixed intensive care unit within a university hospital. PATIENTS: Five hundred seventy-two patients (age 59 ± 17 yrs) requiring >72 hrs of intensive care unit treatment. INTERVENTION: Two-step quality program: 1) bottom-up implementation of feeding guideline; and 2) additional presence of an intensive care unit dietitian. The nutrition protocol was based on the European guidelines. MEASUREMENTS AND MAIN RESULTS: Anthropometric data, intensive care unit severity scores, energy delivery, and cumulated energy balance (daily, day 7, and discharge), feeding route (enteral, parenteral, combined, none-oral), length of intensive care unit and hospital stay, and mortality were collected. Altogether 5800 intensive care unit days were analyzed. Patients in period A were healthier with lower Simplified Acute Physiologic Scale and proportion of "rapidly fatal" McCabe scores. Energy delivery and balance increased gradually: impact was particularly marked on cumulated energy deficit on day 7 which improved from -5870 kcal to -3950 kcal (p < .001). Feeding technique changed significantly with progressive increase of days with nutrition therapy (A: 59% days, B: 69%, C: 71%, p < .001), use of enteral nutrition increased from A to B (stable in C), and days on combined and parenteral nutrition increased progressively. Oral energy intakes were low (mean: 385 kcal*day, 6 kcal*kg*day ). Hospital mortality increased with severity of condition in periods B and C. CONCLUSION: A bottom-up protocol improved nutritional support. The presence of the intensive care unit dietitian provided significant additional progression, which were related to early introduction and route of feeding, and which achieved overall better early energy balance.