Special commentary : a call for intensive metabolic support.

PURPOSE OF REVIEW: This special commentary addresses recent clinical reviews regarding appropriate nutrition and metabolic support in the critical care setting. RECENT FINDINGS: There are divergent approaches between North America and Europe for the use of early nutrition support and combined enteral nutrition and parenteral nutrition support possibly due to the commercial availability of specific parenteral nutrients. The advent of intensive insulin therapy has changed the landscape of metabolic support in the intensive care unit, and previous notions about infective risk of parenteral nutrition will need to be re-addressed. Patients with brain failure may benefit from an intensive insulin therapy with a blood glucose target that is higher than that used in patients without brain failure. Patients with heart failure may benefit from the addition of nutritional pharmacology that targets proximate oxidative pathophysiological pathways. Intradialytic parenteral nutrition may be viewed as another form of supplemental parenteral nutrition when enteral nutrition is insufficient in patients on hemodialysis in the intensive care unit. SUMMARY: It is proposed that intensive metabolic support be routinely implemented in the intensive care unit based on the following steps: intensive insulin therapy with an appropriate blood glucose target, nutrition risk assessment, early and if needed combined enteral nutrition and parenteral nutrition to target 20-25 kcal/kg/day and 1.2-1.5 g protein/kg/day, and nutritional and metabolic monitoring.

Optimisation of energy provision with supplemental parenteral nutrition in critically ill patients: a randomised controlled clinical trial.

BACKGROUND: Enteral nutrition (EN) is recommended for patients in the intensive-care unit (ICU), but it does not consistently achieve nutritional goals. We assessed whether delivery of 100% of the energy target from days 4 to 8 in the ICU with EN plus supplemental parenteral nutrition (SPN) could optimise clinical outcome. METHODS: This randomised controlled trial was undertaken in two centres in Switzerland. We enrolled patients on day 3 of admission to the ICU who had received less than 60% of their energy target from EN, were expected to stay for longer than 5 days, and to survive for longer than 7 days. We calculated energy targets with indirect calorimetry on day 3, or if not possible, set targets as 25 and 30 kcal per kg of ideal bodyweight a day for women and men, respectively. Patients were randomly assigned (1:1) by a computer-generated randomisation sequence to receive EN or SPN. The primary outcome was occurrence of nosocomial infection after cessation of intervention (day 8), measured until end of follow-up (day 28), analysed by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00802503. FINDINGS: We randomly assigned 153 patients to SPN and 152 to EN. 30 patients discontinued before the study end. Mean energy delivery between day 4 and 8 was 28 kcal/kg per day (SD 5) for the SPN group (103% [SD 18%] of energy target), compared with 20 kcal/kg per day (7) for the EN group (77% [27%]). Between days 9 and 28, 41 (27%) of 153 patients in the SPN group had a nosocomial infection compared with 58 (38%) of 152 patients in the EN group (hazard ratio 0·65, 95% CI 0·43-0·97; p=0·0338), and the SPN group had a lower mean number of nosocomial infections per patient (-0·42 [-0·79 to -0·05]; p=0·0248). INTERPRETATION: Individually optimised energy supplementation with SPN starting 4 days after ICU admission could reduce nosocomial infections and should be considered as a strategy to improve clinical outcome in patients in the ICU for whom EN is insufficient. FUNDING: Foundation Nutrition 2000Plus, ICU Quality Funds, Baxter, and Fresenius Kabi.

Appropriateness of therapy for active Crohn's disease: results of a multidisciplinary international expert panel-EPACT II

The increasing number of trials testing management strategies for luminal Crohn's disease (CD) has not fitted all the gaps in our knowledge and thus, in clinical. practice, many decisions for CD patients have to be taken without the benefit of high-quality evidence. Methods: A multidisciplinary European expert panel used the RAND Appropriateness Method to develop and rate explicit criteria for the management of individual patients with active, steroid-dependent (ST-D) and steroid-refractory (ST-R) CD. Results: Overall., 296 indications pertaining to mild-to-moderate, severe, ST-D, and ST-R CD were rated. In anti-TNF naive patients, budesonide and prednisone were found to be appropriate for mild-moderate CD, and infliximab (IFX) was appropriate when these had previously failed or had not been tolerated. In patients with a prior successful treatment by IFX, this drug, with or without co-administration of a thiopurine analog, was favoured. Other anti-TNFs were appropriate in the presence of intolerance or resistance to IFX. High-dose steroids, IFX or adlimumab were appropriate in severe active CD. For the 105 indications for ST-D or ST-R disease, the panel considered the thiopurine analogs, methotrexate, IFX, adalimumab, and surgery for limited resection, to be appropriate, depending on the outcome of prior therapies. Anti-TNFs were generally considered appropriate in ST-R. Conclusion: Steroids, including budesonide for mild-to-moderate CD, remain the first-line therapy for active luminal CD. Anti-TNFs, in particular IFX as shown by the amount of available evidence, remain the second-line therapy for most indications. Thiopurine analogs, methotrexate and anti-TNFs are favoured in ST-D patients and ST-R patients. (C) 2009 European Crohn's and Colitis Organisation. Published by Elsevier B.V. All rights reserved.

Caracterização morfomecânica para beneficiamento do fruto da castanha-de-cutia (Couepia edulis)

A castanha-de-cutia (Couepia edulis (Prance) Prance) é um fruto fibroso encontrado na Amazônia Ocidental contendo uma amêndoa muito saborosa que os caboclos daquela região costumam consumir torrada e moída com a farinha de mandioca. Suas qualidades organolépticas tornam-na uma boa candidata para consumo também nos grandes centros urbanos do Brasil e no exterior. Diferentemente do que acontece nas indústrias extratoras de óleo, para o consumo de mesa, as amêndoas inteiras e com boa aparência são mais valorizadas. Esta é a primeira razão para o desenvolvimento de um equipamento de extração da amêndoa; o outro motivo é a inexistência de estudos específicos para o desenvolvimento de metodologias de extração da amêndoa da castanha-de-cutia. Neste trabalho, realizou-se parte das análises recomendadas para o desenvolvimento de um extrator da amêndoa de dentro do fruto: foi avaliado qualitativamente o comportamento reológico e de hidratação do mesocarpo; medidas as irregularidades e a esfericidade da seção transversal do fruto em função do perímetro do fruto; determinadas a excentricidade da seção longitudinal do fruto em função da área total, e a taxa de ocupação da amêndoa nas seções transversal e longitudinal. Estas informações serão usadas para desenvolver uma instrumentação de extração da amêndoa inteira, do fruto, com baixo risco para o operador e adequada para trabalhos em campo e em agroindústrias.

1996-2011: Análisis del soporte nutricional utilizado en los pacientes de la Unidad de Cuidados Intensivos (UCI) del Hospital Arnau de Vilanova (HUAV)

Objetivos: Comparar tres períodos de tiempo (1996-2001; 2002-2006; 2007-2011) a partir del análisis del soporte nutricional en los pacientes de UCI del hospital Arnau de Vilanova (HUAV). A partir de la comparación, elaborar modelos predictivos (basados en árboles de clasificación tipo CHAID y redes neuronales artificiales) del tipo de soporte nutricional a utilizar, según varias variables obtenidas en las primeras 24 horas de ingreso.

Tratamentos pré-germinativos e procedência de sementes do tucumã-do-amazonas para a produção de mudas

A germinação rápida e uniforme das sementes, seguida por pronta emergência das plântulas são características altamente desejáveis na formação de mudas. O objetivo deste trabalho foi avaliar o efeito da procedência das sementes, da frequência de troca de água para a hidratação e de choques de temperatura sobre a germinação e a produção de plântulas de tucumã-do-amazonas (Astrocaryum aculeatum). Os frutos foram obtidos em três locais do Estado do Amazonas: Mercado de Manaus e região de Maués e do Tarumã-Açu. Após limpeza e secagem dos pirênios e extração das sementes, essas foram submetidas à embebição por 15 dias com troca de água: uma e duas vezes ao dia. Após a embebição, foram aplicados os seguintes tratamentos: testemunha sem imersão em H2O; imersão em H2O a 50 e 10ºC por 5 minutos; imersão em H2O a 50ºC por 5 minutos, seguida por 10ºC por mais 5 minutos; imersão em H2O a 10ºC por 5 minutos, seguida por 50ºC por mais 5 minutos. Os tratamentos foram avaliados por meio de pré-germinação, emergência de plântulas no viveiro e produção de mudas. O experimento foi conduzido no delineamento inteiramente ao acaso, com os tratamentos distribuídos em arranjo fatorial 3 x 2 x 5 (locais de procedência x frequências de troca de água x tratamentos de temperatura), em quatro repetições e cinco sementes por parcela. A frequência de troca de água de embebição da semente e a exposição a choques de temperaturas não tem efeito sobre o desempenho germinativo. A procedência de sementes de tucumã-do-amazonas tem efeito na germinação e na produção de mudas.

Sensibilidade à dessecação e aoarmazenamento em sementes de Eugenia pyriformis Cambess. (uvaia)

Objetivou-se com este trabalho avaliar a sensibilidade à dessecação e a longevidade durante o armazenamento de sementes de Eugenia pyriformis Cambess. (uvaia). Os frutos utilizados foram coletados em matrizes localizadas na cidade de Amambai-MS. Para o estudo da sensibilidade à dessecação, foi utilizado o protocolo baseado na redução do nível de hidratação das sementes a cada cinco pontos percentuais, obtendo-se sementes com teores de água de 45; 40; 30; 25; 20; 15; 10 e 5%. Para estudar a longevidade das sementes durante o armazenamento, foram testadas as condições de câmara fria e seca (16±1Cº/40% UR), geladeira (5±1Cº) e freezer (-18±1ºC) durante 30 dias, e as sementes que não foram submetidas ao armazenamento constituíram o tratamento-controle. A semeadura foi realizada entre areia a 20/30ºC com 10h de luz/14h de escuro em B.O.D. As sementes de uvaia são sensíveis à dessecação e não toleraram a secagem a 5% de teor de água. As sementes recém-beneficiadas apresentaram germinação de aproximadamente 77% e com a secagem até 5% houve a redução para 15% de germinação. A diminuição do teor de água provocou a redução da massa fresca, comprimento de raiz primária, hipocótilo e total de plântulas e tempo médio de germinação. As condições de armazenamento sob temperaturas baixas e a secagem reduziram a germinação das sementes, indicando assim o comportamento recalcitrante das sementes de uvaia.

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.

Prenatal Risk Factors and Outcomes in Gastroschisis: A Meta-Analysis.

BACKGROUND AND OBJECTIVE: Gastroschisis is a congenital anomaly with increasing incidence, easy prenatal diagnosis and extremely variable postnatal outcomes. Our objective was to systematically review the evidence regarding the association between prenatal ultrasound signs (intraabdominal bowel dilatation [IABD], extraabdominal bowel dilatation, gastric dilatation [GD], bowel wall thickness, polyhydramnios, and small for gestational age) and perinatal outcomes in gastroschisis (bowel atresia, intra uterine death, neonatal death, time to full enteral feeding, length of total parenteral nutrition and length of in hospital stay). METHODS: Medline, Embase, and Cochrane databases were searched electronically. Studies exploring the association between antenatal ultrasound signs and outcomes in gastroschisis were considered suitable for inclusion. Two reviewers independently extracted relevant data regarding study characteristics and pregnancy outcome. All meta-analyses were computed using individual data random-effect logistic regression, with single study as the cluster unit. RESULTS: Twenty-six studies, including 2023 fetuses, were included. We found significant positive associations between IABD and bowel atresia (odds ratio [OR]: 5.48, 95% confidence interval [CI] 3.1-9.8), polyhydramnios and bowel atresia (OR: 3.76, 95% CI 1.7-8.3), and GD and neonatal death (OR: 5.58, 95% CI 1.3-24.1). No other ultrasound sign was significantly related to any other outcome. CONCLUSIONS: IABD, polyhydramnios, and GD can be used to an extent to identify a subgroup of neonates with a prenatal diagnosis of gastroschisis at higher risk to develop postnatal complications. Data are still inconclusive on the predictive ability of several signs combined, and large prospective studies are needed to improve the quality of prenatal counseling and the neonatal care for this condition.

Metabolic and nutritional support of critically ill patients: consensus and controversies.

The results of recent large-scale clinical trials have led us to review our understanding of the metabolic response to stress and the most appropriate means of managing nutrition in critically ill patients. This review presents an update in this field, identifying and discussing a number of areas for which consensus has been reached and others where controversy remains and presenting areas for future research. We discuss optimal calorie and protein intake, the incidence and management of re-feeding syndrome, the role of gastric residual volume monitoring, the place of supplemental parenteral nutrition when enteral feeding is deemed insufficient, the role of indirect calorimetry, and potential indications for several pharmaconutrients.

How much protein and energy are needed to equilibrate nitrogen and energy balances in ventilated critically ill children?

BACKGROUND & AIMS: Protein and energy requirements in critically ill children are currently based on insufficient data. Moreover, longitudinal measurements of both total urinary nitrogen (TUN) and resting energy expenditure (REE) are lacking. The aim of this study was to investigate how much protein and energy are needed to equilibrate nitrogen and energy balances in ventilated critically ill children on the basis of daily measurements of TUN, REE and protein and energy intakes. Comparisons were made with the guidelines of the American Society for Parenteral and Enteral Nutrition and the Dietary Reference Intakes. METHODS: Children with an expected duration of mechanical ventilation ≥72 h were prospectively recruited. TUN was measured by chemiluminescence, and REE was measured by indirect calorimetry. Generalised linear models for longitudinal data were used to study the relation between protein intake and nitrogen balance and to calculate the minimum intake of protein needed to achieve nitrogen equilibrium. A similar approach was used for energy. Results were compared to the recommended values. RESULTS: Based on 402 measurements performed in 74 children (median age: 21 months), the mean TUN was high at 0.20 (95% CI: 0.20, 0.22) g/kg/d and the REE was 55 (95% CI: 54, 57) kcal/kg/d. Nitrogen and energy balances were achieved with 1.5 (95% CI: 1.4, 1.6) g/kg/d of protein and 58 (95% CI: 53, 63) kcal/kg/d for the entire group, but there were differences among children of different ages. Children required more protein and less energy than the Dietary Reference Intakes. CONCLUSIONS: In critically ill children, TUN was elevated and REE was reduced during the entire period of mechanical ventilation. Minimum intakes of 1.5 g/kg/d of protein and 58 kcal/kg/d can equilibrate nitrogen and energy balances in children up to 4 years old. Older children require more protein.

IV paracetamol versus IV ibuprofen for the treatment of PDA in LBW infants: a randomized controlled trial

Patent ductus arteriosus is a prevalent problem in low birth weight infants and it has an important morbidity and mortality in this group of patients. Classical treatment options include drugs (intravenous cyclooxygenase inhibitors: indomethacin and ibuprofen) and surgical ligation, but these treatments are associated with significant adverse effects. An alternative treatment with fewer side effects is needed. The role of oral paracetamol has gained importance in recent years, this new therapeutic option is being widely studied, and there are already many studies which support oral paracetamol as first line treatment for PDA, due to its better safety profile than classical drugs. In LBW infants is difficult to administer enteral treatment, since they are often multi pathological patients with several complications that preclude oral administration and they usually receive intravenous treatments. This multicenter, prospective, single blinded, randomized, controlled, parallel-group and noninferiority trial is designed to evaluate the efficacy and safety of intravenous paracetamol versus intravenous ibuprofen in the treatment of PDA in LBW infants. Sixty eight infants with echocardiography confirmed PDA will be randomly assigned to receive either intravenous paracetamol or intravenous ibuprofen. The main endpoints will be the rate of ductal closure of each drug and adverse events in each group of treatment

Efeito do triacilglicerídeo de cadeia média, da fibra e do cálcio na disponibilidade de magnésio e de zinco pelo método in vitro e metodologia de superfície de resposta

Nutritional therapy with enteral diets became highly specialized in the last years. This work aims to study the effect of the components of a formulation, namely fiber, calcium and medium-chain triglycerides, for dialysability of minerals. Analysis of multiple variables was done using response surface methodology. The level curve showed that the tertiary interaction MCT-fiber-calcium was the one that presented the highest synergism in the formulation. The proportion of 33% MCT, 25% fiber and 42% calcium, gave the best formulation for availability of magnesium.

Especificidade de Pyrenophora avenae aos tecidos da semente de Avena sativa e sua atividade enzimática

Manchas nos grãos de aveia (Avena sativa) é limitante à sua comercialização por tornar o produto escuro e não permitir seu uso pela indústria alimentícia. A localização do micélio de Pyrenophora avenae nos grãos de aveia e sua atividade enzimática podem esclarecer a causa das manchas. O objetivo deste trabalho foi determinar a localização de P. avenae, na cariopse de aveia, avaliar a sua atividade enzimática e seu efeito sobre proteínas e lipídios dos grãos de aveia. A localização do micélio nos tecidos da cariopse foi determinada após hidratação e cortes da mesma, seguido da análise dos tecidos sob lupa e microscópio. Para avaliação da atividade enzimática foram utilizados 18 isolados de P. avenae obtidos das principais regiões produtoras de aveia do Brasil, avaliando-os quanto às suas atividades amilolítica, proteolítica e lipolítica, sendo realizada por plaqueamento das estruturas vegetativas em meio sólido específico para as enzimas testadas. As determinações do percentual de proteínas e lipídios foram obtidas pelos métodos de Kjeldahl e Bligh & Dyer, respectivamente. O micélio de P. avenae é a principal causa da mancha nos grãos de aveia, localizando-se nos três tecidos do pericarpo. O fitopatógeno apresenta boa atividade enzimática para lipase e protease porém insignificante para a amilase. Os grãos de aveia manchados e sadios não diferiram nos teores de proteínas e de lipídios. Esses teores foram mais elevados nos tecidos superficiais do pericarpo e aleurona independente da presença ou não de manchas, justificando o crescimento superficial de P. avenae sobre os grãos de aveia.

Chapa aglomerada de cimento-madeira de Hevea brasiliensis Müll. Arg.

Chapas de partículas de cimento-madeira foram confeccionadas com a madeira de quatro clones de Hevea brasiliensis Müll. Arg. (seringueira): IAN 717, IAN 873, GT 711 e AVROS 1301. Confeccionaram-se as chapas na proporção de 1:4:1 (madeira:cimento:água) por peso e nas dimensões de 450 x 450 x 13 mm e densidade nominal de 1,4 g/cm³, com a adição de 4% de cloreto de cálcio di-hidratado (CaCl2.2H2O) como acelerador. Foram testadas partículas fervidas e não-fervidas dos quatro clones, totalizando oito tratamentos, sendo em cada um destes, com quatro repetições, avaliadas as propriedades mecânicas e físicas das chapas, segundo a norma ASTM D 1037 - 96a. De forma geral, os melhores resultados de propriedades físicas e mecânicas foram obtidos nas chapas com partículas do clone AVROS 1301. No teste de hidratação do cimento, a madeira de seringueira in natura foi classificada como de "inibição extrema", porém com a adição de CaCl2 o foi como de "baixa inibição". Essa madeira se mostrou tecnicamente viável à produção de chapas de cimento-madeira, independentemente do clone.