Detection of cognitive impairment with the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) in adolescents with psychotic symptomatology.

Cognitive impairment has been identified in the early phase of schizophrenia spectrum disorders, and is a major contributor to disease-related disability. While screening tools assessing cognitive impairment have been validated for adult schizophrenic populations, there is a need for brief, easily administered, standardized instruments that provide clinically relevant information for adolescents. This study examines the utility of the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) in identifying and quantifying neurocognitive impairment in adolescents with schizophrenia spectrum disorders and other serious psychiatric illnesses. 112 adolescents, including 32 healthy subjects and 80 patients, were administered the RBANS. Patients with psychotic disorders demonstrated significant impairment on the RBANS total score compared to patients with other disorders and healthy controls, but this impairment appeared somewhat less severe than is typically reported for in adult patients with schizophrenia on this measure. The RBANS appears to be sensitive in the detection of neurocognitive impairment in a psychiatric population of adolescents with psychotic symptomatology, and may therefore have utility as a clinical screening instrument and/or neurocognitive outcome measure in this population.

Stroke initial severity and outcome relative to insurance status in a universal health care system in Switzerland

Contexte et but de l'étude :Le statut socio-économique est suspecté d'avoir une influence significative sur l'incidence des attaques cérébrales (AVC), sur les facteurs de risque cardio-vasculaire, ainsi que sur le pronostic. L'influence de ce statut socio-économique sur la sévérité de l'AVC et sur les mécanismes physiopathologiques sous-jacents est moins connue.Méthode :Sur une période de 4 ans, nous avons collecté de manière prospective (dans un registre) des données concernant tous les patients avec AVC aigus admis à l'Unité Cérébrovasculaire du CHUV. Les données comprenaient le statut assécurologique du patient (assurance privée ou générale), les données démographiques, les facteurs de risque cérébrovasculaires, l'utilisation de traitements aigus de recanalisation vasculaire, le délai avant l'admission à l'hôpital, ainsi que la sévérité et le pronostic de l'AVC en phase aiguë, à 7 jours et à 3 mois des symptômes. Les patients avec assurance privée ont été comparés à ceux avec assurance générale.Résultats :Sur 1062 patients avec AVC, 203 avaient une assurance privée et 859 avaient une assurance générale. Il y a avait 585 hommes et 477 femmes. Les deux populations étaient similaires en âge. Les facteurs de risque cardio-vasculaire, la médication préventive, le délai d'arrivée à l'hôpital, l'incidence du taux de thrombolyse et l'étiologie de l'AVC ne différaient pas dans les deux populations. Le score de gravité de l'AVC en phase aiguë, mesuré par le NIHSS, était significativement plus élevé chez les patients avec assurance générale. Un pronostic favorable, mesuré par le score de Rankin modifié (mRS), était plus fréquemment obtenu à 7 jours et à 3 mois chez les patients avec assurance privée.Commentaires :Un statut socio-économique bas est associé à une incidence plus élevée de maladies cérébrovasculaires ainsi qu'à un plus mauvais pronostic, comme cela a été démontré dans différents pays. Il a été suspecté que l'accès à une prise en charge spécialisée en phase aiguë ou en rééducation soit différent selon le statut socio-économique. Comme la Suisse a un système de santé universel, avec une couverture assécurologique obligatoire pour chaque habitant, il y a là une occasion unique de comparer l'influence de l'aspect socio-économique sur la sévérité et le pronostic de l'AVC. De plus, les patients ont été admis dans la même Unité Cérébrovasculaire et pris en charge par la même équipe médicale.Conclusion et perspectives :Le lien entre le statut assécurologique et le statut socio-économique a déjà été prouvé par le passé dans d'autres pays. Nous avons mis en évidence une sévérité plus importante et un plus mauvais pronostic chez les patients avec assurance générale dans la population étudiée. L'étiologie de cette différence dans un système de santé à couverture universelle comme celui de la Suisse reste peu claire. Elle devrait être étudiée à plus grande échelle.

Trabecular Bone Score: A Noninvasive Analytical Method Based Upon the DXA Image.

The trabecular bone score (TBS) is a gray-level textural metric that can be extracted from the two-dimensional lumbar spine dual-energy X-ray absorptiometry (DXA) image. TBS is related to bone microarchitecture and provides skeletal information that is not captured from the standard bone mineral density (BMD) measurement. Based on experimental variograms of the projected DXA image, TBS has the potential to discern differences between DXA scans that show similar BMD measurements. An elevated TBS value correlates with better skeletal microstructure; a low TBS value correlates with weaker skeletal microstructure. Lumbar spine TBS has been evaluated in cross-sectional and longitudinal studies. The following conclusions are based upon publications reviewed in this article: 1) TBS gives lower values in postmenopausal women and in men with previous fragility fractures than their nonfractured counterparts; 2) TBS is complementary to data available by lumbar spine DXA measurements; 3) TBS results are lower in women who have sustained a fragility fracture but in whom DXA does not indicate osteoporosis or even osteopenia; 4) TBS predicts fracture risk as well as lumbar spine BMD measurements in postmenopausal women; 5) efficacious therapies for osteoporosis differ in the extent to which they influence the TBS; 6) TBS is associated with fracture risk in individuals with conditions related to reduced bone mass or bone quality. Based on these data, lumbar spine TBS holds promise as an emerging technology that could well become a valuable clinical tool in the diagnosis of osteoporosis and in fracture risk assessment. © 2014 American Society for Bone and Mineral Research.

Respiratory viruses in the pediatric intensive care unit: prevalence and clinical aspects

A survey was conducted in two pediatric intensive care units in hospitals in Porto Alegre, Brazil, in order to monitor the main respiratory viruses present in bronchiolitis and/or pneumonia and their involvement in the severity of viral respiratory infections. Viral respiratory infection prevalence was 38.7%. In bronchiolitis, respiratory syncytial virus (RSV) was detected in 36% of the cases. In pneumonia, the prevalence rates were similar for adenovirus (10.3%) and RSV (7.7%). There was a difference among the viruses detected in terms of frequency of clinical findings indicating greater severity. Frequency of crackles in patients with RSV (47.3%) showed a borderline significance (p = 0.055, Fisher's exact test) as compared to those with adenovirus (87.5%). The overall case fatality rate in this study was 2.7%, and adenovirus showed a significantly higher case fatality rate (25%) than RSV (2.8%) (p = 0.005). Injected antibiotics were used in 49% of the children with RSV and 60% of those with adenovirus. Adenovirus was not detected in any of the 33 children submitted to oxygen therapy.

Severity of endoscopically detected esophageal inflammatory and fibrostenotic features correlates with degree of esophageal eosinophilia in adults with eosinophilic esophagitis

Background: Eosinophilic esophagitis (EoE) has emerged as a leading cause of dysphagia in adults. Characteristic esophageal features on endoscopy include structural/fibrostenotic (rings, narrow caliber, strictures) and inflammatory manifestations (longitudinal furrows, exudates, edema). Aim: The purpose of this study was to correlate the clinical, endoscopic and histopathologic features in adult EoE patients. Methods: A total of 106 encounters of 81 patients with EoE were analyzed. Data included an EoE-directed symptom-severity patient questionnaire evaluating symptoms of dysphagia (frequency, intensity, duration), meal duration, chest pain, and overall symptom severity. Video recordings of endoscopies were reviewed in a blinded manner using a classification and grading scheme for the esophageal features of EoE. Histopathology was reviewed for peak eosinophil count/high power field by pathologists blinded to the patients' clinical status. Associations between endoscopic features, histology and symptoms were evaluated using the Spearman rank correlation analysis. Results: The endoscopic severity of both structural and inflammatory esophageal features of EoE, including rings, exudates, longitudinal furrows, and edema, correlated significantly with peak eosinophil counts (see Table 1). Presence of "crepe paper mucosa" did not demonstrate significant association with peak eosinophil counts. Both structural (rings, narrow-caliber esophagus and strictures) and inflammatory (furrows, exudates and edema) composite endoscopic scores demonstrated a strong correlation with peak eosinophil counts. The strongest association with the degree of esophageal eosinophilia was found with a combination of both structural and inflammatory findings (p < 0.0001). The esophageal diameter (in mm) was negatively correlated with overall symptom severity (Spearman's rho = -0.4883, P = 0.0339). None of the individual or combined patient reported symptoms correlated significantly with either endoscopic or histopathologic findings. Conclusion: The severity of both structural and inflammatory endoscopic features associated with EoE is significantly associated with the degree of esophageal eosinophilia. Patient reported symptom severity was not associated with the degree of esophageal eosinophilia. Esophageal stricture diameter was inversely correlated with EoE symptom severity. The prognostic and therapeutic implications of these observations need to be determined.

Red cell distribution width does not predict stroke severity or functional outcome.

INTRODUCTION: Red cell distribution width was recently identified as a predictor of cardiovascular and all-cause mortality in patients with previous stroke. Red cell distribution width is also higher in patients with stroke compared with those without. However, there are no data on the association of red cell distribution width, assessed during the acute phase of ischemic stroke, with stroke severity and functional outcome. In the present study, we sought to investigate this relationship and ascertain the main determinants of red cell distribution width in this population. METHODS: We used data from the Acute Stroke Registry and Analysis of Lausanne for patients between January 2003 and December 2008. Red cell distribution width was generated at admission by the Sysmex XE-2100 automated cell counter from ethylene diamine tetraacetic acid blood samples stored at room temperature until measurement. An χ(2) -test was performed to compare frequencies of categorical variables between different red cell distribution width quartiles, and one-way analysis of variance for continuous variables. The effect of red cell distribution width on severity and functional outcome was investigated in univariate and multivariate robust regression analysis. Level of significance was set at 95%. RESULTS: There were 1504 patients (72±15·76 years, 43·9% females) included in the analysis. Red cell distribution width was significantly associated to NIHSS (β-value=0·24, P=0·01) and functional outcome (odds ratio=10·73 for poor outcome, P<0·001) at univariate analysis but not multivariate. Prehospital Rankin score (β=0·19, P<0·001), serum creatinine (β=0·008, P<0·001), hemoglobin (β=-0·009, P<0·001), mean platelet volume (β=0·09, P<0·05), age (β=0·02, P<0·001), low ejection fraction (β=0·66, P<0·001) and antihypertensive treatment (β=0·32, P<0·001) were independent determinants of red cell distribution width. CONCLUSIONS: Red cell distribution width, assessed during the early phase of acute ischemic stroke, does not predict severity or functional outcome.

The prediction of cardiovascular events is improved by combination of Framingham risk score and subclinical atherosclerosis imaging

Purpose: In primary prevention of cardiovascular disease (CVD), it is accepted that the intensity of risk factor treatment should be guided by the magnitude of absolute risk. Risk factors tools like Framingham risk score (FHS) or noninvasive atherosclerosis imaging tests are available to detect high risk subjects. However, these methods are imperfect and may misclassify a large number of individuals. The purpose of this prospective study was to evaluate whether the prediction of future cardiovascular events (CVE) can be improved when subclinical imaging atherosclerosis (SCATS) is combined with the FRS in asymptomatic subjects. Methods: Overall, 1038 asymptomatic subjects (413 women, 625 men, mean age 49.1±12.8 years) were assessed for their cardiovascular risk using the FRS. B-mode ultrasonography on carotid and femoral arteries was performed by two investigators to detect atherosclerotic plaques (focal thickening of intima-media > 1.2 mm) and to measure carotid intima-media thickness (C-IMT). The severity of SCATS was expressed by an ATS-burden Score (ABS) reflecting the number of the arterial sites with >1 plaques (range 0-4). CVE were defined as fatal or non fatal acute coronary syndrome, stroke, or angioplasty for peripheral artery disease. Results: during a mean follow-up of 4.9±3.1 years, 61 CVE were recorded. Event rates the rate of CVE increased significantly from 2.7% to 39.1% according to the ABS (p<0.001) and from 4% to 24.6% according to the quartiles of C-IMT. Similarly, FRS predicted CVE (p<0.001). When computing the angiographic markers of SCATS in addition of FRS, we observed an improvement of net reclassification rate of 16.6% (p< 0.04) for ABS as compared to 5.5% (p = 0.26) for C-IMT. Conclusion: these results indicate that the detection of subjects requiring more attention to prevent CVE can be significantly improved when using both FRS and SCATS imaging.

Beyond sepsis pathophysiology with cytokines: what is their value as biomarkers for disease severity?

Sepsis is a major challenge in medicine. It is a common and frequently fatal infectious condition. The incidence continues to increase, with unacceptably high mortality rates, despite the use of specific antibiotics, aggressive operative intervention, nutritional support, and anti-inflammatory therapies. Typically, septic patients exhibit a high degree of heterogeneity due to variables such as age, weight, gender, the presence of secondary disease, the state of the immune system, and the severity of the infection. We are at urgent need for biomarkers and reliable measurements that can be applied to risk stratification of septic patients and that would easily identify those patients at the highest risk of a poor outcome. Such markers would be of fundamental importance to decision making for early intervention therapy or for the design of septic clinical trials. In the present work, we will review current biomarkers for sepsis severity and especially the use of cytokines as biomarkers with important pathophysiological role.

Embolic strokes of undetermined source in the athens stroke registry: a descriptive analysis.

BACKGROUND AND PURPOSE: A new clinical construct termed embolic stroke of undetermined source (ESUS) was recently introduced, but no such population has been described yet. Our aim is to provide a detailed descriptive analysis of an ESUS population derived from a large prospective ischemic stroke registry using the proposed diagnostic criteria. METHODS: The criteria proposed by the Cryptogenic Stroke/ESUS International Working Group were applied to the Athens Stroke Registry to identify all ESUS patients. ESUS was defined as a radiologically confirmed nonlacunar brain infarct in the absence of (a) extracranial or intracranial atherosclerosis causing ≥50% luminal stenosis in arteries supplying the ischemic area, (b) major-risk cardioembolic source, and (c) any other specific cause of stroke. RESULTS: Among 2735 patients admitted between 1992 and 2011, 275 (10.0%) were classified as ESUS. In the majority of ESUS (74.2%), symptoms were maximal at onset. ESUS were of moderate severity (median National Institute Health Stroke Scale score, 5). The most prevalent risk factor was arterial hypertension (64.7%), and 50.9% of patients were dyslipidemic. Among potential causes of the ESUS, covert atrial fibrillation (AF) was the most prevalent: in 30 (10.9%) patients, AF was diagnosed during hospitalization for stroke recurrence, whereas in 50 (18.2%) patients AF was detected after repeated ECG monitoring during follow-up. Also, covert AF was strongly suggested in 38 patients (13.8%) but never recorded. CONCLUSIONS: About 10% of patients with first-ever ischemic stroke met criteria for ESUS; covert paroxysmal AF seems to be a frequent cause of ESUS.

Clinical outcome after trimipramine in patients with delusional depression - a pilot study

The treatment of delusional depression is a major challenge in psychopharmacology. Hypothalamic-pituitary-adrenocortical (HPA) overdrive may contribute, via increased dopaminergic activity, to the pathophysiology of the disorder. Trimipramine appears to be an interesting potential candidate, since it is an atypical antidepressant that is known to inhibit HPA activity. In a four-week open trial we investigated its effects in 15 inpatients with delusional depression. The dosage was increased within 7 days up to 300 - 400 mg/d and was then maintained for three weeks. Psychometric assessments and safety monitoring were conducted weekly. Assessment of the HPA activity was achieved by a combined dexamethasone suppression/corticotropin-releasing hormone stimulation (Dex/CRH) test before and after four weeks of treatment. Therapeutic response was defined as a decrease in the HAMD-score of at least 50 %. Eight out of 13 completers were rated as responders. Therapeutic response was associated with L, D-trimipramine concentrations higher than 160 ng/ml. Intent-to-treat analysis showed significant improvement in psychometric variables. Despite the high dosage, the substance was generally well tolerated, with the exception of one patient who suffered from a hypotensive reaction. Mean +/- SD concentration of L-trimipramine and D-trimipramine were 138 +/- 61 ng/ml and 119 +/- 50 ng/ml at a final dose of 346 +/- 50 mg/d. The ACTH and cortisol area under the curve in the Dex/CRH tests decreased significantly, reflecting a decrease of activity in the HPA system. We suggest that the clinical use of high-dose trimipramine in delusional depression seems to be a promising treatment strategy.

Behaviour evaluation for risk-taking adolescents (BERTA): an easy to use and assess instrument to detect adolescent risky behaviours in a clinical setting.

To create an instrument to be used in an outpatient clinic to detect adolescents prone to risk-taking behaviours. Based on previous research, five identified variables (relationship with parents and teachers, liking going to school, average grades, and level of religiosity) were used to create a screening tool to detect at least one of ten risky behaviours (tobacco, alcohol, cannabis and other illegal drugs use; sexual intercourse and sexual risky behaviour; driving while intoxicated, riding with an intoxicated driver, not always using a seat belt, and not always using a helmet). The instrument was tested using the Barcelona Adolescent Health Survey 1993. A Receiver Operating Characteristics curve was used to find the best cut-off point between high and low risk score. Odds ratios and 95% confidence intervals were calculated to detect at least one risky behaviour and for each individual behaviour. In order to assess its predictive value, the analysis was repeated using the Barcelona Adolescent Health Survey 1999. In both cases, analyses were conducted for the whole sample and for younger and older adolescents. Adolescents with a high-risk score were more likely to take at least one risky behaviour both when the whole sample was analysed and by age groups. With very few exceptions, the Behaviour Evaluation for Risk-Taking Adolescents showed significant odds ratios for each individual variable. CONCLUSION: The Behaviour Evaluation for Risk-Taking Adolescents has shown its potential as an easy to use instrument to screen for risk-taking behaviours. Future research must aim towards assessing this instrument's predictive value in the clinical setting and it's application to other populations.

Prevalence and clinical aspects of respiratory syncytial virus A and B groups in children seen at Hospital de Clínicas of Uberlândia, MG, Brazil

Respiratory syncytial virus (RSV) is well recognized as the most important pathogen causing acute respiratory disease in infants and young children, mainly in the form of bronchiolitis and pneumonia. Two major antigenic groups, A and B, have been identified; however, there is disagreement about the severity of the diseases caused by these two types. This study investigated a possible association between RSV groups and severity of disease. Reverse transcription-polymerase chain reaction was used to characterize 128 RSV nasopharyngeal specimens from children less than five years old experiencing acute respiratory disease. A total of 82 of 128 samples (64.1%) could be typed, and, of these, 78% were group A, and 22% were group B. Severity was measured by clinical evaluation associated with demographic factors: for RSV A-infected patients, 53.1% were hospitalized, whereas for RSV B patients, 27.8% were hospitalized (p = 0.07). Around 35.0% of the patients presented risk factors for severity (e.g., prematurity). For those without risk factors, the hospitalization occurred in 47.6% of patients infected with RSV A and in 18.2% infected with RSV B. There was a trend for RSV B infections to be milder than those of RSV A. Even though RSV A-infected patients, including cases without underlying condition and prematurity, were more likely to require hospitalization than those infected by RSV B, the disease severity could not to be attributed to the RSV groups.

Validation of the instability shoulder index score in a multicenter reliability study in 114 consecutive cases.

BACKGROUND: Anterior shoulder stabilization surgery with the arthroscopic Bankart procedure can have a high recurrence rate in certain patients. Identifying these patients to modify outcomes has become a focal point of research. PURPOSE: The Instability Shoulder Index Score (ISIS) was developed to predict the success of arthroscopic Bankart repair. Scores range from 0 to 10, with higher scores predicting a higher risk of recurrence after stabilization. The interobserver reliability of the score is not known. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: This is a prospective multicenter (North America and Europe) study of patients suffering from shoulder instability and waiting for stabilization surgery. Five pairs of independent evaluators were asked to score patient instability severity with the ISIS. Patients also completed functional scores (Western Ontario Shoulder Instability Index [WOSI], Disabilities of the Arm, Shoulder and Hand-short version [QuickDASH], and Walch-Duplay test). Data on age, sex, number of dislocations, and type of surgery were collected. The test-retest method and intraclass correlation coefficient (ICC: >0.75 = good, >0.85 = very good, and >0.9 = excellent) were used for analysis. RESULTS: A total of 114 patients with anterior shoulder instability were included, of whom 89 (78%) were men. The mean age was 28 years. The ISIS was very reliable, with an ICC of 0.933. The mean number of dislocations per patient was higher in patients who had an ISIS of ≥6 (25 vs 14; P = .05). Patients who underwent more complex arthroscopic procedures such as Hill-Sachs remplissage or open Latarjet had higher preoperative ISIS outcomes, with a mean score of 4.8 versus 3.4, respectively (P = .002). There was no correlation between the ISIS and the quality-of-life questionnaires, with Pearson correlations all >0.05 (WOSI = 0.39; QuickDASH = 0.97; Walch-Duplay = 0.08). CONCLUSION: Our results show that the ISIS is reliable when used in a multicenter study with anterior traumatic instability populations. There was no correlation between the ISIS and the quality-of-life questionnaires, but surgical decisions reflected its increased use.

Variability of indication criteria in knee and hip replacement: an observational study

BACKGROUND. Total knee (TKR) and hip (THR) replacement (arthroplasty) are effective surgical procedures that relieve pain, improve patients' quality of life and increase functional capacity. Studies on variations in medical practice usually place the indications for performing these procedures to be highly variable, because surgeons appear to follow different criteria when recommending surgery in patients with different severity levels. We therefore proposed a study to evaluate inter-hospital variability in arthroplasty indication. METHODS. The pre-surgical condition of 1603 patients included was compared by their personal characteristics, clinical situation and self-perceived health status. Patients were asked to complete two health-related quality of life questionnaires: the generic SF-12 (Short Form) and the specific WOMAC (Western Ontario and Mcmaster Universities) scale. The type of patient undergoing primary arthroplasty was similar in the 15 different hospitals evaluated.The variability in baseline WOMAC score between hospitals in THR and TKR indication was described by range, mean and standard deviation (SD), mean and standard deviation weighted by the number of procedures at each hospital, high/low ratio or extremal quotient (EQ5-95), variation coefficient (CV5-95) and weighted variation coefficient (WCV5-95) for 5-95 percentile range. The variability in subjective and objective signs was evaluated using median, range and WCV5-95. The appropriateness of the procedures performed was calculated using a specific threshold proposed by Quintana et al for assessing pain and functional capacity. RESULTS. The variability expressed as WCV5-95 was very low, between 0.05 and 0.11 for all three dimensions on WOMAC scale for both types of procedure in all participating hospitals. The variability in the physical and mental SF-12 components was very low for both types of procedure (0.08 and 0.07 for hip and 0.03 and 0.07 for knee surgery patients). However, a moderate-high variability was detected in subjective-objective signs. Among all the surgeries performed, approximately a quarter of them could be considered to be inappropriate. CONCLUSIONS. A greater inter-hospital variability was observed for objective than for subjective signs for both procedures, suggesting that the differences in clinical criteria followed by surgeons when indicating arthroplasty are the main responsible factors for the variation in surgery rates.

Oxidative stress is increased in critically ill patients according to antioxidant vitamins intake, independent of severity: a cohort study

Introduction. Critically ill patients suffer from oxidative stress caused by reactive oxygen species (ROS) and reactive nitrogen species (RNS). Although ROS/RNS are constantly produced under normal circumstances, critical illness can drastically increase their production. These patients have reduced plasma and intracellular levels of antioxidants and free electron scavengers or cofactors, and decreased activity of the enzymatic system involved in ROS detoxification. The pro-oxidant/antioxidant balance is of functional relevance during critical illness because it is involved in the pathogenesis of multiple organ failure. In this study the objective was to evaluate the relation between oxidative stress in critically ill patients and antioxidant vitamin intake and severity of illness. Methods. Spectrophotometry was used to measure in plasma the total antioxidant capacity and levels of lipid peroxide, carbonyl group, total protein, bilirubin and uric acid at two time points: at intensive care unit (ICU) admission and on day seven. Daily diet records were kept and compliance with recommended dietary allowance (RDA) of antioxidant vitamins (A, C and E) was assessed. Results. Between admission and day seven in the ICU, significant increases in lipid peroxide and carbonyl group were associated with decreased antioxidant capacity and greater deterioration in Sequential Organ Failure Assessment score. There was significantly greater worsening in oxidative stress parameters in patients who received antioxidant vitamins at below 66% of RDA than in those who received antioxidant vitamins at above 66% of RDA. An antioxidant vitamin intake from 66% to 100% of RDA reduced the risk for worsening oxidative stress by 94% (ods ratio 0.06, 95% confidence interval 0.010 to 0.39), regardless of change in severity of illness (Sequential Organ Failure Assessment score). Conclusion. The critical condition of patients admitted to the ICU is associated with worsening oxidative stress. Intake of antioxidant vitamins below 66% of RDA and alteration in endogenous levels of substances with antioxidant capacity are related to redox imbalance in critical ill patients. Therefore, intake of antioxidant vitamins should be carefully monitored so that it is as close as possible to RDA.