Pilot study with a glutamine-supplemented enteral formula in critically ill infants

Seriously ill infants often display protein-calorie malnutrition due to the metabolic demands of sepsis and respiratory failure. Glutamine has been classified as a conditionally essential amino acid, with special usefulness in critical patients. Immunomodulation, gut protection, and prevention of protein depletion are mentioned among its positive effects in such circumstances. With the intent of evaluating the tolerance and clinical impact of a glutamine supplement in seriously ill infants, a prospective randomized study was done with nine patients. Anthropometric and biochemical determinations were made, and length of stay in the intensive care unit (ICU), in the hospital, and under artificial ventilation, and septic morbidity and mortality were tabulated. Infants in the treatment group (n=5) were enterally administered 0.3 g/kg of glutamine, whereas controls received 0.3 g/kg of casein during a standard period of five days. Septic complications occurred in 75% of the controls (3/4) versus 20% of the glutamine-treated group (1/5, p<=0.10), and two patients in the control group died of bacterial infections (50% vs. 0%, p<=0.10). Days in the ICU, in the hospital, and with ventilation numerically favored glutamine therapy, although without statistical significance. The supplements were usually well tolerated, and no patient required discontinuation of the program. The conclusion was that glutamine supplementation was safe and tended to be associated with less infectious morbidity and mortality in this high-risk population.

Low blood glucose levels and other complications during growth hormone supplementation in sepsis

Blood glucose levels in the high normal range or even moderate hyperglycemia is the expected profile in septic postoperative patients receiving high-calorie enteral alimentation. The addition of growth hormone as an anabolic agent should additionally reinforce this tendency. In a cancer patient undergoing partial gastrectomy with lymphadenectomy and suffering from postoperative subphrenic abscess and prolonged sepsis, tube feeding (38.3 kcal/kg/day) and growth hormone (0.17 IU/kg/day) were simultaneously administered for 25 days. Blood glucose levels were in the lower limits of the normal range before growth hormone introduction, and continued with a similar tendency during most of the therapeutic period. Two additional complications, namely heart arrest and peripheral edema, were documented during the same period. It is concluded that sepsis was the most likely mechanism for low glucose values, and that high-calorie enteral diet and growth hormone supplementation did not prevent that result. It is uncertain whether heart arrest was due to the drug, but its association with peripheral edema is well documented in clinical series.

Changes in body fluid and energy compartments during prolonged hunger strike

Prolonged total food deprivation in non-obese adults is rare, and few studies have documented body composition changes in this setting. In a group of eight hunger strikers who refused alimentation for 43 days, water and energy compartments were estimated, aiming to assess the impact of progressive starvation. Measurements included body mass index (BMI), triceps skinfold (TSF), arm muscle circumference (AMC), and bioimpedance (BIA) determinations of water, fat, lean body mass (LBM), and total resistance. Indirect calorimetry was also performed in one occasion. The age of the group was 43.3±6.2 years (seven males, one female). Only water, intermittent vitamins and electrolytes were ingested, and average weight loss reached 17.9%. On the last two days of the fast (43rd-44th day) rapid intravenous fluid, electrolyte, and vitamin replenishment were provided before proceeding with realimentation. Body fat decreased approximately 60% (BIA and TSF), whereas BMI reduced only 18%. Initial fat was estimated by BIA as 52.2±5.4% of body weight, and even on the 43rd day it was still measured as 19.7±3.8% of weight. TSF findings were much lower and commensurate with other anthropometric results. Water was comparatively low with high total resistance, and these findings rapidly reversed upon the intravenous rapid hydration. At the end of the starvation period, BMI (21.5±2.6 kg/m²) and most anthropometric determinations were still acceptable, suggesting efficient energy and muscle conservation. Conclusions: 1) All compartments diminished during fasting, but body fat was by far the most affected; 2) Total water was low and total body resistance comparatively elevated, but these findings rapidly reversed upon rehydration; 3) Exaggerated fat percentage estimates from BIA tests and simultaneous increase in lean body mass estimates suggested that this method was inappropriate for assessing energy compartments in the studied population; 4) Patients were not morphologically malnourished after 43 days of fasting; however, the prognostic impact of other impairments was not considered in this analysis.

Cost of drugs manufactured by the University Hospital - role of the Central Pharmacy

The hospital pharmacy in large and advanced institutions has evolved from a simple storage and distribution unit into a highly specialized manipulation and dispensation center, responsible for the handling of hundreds of clinical requests, many of them unique and not obtainable from commercial companies. It was therefore quite natural that in many environments, a manufacturing service was gradually established, to cater to both conventional and extraordinary demands of the medical staff. That was the case of Hospital das Clinicas, where multiple categories of drugs are routinely produced inside the pharmacy. However, cost-containment imperatives dictate that such activities be reassessed in the light of their efficiency and essentiality. METHODS: In a prospective study, the output of the Manufacturing Service of the Central Pharmacy during a 12-month period was documented and classified into three types. Group I comprised drugs similar to commercially distributed products, Group II included exclusive formulations for routine consumption, and Group III dealt with special demands related to clinical investigations. RESULTS: Findings for the three categories indicated that these groups represented 34.4%, 45.3%, and 20.3% of total manufacture orders, respectively. Costs of production were assessed and compared with market prices for Group 1 preparations, indicating savings of 63.5%. When applied to the other groups, for which direct equivalent in market value did not exist, these results would suggest total yearly savings of over 5 100 000 US dollars. Even considering that these calculations leave out many components of cost, notably those concerning marketing and distribution, it might still be concluded that at least part of the savings achieved were real. CONCLUSIONS: The observed savings, allied with the convenience and reliability with which the Central Pharmacy performed its obligations, support the contention that internal manufacture of pharmaceutical formulations was a cost-effective alternative in the described setting.

Effects of continuous versus bolus infusion of enteral nutrition in critical patients

PURPOSE: Enteral alimentation is the preferred modality of support in critical patients who have acceptable digestive function and are unable to eat orally, but the advantages of continuous versus intermittent administration are surrounded by controversy. With the purpose of identifying the benefits and complications of each technique, a prospective controlled study with matched subjects was conducted. PATIENTS AND METHODS: Twenty-eight consecutive candidates for enteral feeding were divided into 2 groups (n = 14 each) that were matched for diagnosis and APACHE II score. A commercial immune-stimulating polymeric diet was administered via nasogastric tube by electronic pump in the proportion of 25 kcal/kg/day, either as a 1-hour bolus every 3 hours (Group I), or continuously for 24 hours (Group II), over a 3-day period. Anthropometrics, biochemical measurements, recording of administered drugs and other therapies, thorax X-ray, measurement of abdominal circumference, monitoring of gastric residue, and clinical and nutritional assessments were performed at least once daily. The principal measured outcomes of this protocol were frequency of abdominal distention and pulmonary aspiration, and efficacy in supplying the desired amount of nutrients. RESULTS: Nearly half of the total population (46.4%) exhibited high gastric residues on at least 1 occasion, but only 1 confirmed episode of pulmonary aspiration occurred (3.6%). Both groups displayed a moderate number of complications, without differences. Food input during the first day was greater in Group II (approximately 20% difference), but by the third day, both groups displayed similarly small deficits in total furnished volume of about 10%, when compared with the prescribed diet. CONCLUSIONS: Both administration modalities permitted practical and effective administration of the diet with frequent registered abnormalities but few clinically significant problems. The two groups were similar in this regard, without statistical differences, probably because of meticulous technique, careful monitoring, strict patient matching, and conservative amounts of diet employed in both situations. Further studies with additional populations, diagnostic groups, and dietetic prescriptions should be performed in order to elucidate the differences between these commonly used feeding modalities.

Laparoscopic versus open splenectomy in the management of hematologic diseases

Splenectomy is the best available treatment for severe forms of hereditary spherocytosis, idiopathic thrombocytopenic purpura, and other hematologic conditions when these prove refractory to conservative management. It has been employed for many decades with low mortality and favorable remission rates. The use of laparoscopic splenectomy in recent years has been rapidly and even enthusiastically adopted in this field. However, the exact role of laparoscopic versus open surgery for hematologic diseases is still debated. In this study of 58 adult patients, laparoscopic procedures were compared with conventional splenectomies for similar indications. METHODS: All patients were operated on within an 8-year period. Subjects underwent similar procedures under the supervision of the same surgical school and were compared regarding age, gender, body mass index, and diagnosis. Laparoscopically managed cases (Group I, n = 30) were prospectively followed according to a written protocol, whereas the same investigation was retrospectively done with regard to traditional laparotomy (Group II, n = 28). Methods included general and demographic findings, duration and technical steps of operation, blood loss, weight of spleen, need for conversion (in minimally invasive subjects), intraoperative and postoperative complications, time until realimentation, postoperative hospitalization, mortality, and late follow-up including recurrence rate. RESULTS: Idiopathic thrombocytopenic purpura was the surgical indication in over 50% of the patients in both groups, but familial spherocytosis, thalassemia, myelodysplasia, and lymphomas were also represented in this series. Laparoscopic procedures took more time to perform (P = 0.004), and postoperative hospitalization was 2 days shorter, but this difference was not statistically significant. Postoperative hematocrit and volume of blood transfusions was equivalent, although the laparoscopic cases had a somewhat lower preoperative hematocrit (NS) and displayed better recovery for this measurement (P = 0.03). More patients in Group I were able to accept oral food on the first day than subjects undergoing conventional operations (P < 0.05). Relatively few conversions were necessary during the minimally invasive surgeries (13.3%), and postoperative early and late complications as well as recurrences occurred in similar proportions. Also, the mean weight of the spleen was not statistically different between the groups, although there was a marked numerical tendency toward larger masses in conventional procedures. No spleen in Group I exceeded 2.0 kg, whereas in Group II values up to 4.0 kg occurred, and the mean weight was 50% higher in the latter group. CONCLUSIONS: 1) Minimally invasive splenectomy was essentially comparable to open surgery with regard to safety, efficacy, and late results; 2) Advantages concerning shorter postoperative hospitalization could not be shown, despite earlier food intake and a non-significant tendency toward earlier discharge; 3) This new modality should be considered an option in cases of hematologic conditions whenever the spleen is not hugely enlarged.

Subjective versus objective stress in noncritically ill hospitalized and outpatient adult men

A cross-sectional study of 120 subjects was performed with the purpose of evaluating stress hormones and emotional stress (anxiety) in outpatient and hospitalized subjects. The aims were to determine the degree of objective stress, as well as to correlate this finding with subjective findings, estimated using Beck's Anxiety Inventory.. METHOD: Three populations were investigated, namely outpatient clinical cases (Group I, n = 30), hospitalized clinical individuals (Group II, n = 30), and hospitalized surgical candidates (Group III, n = 30). Controls (Group IV, n = 30) were healthy volunteers who were health-care professionals and students. To avoid hormone interactions, only men were enrolled in all groups. All hospitalized subjects were tested on admission and before therapeutic interventions. Fasting epinephrine, norepinephrine, and cortisol were measured in the morning, and Beck's Anxiety Inventory was adminstered by a trained psychologist. RESULTS: The 3 patient groups displayed higher anxiety levels than the controls. Hormone concentrations did not present remarkable changes and did not correlate with subjective stress (anxiety). CONCLUSIONS: 1) Subjective disorders (as determined with Beck's Anxiety Inventory ) were a common finding in both outpatient and hospitalized populations, without differences between the various groups; 2) Objective stress (as determined by elevated hormone levels) was more difficult to confirm-findings rarely exceeded the reference range; 3) Correlation between the two variables could not be demonstrated; 4) Further studies are necessary to define stress quantification and interpretation in patient populations, especially in relationship with nutritional diagnosis and dietetic prescription.

Pulmonary function and aerobic capacity in asymptomatic bariatric candidates with very severe morbid obesity

PURPOSE: Aerobic capacity and respiratory function may be compromised in obesity, but few studies have been done in highly obese bariatric candidates. In a prospective study, these variables were documented in the preoperative period, aiming to define possible physiologic limitations in a apparently healthy and asymptomatic population. METHOD: Forty-six consecutively enrolled adults (age 39.6 ± 8.4 years, 87.0% females, body mass index /BMI 49.6 ± 6.3 kg/m² ) were analyzed. Ventilatory variables were investigated by automated spirometry, aerobic capacity was estimated by a modified Bruce test in an ergometric treadmill, and body composition was determined by bioimpedance analysis. RESULTS: Total fat was greatly increased (46.4 ± 4.6% of body weight) and body water reduced (47.3 ± 4.6 % body weight), as expected for such obese group. Spirometric findings including forced vital capacity of 3.3 ± 0.8 L and forced expiratory volume-1 second of 2.6 ± 0.6 L were usually acceptable for age and gender, but mild restrictive pulmonary insufficiency was diagnosed in 20.9%. Aerobic capacity was more markedly diminished, as reflected by very modest maximal time (4.5 ± 1.1 min) and distance (322 ±142 m) along with proportionally elevated maximal oxygen consumption (23.4 ± 9.5 mL/kg/min) achieved by these subjects during test exercise. CONCLUSIONS: 1) Cardiopulmonary evaluation was feasible and well-tolerated in this severely obese population; 2) Mean spirometric variables were not diminished in this study, but part of the population displayed mild restrictive changes; 3) Exercise tolerance was very negatively influenced by obesity, resulting in reduced endurance and excessive metabolic cost for the treadmill run; 4) More attention to fitness and aerobic capacity is recommended for seriously obese bariatric candidates;

Influence of ageing on the properties of bitumen from asphalt mixtures with recycled concrete aggregates

The reuse of recycled concrete aggregates in new hot-mix asphalt can be a more sustainable method of production, but these mixtures may need a heat treatment before compaction to improve their water sensitivity performance. A direct consequence of this treatment is an increase in the hot-mix asphalt resilient modulus. The aim of this paper is to analyse the effect of ageing on the stiffness of asphalt mixtures with different amounts of recycled concrete aggregates, before and after a heat treatment, which was analysed through the assessment of its bitumen properties. Moreover, this paper also aims to analyse whether the rolling thin-film oven test is able to simulate the ageing effect of the heat treatment. In the laboratory work, a paving grade bitumen B50/70 has been used to produce asphalt mixtures with 0% and 30% recycled concrete aggregates, and the bitumen was later characterised (using penetration, softening point, dynamic viscosity and dynamic shear rheometer tests) in various situations, such as when using virgin bitumen, short-term aged bitumen, aged bitumen after heat treatment (simulated with 4 h of rolling thin-film oven test) and bitumen samples recovered from asphalt mixtures with different production mixes (0% and 30% recycled concrete aggregate) and heat treatment conditions (0 and 4 h of curing time in the oven). Based on the results obtained, it could be concluded that the ageing resulting from the heat treatment is the primary cause of the hot-mix asphalt's increased stiffness, while recycled concrete aggregate content has a small influence. Moreover, it could be concluded that when there is no curing time, the recycled concrete aggregate protects the bitumen against ageing. Additionally, it could be stated that the rolling thin-film test is able to adequately simulate the ageing effect of the heat treatment. Thus, this test is useful for determining the ageing suffered by the bitumen when the recycled concrete aggregate mixture is manufactured using a heat treatment.

Recycled asphalt mixtures produced with high percentage of different waste materials

The use of sustainable solutions in construction is not just an option, but is increasingly becoming a need of the Society. Thus, nowadays the recycling of waste materials is a growing technology that needs to be continuously improved, namely by researching new solutions for waste valorisation and by increasing the amount of wastes reused. In the paving industry, the reuse of reclaimed asphalt (RA) is becoming common practice, but needs further research work. Thus, this study aims to increase the incorporation of RA and other waste materials in the production of recycled asphalt mixtures in order to improve their mechanical, environmental and economic performance. Recycled mixtures with 50% RA were analysed in this study, including: i) RA selection, preparation and characterization; ii) incorporation of other waste materials as binder additives or modifiers, like used motor oil (UMO) and waste high density polyethylene (HDPE); iii) production of different mixtures (without additives; with UMO; with UMO and HDPE) and comparison of their performance in order to assess the main advantages of each solution. With this study it was concluded that up to 7.5 % of UMO and 4.0 % of HDPE can be used in a new modified binder for asphalt mixtures with 50 % of RA, which have excellent properties concerning the rutting with WTS = 0.02 mm/103 cycles, the fatigue resistance with ε6 = 160.4, and water sensitivity with an ITSR of 81.9 %.

Recycled asphalt mixtures with foamed bitumen: an alternative to build ecofriendly road pavements

Nowadays, recycling has become a very important objective for the society in the scope of a closed loop product life cycle. In recent years, new recycling techniques have been developed in the area of road pavements that allow the incorporation of high percentages of reclaimed asphalt (RA) materials in recycled asphalt mixtures. The use of foamed bitumen for production of recycled asphalt mixtures is one of those techniques, which also allows the reduction of the mixing temperatures (warm mix technology). However, it is important to evaluate if this solution can maintain or improve the performance of the resulting mixtures. Thus, the main aim of the present study is to assess the performance of warm recycled asphalt mixtures incorporating foamed bitumen as the new binder and 50% RA, in comparison with a control mixture using conventional bitumen. Four mixtures have been produced with 50% RA, one of them at typical high mixing temperatures with a conventional bitumen (control mixture) and the other three with foamed bitumen at different production temperatures. These four mixtures were tested to evaluate their compactability and water sensitivity. The laboratory test results showed that the production of recycled mixtures with foamed bitumen can be reduced by 40ºC without changing the performance of the resulting mixtures.

Can oil, plastic and RAP wastes have a new life in novel asphalt mixtures?

The pavement recycling allows to reuse reclaimed asphalt pavement (RAP) or other waste materials in new asphalt mixtures for road construction or rehabilitation, thus re-ducing the use of virgin materials (aggregates and bitumen). Thus, the main aim of this study is to minimize the use of natural resources through the reuse of three waste materials: HDPE, mo-tor oil and RAP. Different amounts of waste motor oil and HDPE were added to an asphalt binder with 50% aged bitumen. The best solutions to produce the modified binders (4.5 to 5.0% HDPE and 10 % waste motor oil) performed as well as a conventional bitumen although they only used 35 % of virgin bitumen. Asphalt mixtures with 50 % RAP were produced with the selected modified binders, improving some characteristics in comparison with conventional asphalt mixtures. In conclusion, these wastes can revive in new asphalt mixtures.

Evaluation of foamed bitumen efficiency in warm asphalt mixtures recycling

The recycling of pavements is nowadays a very important question to the road paving industry. With the objective of incorporating higher percentages of reclaimed asphalt (RA) materials in recycled asphalt mixtures, new techniques have been developed in the last years. The use of foamed bitumen is normally associated with the production of cold asphalt mixtures, which usually show lower quality standards. However, the objective of the work presented in this paper is to assess the use of foamed bitumen as the binder of warm asphalt mixtures incorporating 30% RA, which have quality standards similar to those of conventional mixtures. Thus, five mixtures have been produced with 30% RA, one of them with a conventional bitumen (control mix) and the others with foamed bitumen at different production temperatures. The mixtures were tested for compactability and water sensitivity and the results show a possible reduction of 25 ºC in the production temperatures, while the water sensitivity test results were kept close to 90 %.

Plastic waste use as aggregate and binder modifier in open-graded asphalts

Road pavements are very important infrastructures for the Society, but they can cause serious environmental impacts during construction, operation and rehabilitation phases. Thus, it is essential to develop surface paving solutions that promote not only the durability but also a comfortable and safe use. In fact, this work aims to study the properties of new opengraded mixtures for surface layers produced with plastic wastes. First, HDPE and EVA wastes were used as bitumen modifiers, and then another plastic waste (PEX) replaced part of the aggregates. After studying the modified binders, the open-graded mixtures were designed, and then they were tested concerning their particle loss, rutting resistance, surface texture and damping effect. It was concluded that both ways of using the plastic wastes can improve the mechanical and functional properties of the open-graded mixtures related to the pavement performance.