Negative impact of hypocaloric feeding and energy balance on clinical outcome in ICU patients

Résumé Introduction : Les patients nécessitant une prise en charge prolongée en milieu de soins intensifs et présentant une évolution compliquée, développent une réponse métabolique intense caractérisée généralement par un hypermétabolisme et un catabolisme protéique. La sévérité de leur atteinte pathologique expose ces patients à la malnutrition, due principalement à un apport nutritionnel insuffisant, et entraînant une balance énergétique déficitaire. Dans un nombre important d'unités de soins intensifs la nutrition des patients n'apparaît pas comme un objectif prioritaire de la prise en charge. En menant une étude prospective d'observation afin d'analyser la relation entre la balance énergétique et le pronostic clinique des patients avec séjours prolongés en soins intensifs, nous souhaitions changer cette attitude et démonter l'effet délétère de la malnutrition chez ce type de patient. Méthodes : Sur une période de 2 ans, tous les patients, dont le séjour en soins intensifs fut de 5 jours ou plus, ont été enrôlés. Les besoins en énergie pour chaque patient ont été déterminés soit par calorimétrie indirecte, soit au moyen d'une formule prenant en compte le poids du patient (30 kcal/kg/jour). Les patients ayant bénéficié d'une calorimétrie indirecte ont par ailleurs vérifié la justesse de la formule appliquée. L'âge, le sexe le poids préopératoire, la taille, et le « Body mass index » index de masse corporelle reconnu en milieu clinique ont été relevés. L'énergie délivrée l'était soit sous forme nutritionnelle (administration de nutrition entérale, parentérale ou mixte) soit sous forme non-nutritionnelle (perfusions : soluté glucosé, apport lipidique non nutritionnel). Les données de nutrition (cible théorique, cible prescrite, énergie nutritionnelle, énergie non-nutritionnelle, énergie totale, balance énergétique nutritionnelle, balance énergétique totale), et d'évolution clinique (nombre des jours de ventilation mécanique, nombre d'infections, utilisation des antibiotiques, durée du séjour, complications neurologiques, respiratoires gastro-intestinales, cardiovasculaires, rénales et hépatiques, scores de gravité pour patients en soins intensifs, valeurs hématologiques, sériques, microbiologiques) ont été analysées pour chacun des 669 jours de soins intensifs vécus par un total de 48 patients. Résultats : 48 patients de 57±16 ans dont le séjour a varié entre 5 et 49 jours (motif d'admission : polytraumatisés 10; chirurgie cardiaque 13; insuffisance respiratoire 7; pathologie gastro-intestinale 3; sepsis 3; transplantation 4; autre 8) ont été retenus. Si nous n'avons pu démontrer une relation entre la balance énergétique et plus particulièrement, le déficit énergétique, et la mortalité, il existe une relation hautement significative entre le déficit énergétique et la morbidité, à savoir les complications et les infections, qui prolongent naturellement la durée du séjour. De plus, bien que l'étude ne comporte aucune intervention et que nous ne puissions avancer qu'il existe une relation de cause à effet, l'analyse par régression multiple montre que le facteur pronostic le plus fiable est justement la balance énergétique, au détriment des scores habituellement utilisés en soins intensifs. L'évolution est indépendante tant de l'âge et du sexe, que du status nutritionnel préopératoire. L'étude ne prévoyait pas de récolter des données économiques : nous ne pouvons pas, dès lors, affirmer que l'augmentation des coûts engendrée par un séjour prolongé en unité de soins intensifs est induite par un déficit énergétique, même si le bon sens nous laisse penser qu'un séjour plus court engendre un coût moindre. Cette étude attire aussi l'attention sur l'origine du déficit énergétique : il se creuse au cours de la première semaine en soins intensifs, et pourrait donc être prévenu par une intervention nutritionnelle précoce, alors que les recommandations actuelles préconisent un apport énergétique, sous forme de nutrition artificielle, qu'à partir de 48 heures de séjour aux soins intensifs. Conclusions : L'étude montre que pour les patients de soins intensifs les plus graves, la balance énergétique devrait être considérée comme un objectif important de la prise en charge, nécessitant l'application d'un protocole de nutrition précoce. Enfin comme l'évolution à l'admission des patients est souvent imprévisible, et que le déficit s'installe dès la première semaine, il est légitime de s'interroger sur la nécessité d'appliquer ce protocole à tous les patients de soins intensifs et ceci dès leur admission. Summary Background and aims: Critically ill patients with complicated evolution are frequently hypermetabolic, catabolic, and at risk of underfeeding. The study aimed at assessing the relationship between energy balance and outcome in critically ill patients. Methods: Prospective observational study conducted in consecutive patients staying 5 days in the surgical ICU of a University hospital. Demographic data, time to feeding, route, energy delivery, and outcome were recorded. Energy balance was calculated as energy delivery minus target. Data in means+ SD, linear regressions between energy balance and outcome variables. Results: Forty eight patients aged 57±16 years were investigated; complete data are available in 669 days. Mechanical ventilation lasted 11±8 days, ICU stay 15+9 was days, and 30-days mortality was 38%. Time to feeding was 3.1 ±2.2 days. Enteral nutrition was the most frequent route with 433 days. Mean daily energy delivery was 1090±930 kcal. Combining enteral and parenteral nutrition achieved highest energy delivery. Cumulated energy balance was between -12,600+ 10,520 kcal, and correlated with complications (P<0.001), already after 1 week. Conclusion: Negative energy balances were correlated with increasing number of complications, particularly infections. Energy debt appears as a promising tool for nutritional follow-up, which should be further tested. Delaying initiation of nutritional support exposes the patients to energy deficits that cannot be compensated later on.

Growth and magnetic properties of multiferroic LaxBi1-xMnO3 thin films

A comparative study of LaxBi1-xMnO3 thin films grown on SrTiO3 substrates is reported. It is shown that these films grow epitaxially in a narrow pressure-temperature range. A detailed structural and compositional characterization of the films is performed within the growth window. The structure and the magnetization of this system are investigated. We find a clear correlation between the magnetization and the unit-cell volume that we ascribe to Bi deficiency and the resultant introduction of a mixed valence on the Mn ions. On these grounds, we show that the reduced magnetization of LaxBi1-xMnO3 thin films compared to the bulk can be explained quantitatively by a simple model, taking into account the deviation from nominal composition and the Goodenough-Kanamori-Anderson rules of magnetic interactions.

Structure and magnetic properties of Sm/Fe multilayers versus substrate temperature

Three Sm(2 Å)/Fe(3 Å) multilayers have been made using two electron beams in a high vacuum chamber onto very thin Kapton foils at different substrate temperatures, (Ts=40°C, 150°C and 230°C), with the same total thickness of 3000 Å. We have found that the substrate temperature strongly affects structure and magnetic properties of the samples. For a substrate temperature of 150°C the sample behaves as a three dimensional random magnet.

Bactericidal/permeability-increasing protein (BPI) and BPI homologs at mucosal sites.

At mucosal surfaces, we must co-exist with a high density of diverse microorganisms; therefore, protection against these occurs on multiple levels. Leukocyte- and epithelial derived-antimicrobial peptides and proteins (AMPs) comprise an essential component of immune defense. These molecules possess antibacterial, antifungal and signalling properties and probably contribute to defence and maintenance of homeostasis between the host and commensal microorganisms. Among these AMPs is bactericidal/permeability-increasing protein (BPI), an antimicrobial protein with potent endotoxin-neutralising activity, and several homologs. This review explores the roles of BPI and and its homologs at the mucosal interface. Congeners of BPI are under biopharmaceutical development as novel anti-infective agents, highlighting the potential therapeutic relevance of this protein family.

Dielectric anomaly and magnetic response of epitaxial orthorhombic YMnO3 thin films

The structure, magnetic response, and dielectric response of the grown epitaxial thin films of the orthorhombic phase of YMnO3 oxide on Nb:SrTiO3 (001) substrates have been measured. We have found that a substrate-induced strain produces an in-plane compression of the YMnO3 unit cell. The magnetization versus temperature curves display a significant zero-field cooling (ZFC)-field cooling hysteresis below the Nel temperature (TN 45 K). The dielectric constant increases gradually (up to 26%) below the TN and mimics the ZFC magnetization curve. We argue that these effects could be a manifestation of magnetoelectric coupling in YMnO3 thin films and that the magnetic structure of YMnO3 can be controlled by substrate selection and/or growth conditions.

Real-time motion correction in navigator-gated free-breathing double-oblique submillimeter 3D right coronary artery magnetic resonance angiography.

RATIONALE AND OBJECTIVES: The purpose of this study was the investigation of the impact of real-time adaptive motion correction on image quality in navigator-gated, free-breathing, double-oblique three-dimensional (3D) submillimeter right coronary magnetic resonance angiography (MRA). MATERIALS AND METHODS: Free-breathing 3D right coronary MRA with real-time navigator technology was performed in 10 healthy adult subjects with an in-plane spatial resolution of 700 x 700 microm. Identical double-oblique coronary MR-angiograms were performed with navigator gating alone and combined navigator gating and real-time adaptive motion correction. Quantitative objective parameters of contrast-to-noise ratio (CNR) and vessel sharpness and subjective image quality scores were compared. RESULTS: Superior vessel sharpness, increased CNR, and superior image quality scores were found with combined navigator gating and real-time adaptive motion correction (vs. navigator gating alone; P < 0.01 for all comparisons). CONCLUSION: Real-time adaptive motion correction objectively and subjectively improves image quality in 3D navigator-gated free-breathing double-oblique submillimeter right coronary MRA.

Magnetoresistance at artificial interfaces in the itinerant SrRuO3 ferromagnet

The magnetoresistance across interfaces in the itinerant ferromagnetic oxide SrRuO3 have been studied. To define appropriately the interfaces, epitaxial thin films have been grown on bicrystalline and laser-patterned SrTiO3 substrates. Comparison is made with results obtained on similar experiments using the double-exchange ferromagnetic oxide La2/3Sr1/3MnO3. It is found that in SrRuO3, interfaces induce a substantial negative magnetoresistance, although no traces of the low-field spin tunneling magnetoresistance are found. We discuss these results on the basis of the distinct degree of spin polarization in ruthenates and manganites and the different nature of the surface magnetic layer formed at interfaces.

SrRuO3/SrTiO3/SrRuO3 heterostructures for magnetic tunnel junctions

We report on the growth and characterization of SrRuO3 single layers and SrRuO3/SrTiO3/SrRuO3 heterostructures grown on SrTiO3(100) substrates. The thickness dependence of the coercivity was determined for these single layers. Heterostructures with barrier thickness tb=1, 2.5, and 4 nm were fabricated, with electrodes having thickness ranging from 10 to 100 nm. The hysteresis loops of heterostructures with tb=2.5¿nm, 4 nm reveal uncoupled magnetic switching of the electrodes. Therefore, these heterostructures can be used for the fabrication of magnetic tunneling junctions.

Influence of the dipolar interactions in the magnetization reversal asymmetry of hard-soft magnetic ribbons

Partial crystallization of the metallic glass Co66Si16B12Fe4Mo2 was performed by annealing at temperatures between 500 and 540°C for 10-20 min, resulting in crystallite volume fractions of (0.7-5)×10¿3 and sizes of 50-100 nm. This two-phase alloy presents a remarkable feature: a hysteresis loop shift that can be tailored by simply premagnetizing the sample in the adequate magnetic field. Shifts as large as five times the coercive field have been obtained which make them interesting for application as magnetic cores in dc pulse transformers. The asymetrical magnetic reversal is explained in terms of the magnetic dipolar field interaction and the observed hysteresis loops have been satisfactorily simulated by a modification of Stoner-Wohlfarth¿s model of coherent rotations.

Synthesis, structure, and magnetic studies on self-assembled BiFeO3-CoFe2O4 nanocomposite thin films

Self-assembled (0.65)BiFeO3-(0.35)CoFe2O4 (BFO-CFO) nanostructures were deposited on SrTiO3 (001) and (111) substrates by pulsed laser deposition at various temperatures from 500 to 800°C. The crystal phases and the lattice strain for the two different substrate orientations have been determined and compared. The films grow epitaxial on both substrates but separation of the spinel and perovskite crystallites, without parasitic phases, is only obtained for growth temperatures of around 600-650°C. The BFO crystallites are out-of-plane expanded on STO(001), whereas they are almost relaxed on (111). In contrast, CFO crystallites grow out-of-plane compressed on both substrates. The asymmetric behavior of the cell parameters of CFO and BFO is discussed on the basis of the role of the epitaxial stress caused by the substrate and the spinel-perovskite interfacial stress. It is concluded that interfacial stress dominates the elastic properties of CFO crystallites and thus it may play a fundamental on the interface magnetoelectric coupling in these nanocomposites.

Magnetoelasticity and magnetoresistance in Cu-Al-Mn shape-memory alloys

We study the effect of a magnetic field on the martensitic transition of a Cu-Al-Mn shape-memory alloy. The martensitic transition has been studied through resistance measurements under applied magnetic fields ranging from 0 to 50 kOe. Negative magnetoresistance showing an almost linear dependence with the square of the magnetization has been observed. This magnetoresistive effect is associated with the existence of small ferromagnetic Mn-clusters. Its strength and thermal dependence is different in both phases. The martensitic transition temperature is slightly increased and its spread in temperature significantly reduced upon increasing the field. These results show the existence of magnetoelastic coupling, which favors the nucleation of those martensitic variants with the easy magnetization axis aligned with the field.

Erasing the glassy state in magnetic fine particles

BaFe10.4Co0.8Ti0.8O19 magnetic fine particles exhibit most of the features attributed to glassy behavior, e.g., irreversibility in the hysteresis loops and in the zero-field-cooling and field-cooling curves extends up to very high fields, and aging and magnetic training phenomena occur. However, the multivalley energy structure of the glassy state can be strongly modified by a field-cooling process at a moderate field. Slow relaxation experiments demonstrate that the intrinsic energy barriers of the individual particles dominate the behavior of the system at high cooling fields, while the energy states corresponding to collective glassy behavior play the dominant role at low cooling fields.

Reply to "Comment on 'Erasing glassy state in magnetic fine particles'"

The Comment affirms that no phase transition occurs in spin-glass systems with an applied magnetic field. However, only according to the droplet model is this result expected. Other models do not predict this result and, consequently, it is under current discussion. In addition, we show how the experimental results obtained in our system correspond to a cluster glass rather than to a true spin glass.