Does enternal nutrition affect clinical outcome? A systematic review of the randomized trials

Background: Both parenteral nutrition (PN) and enteral nutrition (EN) are widely advocated as adjunctive care in patients with various diseases. A systematic review of 82 randomized controlled trials (RCTs) of PN published in 2001 found little, if any, effect on mortality, morbidity, or duration of hospital stay; in some situations, PN increased infectious complication rates. Objective: To assess the effect of EN or volitional nutrition support (VNS) in individual disease states from available randomized controlled trials (RCTs). Design: We conducted a systematic review. RCTs comparing EN or VNS to untreated controls, or comparing EN to PN, were identified and separated according to the underlying disease state. Meta-analysis was performed when at least 3 RCTs provided data. The evidence from the RCTs was summarized into one of five grades. A or B indicated the presence of strong or weak (low quality RCTs) evidence supporting the use of the intervention. C indicated a lack of adequate evidence to make any decision about efficacy. D indicated that limited data could not support the intervention. E indicated either that strong data found no effect, or that either strong or weak data suggested that the intervention caused harm. Patients and settings: RCTs could include either hospitalized or non-hospitalized patients. The EN or VNS had to be provided as part of a treatment plan for an underlying disease process. Interventions: The RCT had to compare recipients of either EN or VNS to controls not receiving any type of artificial nutrition or had to compare recipients of EN with recipients of PN. Outcome measures: Mortality, morbidity (disease-specific), duration of hospitalization, cost, or interventional complications. Summary of grading: A – No indication was identified. B – EN or VNS in the perioperative patient or in patients with chronic liver disease; EN in critically ill patients or low birth weight infants (trophic feeding); VNS in malnourished geriatric patients. (The low quality trials found a significant difference in survival favoring the VNS recipients in the malnourished geriatric patient trials; two high quality trials found non-significant differences that favored VNS as well.) C – EN or VNS in liver transplantation, cystic fibrosis, renal failure, pediatric conditions other than low birth weight infants, well-nourished geriatric patients, non-stroke neurologic conditions, AIDS; EN in acute pancreatitis, chronic obstructive pulmonary disease, non-malnourished geriatric patients; VNS in inflammatory bowel disease, arthritis, cardiac disease, pregnancy, allergic patients, preoperative bowel preparation D – EN or VNS in patients receiving non-surgical cancer treatment or in patients with hip fractures; EN in patients with inflammatory bowel disease; VNS in patients with chronic obstructive pulmonary disease E – EN in the first week in dysphagic, or VNS at any time in non-dysphagic, stroke patients who are not malnourished; dysphagia persisting for weeks will presumably ultimately require EN. Conclusions: There is strong evidence for not using EN in the first week in dysphagic, and not using VNS at all in non-dysphagic, stroke patients who are not malnourished. There is reasonable evidence for using VNS in malnourished geriatric patients. The recommendations to consider EN/VNS in perioperative/liver/critically ill/low birth weight patients are limited by the low quality of the RCTs. No evidence could be identified to justify the use of EN/VNS in other disease states

Low plasma cefepime levels in critically ill septic patients: pharmacokinetic modelling indicates improved troughs with revised dosing

The pharmacokinetics of a 2-g bolus of cefepime were measured in critically ill patients with normal renal function. Variable and low trough plasma drug concentrations were found, and 8 of 10 patients had levels below the MIC at which 50% of the isolates are inhibited for Pseudomonas aeruginosa. Computer simulations predicted that continuous infusion and shorter dosing intervals would increase trough levels

A general low frequency acoustic radiation capability for NASTRAN

A new capability called NASHUA is described for calculating the radiated acoustic sound pressure field exterior to a harmonically-excited arbitrary submerged 3-D elastic structure. The surface fluid pressures and velocities are first calculated by coupling a NASTRAN finite element model of the structure with a discretized form of the Helmholtz surface integral equation for the exterior fluid. After the fluid impedance is calculated, most of the required matrix operations are performed using the general matrix manipulation package (DMAP) available in NASTRAN. Far field radiated pressures are then calculated from the surface solution using the Helmholtz exterior integral equation. Other output quantities include the maximum sound pressure levels in each of the three coordinate planes, the rms and average surface pressures and normal velocities, the total radiated power and the radiation efficiency. The overall approach is illustrated and validated using known analytic solutions for submerged spherical shells subjected to both uniform and nonuniform applied loads

Case studies to illustrate good practice in the management of non-tuberculous mycobacterial pulmonary disease

Pulmonary disease caused by non-tuberculous mycobacteria (NTM-PD) can be a complex condition for health care providers to manage, and delayed diagnosis and treatment failure are common. Here we present three case studies that illustrate key challenges in the diagnosis and treatment of NTM-PD, and provide guidance on these issues. In addition, we make recommendations on how the overall management of NTM-PD may be improved, through strategies such as physician education to recognise NTM-PD, and the development of multidisciplinary teams and patient-support groups

Who gets a laboratory positive diagnosis of Mycoplasma pneumoniae: A 10-year retrospective analysis

OBJECTIVE: Mycoplasma pneumoniae (M. pneumoniae) is thought to cause up to a third of community acquired pneumonias (CAP), but may be undiagnosed due to limitations with current diagnostics, and untreated given the frequent use of B-lactams to which M. pneumoniae is not susceptible. We performed a ten-year retrospective analysis to identify the typical characteristics of a patient with a laboratory positive diagnosis of M. pneumoniae. METHODS: Laboratory diagnosis of M. pneumoniae was performed using Polymerase Chain Reaction (PCR) and Serology (passive particle agglutination (PPA) and Enzyme-linked immunosorbent (EIA) assays). Data were collected on all patients tested for M. pneumoniae between 2009 and 2019. RESULTS: 19,090 PCR and 4530 serology samples were tested for M. pneumoniae with 278 positive results. The positive group had a median age of 40 years (interquartile range 30–41 years); Median C-reactive Protein (CRP) was 71 mg/L, White blood Cell Count (WBC) 7 × 10^{9}. 80% had an abnormal Chest X-ray. Intensive Care Unit (ICU) admission occurred in 4.5%; 1.3% patients died. 29% of patients were positive on both serology and PCR testing platforms. CONCLUSIONS: The characteristics reported here could be used as guidance on who is treated for M. pneumoniae. We propose that testing for M. pneumoniae needs to be performed systematically in patients with CAP; and that targeted atypical pathogen cover should be considered in preference to B-lactam mono-therapy for all patients with these characteristics

Local syzygies of multiplier ideals

In recent years, multiplier ideals have found many applications in local and global algebraic geometry. Because of their importance, there has been some interest in the question of which ideals on a smooth complex variety can be realized as multiplier ideals. Other than integral closure no local obstructions have been known up to now, and in dimension two it was established by Favre-Jonsson and Lipman-Watanabe that any integrally closed ideal is locally a multiplier ideal. We prove the somewhat unexpected result that multiplier ideals in fact satisfy some rather strong algebraic properties involving higher syzygies. It follows that in dimensions three and higher, multiplier ideals are very special among all integrally closed ideals.Comment: 8 page