Enteral versus parenteral early nutrition in ventilated adults with shock: a randomised, controlled, multicentre, open-label, parallel-group study (NUTRIREA-2)

BACKGROUND: Whether the route of early feeding affects outcomes of patients with severe critical illnesses is controversial. We hypothesised that outcomes were better with early first-line enteral nutrition than with early first-line parenteral nutrition. METHODS: In this randomised, controlled, multicentre, open-label, parallel-group study (NUTRIREA-2 trial) done at 44 French intensive-care units (ICUs), adults (18 years or older) receiving invasive mechanical ventilation and vasopressor support for shock were randomly assigned (1:1) to either parenteral nutrition or enteral nutrition, both targeting normocaloric goals (20-25 kcal/kg per day), within 24 h after intubation. Randomisation was stratified by centre using permutation blocks of variable sizes. Given that route of nutrition cannot be masked, blinding of the physicians and nurses was not feasible. Patients receiving parenteral nutrition could be switched to enteral nutrition after at least 72 h in the event of shock resolution (no vasopressor support for 24 consecutive hours and arterial lactate <2 mmol/L). The primary endpoint was mortality on day 28 after randomisation in the intention-to-treat-population. This study is registered with ClinicalTrials.gov, number NCT01802099. FINDINGS: After the second interim analysis, the independent Data Safety and Monitoring Board deemed that completing patient enrolment was unlikely to significantly change the results of the trial and recommended stopping patient recruitment. Between March 22, 2013, and June 30, 2015, 2410 patients were enrolled and randomly assigned; 1202 to the enteral group and 1208 to the parenteral group. By day 28, 443 (37%) of 1202 patients in the enteral group and 422 (35%) of 1208 patients in the parenteral group had died (absolute difference estimate 2·0%; [95% CI -1·9 to 5·8]; p=0·33). Cumulative incidence of patients with ICU-acquired infections did not differ between the enteral group (173 [14%]) and the parenteral group (194 [16%]; hazard ratio [HR] 0·89 [95% CI 0·72-1·09]; p=0·25). Compared with the parenteral group, the enteral group had higher cumulative incidences of patients with vomiting (406 [34%] vs 246 [20%]; HR 1·89 [1·62-2·20]; p<0·0001), diarrhoea (432 [36%] vs 393 [33%]; 1·20 [1·05-1·37]; p=0·009), bowel ischaemia (19 [2%] vs five [<1%]; 3·84 [1·43-10·3]; p=0·007), and acute colonic pseudo-obstruction (11 [1%] vs three [<1%]; 3·7 [1·03-13·2; p=0·04). INTERPRETATION: In critically ill adults with shock, early isocaloric enteral nutrition did not reduce mortality or the risk of secondary infections but was associated with a greater risk of digestive complications compared with early isocaloric parenteral nutrition. FUNDING: La Roche-sur-Yon Departmental Hospital and French Ministry of Health

Impact of early enteral versus parenteral nutrition on mortality in patients requiring mechanical ventilation and catecholamines: study protocol for a randomized controlled trial (NUTRIREA-2)

BACKGROUND: Nutritional support is crucial to the management of patients receiving invasive mechanical ventilation (IMV) and the most commonly prescribed treatment in intensive care units (ICUs). International guidelines consistently indicate that enteral nutrition (EN) should be preferred over parenteral nutrition (PN) whenever possible and started as early as possible. However, no adequately designed study has evaluated whether a specific nutritional modality is associated with decreased mortality. The primary goal of this trial is to assess the hypothesis that early first-line EN, as compared to early first-line PN, decreases day 28 all-cause mortality in patients receiving IMV and vasoactive drugs for shock. METHODS/DESIGN: The NUTRIREA-2 study is a multicenter, open-label, parallel-group, randomized controlled trial comparing early PN versus early EN in critically ill patients requiring IMV for an expected duration of at least 48 hours, combined with vasoactive drugs, for shock. Patients will be allocated at random to first-line PN for at least 72 hours or to first-line EN. In both groups, nutritional support will be started within 24 hours after IMV initiation. Calorie targets will be 20 to 25 kcal/kg/day during the first week, then 25 to 30 kcal/kg/day thereafter. Patients receiving PN may be switched to EN after at least 72 hours in the event of shock resolution (no vasoactive drugs for 24 consecutive hours and arterial lactic acid level below 2 mmol/L). On day 7, all patients receiving PN and having no contraindications to EN will be switched to EN. In both groups, supplemental PN may be added to EN after day 7 in patients with persistent intolerance to EN and inadequate calorie intake. We plan to recruit 2,854 patients at 44 participating ICUs. DISCUSSION: The NUTRIREA-2 study is the first large randomized controlled trial designed to assess the hypothesis that early EN improves survival compared to early PN in ICU patients. Enrollment started on 22 March 2013 and is expected to end in November 2015. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01802099 (registered 27 February 2013)

High resolution measurement of fragment mass-charge-kinetic energy correlations in the cold fragmentation region of thermal fission of 235U

The performance of a back-to-back gridded ionization chamber containing an extremely thin fissile target has been investigated for studying the cold fragmentation phenomenon : primary fragment kinetic energy is measured with a resolution much better than 300 keV; mass separation is total and for each mass, a good charge separation is obtained. The evolution of the charge distribution as a function of the fragments' total kinetic energy is discussed for the mass-ratio 132/104.Les performances d'une double chambre d'ionisation à grilles contenant une cible fissile extrêmement mince ont été explorées dans le but d'étudier le phénomène de fragmentation froide ; l'énergie cinétique primaire des fragments est mesurée avec une résolution bien meilleure que 300 keV, la séparation des masses est totale et, pour chacune d'elles, une bonne séparation des charges est obtenue. Une discussion de l'évolution de la distribution des charges en fonction de l'énergie cinétique totale des fragments est faite pour le rapport de masses 132/104

Photoelectrochemical Hydrogen Generation and Concomitant Organic Dye Oxidation under TiO2 Nanotube

The present work describes the photoelectrochemical hydrogen generation during a photodegradation of an organic compound. For this, it was chosen the reactive black 5 dye as a model of organic pollutant and its oxidation under TiO2 nanotube in a two compartment cell. The photoelectrocatalysis is conducted in 0.1 mol L-1 Na2SO4 pH 6 medium under photoanode biased at +1.0 V (SCE) and activated by UV and visible light using 150W Xe-Arc lamp (Oriel) and 125 W Hg lamp (Osram). The concomitant hydrogen production was monitored at cathodic compartment using a Pt cathode. Using optimized condition of Na2SO4 0.1 mol L-1 pH 6 as supporting electrolyte, applied potential of +1.0V it was verified 100% of discoloration and 72% of TOC removal of 1.0 x 10(-5) mol L-1 Reactive Black 5 dye after 120 min of treatment (rate constant of 10.6 x10(-2) min(-1)). The concomitant hydrogen generation was 44% in this condition

Morphological quantification of hierarchical geomaterials by X-ray nano-CT bridges the gap from nano to micro length scales

International audienceMorphological quantification of the complex structure of hierarchical geomaterials is of great relevance for Earth science and environmental engineering, among others. To date, methods that quantify the 3D morphology on length scales ranging from a few tens of nanometers to several hundred nanometers have had limited success. We demonstrate, for the first time, that it is possible to go beyond visualization and to extract quantitative morphological information from X-ray images in the aforementioned length scales. As examples, two different hierarchical geomaterials exhibiting complex porous structures ranging from nanometer to macroscopic scale are studied: a flocculated clay water suspension and two hydrated cement pastes. We show that from a single projection image it is possible to perform a direct computation of the ultra-small angle-scattering spectra. The predictions matched very well the experimental data obtained by the best ultra-small angle-scattering experimental setups as observed for the cement paste. In this context, we demonstrate that the structure of flocculated clay suspension exhibit two well-distinct regimes of aggregation, a dense mass fractal aggregation at short distance and a more open structure at large distance, which can be generated by a 3D reaction limited cluster-cluster aggregation process. For the first time, a high-resolution 3D image of fibrillar cement paste cluster was obtained from limited angle nanotomograph