Nutrition evaluation and management of critically ill patients with COVID-19 during post–intensive care rehabilitation

Background: Among hospitalized patients with coronavirus disease 2019 (COVID-19), up to 12% may require intensive care unit (ICU) management. The aim of this prospective cohort study is to assess nutrition status and outcome in patients with COVID-19 following ICU discharge. Methods: Patients requiring a minimum of 14 days’ stay in the ICU with mechanical ventilation were included. Nutrition status was assessed at inclusion (ICU discharge) and follow-up (after 15, 30, and 60 days). All patients had standardized medical nutrition therapy with defined targets regarding energy (30 kcal/kg/d) and protein intake (1.5 g/kg/d). Results: Fifteen patients were included (67% males); the median age was 60 (33–75) years old. Body mass index at ICU admission was 25.7 (IQR, 24–31) kg/m². After a median ICU stay of 33 (IQR, 26–39) days, malnutrition was present in all patients (11.3% median weight loss and/or low muscle mass based on handgrip strength measurement). Because of postintubation dysphagia in 60% of patients, enteral nutrition was administered (57% nasogastric tube; 43% percutaneous endoscopic gastrostomy). After 2 months, a significant improvement in muscle strength was observed (median handgrip strength, 64.7% [IQR, 51%–73%] of the predicted values for age vs 19% [IQR, 4.8%–28.4%] at ICU discharge [P < 0.0005]), as well as weight gain of 4.3 kg (IQR, 2.7–6.7 kg) (P < 0.0002). Conclusions: Critically ill patients with COVID-19 requiring ICU admission and mechanical ventilation have malnutrition and low muscle mass at ICU discharge. Nutrition parameters improve during rehabilitation with standardized medical nutrition therapy.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Endoscopic management of enteral tubes in adult patients-Part 2: Peri-and post-procedural managementEuropean Society of Gastrointestinal Endoscopy (ESGE) Guideline

Main recommendations ESGE recommends the pull technique as the standard method for percutaneous endoscopic gastrostomy (PEG) placement. Strong recommendation, low quality evidence. ESGE recommends the direct percutaneous introducer (push) technique for PEG placement in cases where the pull method is contraindicated, for example in severe esophageal stenosis or in patients with head and neck cancer (HNC) or esophageal cancer. Strong recommendation, low quality evidence. ESGE recommends the intravenous administration of a prophylactic single dose of a beta-lactam antibiotic (or appropriate alternative antibiotic, in the case of allergy) to decrease the risk of post-procedural wound infection. Strong recommendation, moderate quality evidence. ESGE recommends that inadvertent insertion of a nasogastric tube (NGT) into the respiratory tract should be considered a serious but avoidable adverse event (AE). Strong recommendation, low quality evidence. ESGE recommends that each institution should have a dedicated protocol to confirm correct positioning of NGTs placed blindly at the patient's bedside; this should include: radiography, pH testing of the aspirate, and end-tidal carbon dioxide monitoring, but not auscultation alone. Strong recommendation, low quality evidence. ESGE recommends confirmation of correct NGT placement by radiography in high-risk patients (intensive care unit [ICU] patients or those with altered consciousness or absent gag/cough reflex). Strong recommendation, low quality evidence. ESGE recommends that EN may be started within 3-4 hours after uncomplicated placement of a PEG or PEG-J. Strong recommendation, high quality evidence. ESGE recommends that daily tube mobilization (pushing inward) along with a loose position of the external PEG bumper (1-2cm from the abdominal wall) could mitigate the risk of development of buried bumper syndrome. Strong recommendation, low quality evidence

The transcription factors Runx3 and ThPOK cross-regulate acquisition of cytotoxic function by human Th1 lymphocytes

International audienceCytotoxic CD4 (CD4(CTX)) T cells are emerging as an important component of antiviral and antitumor immunity, but the molecular basis of their development remains poorly understood. In the context of human cytomegalovirus infection, a significant proportion of CD4 T cells displays cytotoxic functions. We observed that the transcriptional program of these cells was enriched in CD8 T cell lineage genes despite the absence of ThPOK downregulation. We further show that establishment of CD4(CTX)-specific transcriptional and epigenetic programs occurred in a stepwise fashion along the Th1-differentiation pathway. In vitro, prolonged activation of naive CD4 T cells in presence of Th1 polarizing cytokines led to the acquisition of perforin-dependent cytotoxic activity. This process was dependent on the Th1 transcription factor Runx3 and was limited by the sustained expression of ThPOK. This work elucidates the molecular program of human CD4(CTX) T cells and identifies potential targets for immunotherapy against viral infections and cancer