Evaluation of nutritional status in pediatric intensive care unit patients: the results of a multicenter, prospective study in Turkey

IntroductionMalnutrition is defined as a pathological condition arising from deficient or imbalanced intake of nutritional elements. Factors such as increasing metabolic demands during the disease course in the hospitalized patients and inadequate calorie intake increase the risk of malnutrition. The aim of the present study is to evaluate nutritional status of patients admitted to pediatric intensive care units (PICU) in Turkey, examine the effect of nutrition on the treatment process and draw attention to the need for regulating nutritional support of patients while continuing existing therapies.Material and MethodIn this prospective multicenter study, the data was collected over a period of one month from PICUs participating in the PICU Nutrition Study Group in Turkey. Anthropometric data of the patients, calorie intake, 90-day mortality, need for mechanical ventilation, length of hospital stay and length of stay in intensive care unit were recorded and the relationship between these parameters was examined.ResultsOf the 614 patients included in the study, malnutrition was detected in 45.4% of the patients. Enteral feeding was initiated in 40.6% (n = 249) of the patients at day one upon admission to the intensive care unit. In the first 48 h, 86.82% (n = 533) of the patients achieved the target calorie intake, and 81.65% (n = 307) of the 376 patients remaining in the intensive care unit achieved the target calorie intake at the end of one week. The risk of mortality decreased with increasing upper mid-arm circumference and triceps skin fold thickness Z-score (OR = 0.871/0.894; p = 0.027/0.024). The risk of mortality was 2.723 times higher in patients who did not achieve the target calorie intake at first 48 h (p = 0.006) and the risk was 3.829 times higher in patients who did not achieve the target calorie intake at the end of one week (p = 0.001). The risk of mortality decreased with increasing triceps skin fold thickness Z-score (OR = 0.894; p = 0.024).ConclusionTimely and appropriate nutritional support in critically ill patients favorably affects the clinical course. The results of the present study suggest that mortality rate is higher in patients who fail to achieve the target calorie intake at first 48 h and day seven of admission to the intensive care unit. The risk of mortality decreases with increasing triceps skin fold thickness Z-score

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Azalmiş görme duyusu, azalmiş plantar duyu ve kas zayifliğinin plantar basinç dağilimi üzerine etkisi

Amaç: Azalmış görme, azalmış plantar duyu ve kas zayıflığının plantar basınç dağılımı üzerindeki etkisini incelemektir. Bu faktörler sağlıklı olgularda ayrı olarak simüle edilmiştir. Gereç ve Yöntem: Çalışma grubu 12'si erkek 8'i kadın olan, 20 ila 44 yaş aralığındaki 20 sağlıklı olgudan oluşmuştur. Olgular tercih ettikleri yürüme hızlarıyla beş farklı koşulda yürümüştür. İlk koşul, normal yürüyüş paterniyle yürüme idi. İkincisi her olgunun, kilosunun %40'ına eşit ağırlık içeren bir yelek giymesiyle gerçekleştirilen simüle edilmiş kas zayıflığı yürümesiydi. Üçüncü koşul, ayakların 12 dakika buza batırılmalarından sonraki azalmış plantar duyu yürümesiydi. Dördüncüsü, üstünde siyah alanlar bulunan düz camlı bir gözlük ile sağlanan azalmış görme idi. Beşinci yürüme koşulu ise buz, ağırlık yeleği ve gözlüğün kombinasyonuydu. Ayağın plantar yüzü arka ayak iki, orta ayak iki, metatarsal başlar üç (1, 2, 3-4-5) ve parmaklar üç (1, 2, 3-4-5) olmak üzere on farklı alana bölünmüştür. Bulgular: Azalmış plantar duyu koşulunda pik ilk, ikinci ve üçüncü metatarsal başların altında anlamlı olarak arttı. Bulanık görme koşulunda pik basınç ikinci, üçüncü, dördüncü ve beşinci ayak parmaklarının altında anlamlı olarak arttı (p?0,05). Simüle edilmiş kas zayıflığı koşulunda pik basınç, medial ve lateral topuk, ikinci, üçüncü, dördüncü ve beşinci ayak parmaklarının altında ise anlamlı olarak arttı. Kombine koşulda pik basınç medial ve lateral orta ayak, ilk, ikinci, üçüncü, dördüncü ve beşinci metatarsal başların altında anlamlı olarak arttı. Sonuç: Azalmış plantar duyu simülasyonu tüm metatarsal başlardaæ azalmış görme simülasyonu ikinci, üçüncü, dördüncü ve beşinci ayak parmaklarındaæ kas zayıflığı simülasyonu ise topukta yüksek basınca yol açarken kombine koşul simülasyonu tüm metatarsal başlarda, lateral ve medial orta ayakta basıncı artırır. Anahtar kelimeler: Azalmış plantar duyu, azalmış görme, simüle edilmiş kas zayıflığı, diyabetik ayak, plantar basınç Purpose: To examine the influence of reduced vision, reduced plantar sensation and muscle weakness on plantar pressure distribution. These factors were seperately simulated on disease-free cases. Material and Methods: The study group consisted of 20 healthy subjects (12M- 8F) ranged in age from 20 to 44 years. Subjects walked in five different conditions with their preferred walking speed. First was normal condition walking in normal gait pattern. Second was simulated muscle weakness walking by wearing waistcoat contains 40% of subject's body weight. Third was reduced plantar sensation walking after 12 minutes ice immersion approach. Fourth was reduced vision by a pair of plane eyeglasess covered by black dots. Fifth walking condition was combination of iced feet, weight vest, and glasses. Plantar surface of the foot divided into ten different areas as two areas for hindfoot, two areas for midfoot, three areas for MTHs (1, 2, 3-4-5) and three areas for toes (1, 2, 3-4-5). Results: The peak pressure under the first, second and third metatarsal head were significantly increased under reduced plantar sensibility. The peak pressures increased significantly under the second and the third to fifth toes under blured vision (p?0.05). The peak pressure under the medial and lateral heel, second, and third to fifth toes were significantly increased under simulated muscle weakness. The peak pressure under medial, lateral midfoot, first, second, and third to fifth metatarsal heads were significantly increased under combined condition. Conclusion: Reduced plantar sensation simulation results in high pressure under all metatarsal heads, reduced vision simulation results in high pressure under the second and the third to fifth toes, muscle weakness simulation results in high pressure under heel. However, combined condition simulation increase the pressure under all metarsal heads, lateral and medial midfoot. Key words: Reduced plantar sensation, reduced vision, simulated muscle weakness, diabetic foot, plantar pressur

Does adding mobilization to stretching improve outcomes for people with frozen shoulder? A randomized controlled clinical trial

Objective: To assess the effectiveness of joint mobilization combined with stretching exercises in patients with frozen shoulder

Clinical Implication of Latent Myofascial Trigger Point

Myofascial trigger points (MTrPs) are hyperirritable points located within a taut band of skeletal muscle or fascia, which cause referred pain, local tenderness and autonomic changes when compressed. There are fundamental differences between the effects produced by the two basic types of MTrPs (active and latent). Active trigger points (ATrPs) usually produce referred pain and tenderness. In contrast, latent trigger points (LTrPs) are foci of hyperirritability in a taut band of muscle, which are clinically associated with a local twitch response, tenderness and/or referred pain upon manual examination. LTrPs may be found in many pain-free skeletal muscles and may be "activated" and converted to ATrPs by continuous detrimental stimuli. ATrPs can be inactivated by different treatment strategies; however, they never fully disappear but rather convert to the latent form. Therefore, the diagnosis and treatment of LTrPs is important. This review highlights the clinical implication of LTrPs