Management of gastrointestinal failure in the adult critical care setting.

Gastrointestinal failure is a polymorphic syndrome with multiple causes. Managing the different situations from a practical, metabolic, and nutritional point of view is challenging, which the present review will try to address. Acute gastrointestinal injury (AGI) has been defined and has evolved into a concept of gastrointestinal dysfunction score (GIDS) built on the model of Sequential Organ Failure Assessment (SOFA) score, and ranging from 0 (no risk) to 4 (life threatening). But there is yet no specific, reliable and reproducible, biomarker linked to it. Evaluating the risk with the Nutrition Risk Screening (NRS) score is the first step whenever addressing nutrition therapy. Depending on the severity of the gastrointestinal failure and its clinical manifestations, nutritional management needs to be individualized but always including prevention of undernutrition and dehydration, and administration of target essential micronutrients. The use of fibers in enteral feeding solutions has gained acceptance and is even recommended based on microbiome findings. Parenteral nutrition whether alone or combined to enteral feeding is indicated whenever the intestine is unable to process the needs. The heterogeneity of gastrointestinal insufficiency precludes a uniform nutritional management of all critically ill patients but justifies its early detection and the implementation of individualized care

The nuclear shell effects near the r-process path in the relativistic Hartree-Bogoliubov theory

We have investigated the evolution of the shell structure of nuclei in going from the r-process path to the neutron drip line within the framework of the Relativistic Hartree-Bogoliubov (RHB) theory. By introducing the quartic self-coupling of $\omega$ meson in the RHB theory in addition to the non-linear scalar coupling of $\sigma$ meson, we reproduce the available data on the shell effects about the waiting-point nucleus $^{80}$Zn. With this approach, it is shown that the shell effects at N=82 in the inaccessible region of the r-process path become milder as compared to the Lagrangian with the scalar self-coupling only. However, the shell effects remain stronger as compared to the quenching exhibited by the HFB+SkP approach. It is also shown that in reaching out to the extreme point at the neutron drip line, a terminal situation arises where the shell structure at the magic number is washed out significantly.Comment: 18 pages (revtex), 8 ps figures, to appear in Phys. Rev.

Supplemental parenteral nutrition in intensive care patients: A cost saving strategy.

The Swiss supplemental parenteral nutrition (SPN) study demonstrated that optimised energy provision combining enteral nutrition (EN) and SPN reduces nosocomial infections in critically ill adults who fail to achieve targeted energy delivery with EN alone. To assess the economic impact of this strategy, we performed a cost-effectiveness analysis using data from the SPN study. Multivariable regression analyses were performed to characterise the relationships between SPN, cumulative energy deficit, nosocomial infection, and resource consumption. The results were used as inputs for a deterministic simulation model evaluating the cost-effectiveness of SPN administered on days 4-8 in patients who fail to achieve ≥60% of targeted energy delivery with EN by day 3. Cost data were derived primarily from Swiss diagnosis-related case costs and official labour statistics. Provision of SPN on days 4-8 was associated with a mean decrease of 2320 ± 338 kcal in cumulative energy deficit compared with EN alone (p < 0.001). Logistic regression analysis showed that each 1000 kcal decrease in cumulative energy deficit was associated with a 10% reduction in the risk of nosocomial infection (odds ratio 0.90; 95% confidence interval 0.83-0.99; p < 0.05). The incremental cost per avoided infection was -63,048 CHF, indicating that the reduction in infection was achieved at a lower cost. Optimisation of energy provision using SPN is a cost-saving strategy in critically ill adults for whom EN is insufficient to meet energy requirements

Parenteral nutrition in the intensive care unit: cautious use improves outcome.

Critical illness is characterised by nutritional and metabolic disorders, resulting in increased muscle catabolism, fat-free mass loss, and hyperglycaemia. The objective of the nutritional support is to limit fat-free mass loss, which has negative consequences on clinical outcome and recovery. Early enteral nutrition is recommended by current guidelines as the first choice feeding route in ICU patients. However, enteral nutrition alone is frequently associated with insufficient coverage of the energy requirements, and subsequently energy deficit is correlated to worsened clinical outcome. Controlled trials have demonstrated that, in case of failure or contraindications to full enteral nutrition, parenteral nutrition administration on top of insufficient enteral nutrition within the first four days after admission could improve the clinical outcome, and may attenuate fat-free mass loss. Parenteral nutrition is cautious if all-in-one solutions are used, glycaemia controlled, and overnutrition avoided. Conversely, the systematic use of parenteral nutrition in the ICU patients without clear indication is not recommended during the first 48 hours. Specific methods, such as thigh ultra-sound imaging, 3rd lumbar vertebra-targeted computerised tomography and bioimpedance electrical analysis, may be helpful in the future to monitor fat-free mass during the ICU stay. Clinical studies are warranted to demonstrate whether an optimal nutritional management during the ICU stay promotes muscle mass and function, the recovery after critical illness and reduces the overall costs

Micronutrient Deficiencies in Medical and Surgical Inpatients

Inpatients are threatened by global malnutrition, but also by specific micronutrient (i.e., trace element and vitamins) deficiencies that frequently are overseen in the differential diagnosis of major organ dysfunctions. Some of them are related to specific geographic risks (iodine, iron, selenium, zinc, vitamin A), while others are pathology related, and finally many are associated with specific feeding patterns, including low dose enteral feeding. Among the pathologies in which laboratory blood investigations should include a micronutrient outwork, anemia is in the front line, followed by obesity with bariatric surgery, chronic liver disease, kidney disease, inflammatory bowel disease, cardiomyopathies and heart failure. The micronutrients at the highest risk are iron, zinc, thiamine, vitamin B12 and vitamin C. Admission to hospital has been linked with an additional risk of malnutrition-feeding below 1500 kcal/day was frequent and has been associated with a structural additional risk of insufficient micronutrient intake to cover basal needs. Although not evidence based, systematic administration of liberal thiamine doses upon admission, and daily complementation of inpatients' food and enteral feeding solutions with multi-micronutrient tablets might be considered

A new numerical method for obtaining gluon distribution functions G(x,Q2)=xg(x,Q2)G(x,Q^2)=xg(x,Q^2), from the proton structure function F2γp(x,Q2)F_2^{\gamma p}(x,Q^2)

An exact expression for the leading-order (LO) gluon distribution function $G(x,Q^2)=xg(x,Q^2)$ from the DGLAP evolution equation for the proton structure function $F_2^{\gamma p}(x,Q^2)$ for deep inelastic $\gamma^* p$ scattering has recently been obtained [M. M. Block, L. Durand and D. W. McKay, Phys. Rev. D{\bf 79}, 014031, (2009)] for massless quarks, using Laplace transformation techniques. Here, we develop a fast and accurate numerical inverse Laplace transformation algorithm, required to invert the Laplace transforms needed to evaluate $G(x,Q^2)$, and compare it to the exact solution. We obtain accuracies of less than 1 part in 1000 over the entire $x$ and $Q^2$ spectrum. Since no analytic Laplace inversion is possible for next-to-leading order (NLO) and higher orders, this numerical algorithm will enable one to obtain accurate NLO (and NNLO) gluon distributions, using only experimental measurements of $F_2^{\gamma p}(x,Q^2)$.Comment: 9 pages, 2 figure

Autologous keratinocyte suspension in platelet concentrate accelerates and enhances wound healing - a prospective randomized clinical trial on skin graft donor sites: platelet concentrate and keratinocytes on donor sites.

BACKGROUND: Wound healing involves complex mechanisms, which, if properly chaperoned, can enhance patient recovery. The abilities of platelets and keratinocytes may be harnessed in order to stimulate wound healing through the formation of platelet clots, the release of several growth factors and cytokines, and cell proliferation. The aim of the study was to test whether autologous keratinocyte suspensions in platelet concentrate would improve wound healing. The study was conducted at the Lausanne University Hospital, Switzerland in 45 patients, randomized to three different topical treatment groups: standard treatment serving as control, autologous platelet concentrate (PC) and keratinocytes suspended in autologous platelet concentrate (PC + K). Split thickness skin graft donor sites were chosen on the anterolateral thighs of patients undergoing plastic surgery for a variety of defects. Wound healing was assessed by the duration and quality of the healing process. Pain intensity was evaluated at day five. RESULTS: Healing time was reduced from 13.9 ± 0.5 days (mean ± SEM) in the control group to 7.2 ± 0.2 days in the PC group (P < 0.01). An addition of keratinocytes in suspension further reduced the healing time to 5.7 ± 0.2 days. Pain was reduced in both the PC and PC + K groups. Data showed a statistically detectable advantage of using PC + K over PC alone (P < 0.01). CONCLUSION: The results demonstrate the positive contribution of autologous platelets combined with keratinocytes in stimulating wound healing and reducing pain. This strikingly simple approach could have a significant impact on patient care, especially critically burned victims for whom time is of the essence. CLINICAL TRIAL REGISTRY INFORMATION: Protocol Record Identification Number: 132/03Registry URL: http://www.clinicaltrials.gov