Enteral Nutrition Support in Burn Care: A Review of Current Recommendations as Instituted in the Ross Tilley Burn Centre

Failure to adequately address the increased levels of inflammatory mediators, catecholamines and corticosteroids central to the hypermetabolic response post burn injury can lead to catastrophic results. One of the most important perturbations is provision of adequate and early nutrition. The provision of the right balance of macro and micronutrients, along with additional antioxidants is essential to mitigating the hypermetabolic and hypercatabolic state that results following a burn injury. As it is now widely accepted that enteral feeding is best practice for the burn population research has been more closely examining the individual components of enteral nutrition support. Recently fat to carbohydrate ratios, glutamine and antioxidants have made up the balance of this focus. This paper provides a review of the most recent literature examining each of these components and discusses the practices adopted in the Ross Tilley Burn Centre at Sunnybrook Health Sciences Centre.     

老年烧伤患者的营养状态评价

目的分析反映老年烧伤患者营养状态的指标的变化规律，以指导营养支持治疗。方法以2004年1月-2007年10月入院的83例年龄超过60岁的轻度烧伤老年患者作为研究对象，以同期人院的20例中青年烧伤患者作对照。将不同性别的老年患者按年龄分别分为60—69岁、70—79岁、≥80岁组，共6组。于入院次日晨起抽取患者空腹静脉血，检测血清总蛋白、白蛋白、前白蛋白、胆碱酯酶、血红蛋白水平，淋巴细胞数、淋巴细胞百分比，并将各指标与年龄进行相关性分析，统计患者营养不良的发生率。结果与中青年烧伤患者比较，各年龄段老年烧伤患者的血清总蛋白、白蛋白、前白蛋白、胆碱酯酶水平、淋巴细胞数、淋巴细胞百分比均不同程度下降，且与年龄呈显著负相关。老年烧伤患者营养不良的总发生率为28．9％，各年龄组营养不良发生率的差异具有显著性（P=0．002），≥80岁组最高（72．7％），60—69岁组最低（18．8％）。老年女性营养不良发生率（40．4％）显著高于男性（13．9％，P=0．000）。结论营养不良在老年烧伤患者中较普遍，年龄越大发生率越高，特别是老年女性，应根据老年烧伤患者营养不良的发生特点采取适当的营养支持措施。     

Malnutrition in Hospitalized Pediatric Patients: Assessment,Prevalence, and Association to Adverse Outcomes

Malnutrition is a frequent finding in pediatric health care settings in the form of undernutrition or excess body weight. Its increasing prevalence and impact on overall health status, which is reflected in the adverse outcomes, renders imperative the application of commonly accepted and evidence-based practices and tools by health care providers. Nutrition risk screening on admission and nutrition status evaluation are key points during clinical management of hospitalized pediatric patients, in order to prevent health deterioration that can lead to serious complications and growth consequences. In addition, anthropometric data based on commonly accepted universal growth standards can give accurate results for nutrition status. Both nutrition risk screening and nutrition status assessment are techniques that should be routinely implemented, based on commonly accepted growth standards and methodology, and linked to clinical outcomes. The aim of the present review was to address the issue of hospital malnutrition in pediatric settings in terms of prevalence, outline nutrition status evaluation and nutrition screening process using different criteria and available tools, and present its relationship with outcome measures.

Key teaching points

? Malnutrition—underweight or excess body weight—is a frequent imbalance in pediatric settings that affects physical growth and results in undesirable clinical outcomes. ? Anthropometry interpretation through growth charts and nutrition screening are cornerstones for the assessment of malnutrition.To date no commonly accepted anthropometric criteria or nutrition screening tools are used in hospitalized pediatric patients. ? Commonly accepted nutrition status and screening processes based on the World Health Organization's growth standards can contribute to the overall hospital nutrition care of pediatric patients.     

Cost-Effectiveness of a Nonpharmacological Intervention in Pediatric Burn Care

ObjectiveTo report the cost-effectiveness of a tailored handheld computerized procedural preparation and distraction intervention (Ditto) used during pediatric burn wound care in comparison to standard practice.MethodsAn economic evaluation was performed alongside a randomized controlled trial of 75 children aged 4 to 13 years who presented with a burn to the Royal Children’s Hospital, Brisbane, Australia. Participants were randomized to either the Ditto intervention (n = 35) or standard practice (n = 40) to measure the effect of the intervention on days taken for burns to re-epithelialize. Direct medical, direct nonmedical, and indirect cost data during burn re-epithelialization were extracted from the randomized controlled trial data and combined with scar management cost data obtained retrospectively from medical charts. Nonparametric bootstrapping was used to estimate statistical uncertainty in cost and effect differences and cost-effectiveness ratios.ResultsOn average, the Ditto intervention reduced the time to re-epithelialize by 3 days at AU$194 less cost for each patient compared with standard practice. The incremental cost-effectiveness plane showed that 78% of the simulated results were within the more effective and less costly quadrant and 22% were in the more effective and more costly quadrant, suggesting a 78% probability that the Ditto intervention dominates standard practice (i.e., cost-saving). At a willingness-to-pay threshold of AU$120, there is a 95% probability that the Ditto intervention is cost-effective (or cost-saving) against standard care.ConclusionsThis economic evaluation showed the Ditto intervention to be highly cost-effective against standard practice at a minimal cost for the significant benefits gained, supporting the implementation of the Ditto intervention during burn wound care.     

睡眠剥夺对机体的影响

随着人们的生活节奏越来越快,睡眠剥夺现象日益常见。睡眠不足的人会感到烦躁、学习效率下降等。长期睡眠缺失会导致肥胖、心脏病、高血压和糖尿病甚至缩短寿命。本文将从睡眠剥夺对精神、神经系统的影响;对内分泌、代谢的影响;对免疫系统的影响;睡眠剥夺与应激;睡眠剥夺的临床应用等方面来阐述睡眠剥夺对机体的影响。     

Sleep patterns in relation to dietary patterns and cardio‐metabolic risk: An update from Drummond Pump Priming Award recipients

This article provides an update on the project ‘Sleep patterns in relation to dietary patterns and cardio‐metabolic risk’, which received funding from the British Nutrition Foundation (BNF) Drummond Pump Priming Award. Studying the relationship between sleep, the biological clock, timing of eating and nutrition is part of a new research area termed chrono‐nutrition. With the help of the BNF award, a PhD project was set up to investigate the effects of sleep duration and quality on energy balance, dietary intake and quality, and cardio‐metabolic risk factors. The project included three studies: (1) a systematic review and meta‐analysis investigating whether partial sleep deprivation results in positive energy balance; (2) a cross‐sectional study exploring associations between energy balance, dietary intake and quality, chrono‐nutrition and cardio‐metabolic risk factors; and (3) a randomised controlled intervention feasibility study investigating whether sleep extension in participants with chronic mild sleep deprivation can improve energy balance, diet quality, body composition and cardio‐metabolic risk profile. The systematic review showed that partial sleep deprivation results in a net positive energy balance arising from a significantly higher energy intake of 385 kcal/day, with no compensatory effect on energy expenditure. Results from the cross‐sectional and randomised controlled feasibility studies are expected later this year. Overall, the project will help to establish whether sleep extension can be used in combination with existing weight management strategies to reduce the burden of obesity and metabolic dysregulation, which are major public health threats.     

Back to basics: Estimating energy requirements for adult hospital patients

Predictive equations are a quick and non‐invasive way to estimate a patient's energy requirements, and can be a useful tool when used appropriately. However, as with any tool, the skill and experience of the user will affect the quality of the result. This paper looks at the origins and limitations of some of the more commonly used equations. Considerations in their use and interpretation, such as the use of injury and activity factors, adjusting weight and non‐protein calories, are also discussed.     

An Evaluation of the Nutrition Services for the Elderly

No abstract available for this article.     

Dysmetabolism and Sleep Fragmentation in Obstructive Sleep Apnea Patients Run Independently of High Caffeine Consumption

Daytime hypersomnolence, the prime feature of obstructive sleep apnea (OSA), frequently leads to high coffee consumption. Nevertheless, some clinicians ask for patients’ caffeine avoidance. Caffeinated drinks are sometimes associated with more severe OSA. However, these effects are not consensual. Here we investigated the effect of caffeine consumption on sleep architecture and apnea/hypopnea index in OSA. Also, the impact of caffeine on variables related with dysmetabolism, dyslipidemia, and sympathetic nervous system (SNS) dysfunction were investigated. A total of 65 patients diagnosed with OSA and 32 without OSA were included after given written informed consent. Polysomnographic studies were performed. Blood was collected to quantify caffeine and its metabolites in plasma and biochemical parameters. 24 h urine samples were collected for catecholamines measurement. Statistical analyses were performed by SPSS: (1) non-parametric Mann-Whitney test to compare variables between controls and OSA; (2) multivariate logistic regression testing the effect of caffeine on sets of variables in the 2 groups; and (3) Spearmans’ correlation between caffeine levels and comorbidities in patients with OSA. As expected OSA development is associated with dyslipidemia, dysmetabolism, SNS dysfunction, and sleep fragmentation. There was also a significant increase in plasma caffeine levels in the OSA group. However, the higher consumption of caffeine by OSA patients do not alter any of these associations. These results showed that there is no apparent rationale for caffeine avoidance in chronic consumers with OSA.     

OSAHS与单纯鼾症儿童睡眠效率及睡眠结构分析

目的探讨儿童阻塞性睡眠呼吸暂停低通气综合征(OSAHS)与单纯鼾症(PS)儿童夜间睡眠效率和睡眠结构的分析。方法对32例OSAHS儿童和27例PS儿童进行全夜多导睡眠图(PSG)监测,观察夜间睡眠效率和睡眠结构各项指标,并进行比较。结果OSAHS组患儿的睡眠效率显著低于PS组(P<0.01);与PS组及正常值比较,OSAHS组的睡眠结构存在以下差异睡眠Ⅰ期显著高于PS组和正常值(P<0.01),睡眠Ⅱ期、慢波睡眠、快动眼睡眠显著低于PS组和正常值(P<0.01)。PS组的睡眠结构分析基本均在正常范围,但睡眠效率有所下降。结论OSAHS可引起儿童睡眠结构紊乱和睡眠效率下降。     

阻塞性睡眠呼吸暂停综合征患者代谢综合征的患病情况

目的分析阻塞性睡眠呼吸暂停综合征（OSAHS）患者中代谢综合征（MS）及其各构成组分的患病情况。方法对28例对照组和148例OSAHS组（46例轻度、35例中度和67例重度）的患者检测并分析形体参数和血液生化指标。结果（1）重度OSAHS组的HDL-C低于对照组和轻度OSAHS组（P〈0.05）;重度OSAHS组的FPG高于对照组（P〈0.05）;中重度OSAHS组的SBP高于对照组（P〈0.05）,重度OSAHS组的DBP高于对照组（P〈0.05）;重度OS-AHS组的BMI、腰围显著高于对照组、轻度和中度OSAHS组（P〈0.05-0.01）,中度OSAHS组的BMI、腰围显著高于对照组（P〈0.05-0.01）,轻度OSAHS组的腰围高于对照组（P〈0.05）;重度OSAHS组颈围高于对照组和轻度OSAHS组（P〈0.05）。（2）趋势χ^2检验显示四组肥胖、高血压、高血糖患病率间存在差异（P〈0.01-0.001）,且随着OSAHS程度的加重有升高趋势（P〈0.05-0.001）。（3）四组MS的患病率间存在差异（P〈0.01）,且随着OSAHS程度的加重有升高趋势（P〈0.05）。结论OSAHS尤其重度OSAHS组与MS的各主要症候密切相关,随着OSAHS程度的加重肥胖、高血压、高血糖和MS患病率有升高趋势。     

癫痫患者剥夺睡眠—睡眠与药物诱导睡眠脑电图的对照研究

目的探讨癫痫患者药物诱导睡眠和剥夺睡眠—睡眠脑电图(EEG)差别,评估两者对癫痫(EP)诊断价值。方法对临床上已确诊为癫痫患者364例,随机分为剥夺睡眠—睡眠和药物诱导睡眠两组,分别进行觉醒及睡眠EEG描记,并对两组病例睡眠周期及睡眠各期EEG表现分析对比。结果药物诱导睡眠组、剥夺睡眠—睡眠组常规清醒脑电图异常波阳性率分别为39.9%、41.7%,二组异常波检出率无显著差异(P>0.05);两组睡眠脑电图异常波阳性率分别为80.4%、85.0%,异常波阳性率剥夺睡眠—睡眠组略高于药物诱导睡眠组;癫痫样放电阳性率分别为59.9%、89.1%,两组癫痫样放电均易在NREM睡眠Ⅰ—Ⅱ期出现,癫痫样放电阳性率剥夺睡眠组明显高于药物诱导睡眠组,二者差异有统计学意义(P<0.001)。结论剥夺睡眠—睡眠、药物诱导睡眠均可提高癫痫诊断率,剥夺睡眠—睡眠联合诱发试验在癫痫病人的诊断中优于药物诱导睡眠诱发试验。     

Sleep disturbances in a community sample from preschool to school age

Objective To study the prevalence of various sleep problems at school age in a Finnish community sample and to evaluate the persistence of the sleep problems from the preschool age to school age in a 4‐year follow‐up. Methods Parents completed the Sleep Disturbance Scale for Children questionnaire on their child's sleep during the preschool years (3–6 years) and again during the school years (7–11 years). At follow‐up the parents also completed a questionnaire on family structure and socio‐economic status. Results The parents of 481 children completed the questionnaires during both the first study and the follow‐up (girls 49%, boys 51%; mean age 9, range 7–11). At the population level, sleep problems slightly declined from preschool to school age (P < 0.05). However, sleep problems at preschool age showed a strong persistence to school age. At the follow‐up, 35% of the children who were considered to have a sleep disorder at preschool age still suffered from it at school age. At the community level, this equates to 9% of the children. The children with no sleep problems at preschool age rarely developed sleep problems at school age. Conclusions This study showed that various types of sleep problems are common at school age. Sleep problems persisted from preschool to school age at the individual level. It is important to recognize all types of sleep problems, especially persistent ones. Persistent sleep problems in children may cause and exacerbate other somatic, cognitive and psychiatric problems. Therefore, more attention should be focused on sleep problems in paediatric health care with interventions aimed particularly at children with prolonged sleep problems.     

Associations between Red Meat Intake and Sleep Parameters in Patients with Obstructive Sleep Apnea

BackgroundAlthough lifestyle changes have been investigated as a therapeutic choice in regard to obstructive sleep apnea (OSA) severity, data exploring associations between apnea and hypopnea indices and dietary habits are scarce.ObjectiveThe aim was to investigate possible relationships between apnea and hypopnea indices and red meat intake in a cohort of Greek patients with mild or moderate to severe OSA evaluated by polysomnography.DesignThis is a cross-sectional study. Data were collected from November 2014 through July 2018.Participants/settingThe sample consisted of 243 patients (21 to 70 years old) who were recently diagnosed with OSA, by overnight attended polysomnography in the Sleep Disorders Center of “Evangelismos” Hospital, Athens Medical School (Greece). The patients included were free of other chronic diseases and had not changed their dietary habits for at least 6 months before evaluation.Main outcome measuresInformation on participants’ dietary intake, food group consumption, physical activity, smoking, sleep habits, and anthropometric measures were collected. Dietary intake was evaluated by food frequency questionnaire and 24-hour dietary recalls. Adherence to the Mediterranean diet was also evaluated using the Mediterranean Diet Score.Statistical analyses performedGeneral linear models were used to examine the relation between red meat intake and sleep parameters, while adjusting for potential confounders. Multiple logistic regression was also applied to estimate the association between red meat intake and the likelihood of severe OSA.ResultsHigher intakes of total red meat and unprocessed red meat were associated with higher values of apnea and hypopnea indices, after controlling for age, sex, waist circumference, socioeconomic parameters, smoking, physical activity, adequacy of nighttime sleep, and intake of foods or food components in the Mediterranean diet other than red meat (P trend for increasing quartiles of intake ≤0.02). Compared with patients in the lowest quartile of energy-adjusted total red meat intake (≤0.59 servings/day per 1,000 kcal), patients in the highest quartile (≥1.18 servings/day) had three times higher likelihood of having severe OSA (odds ratio: 3.09, 95% CI: 1.17 to 8.14).ConclusionsThe results provide evidence of a positive association between total red meat and unprocessed red meat intake with apnea or hypopnea indices and suggest that red meat consumption is associated with OSA severity.     

Toward the Development of Predictive Equations for Resting Metabolic Rate in Acutely Ill Spontaneously Breathing Patients

Background: There are many equations used for calculating energy needs of nutrition support patients but few developed specifically for the subset of spontaneously breathing acutely ill patients. The purpose of the current study was to validate existing equations and to start developing new equations for this cohort. Methods: Acutely ill patients not requiring mechanical ventilation had their resting metabolic rate measured using an indirect calorimeter. Metabolic rate was also calculated using the Mifflin–St Jeor equation, the Ireton‐Jones equation for spontaneously breathing patients, and a modification of the Penn State equation in which the minute ventilation‐dependent variable was removed. These calculated values were compared with measured expenditure and considered accurate if they fell within 10% of the measurement. Results: Fifty‐five patients were measured successfully. The modified Penn State equation was accurate in 71% of patients compared with 44% for Ireton‐Jones and 42% for Mifflin–St Jeor. Several forms of a new equation were outlined but not validated. The equation with the highest R² (0.82) was as follows: resting metabolic rate (kcal/d) = weight in kg (20) ? age in years (3) + male sex (197) + body mass index in kg/m² (25.9) + mean heart rate in beats/min (9.4) + 89. Conclusions: A modification of the Penn State equation for predicting resting metabolic rate was shown to accurately predict resting metabolic rate in acutely ill, spontaneously breathing patients if body mass index was ≥20.5 kg/m². A new set of population‐specific equations was outlined but should not be used until validated.     

Malnutrition Diagnoses in Hospitalized Patients

Malnutrition is common among hospitalized patients in the United States, and its coded prevalence is increasing. Malnutrition is known to be associated with increased morbidity, mortality and healthcare costs. Although national data indicate that the number of malnutrition diagnoses among hospital discharges has been steadily rising, an in‐depth examination of the demographic and clinical characteristics of these patients has not been conducted. We examined data from the 2010 Healthcare Cost and Utilization Project (HCUP), the most recent nationally‐representative data describing U.S. hospital discharges. Using ICD‐9 codes, we constructed a composite variable indicating a diagnosis of malnutrition. Based on our definition, 3.2% of all U.S. hospital discharges in 2010 had this diagnosis. Relative to patients without a malnutrition diagnosis, those with the diagnosis were older, had longer lengths of stay and incurred higher costs. These patients were more likely to have 27 of 29 comorbidities assessed in HCUP. Finally, discharge to home care was twice as common among malnourished patients, and a discharge of death was more than 5 times as common among patients with a malnutrition diagnosis. Taken together, these nationally representative, cross‐sectional data indicate that hospitalized patients discharged with a diagnosis of malnutrition are older and sicker and their inpatient care is more expensive than their counterparts without this diagnosis.