Gastric versus post-pyloric feeding: a systematic review

Background  

Our objective was to evaluate the impact of gastric versus post-pyloric feeding on the incidence of pneumonia, caloric intake, intensive care unit (ICU) length of stay (LOS), and mortality in critically ill and injured ICU patients.     

Gastric versus postpyloric feeding

Feeding into the small bowel is often recommended to improve nutrient delivery for critically ill patients, and thus improve outcome and reduce complications associated with enteral feeding. Risks and benefits of gastric feeding, use of motility agents, postpyloric feeding, and obtaining small bowel access are discussed here. Randomized clinical trials directly comparing postpyloric with gastric feeds are also evaluated. These small, underpowered studies demonstrate small but clinically important differences in important outcomes (pneumonia), but are weakened by significant heterogeneity. Current evidence does not support routine use of postpyloric feeding in the critically ill. A standardized approach to optimizing benefits and minimizing risks with enteral nutrition delivery will help clinicians identify patients who would benefit from small bowel feeding.     

Normocaloric versus hypocaloric feeding on the outcomes of ICU patients: a systematic review and meta-analysis

Introduction

Current clinical practice guidelines recommend providing ICU patients a daily caloric intake estimated to match 80–100 % of energy expenditure (normocaloric goals). However, recent clinical trials of intentional hypocaloric feeding question this approach.

Methods

We performed a systematic review and meta-analysis to compare the outcomes of ICU patients randomized to intentional hypocaloric or normocaloric goals. We included randomized controlled trials that enrolled ICU patients and compared intentional hypocaloric with normocaloric nutritional goals. We included studies that evaluated both trophic feeding as well as permissive underfeeding. Data sources included MEDLINE, Cochrane Register of Controlled Trials and citation review of relevant primary and review articles. The outcomes of interest included hospital acquired infection, hospital mortality, ICU length of stay (LOS) and ventilator-free days (VFDs).

Results

Six studies which enrolled 2517 patients met our inclusion criteria. The mean age and body mass index (BMI) across the studies were 53 ± 5 years and 29.1 ± 1.5 kg/m², respectively. Two studies compared normocaloric feeding (77 % of goal) with trophic feeding (20 % of goal), while four studies compared normocaloric feeding (72 % of goal) with permissive underfeeding (49 % of goal). Overall, there was no significant difference in the risk of infectious complications (OR 1.03; 95 % CI 0.84–1.27, I ² = 16 %), hospital mortality (OR 0.91; 95 % CI 0.75–1.11, I ² = 8 %) or ICU LOS (mean difference 0.05 days; 95 % CI 1.33–1.44 days; I ² = 37 %) between groups. VFDs were reported in three studies with no significant difference between the normocaloric and intentional hypocaloric groups (data not pooled).

Conclusion

This meta-analysis demonstrated no difference in the risk of acquired infections, hospital mortality, ICU length of stay or ventilator-free days between patients receiving intentional hypocaloric as compared to normocaloric nutritional goals.

     

ABO-identical versus nonidentical platelet transfusion: a systematic review

BACKGROUND: The significance of ABO matching for platelet (PLT) transfusion has not been clearly defined. The primary objective of this report is to assess whether ABO-identical PLT transfusion is associated with improved mortality and/or morbidity for patients with hematologic/oncologic disorders.
STUDY DESIGN AND METHODS: A systematic review to January 2009 was conducted. Data on mortality, morbidity, PLT refractoriness, and PLT increment after transfusion were abstracted.
RESULTS: A total of 100 citations were identified. Nineteen studies were included in the systematic review. A total of 1502 patients from three randomized controlled trials and 16 observational studies were included. Survival, bleeding events, and transfusion reactions were only considered as secondary outcomes in the reports reviewed. The PLT count increment was the primary outcome of several studies and was consistently higher with ABO-identical PLT transfusion. The largest difference in increment between ABO-identical and nonidentical PLT transfusion was 4 × 10⁹/L. No consistent benefit in clinical outcomes was noted. Survival was assessed in three reports with conflicting results. Although two studies described bleeding as an outcome, the assessment of hemorrhage was considered inadequate. In six studies, ABO-nonidentical PLT transfusion was not associated with transfusion reactions, and the results from four studies addressing the impact of ABO-identical PLT transfusion on PLT and red blood cell utilization were conflicting.
CONCLUSION: ABO-identical PLT transfusion results in a higher PLT increment. Randomized controlled trials are required to definitely determine the effect of ABO-identical PLT transfusion on survival, bleeding events, or transfusion reactions.     

Antidepressants versus psychotherapy for bulimia nervosa: a systematic review

OBJECTIVE: To assess the efficacy and acceptability of antidepressants compared to psychotherapy as single approaches for the treatment of bulimia nervosa. METHOD: Dichotomous outcomes were analysed by calculating relative risks and continuous outcomes by calculating effect sizes. The number needed to treat (or harm) was calculated. Methodological quality of trials and heterogeneity in the results were evaluated. RESULTS: A meta-analysis including five randomized controlled trials showed a non-significant difference in short-term remission of bulimic symptoms favouring psychotherapy. Remission rates were 20% for antidepressants and 39% for psychotherapy (P = 0.07). Dropout rates were higher (P = 0.027) for antidepressants (40%) than for psychotherapy (18%). The number needed to harm (NNH) was 4. DISCUSSION: Psychotherapy was superior to antidepressants, but using a more conservative statistical approach this difference, although clinically relevant, was not significant. The number of trials might be insufficient to show the significance of a 20% absolute risk reduction in efficacy. Psychotherapy was a better accepted treatment.     

Gastric versus transpyloric feeding in severe traumatic brain injury: a prospective, randomized trial

Purpose  

To evaluate the efficacy of transpyloric feeding (TPF) compared with gastric feeding (GF) with regard to the incidence of ventilator-associated pneumonia in severe traumatic brain injury patients (TBI).     

Erythromycin versus metoclopramide for post-pyloric spiral nasoenteric tube placement: a randomized non-inferiority trial

Purpose

To determine whether erythromycin is non-inferior to metoclopramide in facilitating post-pyloric placement of self-propelled spiral nasoenteric tubes (NETs) in critically ill patients.

Methods

A prospective, multicenter, open-label, parallel, and non-inferiority randomized controlled trial was conducted comparing erythromycin with metoclopramide in facilitating post-pyloric placement of spiral NETs in critically ill patients admitted to intensive care units (ICUs) of eight tertiary hospitals in China. The primary outcome was procedure success defined as post-pyloric placement (spiral NETs reached the first portion of the duodenum or beyond confirmed by abdominal radiography 24 h after tube insertion).

Results

A total of 5688 patients were admitted to the ICUs. Of these, in 355 patients there was a plan to insert a nasoenteric feeding tube, of whom 332 were randomized, with 167 patients assigned to the erythromycin group and 165 patients assigned to the metoclopramide group. The success rate of post-pyloric placement was 57.5% (96/167) in the erythromycin group, as compared with 50.3% (83/165) in the metoclopramide group (a difference of 7.2%, 95% CI ??3.5% to 17.9%), in the intention-to-treat analysis, not including the prespecified margin of ??10% for non-inferiority. The success rates of post-D1 (reaching the second portion of the duodenum or beyond), post-D2 (reaching the third portion of the duodenum or beyond), post-D3 (reaching the fourth portion of the duodenum or beyond), and proximal jejunum placement and the incidence of any adverse events were not significantly different between the groups.

Conclusions

Erythromycin is non-inferior to metoclopramide in facilitating post-pyloric placement of spiral NETs in critically ill patients. The success rates of post-D1, post-D2, post-D3, and proximal jejunum placement were not significantly different.

     

A novel method of post-pyloric feeding tube placement at bedside

Purpose

Post-pyloric feeding tube placement is often difficult, and special equipment or peristalsis agents are used to aid insertion. Although several reports have described blind techniques for post-pyloric feeding-tube placement, no general consensus about method preference has been achieved.

Materials and Methods

The technique is performed as follows: via the nostril, a stylet-tipped feeding tube is advanced about 70 cm; to confirm tip location to the right of the epigastric area, towards the right hypochondriac region, 5 mL shots of air are injected to enable touch detection of bubbling; finally, the tube is advanced to a length of 100 cm, during which the strength of bubbling seems to diminish under palpation.

Results

We prospectively enrolled consecutive patients whose oral intake was expected to be difficult for 48 hours in the intensive care unit. Forty-one patients were enrolled and the rate of successful placement at first attempt was 95.1%. Mean duration for successful placement was 15 minutes.

Conclusions

With a novel technique, from the bedside, without special tools or drugs, we successfully placed post-pyloric feeding tubes. Essential points when inserting the tube are confirmation of the location of the tube tip by palpation of injected air, and to avoid deflection and looping.     

Gastric versus small-bowel tube feeding in the intensive care unit: a prospective comparison of efficacy

OBJECTIVE: To compare the outcomes of intensive care unit patients fed through a nasogastric vs. a nasal-small-bowel tube including the time from tube placement to feeding, time to reach goal rate, and adverse events. DESIGN: Sixty patients were prospectively randomized to receive gastric or small-bowel tube feedings. Nursing staff attempted to place a feeding tube in the desired position, and placement was confirmed radiographically after each bedside attempt. After two unsuccessful attempts, the feeding tube was placed under fluoroscopy. Feedings were started at 30 mL/hr and advanced to the patient's specific goal rate. SETTING: Twenty-bed medical intensive care unit. PATIENTS: Sixty medical patients admitted/transferred to the intensive care unit. INTERVENTIONS: Tube feeds were held for 2 hrs if any residual was >200 mL. MEASUREMENTS: Times were recorded at the initial tube insertion, onset of feeding, achievement of goal rate, and termination of feeding. Adverse outcomes included witnessed aspiration, vomiting, and clinical/radiographic evidence of aspiration. Patients were followed up for the duration of feeding, until leaving the intensive care unit, or for a maximum of 14 days. MAIN RESULTS: Patients fed in the stomach received nutrition sooner from initial placement attempt (11.2 hrs vs. 27.0 hrs) and with fewer attempts (one vs. two) than those fed in the small bowel. Patients achieve goal rate sooner (28.8 hrs vs. 43.0 hrs) with gastric feeding compared with small-bowel feeding. There was no difference in aspiration events. CONCLUSIONS: Gastric feeding demonstrates no increase in aspiration or other adverse outcomes compared with small-bowel feeding in the intensive care unit. Gastric feeding can be started and advanced to goal sooner with fewer placement attempts than small-bowel feeding.     

Gastric tonometry guided therapy in critical care patients: a systematic review and meta-analysis

IntroductionThe value of gastric intramucosal pH (pHi) can be calculated from the tonometrically measured partial pressure of carbon dioxide (P_CO2) in the stomach and the arterial bicarbonate content. Low pHi and increase of the difference between gastric mucosal and arterial P_CO2 (P_CO2 gap) reflect splanchnic hypoperfusion and are good indicators of poor prognosis. Some randomized controlled trials (RCTs) were performed based on the theory that normalizing the low pHi or P_CO2 gap could improve the outcomes of critical care patients. However, the conclusions of these RCTs were divergent. Therefore, we performed a systematic review and meta-analysis to assess the effects of this goal directed therapy on patient outcome in Intensive Care Units (ICUs).MethodsWe searched PubMed, EMBASE, the Cochrane Library and ClinicalTrials.gov for randomized controlled trials comparing gastric tonometry guided therapy with control groups. Baseline characteristics of each included RCT were extracted and displayed in a table. We calculated pooled odds ratios (ORs) with 95% confidence intervals (CIs) for dichotomous outcomes. Another measure of effect (risk difference, RD) was used to reassess the effects of gastric tonometry on total mortality. We performed sensitivity analysis for total mortality. Continuous outcomes were presented as standardised mean differences (SMDs) together with 95% CIs.ResultsThe gastric tonometry guided therapy significantly reduced total mortality (OR, 0.732; 95% CI, 0.536 to 0.999, P = 0.049; I² = 0%; RD, −0.056; 95% CI, −0.109 to −0.003, P = 0.038; I² = 0%) when compared with control groups. However, after excluding the patients with normal pHi on admission, the beneficial effects of this therapy did not exist (OR, 0.736; 95% CI 0.506 to 1.071, P = 0.109; I² = 0%). ICU length of stay, hospital length of stay and days intubated were not significantly improved by this therapy.ConclusionsIn critical care patients, gastric tonometry guided therapy can reduce total mortality. Patients with normal pHi on admission contributed to the ultimate result of this outcome; it may indicate that these patients may be more sensitive to this therapy.     

Corticosteroids for sepsis: registry versus Cochrane systematic review!

A recent report from the PROGRESS registry highlighted that low dose corticosteroids are widely used in patients with sepsis around the world. In this report, corticosteroids may be associated with increased morbidity and mortality. However, these findings should be viewed with caution given that this study has several inherent flaws because of its retrospective nature and the lack of controlled use of corticosteroids. In this commentary, these findings are contrasted with those of a recent Cochrane systematic review.     

Iridology: a systematic review

This study is a literature review about Iridology/Irisdiagnose in the period from 1970 to 2005. The objective was to identify the worldwide scientific publications (articles) in this field and the opinions about the method. Twenty-five articles were found, four of them from Brazilian authors. About the category, 1 was literature review, 12 research studies and 12 updates, historical reviews or editorials. The countries that have contributed more with the studies were Brazil and Russia. Fifteen of those are in favor of the method and 10 are against it. In conclusion, it is necessary to develop more studies inside the methodological rigor, once Iridology brings hope to preventive medicine.     

A randomised controlled comparison of early post-pyloric versus early gastric feeding to meet nutritional targets in ventilated intensive care patients

Introduction  

To compare outcomes from early post-pyloric to gastric feeding in ventilated, critically ill patients in a medical intensive care unit (ICU).     

射频消融与外科手术治疗甲状腺微小乳头状癌疗效的系统评价

目的 系统评价射频消融与外科手术治疗甲状腺微小乳头状癌(papillary thyroid microcarcinoma,PTMC)的疗效和安全性。资料与方法 计算机检索自建库至2021年11月在PubMed、Cochrane图书馆、Embase、Web of Science、中国知网、万方、维普、中国生物医学文献数据库上公开发表的射频消融与外科手术治疗PTMC的相关文献。2名研究者严格按照纳入及排除标准独立进行文献筛选、资料提取并对纳入文献进行质量评价,采用Revman5.4进行Meta分析。结果 共纳入8篇文献,共1932例患者,其中射频消融组972例,外科手术组960例。Meta分析结果显示：射频消融组较外科手术组术后并发症少［RR=0.28,95％CI(0.12,0.63),P=0.002］,手术时间短［MD=-54.65,95％CI(-65.83,-43.46),P＜0.05］,术中失血量少［MD=-25.15,95％CI(-29.10,-21.20),P＜0.05］,术后住院时间短［MD=-2.48,95％CI(-3.00,-1.95),P＜0.05］,差异均具有统计学意义(P＜0.05);术后复发或转移发生率与外科手术相当［RR=1.14,95％CI(0.52,2.51),P=0.74］,差异无统计学意义(P＞0.05)。结论 超声引导下射频消融较外科手术具有诸多优势,在PTMC的治疗中具有较高临床应用价值。     

Thoracic manipulation versus mobilization in patients with mechanical neck pain: a systematic review

Objectives:

Thoracic manipulation is widely used in physical therapy and has been shown to be effective at addressing mechanical neck pain. However, thoracic mobilization may produce similar effects. The purpose of this systematic review was to evaluate the current literature regarding the effectiveness of thoracic manipulation versus mobilization in patients with mechanical neck pain.

Methods:

ProQuest, NCBI-PubMed, APTA's Hooked on Evidence, Cochrane Library, CINAHL and SPORTDiscus were searched to identify relevant studies. Fourteen studies meeting the inclusion criteria were analyzed using the Physiotherapy Evidence Database (PEDro) scale and the GRADE approach.

Results:

The literature as assessed by the PEDro scale was fair and the GRADE method showed overall quality ranging from very low to moderate quality. The 14 included studies showed positive outcomes on cervical pain levels, range of motion, and/or disability with the use of thoracic manipulation or mobilization. There was a paucity of literature directly comparing thoracic manipulation and mobilization.

Discussion:

Current limitations in the body of research, specifically regarding the use of thoracic mobilization, limit the recommendation of its use compared to thoracic manipulation for patients with mechanical neck pain. There is, however, a significant amount of evidence, although of varied quality, for the short-term benefits of thoracic manipulation in treating patients with this condition. Further high quality research is necessary to determine which technique is more effective in treating patients with mechanical neck pain.     

Biphasic versus monophasic defibrillation in out-of-hospital cardiac arrest: a systematic review and meta-analysis

ObjectiveBiphasic defibrillation is more effective than monophasic one in controlled in-hospital conditions. The present review evaluated the performance of both waveforms in the defibrillation of patients of out-of-hospital cardiac arrest (OHCA) with initial ventricular fibrillation (Vf) rhythm under the context of current recommendations for cardiopulmonary resuscitation.MethodsFrom inception to June 2012, Medline, Embase, and the Cochrane Central Register of Controlled Trials were searched systemically for randomized controlled trials (RCTs) and observational cohort studies that compared the effects of biphasic and monophasic shocks on Vf termination, return of spontaneous circulation (ROSC), and survival to hospital discharge in OHCA patients with initial Vf rhythm. No restrictions were applied regarding language, population, or publication year.ResultsFour RCTs including 572 patients were identified from 131 potentially relevant references for meta-analysis. The synthesis of these RCTs yielded fixed-effect pooled risk ratios (RRs) for biphasic and monophasic waveforms on Vf termination survival to hospital discharge (RR, 1.14; 95% CI, [0.84-1.54]).ConclusionBiphasic waveforms did not seem superior to monophasic ones with respect to Vf termination, ROSC, or survival to hospital discharge in OHCA patients with initial Vf rhythm under the context of current guidelines. However, most trials were conducted in accordance with previous guidelines for cardiopulmonary resuscitation. Therefore, further trials are needed to clarify this issue.     

单侧与双侧股动脉穿刺行子宫动脉栓塞的系统评价

目的:系统评价单侧与双侧股动脉穿刺在行子宫动脉栓塞治疗中的应用价值与安全性.方法:计算机检索Cochrane Library、MEDLINE、EMbase和中国生物医学文献数据库,检索时限为建库至2012年7月.按纳入与排除标准选择文献、评价质量、提取数据.用RevMan 5.0.22软件进行Meta分析.结果:共纳入2篇文献,l篇为随机对照试验,共57例患者,结果双侧股动脉穿刺组较单侧组曝光时间及手术时间明显缩短,但两组在剂量-面积乘积(DAP)上无统计学差异.另1篇为前瞻性非随机对照试验,共24例患者,结果双侧股动脉穿刺组较单侧组曝光时间明显缩短,但两组在手术时间及DAP上无统计学差异.结论:目前证据表明双侧股动脉穿刺行子宫动脉栓塞术可能减少曝光时间并不增加术后并发症.但因纳入研究数量少,论证强度较弱,本研究结果尚需要开展更多高质量随机对照研究来进一步证实.