New airway device for ventilation and monitoring in pediatric patients undergoing MRI study

A method of administering continuous positive airway pressure via a new airway device to prevent upper airway obstruction and preserve spontaneous respiration under total intravenous anesthesia has been adapted for children undergoing deep sedation for MRI studies. Presented herein is a retrospective study of 45 pediatric patients, ages 5 months to 7 years, who underwent an MRI study under general anesthesia using a modified nasal vestibule airway (NVA^?), a pressure-sealing nasal cannula that can be used in conjunction with an anesthesia circuit to deliver nasal-CPAP during anesthesia. After inhalation induction of anesthesia with sevoflurane, an intravenous infusion of propofol was used to maintain anesthesia. A NVA^?, downsized to fit the nasal vestibule of the child, was inserted, taped in place, and connected to a Mapleson F circuit. An extra long extension of corrugated tubing, a SNOR-SCOPE^? circuit stethoscope, and the fluctuations of a reservoir bag allowed monitoring and assisted respirations from the foot of the MRI table. Other monitors included CO₂ sampled at the mouth and the fluctuations of a PORTEX^? disposable pressure gauge. The records of 45 pediatric patients were reviewed. No significant anesthesia complications were found. A new approach is offered to maintain airway patency, monitoring and spontaneous respirations in pediatric patients undergoing MRI study. This pressure-sealing nasal cannula can deliver CPAP under anesthesia while avoiding the requirement of an invasive airway and facilitating additional monitoring and control not possible with an ordinary nasal cannula. This NVA may be used in other locations in pediatric patients where endotracheal intubation is not necessary or impossible.     

Comparison between Nageotte and flow cytometric counting of residual leucocytes in freshly prepared leucocyte-reduced red blood cell components

Background

Flow cytometry (FC) and Nageotte hemocytometry represent the most widely accepted methods for counting residual white blood cells (rWBCs) in leucocyte-reduced (LR) blood components. Our aim was to study the agreement between the two methods, under real working blood bank conditions.

Apneic oxygenation reduces hypoxemia during endotracheal intubation in the pediatric emergency department

Background

Apneic oxygenation (AO) has been evaluated in adult patients as a means of reducing hypoxemia during endotracheal intubation (ETI). While less studied in pediatric patients, its practice has been largely adopted.

A new approach for diagnosing chronic myelomonocytic leukemia using structural parameters of Sysmex XNTM analyzers in routine laboratory practice

According to WHO recommendations, diagnosis of chronic myelomonocytic leukemia (CMML) beforehand requires microscopic examination of peripheral blood to identify dysplasia and/or blasts when monocytes are greater or equal to 1.0?×?10⁹/L and 10% of leucocytes. We analyzed parameters derived from Sysmex^TM XN analyzers to improve the management of microscopic examination for monocytosis. We analyzed results of the complete blood count and the positioning and dispersion parameters of polymorphonuclear neutrophils and monocytes in 61 patients presenting with CMML and 635 control patients presenting with a reactive monocytosis. We used logistic regression and multivariate analysis to define a score for smear review. Three parameters were selected: neutrophil/monocyte ratio, structural neutrophil dispersion (Ne-WX) and monocyte absolute value. We established an equation in which the threshold of 0.160 guided microscopic examination in the search for CMML abnormalities with a sensitivity of 0.967 and a specificity of 0.978 in the learning cohort (696 samples) and 0.923 and 0.936 in the validation cohort (1809 samples) respectively. We created a score for microscopic smear examination of patients presenting with a monocytosis greater or equal to 1.0?×?10⁹/L and 10% of leucocytes, improving efficiency in laboratory routine practice.     

Flux of selected body fluid constituents and benzylpenicillin in polyacrylamide hydrogel (PAAG)

The polyacrylamide hydrogel (PAAG) Aquamid® (Contura International A/S Soeborg, Denmark) is one of the new macromolecules that are used as implants and tissue fillers in reconstruction and aesthetic surgery. This study showed, by means of radioactive isotope methods, that PAAG can exchange both physiological and non‐physiological constituents very efficiently with the surrounding medium. The efflux (J, mole/(cm² × s), 25 °C, pH 7.2) of water (4.4 × 10^?5), chloride (2.4 × 10^?7), urea (1.0 × 10^?9), and glucose (1.1 × 10^?9) was 3‐40x greater than in human red blood cells. PAAG was also accessible to sucrose, inulin, and benzylpenicillin that could not permeate biological cell membranes. The conclusion of the study is that the hydrogel structure created no significant barrier to the exchange of solvent and solutes with the surrounding medium. Copyright © 2011 John Wiley & Sons, Ltd.     

Performance evaluation of leukocyte differential on the hematology analyzer Celltac G compared with two hematology analyzers,reference flow cytometry method,and two manual methods

BackgroundThe automated hematology analyzer Celltac G (Nihon Kohden) was designed to improve leukocyte differential performance. Comparison with analyzers using different leukocyte detection principles and differential leukocyte count on wedge film (Wedge‐Diff) shows its clinical utility, and comparison with immunophenotypic leukocyte differential reference method (FCM‐Ref) shows its accuracy performance.MethodsFor method comparison, 598 clinical samples and 46 healthy volunteer samples were selected. The two comparative hematology analyzers (CAAs) used were XN‐9000 (Sysmex) and CELL‐DYN Sapphire (Abbott). The FCM‐Ref provided by the Japanese Society for Laboratory Hematology was selected, and a flow cytometer Navios (Beckman‐Coulter) was used. In manual differential, two kinds of automated slide makers were used: SP‐10 (Sysmex) for wedge technique and SPINNER‐2000 (Lion‐Power) for spinner technique. The spinner technique avoids the issue of Wedge‐Diff smudge cells by removing the risk of breaking cells and non‐uniformity of blood cell distribution on films (Spinner‐Diff).ResultsThe Celltac G showed sufficient comparability (r = 0.67–1.00) with the CAAs for each leukocyte differential counting value at 0.00–40.87(10⁹/L), and sufficient comparability (r = 0.73–0.97) with FCM‐Ref for each leukocyte differential percentage at 0.4–78.5. The identification ratio of the FCM‐Ref in CD45‐positive cells was 99.7% (99.4% to 99.8%). Differences were found between FCM‐Ref/Celltac G/XN‐9000/Spinner‐Diff and Wedge‐Diff for monocytes and neutrophils. The appearance ratio of smudge cells on wedge and spinner film was 12.5% and 0.5%.ConclusionThe Celltac G hematology analyzer''s leukocyte differential showed adequate accuracy compared with the CAAs, FCM‐Ref, and two manual methods and was considered suitable for clinical use.     

NMR determination of free gallium(III) ions in aqueous solutions of Ga complexes, “cold” analogs of PET/SPECT tracers

Ga complexes are widely used as radiopharmaceuticals for PET or SPECT imaging and as therapeutic agents. At physiological pH, free gallium(III) ions can stably exist as soluble gallate [Ga(OH)₄]^?, a nephrotoxic compound whose presence should be avoided. Any Ga complex, therefore, should be carefully checked for the absence of gallate before use. Here we show that ⁷¹Ga NMR is a useful tool to rapidly detect the presence of gallate in aqueous solutions of Ga complexes and to follow the purification steps of the Ga complex solutions. Copyright © 2011 John Wiley & Sons, Ltd.     

Peptidoglycan and lipoteichoic acid,components of the streptococcal cell wall,have marked and differential effects on adhesion molecule expression and the production of reactive oxygen species in human whole blood leukocytes

Objective: To investigate whether lactate levels may vary in relation to time, substrate concentration and blood cells counts. Methods: In this study 110 samples from the daily clinical routine blood samples were collected. Determinations of lactate were made at different times where the samples had not been left for more than 120?min at room temperature (24°C) or in the fridge (4°C). The influence of glucose and blood cells on lactate production was also estimated. The rate in change of concentration (slope) and the increase expected at the beginning (intercept) were estimated through linear regression using a longitudinal marginal method. Results: The time‐related change in lactate was significantly higher at room temperature (0.012?mmol?L^?1?min^?1) than at 4°C (0.0035?mmol?L^?1?min^?1) (p<0.0001). There was a significantly positive relationship between blood cells (mainly leucocytes) and the rate of reaction at room temperature. Conclusions: A delay in the processing of a whole blood sample of more than 15?min at room temperature or an hour in the fridge entails an important overestimation of the initial lactate levels. Pronounced leucocytosis (higher than 6×10¹⁰/L) meaningfully cut down the stability period (10?min).     

Cardiac effects of granisetron in a prospective crossover randomized dose comparison trial

Purpose

Cardiac side effects of granisetron have been studied mostly in adult patients that are using cardiotoxic chemotherapeutics. There is limited evidence in pediatric age group and no information in pediatric oncology patients with non-cardiotoxic chemotherapeutics.

Methods

In this prospective, crossover randomized study, the cardiac side effects of granisetron are compared in pediatric oncology patients who had carboplatin based chemotherapy. They were randomized to receive either 10 or 40 μg kg^?1 dose^?1 of granisetron before each cycle of chemotherapy. We drew blood for creatine phosphokinase (CPK), CPK-muscle band (MB) and Troponin-T before and 24?h after administering granisetron. Electrocardiography (ECG) tracings were taken at 0, 1, 2, 3, 6 and 24?h of granisetron. Twenty-four hours Holter ECG monitorisation was performed after each granisetron infusion.

Results

A total of 16 patients (median 8.7?years of age) were treated with weekly consecutive courses of carboplatin. There was bradycardia (p?=?0.000) in patients that had granisetron at 40 μg/kg and PR interval was shortened in patients that had granisetron at 10 μg/kg dose (p?=?0.021). At both doses of granisetron, QTc interval and dispersion were found to be similar. CPK, CK-MB and Troponin-T values were found to be normal before and 24?h after granisetron infusion.

Conclusions

As the first study that has studied cardiac side effects of granisetron in patients that are not using cardiotoxic chemotherapeutics, we conclude that granisetron at 40 μg kg^?1 dose^?1 causes bradycardia only. We have also demonstrated that granisetron does not cause any clinically cardiac side effects either at 10 or 40 μg kg^?1 dose^?1. However, our results should be supported by prospective randomized studies with larger samples of patient groups.     

Simple and precise detection of UGT1A1 polymorphisms with a modified loop-hybrid mobility shift assay using Cy5-labeled loop probes

BackgroundIrinotecan, an inhibitor of topoisomerase I, has been widely used as an important anti-cancer therapeutic drug. Deleterious effects of the drug in hypersensitive patients are known to be associated with genetic polymorphisms of the UGT1A1 gene, namely the polymorphic variants, ^?28 and ^?6.MethodsA modified form of loop-hybrid mobility shift assay using a Cy5-tagged loop-hybrid probe was proposed as a precise and easy method of determining TA repeat polymorphisms at the ^?28 locus.ResultsIn this modified method, only loop-hybrid bands were detected by a Cy5-fluorescent signal, despite several irregular electrophoretic bands due to TA repeats in the PCR product.ConclusionsWhen a loop-hybrid using a Cy5-tagged probe for the ^?28 locus and ^?6 locus were combined and used for mobility shift assay, simultaneous typing of the ^?28 and ^?6 variants was achieved in a single lane.     

Urinary albumin excretion in a population based sample of 1011 middle aged non-diabetic subjects

Jensen JS, Feldt-Rasmussen B, Borch-Johnsen K, Jensen G and The Copenhagen City Heart Study Group. Urinary albumin excretion in a population based sample of 1011 middle-aged non-diabetic subjects. Scand J Clin Lab Invest 1993; 53: 867-872

Increased urinary albumin excretion rate (UAER) especially in the range of 20-200 μg min^?1, termed microalbuminuria, has been proposed as a risk marker and predictor for cardiovascular disease in non-diabetic subjects. Thus it would be of importance to describe the distribution of UAER in the non-diabetic population. Among 1011 30-70-year-old subjects without diabetes mellitus or urinary tract infection, who were invited to participate in a population based epidemiological study, the albumin concentration was measured in an overnight urine sample. The measurement was performed by an ELISA method. The UAER was calculated in units of μgmin^?1 as urinary albumin concentration × urine volume/urine collection time. The distribution of UAER was positively skewed with a median value of 2.3μgmin^?1 and a 5-95 inter-percentile range of 0-11.0μgmin^?1. The UAER held constant with age, but males had higher UAER than females, 2.6 (0-13.5)μgmin^?1 vs 2.2 (0-8.3)μgmin^?1; p < 0.005. The prevalence of microalbuminuria, defined as an UAER in the range of 15-150μgmin^?1 in an overnight urine sample, was 3% (95% C.I. interval: 1.9-4.0). These findings suggest, that the level of UAER which might notify increased cardiovascular risk, is lower than in patients with diabetes mellitus, if it is considered to be of any clinical relevance.     

Accuracy and responsiveness of the stepwatch activity monitor and ActivPAL in patients with COPD when walking with and without a rollator

Purpose: To evaluate the measurement properties of the StepWatch^? Activity Monitor (SAM) and ActivPAL in COPD. Method: Whilst wearing both monitors, participants performed walking tasks at two self-selected speeds, with and without a rollator. Steps obtained using the monitors were compared with that measured by direct observation. Results: Twenty participants aged 73?±?9 years (FEV₁?=?35?±?13% pred; 8 males) completed the study. Average speeds for the slow and normal walking tasks were 34?±?7 m·min^?1and 46?±?10 m·min^?1, respectively. Agreement between steps recorded by the SAM with steps counted was similar irrespective of speed or rollator use (p?=?0.63) with a mean difference and limit of agreement (LOA) of 2 steps·min^?1 and 6 steps·min^?1, respectively. Agreement for the ActivPAL was worse at slow speeds (mean difference 7 steps·min^?1; LOA 10 steps·min^?1) compared with normal speeds (mean difference 4 steps·min^?1; LOA 5 steps·min^?1) (p?=?0.03), but was unaffected by rollator use. The change in step rate between slow and normal walking via direct observation was 12?±?7 steps·min^?1 which was similar to that detected by the SAM (12?±?6 steps·min^?1) and ActivPAL (14?±?7 steps·min^?1). Conclusions: The SAM can be used to detect steps in people who walk very slowly including those who use a rollator. Both devices were sensitive to small changes.

Implications for Rehabilitation

• The evaluation of physical activity (PA) before and after pulmonary rehabilitation in people with chronic obstructive pulmonary disease (COPD) has evolved to be an important outcome measure.

• Selecting an appropriate device to obtain valid measures of PA remains a challenge, especially for those individuals who walk slowly or use a rollator to assist with ambulation.

• The StepWatchTM Activity Monitor and the ActivPAL have been shown in this study to be sensitive to small changes in step rate, thus these devices can be used to assess changes in physical activity in individuals with COPD such as following pulmonary rehabilitation, including those who walk slowly or use a walking aid such as a rollator.

     

Multimodal liposomes for SPECT/MR imaging as a tool for in situ relaxivity measurements

One of the major challenges of MR imaging is the quantification of local concentrations of contrast agents. Cellular uptake strongly influences different parameters such as the water exchange rate and the pool of water protons, and results in alteration of the contrast agent's relaxivity, therefore making it difficult to determine contrast agent concentrations based on the MR signal only. Here, we propose a multimodal radiolabeled paramagnetic liposomal contrast agent that allows simultaneous imaging with SPECT and MRI. As SPECT‐based quantification allows determination of the gadolinium concentration, the MRI signal can be deconvoluted to get an understanding of the cellular location of the contrast agent. The cell experiments indicated a reduction of the relaxivity from 2.7 ± 0.1 m m ^?1 s^?1 to a net relaxivity of 1.7 ± 0.3 m m ^?1 s^?1 upon cellular uptake for RGD targeted liposomes by means of the contrast agent concentration as determined by SPECT. This is not observed for nontargeted liposomes that serve as controls. We show that receptor targeted liposomes in comparison to nontargeted liposomes are taken up into cells faster and into subcellular structures of different sizes. We suggest that the presented multimodal contrast agent provides a functional readout of its response to the biological environment and is furthermore applicable in in vivo measurements. As this approach can be extended to several MRI‐based contrast mechanisms, we foresee a broader use of multimodal SPECT/MRI nanoparticles to serve as in vivo sensors in biological or medical research. Copyright © 2011 John Wiley & Sons, Ltd.     

Evaluation of automated basophil counting by using fluorescence-labelled monoclonal antibodies

The shortcomings of current methods of basophil enumeration detract from the clinical value of the basophil count. Moreover, sophisticated and costly techniques of automated basophil counting hardly can be validated for lack of a suitable reference method. We investigated whether a flow cytometric technique using double staining with fluorescence-labelled monoclonal antibodies (mAb) CD45-FITC and CD14-PE on a Coulter Epics Profile II could be used to evaluate basophil counting performance of hematology analyzers. The technique was compared with the 800-cell manual differential, the Coulter STKS, and the Cobas Argos 5 Diff. Precision: STKS, Argos and Profile II showed a precision analogous to a 2,173, 2,250-, and 14,705-cell differential, respectively, illustrating the superiority of automated methods. Accuracy (150 normal and abnormal samples): Using the Profile II as reference the STKS showed a notably weaker correlation than the Argos (r = 0.581 and 0.718, respectively), although this difference was nearly concealed when the imprecise manual differential served as reference (r = 0.517 and 0.562, respectively). The Profile 11 correlated relatively well with the manual differential (r = 0.730). Analyzing 137 healthy adult subjects, we obtained a reference range of 0.33 to 1.35% (0.020 to 0.102 × 10⁹, basophils/L) for the mAb-based method. These data would recommend mAb-based basophil counting as a valuable tool for instrument evaluation. However, an observed bias of 0.09% against the manual differential suggests that modifications are necessary before this technique can be considered as new reference method. © 1996 Wiley-Liss, Inc.     

Prolactin response to TRH in vitiligo

A more sensitive assay procedure has been developed for the enzyme iduronate 2-sulphate sulphatase which is deficient in the Hunter syndrome. The substrate is the same as previously described by Lim et al. [1], O-(α-l-idopyranosyluronic acid 2-sulphate)-(1 → 4)-2,5 anhydro-d-[³H-1]mannitol 6-sulphate, but, after incubation, it is separated from the product by ion-exchange chromatography on a micro-column of Dowex 1 × 2 (Cl^?) instead of high voltage electrophoresis or ECTEOLA cellulose chromatography.Since the blank correction is then much smaller, a shorter incubation time can be used and conversion of the substrate reduced from approximately 50% down to levels where complications resulting from substrate depletion and product inhibition are minimal. Using whole serum the apparent K_m for the substrate is 0.2 mmol/1.With an incubation time of 20 min, sera from heterozygotes exhibited approximately 35% of the normal levels of iduronate 2-sulphate sulphatase (0.11–0.61, mean 0.34 nmol.h^?1.mg^?1 protein for 21 carriers; 0.24–2.35, mean 0.94 nmol.h^?1.mg^?1 protein for 37 normal females).Serum analyses can thus be used to supplement those on hair roots in the detection of carriers of the Hunter syndrome.     

Day-to-day variation in oxygen consumption and energy expenditure during submaximal treadmill walking in female adolescents

The day-to-day variation in oxygen consumption (V˙O ₂) and energy expenditure (EE) during horizontal treadmill walking was measured using indirect calorimetry in 20 female adolescents (mean age 17·3 years). Two different walking speeds were used: 5 km h^?1 and an individually convenient speed of 3·0 km h^?1 (mean). The two sets of measurements were performed on 2 consecutive days, and great care was taken to minimize possible disturbing factors. The mean V˙O ₂ was 919 ml min^?1 at 5 km h^?1 and 622 ml min^?1 at the individual speed, and the mean values of EE were 4·5 kcal min^?1 and 3·1 kcal min^?1 respectively. The individual day-to-day variation in V˙O ₂ (at 5 km h^?1) was between ?11·7% and +12·6% of the mean V˙O ₂. The coefficient of variation (CV) was 6·4% when values were calculated in ml min^?1 kg^?1. The energy expenditure varied somewhat less between the 2 days (CV = 5·7%). The corresponding value for EE when walking at the individual speed was 7·2%, and the mean day-to day variation in V˙O ₂ was 7·5% (CV). The rate of perceived exertion according to Borg's scale was lower on day 2 (11·9) compared with day 1 (13·0) when walking at 5 km h^?1. There was no difference in heart rate between the 2 days. It is concluded that EE varies somewhat less than V˙O ₂ on successive days, probably because of an interchangeable relationship between breathing gases, depending on which substrate is used for combustion. When using V˙O ₂ and EE for evaluation of physical capacity, the day-to-day variation in the measurements must be taken into consideration.     

Differences in phospholipase A2 activity between males and females and Asian Indians and Caucasians

There is epidemiological evidence that chronic inflammatory diseases occur more frequently in female than in male subjects and prevail differently in various ethnic populations. Phospholipase A₂ (PLA₂) (group II) plays a key role in many inflammatory reactions by releasing free arachidonic acid, which is a prerequisite for the production of proinflammatory lipid mediators. We therefore, measured PLA₂ activity in plasma, serum, leucocytes and lymphocytes in 20 female and 20 male subjects, 10 of each group being of Asian Indian and of Caucasian origin respectively. When PLA₂ activity was measured in crude plasma and serum no dependency from gender and ethnicity was observed. Following acid extraction and heating, PLA₂ activity in plasma was higher in Caucasians (27.8 ± 2.2 nmol L^?1 mg ^?1 protein 60 min^?1) than in Asian Indians (17.9 ± 2.5 nmol L^?1 mg^?1 protein 60 min^?1) (P < 0.005) and higher in females (28.5 ± 2.6 nmol L^?1 mg^?1 protein 60 min^?1) than in males (17.3 ± 2.0 nmol L^?1 mg^?1 protein 60 min^?1) (P < 0.001). Similar differences were observed when only Asian Indian or Caucasian females were compared with their corresponding males. Contrary to plasma, in which the specific activity of PLA₂ increased following acid extraction and heating, the activity was completely abrogated in serum after extraction and heating. Lymphocytes exhibited lower activities of PLA₂ than neutrophils in all four groups of subjects investigated. Females had a tendency towards higher PLA₂ activity in both lymphocytes and neutrophils than males. In conclusion the present investigation revealed an ethnic- and sex-dependent basal activity of PLA₂, a key enzyme in the pathogenesis of chronic inflammatory diseases.     

Publication Track Records as a Metric of Clinical Research Training Effectiveness

Clinical research training programs exist across the country, but no quantitative studies have been performed to evaluate the effectiveness of these programs. The goal of this study was to evaluate the success of the clinical research training program at the University of Cincinnati by comparing the publication histories of pediatric fellows who graduated from the clinical and translational research Master of Science (MS) degree programs between 1995 and 2011 with fellows who did not pursue an MS degree. Among 296 pediatric fellows, 44 of 54 graduates (81%) published at least 1 first‐authored paper, as compared with 149 of 242 (62%) fellows who did not obtain an MS degree (P < 0.01). In multivariable analysis, 3–4 years after program completion, MS graduates published more papers overall (R ² = 0.10) and more first‐authored papers than did non‐MS graduates (R ² = 0.04). These findings suggest that graduate training in clinical and translational research is related to an increase in research productivity as assessed by publication rates.     

Factor XIII – an under diagnosed deficiency – are we using the right assays?

Summary. Background: The clot solubility test is the most widely used method for detection of factor (F)XIII deficiency. However, it will only detect severe deficiencies; consequently mild deficiencies and heterozygous states are probably under diagnosed. Objective: As an alternative first‐line screening test, we assessed an automated quantitative ammonia release assay (QARA). Patients/methods: Inter‐assay imprecision was evaluated with commercial normal and pathological control plasmas (10 replicates on each of 5 days). Using the QARA and other commercial assays a comparative assessment of congenital (FXIII range < 1–70 u dL^?1, n = 9) and acquired (n = 43) deficiencies was made. We also investigated the prevalence of acquired deficiencies in hospitalized patients using residual samples from adult patients (n = 1004) and from a paediatric intensive care unit (ICU, n = 56). Results: Assay imprecision was acceptably low (normal control: mean 86.6 u dL^?1; cv = 2.0%; pathological control: mean 27.5 u dL^?1; cv = 3.8%). Using an iodoacetamide blanking procedure, the QARA results (FXIII range < 1–70 u dL^?1) exhibited close agreement with those from an immuno‐turbidometric FXIII A‐subunit (FXIII‐A) method. There was also good correlation (R² ≥ 0.89) between the QARA (range 20–180 u dL^?1), a second chromogenic assay, the FXIII‐A and FXIII A+B‐subunit ELISA. We found that 21% of samples from adult patients had FXIII levels < 70 u dL^?1 (mean normal ± 2 SD 73–161 u dL^?1) with 6% < 50 u dL^?1. Within the paediatric ICU samples, 52% were < 70 u dL^?1, with 21% < 50 u dL^?1. Conclusions: Our data demonstrates that the automated assay is sensitive, highly reproducible and the results from clinical samples suggest that acquired FXIII deficiency is a relatively common phenomenon in hospital patients after surgery and in ICU.