All-in-one: Conventional versus two different all-in-one solutions for total parenteral nutrition of surgical intensive care patients

Three randomly selected groups of 10 surgical patients under intensive care were prospectively studied concerning the utility and effectiveness of postoperative or posttraumatic parenteral nutrition during 7 days with different solutions: conventional total parenteral nutrition (TPN) with amino acids and glucose (AA/G), or all-in-one solutions with amino acids, fat, and carbohydrates either as glucose (AIO/G) or as a mixture of the polyoles sorbitol and xylitol (AIO/P). The AIO solutions were delivered in stable ready-to-use mixtures and needed no further processing before administration. Efficiency of all regimens in improving nutritional status was documented. Comparing the 3 groups, we found one important difference: the blood glucose level was significantly lower in the AIO/P group than in the other 2 groups with glucose as the carbohydrate (p<0.001). Furthermore, the bilirubin increase observed in all 3 groups, probably a sign of cholestasis, was significantly higher in the AIO/P group versus conventional TPN. We, therefore, conclude that immediate postoperative or posttraumatic nutrition with an AIO solution was safe and its handling simple. In our patients with stress-induced glucose intolerance early after major surgery or trauma, the AIO/P solution without glucose produced less hyperglycemia and compared favorably with conventional TPN or an AIO glucose solution. Both AIO solutions were well tolerated and side effects requiring interruption of the therapy did not occur.

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Resumen Tres grupos de 10 pacientes de cuidado intensivo seleccionados al azar fueron estudiados en forma prospectiva en relación a la utilidad y efectividad de nutrición parenteral postoperatoria o postraumática en el curso de 7 días, con diferentes soluciones: nutrición parenteral total (NPT) convencional con aminoácidos y glucosa (AA/G), soluciones todasen-una con aminoácidos, grasa y carbohidratos como glucosa (TEU/G) o como mezcla de los polioles sorbitol y xilitol (TEU/P). Las soluciones TEU fueron administradas en forma de mezclas estables y listas para uso, las cuales no necesitan ningún procesamiento adicional antes de ser administradas. El grado de eficiencia, en cuanto a su capacidad de mejorar el estado nutricional, de cada uno de estos regímenes fue determinado. Al comparar los tres grupos encontramos como diferencia importante el que el nivel sanguíneo de glucosa apareció significativamente menor en el grupo TEU/P que en los otros dos grupos que recibieron glucosa como carbohidrato (p<0.001). Además, el aumento de bilirrubina observado en los tres grupos, probablemente como signo de colestasis, apareció significativamenta más alto en el grupo TEU/P en comparación con el regimen de NPT convenional libre de grasa. No se observó diferencia significativa entre las dos soluciones TEU. Hemos llegado a la conclusión de que la nutrición en el estado postoperatorio o postraumático immediato con solución TEU es segura y de fácil manejo. En nuestros pacientes con intolerancia a la glucosa inducida por el estrés de la cirugía mayor o del trauma, la solución TEU/P libre de glucosa produjo menos hiperglicemia y se compara favorablemente con la NPT convencional y con la solución TEU/G. Ambas soluciones TEU fueron bien toleradas y no presentaron efectos colaterales que requirieran interrupción de la terapia.

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Résumé Trois groupes de 10 malades soumis à des soins intensifs et sélectionnés au hasard ont fait l'objet d'une étude prospective concernant l'utilité et l'efficacité de l'alimentation parentérale pratiquée pendant une période de 7 jours chez des opérés et des blessés. Plusieurs solutions ont été employées: solution classique contenant des amino-acides et du glucose (AA/G), solutions complexes contenant des amino-acides, des graisses et des hydrates de carbone sous la forme soit de glucose (AIO/G) soit de polyoles: sorbitol et xylitol (AIO/P). Les solutions complexes employées étaient préalablement préparées et ne nécessitaient aucune manipulation. L'efficacité de ces diverses solutions sur l'état nutritif fut analysée. Comparant les trois groupes les auteurs ont constaté une importante différence dans le taux du glucose sanguin, ce taux étant significativement diminué dans le troisième groupe (AIO/P). D'autre part, l'élévation du taux de bilirubine constatée dans les trois groupes, un signe de cholestase, était significativement plus marquée dans le group AIO/P par rapport au soluté classique. Ils concluent de ces faits que l'alimentation à l'aide d'une solution complexe (AIO ou all-in-one) en postopératoire ou chez le blessé est dénuée de dangers et facile à pratiquer. Chez leurs patients qui présentaient une intolérance glucidique induite par le stress post-traumatique ou postopératoire, l'emploi d'une solution du 3ème type (AIO/P) ne contenant pas de glucose ne provoqua pas d'hyperglycémie; elle se compare donc favorablement avec la solution classique et la solution complexe de glucose (AIO/G). Les deux solutions complexes furent bien tolérées et ne provoquèrent pas d'effets secondaires nécessitant l'interruption de l'alimentation parentérale.

     

ASO Visual Abstract: Impact of Race/Ethnicity and County-Level Vulnerability on Receipt of Surgery Among Older Medicare Beneficiaries Diagnosed with Early Pancreatic Cancer

Annals of Surgical Oncology -     

Ectopic T cell receptor expression causes B cell immunodeficiency in transgenic mice

Mice expressing transgenic T cell receptors (TCR) are used to explore important questions in immunity. However, transgene expression may have unexpected effects. We previously reported a B cell immunodeficiency, comprising decreased B cell numbers and diminished antibody responses, in mice that express a transgenic TCR specific for nicotinic acetylcholine receptor; the mice were generated using cassette vectors designed specifically for transgenic TCR expression [see Kouskoff et al. J. Immunol. Methods 1995. 180: 273-280]. We now show data suggesting that this defect is due to the expression and accumulation of TCR alpha and beta chains inside B cells and induction of an endoplasmic reticulum stress response, causing apoptosis at the pre B-I and later B cell stage. Thus, inappropriate transgene expression can profoundly affect B cells, leading to a previously undescribed mechanism of immunodeficiency.     

"Could it be asthma?": the impact of a mass media campaign aimed at raising awareness about asthma in Australia

Asthma is a very common chronic illness in Australia; however,unrecognized and undertreated asthma is responsible for muchpreventable morbidity in the community. In 1988, a coalitionof private and public sector agencies was formed to conducta national mass communications program aimed at increasing awarenessabout asthma. This pilot campaign comprised a mailout to allprimary care physicians and a mass media campaign, entitled"Could it be asthma?". The impact of this media-based strategywas assessed using population surveys of 1300 adults beforeand after the campaign. Following the campaign, recall of recentasthma media messages increased from 24 to 49% (P < 0.001)and the proportion who recognized possible asthma symptoms intheir household increased from 3.4 to 5.5% following the campaign.Of those with symptoms, twice as many reported that they visiteda doctor to have their symptoms assessed after the campaign.Knowledge of asthma symptoms was significantly higher followingthe campaign (P < 0.001), after adjustment for age, sex andthe presence of asthma in the respondents family. The campaignappeared to have some success in raising awareness about asthma,and has been followed by the development of a National AsthmaCampaign in Australia focusing on reducing asthma morbidityand improving its management.     

Reconnecting with relational values in highly conflicted separating couples: A narrative therapy-informed relational interviewing teamwork-based supervision approach

This article outlines a new supervision practice of narrative therapy-informed reflecting team-based relational interviewing for a high-conflict stuck case of a separated middle-aged couple. The article demonstrates the supervision method consisting in five parts. First, the supervisor interviews the couples' relationship while the team watches from behind the one-way mirror. Second, the team responds to the interview while the couple and the supervisor witness their conversation. The couple is then invited to respond back to the team. Furthermore, there is a meta-conversation about the supervision in collaboration with the couple. The intervention ends with therapeutic letter writing to the relationship. The couple showed a meaningful shift in their positioning towards a more relational awareness and found valuable ways for continuing their therapy. The theoretical elements of the approach underpinning practice to tackle high conflict are considered through the illustration of the case.