Effect of low-calorie parenteral nutrition on the incidence and severity of hyperglycemia in surgical patients: a randomized, controlled trial

OBJECTIVE: To determine the effect of a low-calorie parenteral nutrition (PN) regimen on the incidence and severity of hyperglycemia and insulin requirements. DESIGN: Prospective, randomized, clinical trial. SETTING: Urban, university-affiliated, level-I trauma center. PATIENTS: Consecutive surgical patients requiring PN. INTERVENTIONS: Patients were randomized to receive either a low-calorie PN formulation (20 nonprotein kilocalories per kg per day) or a standard PN formulation (30 nonprotein kilocalories per kg per day). Lipid-derived calories were standardized to 1000 kilocalories three times weekly for all patients; consequently, the number of calories varied only by the amount of carbohydrate administered. Protein requirements were individualized on the basis of estimated metabolic stress. Hyperglycemia was defined as a blood glucose level > or = 200 mg/dL. MEASUREMENTS AND MAIN RESULTS: Forty patients were evaluated (low-calorie PN, n = 20; standard PN, n = 20). Demographics of the two groups were similar. The incidence of hyperglycemic events was significantly lower in the low-calorie group (0% [0-0.5] vs. 33.1% [0-58.4]; p = .001]. Additionally, the severity of hyperglycemia was also lower in the low-calorie group (mean glucose area under the curve = 118 +/- 22 [mg x hr]/dL vs. 172 +/- 44 [mg x hr]/dL; p < .001). This resulted in lower average daily insulin requirements (0 [0-0] units vs. 10.9 [0-25.6] units; p < .001.). The only predictor of hyperglycemia was a dextrose administration rate >4 mg/kg/min. CONCLUSIONS:: Administration of a low-calorie PN formulation resulted in fewer and less-severe hyperglycemic events and lower insulin requirements. PN regimens should not exceed a dextrose administration rate of 4 mg/kg/min to avoid hyperglycemic events.     

Brain-derived neurotrophic factor variants are associated with childhood-onset mood disorder: confirmation in a Hungarian sample

Brain-derived neurotrophic factor (BDNF) is a nerve growth factor that has been implicated in the neurobiology of depression. Our group has previously reported an association between a BDNF variant and childhood-onset mood disorder (COMD) in an adult sample from Pittsburgh. We hypothesize that variants at the BDNF locus are associated with COMD. Six BDNF polymorphisms were genotyped in 258 trios having juvenile probands with childhood-onset DSM-IV major depressive or dysthymic disorder. BDNF markers included the (GT)n microsatellite, Val66Met and four other single-nucleotide polymorphisms (SNPs) distributed across the BDNF gene. Family-based association and evolutionary haplotype analysis methods were used. Analysis of linkage disequilibrium (LD) revealed substantial LD among all six polymorphisms. Analyses of the Val66Met polymorphism demonstrated significant overtransmission of the val allele (chi2=7.12, d.f.=1, P=0.0076). Consistent with the pattern of LD, all other SNPs showed significant biased transmission. The (GT)n microsatellite alleles also indicated a trend towards biased transmission (170 bp: Z=2.095, P=0.036). Significant haplotypes involved Val66Met and BDNF2 (P=0.0029). In this Hungarian sample, we found all five BDNF SNPs tested and a haplotype containing the BDNF Val66Met Val allele to be associated with COMD. These results provide evidence that BDNF variants affect liability to juvenile-onset mood disorders, supported by data from two independent samples.     

Immunoenhancement to prevent nosocomial coagulase-negative staphylococcal sepsis in very low-birth-weight infants

Extremely low-birth-weight infants are susceptible to invasion by coagulase-negative staphylococci (CONS). This article reviews the epidemiology, immunology, and microbiology of CONS and describes recent clinical trials of immunoenhancing agents such as intravenous immunoglobulin, granulocyte colony-stimulating factor, granulocyte macrophage colony-stimulating factor, and mouse humanized chimeric anti-lipoteichoic acid antibody.Potential avenues of research to reduce the incidence of nosocomial CONS sepsis in premature neonates are presented.     

Fenoldopam versus nitroprusside for the treatment of hypertensive emergency

BACKGROUND: While sodium nitroprusside remains first-line therapy for hypertensive emergency (HEM), fenoldopam is increasingly being used because of its benign safety profile and potential renal protective effects. OBJECTIVE: To compare the efficacy, safety, and cost of sodium nitroprusside versus fenoldopam for the treatment of HEM. METHODS: This study was a retrospective analysis of consecutive patients with HEM admitted to a university-affiliated, level 1 trauma center from 1999 to 2001 and treated with either nitroprusside (n = 21) or fenoldopam (n = 22) for >30 minutes. Time to reach mean arterial pressure (MAP) goal, change in MAP over time, time to initiation of oral antihypertensive therapy, change in renal function, incidence of cyanide toxicity, and cost of therapy were compared between groups. RESULTS: Demographic parameters were similar between groups, except renal failure, which was more prevalent in the fenoldopam group (10% vs 46%; p = 0.009). Neither the mean +/- SD pretreatment MAP (nitroprusside 168 +/- 19; fenoldopam 163 +/- 19; p = 0.45), time to reach MAP goal (3.6 [0.4-30] vs 4 [1-22] h; p = 0.51), nor infusion duration (18 [0.7-113] vs 18 [3-74] h; p = 0.45) differed between the patient groups. Time to initiation of oral antihypertensive therapy was similar between nitroprusside--(4.5 h [0.5-22] and fenoldopam--(6.5 h [1-100] treated patients; p = 0.65). Additional intravenous antihypertensives were administered to 16 patients in each group (p = 0.80). Change in creatinine clearance and incidence of tachycardia did not differ between groups. No symptoms of cyanide toxicity were detected. Cost of drug therapy was greater with fenoldopam (597.60 dollars, 199.20-6675.20 dollars); than nitroprusside (2.66 dollars, 1.68-3.48 dollars; p < 0.001). CONCLUSIONS: Treatment of HEM with fenoldopam appears to result in patient outcomes equivalent to those with nitroprusside but at a substantially higher cost. Further study is required to delineate the exact role of fenoldopam for treatment of HEM.     

Mandibular bone remodelling in adults: evaluation of panoramic radiographs

OBJECTIVES: To evaluate the changes in the antegonial angle, antegonial depth and gonial angle in edentulous and dentate patients in different age groups and between genders. METHODS: We evaluated 312 panoramic radiographs selected from our files. The images were grouped into four 10-year age groups (by decades). The youngest age group was 40-49 years and the oldest 70-79 years. Gender, dentition status and age were recorded. Measurements were made by two observers. RESULTS: No significant differences were observed for the gonial angle regarding age, gender and edentulism. For antegonial angle, the males (160.86 degrees +/-0.78) had significantly smaller values than females (165.08 degrees +/-0.58) irrespective of the dental status (P<0.0001). Edentulous individuals (161.51 degrees +/-0.83) had a smaller antegonial angle than dentate (165.05 degrees +/-0.76) and partially dentate (163.81 degrees +/-0.81) individuals (P<0.05). The antegonial depth was significantly greater for males than females (2.12 mm+/-0.09 vs 1.46 mm+/-0.07, P<0.0001). Edentulous individuals (1.87 mm+/-0.1) had significantly greater antegonial depth than dentate and partially dentate individuals (1.60 mm+/-0.1 and 1.65 mm+/-0.1, respectively). CONCLUSION: The gonial angle did not show any change with gender, age and dental status whereas the antegonial region had a resorptive pattern in the edentulous mandible. The morphology of the antegonial region was influenced by gender and dental status.     

Immunoglobulin A protease is a virulence factor for gram-negative pneumonia

BACKGROUND: Secretory immunoglobulin A (SIgA) is the principal immunologic defense of respiratory and other mucosal surfaces in the body. SIgA is relatively stable in mucosal secretions. However, cleavage of SIgA by bacterial proteases might render it immunologically inactive and thus contribute to the development of pneumonia as well as other infections. Bacterial species and infection sites might be important in the expression of bacterial protease activity and serve as the impetus to this study. METHODS: Bacterial isolates from respiratory and nonrespiratory sites were incubated with SIgA in vitro. SIgA degradation was determined by size exclusion ultrafiltration and gel electrophoresis. RESULTS: IgA protease activity was evident in gram-negative but not gram-positive respiratory isolates. Gram-negative isolates from nonrespiratory sources did not exhibit IgA protease activity. CONCLUSIONS: Expression of IgA protease activity might be important in the development and subsequent outcome of gram-negative pneumonia in the patient in the surgical intensive care unit.