Resting energy expenditure and nitrogen loss after surgery in chronically undernourished patients

Chronically undernourished patients (n=10) undergoing elective abdominal surgery were assessed with regard to their energy expenditure and urinary nitrogen loss. These measurements were made for 1 week after the surgery, and stress factors for each parameter were computed. The responses of the chronically undernourished patients were compared to those of relatively well nourished patients (n=10) undergoing comparable surgeries. It was found that the postoperative resting energy expenditure (REE) of the chronically undernourished patients was not significantly elevated when compared to their preoperative values (mean±SEM): 1210.66±88.13, 1354.91±86.61, 1215.09±89.68, and 1188.23±86.61 kcal/day preoperatively and on postoperative days 1, 4, and 8, respectively. On the other hand, the postoperative REE of the controls was significantly elevated (p<0.05) over their baseline values: 1357.18±70.81, 1574.66±100.35, 1502.89±109.44, and 1477.23±83.52; kcal/day, respectively, for the same days. The stress factors for the controls were higher than those for the undernourished (1.16 versus 1.12, 1.11 versus 1.00, and 1.09 versus 0.98 on postoperative days 1, 4, and 8, respectively). The urinary nitrogen excretion in both groups (for the 4 days) was not significantly elevated over baseline (6.23±0.87, 7.72±0.71, 8.36±0.87, and 8.04±1.56 grams/day in the undernourished; and 7.59±1.03, 9.57±1.33, 9.49±1.03, and 8.67±0.76 grams/day in the controls. The stress factors for nitrogen excretion were slightly higher in the undernourished group. The data from this study show that the postoperative REE of chronically undernourished subjects is lower than that of well nourished controls. The nitrogen loss, however, is similar in the two groups.

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Resumen Pacientes con desnutrición crónica (n=10) sometidos a cirugía abdominal electiva fueron valorados en cuanto al gasto energético y las pérdidas urinarias de nitrógeno. Se hicieron mediciones una semana después de la cirugía y se calcularon los factores de estrés para cada parámetro. Los datos de los pacientes con desnutrición crónica fueron comparados con los de pacientes relativamente bien nutridos (n=10) sometidos a operaciones comparables. Se encontró que el gasto energético en reposo (REE) de los pacientes con desnutrición crónica no aparece significativamente elevado al compararlo con los valores preoperatorios (1210.66±88.13, 1354.91±86.61, 1215.09 ±89.68, 1188.23±86.61, kcal/día; preoperatorío, días 1, 4, y 8 postoperatorios respectivamente, media ± s.c.m.). Por el contrario, el gasto energético en reposo postoperatorio de los controles apareció significativamente elevado (p<0.05) sobre los niveles bases (1357.18±70.81, 1574.66±100.35, 1502.89±109.44, y 1477.23±83.52 kcal/día; preoperatorio, días 1, 4, y 8 postoperatorios, respectivamente, media ± s.c.m.). Los factores de estrés para los controles resultaron más altos que para los desnutridos (1.16 vs. 1.12, 1.11 vs. 1.00, y 1.09 vs. 0.98; días 1, 4, y 8 postoperatorios, respectivamente). La excreción de nitrógeno urinario (g/día) no resultó significativamente elevada frente al valor de base (6.73±0.87, 7.77±0.71, 8.36±0.87, y 8.04±1.56 en el desnutrido) y 7.59±1.03, 9.57±1.33, 9.49±1.03, y 8.67±0.76 en los controles. Datos preoperatorios y para los días postoperatorios 1, 4, y 8 respectivamente, media ± s.c.m.). Los factores de estrés para la excreción de nitrógeno resultaron ligeramente más altos en el grupo de los pacientes desnutridos. Los datos del presente estudio muestran que el gasto energético postoperatorio de los pacientes con desnutrición crÔnica es menor que el de los controles en buen estado de nutrición. Sin embargo, las pérdidas de nitrógeno son similares en los dos grupos.

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Résumé Les dépenses énergétiques et l'excrétion urinaire azotée ont été mesurées pendant une semaine, après une intervention chirurgicale chez dix patients en état de dénutrition chronique et ont été comparées à celles de dix patients dont l'état nutritionnel était normal. La dépense énergétique de base (DEB) des patients en état de dénutrition chronique n'était pas significativement plus élevée comparée aux valeurs préopératoires [respectivement, en préopératoire, et aux jours postopératoires 1, 4, et 8: 1210.66±88.13, 1354.91±86.61, 1215.09±89.68, 1188.23±86.61 kcal/jour: valeurs (moyenne ± écart-type de la moyenne)]. Les dépenses énergétiques des témoins étaient significativement plus élevées (p<0.05) par rapport à la DEB [respectivement en préopératoire, et aux jours postopératoires 1, 4, et 8: 1357.18±70.81, 1574.66±100.35, 1502.89±109.44, 1477.23±83.52 kcal/jour: valeurs (moyenne ± écart-type de la moyenne)]. Des facteurs de stress en cause dans la dépense énergétique ont été retrouvés plus souvent (mais non significativement) chez les témoins que chez les patients en dénutrition [respectivement, pour les jours postopératoires 1, 4, et 8: 1.16 vs. 1.12, 1.11 vs. 1.00, et 1.09 vs. 0.98, (valeur moyenne ± écart-type de la moyenne)]. L'excrétion azotée (g/jour) n'était pas plus élevée par rapport à la valeur de base (valeur moyenne ± écart-type de la moyenne, respectivement, en préopératoire, et aux jours postopératoires 1, 4, et 8: 6.23±0.87, 7.72±0.71, 8.36±0.87, et 8.04±1.09) chez les patients dénutris comparés à celle des témoins (valeur moyenne ± écart-type de la moyenne, respectivement, en préopératoire, et aux jours postopératoires 1, 4, et 8: 7.59±1.03, 9.57±1.33, 9.49±1.03, et 8.67 ±0.76). Des facteurs de stress en cause dans l'excrétion urinaire d'azote ont été retrouvés plus souvent (mais non significativement) chez les patients en état de dénutrition chronique. Les résultats de cette étude montrent que les dépenses énergétiques post-opératoires chez les patients en état de dénutrition chronique étaient plus basses que chez les patients dont l'état nutritionnel est satsifaisant. L'excrétion d'urée urinaire, par contre, était similaire dans les deux groupes.

     

Successful use of continuous ambulatory peritoneal dialysis in octogenarians

This paper reports experience with 18 patients who started CAPD at an age≥80 years at our centre, with emphasis on results, complications and outcome. There were 12 male and 6 female patients whose mean age was 85 years (range 82–91 years); the median duration on CAPD was 31.5 months (range 2 to 58 months). End-stage renal diseases (ESRD) was caused by nephrosclerosis in 9, diabetes mellitus (DM) and light chain disease in 2 each, chronic glomerulonephritis, membranous nephropathy and IgA nephropathy in 1 each, the cause was unknown in yet another two. Seven patients performed their own dialysis while 11 required assistance. The most common co-morbid conditions were hypertension and angina. Peritonitis, that occurred at a rate of 1 episode per 10.8 patient months was responsible for most of the hospitalizations. Peritonitis necessitated catheter removal in 7 patients, reinsertion was done in 6 of them. Fourteen episodes of exit site infection were encountered in 8 patients, 2 developed pericatheter leak and 1 had a tunnel infection. Of the hernias observed in 4 patients, none were inguinal-2 patients each had umbilical and incisional hernias. Nine patients are still continuing CAPD successfully with a median duration of 29 months (range 11–57 months). One patient was transferred to hemodialysis because of congestive heart failure and eight patients died. The causes of death were peritonitis (3/8), CVA (2/8), pneumonia (1/8) and septicemia (1/8). In one patient, the cause of death was not clearly established. Our survival rate of 80% at 3 years is encouraging and hence we advocate CAPD as an acceptable mode of treatment in octogenarians with ESRD.     

Thermic effect of a meal. 1. Methodology and variation in normal young adults.

The variation in the thermic effect of a meal (TEM) was investigated in two groups of five subjects following a standard test meal. Results demonstrated a 50% lower response over 6 h, in the same subjects, when measured intermittently (protocol 2) as compared with a continuous measurement (protocol 1). The variation in TEM among occasions (measured on three occasions in each subject) was large (coefficient of variation (CV) 18.7%, P less than 0.02). However, the post-meal total energy output (CV 1.4%, P greater than 0.05), non-protein respiratory quotient (CV 1.9%, P greater than 0.05) and substrate oxidation rate were not different (P greater than 0.05) in the same individual on separate occasions. Small variations in the basal metabolic rate (BMR) from occasion to occasion (CV 2.6%) contributed to the variation in TEM. However, after allowing for the changes in BMR, variation in TEM (CV 8.6%, P greater than 0.05) was still sizeable though not statistically significant.     

Surgical treatment of T and Y fractures of the distal humerus

Intercondylar T and Y fractures of the distal humerus in adults present a challenge. Open reduction and internal fixation in 19 cases over a 7-year period gave excellent or good results in 15 cases. Campbell's posterior approach to the elbow joint gave a satisfactory exposure. Anterior transposition of the ulnar nerve is a very useful adjunct to prevent late neuritis. A new method of classification is suggested, taking into account the importance of the supracondylar ridge for adequate stability.     

Maxillomandibular fixation with minihooks: a clinical evaluation

This article provides the clinical evaluation of a simple but effective method of maxillomandibular fixation that eliminates the morbidity attendant to the conventional methods of maxillomandibular fixation. The indications have been defined on the basis of the clinical experience with this technique.     

Transcatheter closure of aortopulmonary window using Amplatzer device.

Two cases of transcatheter closure of aortopulmonary window (APW) using an Amplatzer duct occluder in one and a septal occluder device in the second are described. Transcatheter device closure of APW should be considered when anatomy is favorable in terms of location and size of the defect with absence of associated anomalies.