What are the factors that influence the attainment of satisfactory energy intake in pediatric intensive care unit patients receiving enteral or parenteral nutrition?

ObjectiveChildren admitted to the intensive care unit (ICU) are at risk of inadequate energy intake. Although studies have identified factors contributing to an inadequate energy supply in critically ill children, they did not take into consideration the length of time during which patients received their estimated energy requirements after having achieved a satisfactory energy intake. This study aimed to identify factors associated with the non-attainment of estimated energy requirements and consider the time this energy intake is maintained.MethodsThis was a prospective study involving 207 children hospitalized in the ICU who were receiving enteral and/or parenteral nutrition. The outcome variable studied was whether 90% of the estimated basal metabolic rate was maintained for at least half of the ICU stay (satisfactory energy intake). The exposure variables for outcome were gender, age, diagnosis, use of vasopressors, malnutrition, route of nutritional support, and Pediatric Index of Mortality and Pediatric Logistic Organ Dysfunction scores.ResultsSatisfactory energy intake was attained by 20.8% of the patients, within a mean time of 5.07 ± 2.48 d. In a multivariable analysis, a diagnosis of heart disease (odds ratio 3.62, 95% confidence interval 1.03–12.68, P = 0.045) increased the risk of insufficient energy intake, whereas malnutrition (odds ratio 0.43, 95% confidence interval 0.20–0.92, P = 0.030) and the use of parenteral nutrition (odds ratio 0.34, 95% confidence interval 0.15–0.77, P = 0.001) were protective factors against this outcome.ConclusionA satisfactory energy intake was reached by a small proportion of patients during their ICU stay. Heart disease was an independent risk factor for the non-attainment of satisfactory energy intake, whereas malnutrition and the use of parenteral nutrition were protective factors against this outcome.     

The clinical value of laryngeal electromyography in laryngeal immobility

Although laryngeal electromyography (LEMG) is commonly performed, there are no data confirming its efficacy. We evaluated 40 patients with a laryngoscopic diagnosis of unilateral vocal-fold immobility who underwent LEMG of the thyroarytenoid (TA) and cricothyroid (CT) muscle, with the immobile side of each muscle being compared to the normal side. The immobile side compared to the normal side showed more fibrillation potentials and positive sharp waves for the TA (p = 0.04), longer MUAP duration for the TA (p = 0.04) and CT (p = 0.01), more polyphasic potentials for the TA (p = 0.002), and more frequent decreased recruitment for the TA (p < 0.01) and CT (p = 0.008). Specificity and positive predictive value were around 90%. Sensitivity, negative predictive value and accuracy were around 50%. These results suggest that altered LEMG findings are reliable and they can be used to determine the innervation status of an immobile muscle. Conversely, when the LEMG is normal, the results should be reviewed.     

Single-channel EEG sleep stage classification based on a streamlined set of statistical features in wavelet domain

The main objective of this study was to enhance the performance of sleep stage classification using single-channel electroencephalograms (EEGs), which are highly desirable for many emerging technologies, such as telemedicine and home care. The proposed method consists of decomposing EEGs by a discrete wavelet transform and computing the kurtosis, skewness and variance of its coefficients at selected levels. A random forest predictor is trained to classify each epoch into one of the Rechtschaffen and Kales’ stages. By performing a comprehensive set of tests on 106,376 epochs available from the Physionet public database, it is demonstrated that the use of these three statistical moments has enhanced performance when compared to their application in the time domain. Furthermore, the chosen set of features has the advantage of exhibiting a stable classification performance for all scoring systems, i.e., from 2- to 6-state sleep stages. The stability of the feature set is confirmed with ReliefF tests which show a performance reduction when any individual feature is removed, suggesting that this group of feature cannot be further reduced. The accuracies and kappa coefficients yield higher than 90 % and 0.8, respectively, for all of the 2- to 6-state sleep stage classification cases.     

Making health systems more equitable

Health systems are consistently inequitable, providing more and higher quality services to the well-off, who need them less, than to the poor, who are unable to obtain them. In the absence of a concerted effort to ensure that health systems reach disadvantaged groups more effectively, such inequities are likely to continue. Yet this situation need not be accepted as inevitable, for there are many promising measures that might be pursued: establishment of goals for improved coverage in the poor, rather than in entire populations, and use of those goals to direct planning toward the needs of the disadvantaged; use of one or more of the several techniques that seem to have been effective in at least some of the settings where they have been tried; and empowerment of poor clients to have a more central role in health system design and operation.     

Função Diastólica e Biomarcadores de Participantes de Caminhada de Longa Distância

Background:The effects of long-distance walking on the cardiovascular system have been little studied.Objectives:The general objective of this study was to verify these effects on the behavior of diastolic function and the cardiac biomarkers CK-MB (mass), troponin T, and NT-proBNP, in amateur athletes.Method:This longitudinal study, conducted in 2015, evaluated participants during the following 5 stages: E0 (baseline) before starting the trajectory and the others, E1, E2, E3, and E4, at the end of each day, totaling 244.7 km. At all stages, the biomarkers NT-proBNP, CK-MB (mass), and troponin T were measured. Echocardiogram was performed to analyze the E, A and E'' waves. P < 0.05 was adopted as significant.Results:The study evaluated 25 participants, with an average age of 46 ± 10.5 years and body mass index of 20.2 ± 2.3 kg/m2. Increased values were found for NT-proBNP from E0 to E1, E2, E3, and E4 (p < 0.001), CK-MB (mass) from E0 to E2 (p < 0.001), and E'' wave from E0 to E1, E2, E3, and E4 (p < 0.001). Positive correlations were identified between the following: CK-MB (mass) and troponin T (E1: r = 0.524, p = 0.010; E4: r = 0.413, p = 0.044); CK-MB (mass) and NT-proBNP (E4: r = 0.539, p = 0.006); and E/A and E'' (E0: r = 0.603, p < 0.001; E1: r = 0.639, p < 0.001; E4: r = 0.593, p = 0.002). A negative correlation was found between CK-MB (mass) and E/A (E1: r = −0.428, p = 0.041).Conclusion:The effects of intense, prolonged, and interspersed physical activity were verified based on significant variations in the behavior of CK-MB (mass), NT-proBNP, and the E'' wave. Notwithstanding the alterations found, there were no criteria suggestive of myocardial damagePalavras-chave: Walking, Biomarkers, Biological, Blood Pressure, Troponin-T, Natriuretic Peptide Brain, Athletes, Echocardiography, Doppler/methods     

Rhabdomeric phototransduction initiated by the vertebrate photopigment melanopsin

Melanopsin is the photopigment that confers light sensitivity on intrinsically photosensitive retinal ganglion cells. Mammalian intrinsically photosensitive retinal ganglion cells are involved in the photic synchronization of circadian rhythms to the day-night cycle. Here, we report molecular components of melanopsin signaling using the cultured Xenopus dermal melanophore system. Photo-activated melanopsin is shown to initiate a phosphoinositide signaling pathway similar to that found in invertebrate photo-transduction. In melanophores, light increases the intracellular level of inositol trisphosphate and causes the dispersion of melanosomes. Inhibition of phospholipase C and protein kinase C and chelation of intracellular calcium block the effect of light on melanophores. At least four proteins, 43, 74, 90, and 134 kDa, are phosphorylated by protein kinase C upon light stimulation. This provides evidence of an invertebrate-like light-activated signaling cascade within vertebrate cells.     

Epidemiology, clinical characteristics, outcome, morbidity and mortality in acromegaly based on the Spanish Acromegaly Registry (Registro Espanol de Acromegalia, REA)

OBJECTIVE: To undertake a multicentre epidemiological study reflecting acromegaly in Spain. DESIGN: Voluntary reporting of data on patients with acromegaly to an online database, by the managing physician. METHODS: Data on demographics, diagnosis, estimated date of initial symptoms and diagnosis, pituitary imaging, visual fields, GH and IGF-I concentrations (requested locally), medical, radiotherapy and neurosurgical treatments, morbidity and mortality were collected. RESULTS: Data were included for 1219 patients (60.8% women) with a mean age at diagnosis of 45 years (s.d. 14 years). Reporting was maximal in 1997 (2.1 cases per million inhabitants (c.p.m.) per year); prevalence was globally 36 c.p.m., but varied between 15.7 and 75.8 c.p.m. in different regions. Of 1196 pituitary tumours, most were macroadenomas (73%); 81% of these patients underwent surgery, 45% received radiotherapy and 65% were given medical treatment (somatostatin analogues in 68.3% and dopamine agonists in 31.4%). Cures (GH values (basal or after an oral glucose tolerance test) <2 ng/ml, normal IGF-I, or both) were observed in 40.3% after surgery and 28.2% after radiotherapy. Hypertension (39.1%), diabetes mellitus (37.6%), hypopituitarism (25.7%), goitre (22.4%), carpal tunnel syndrome (18.7%) and sleep apnoea (13.2%) were reported as most frequent morbidities; 6.8% of the patients had cancer (breast in 3.1% of the women and colon in 1.2% of the cohort). Fifty-six patients died at a mean age of 60 years (s.d. 14 years), most commonly of a cardiovascular cause (39.4%); mortality was greater in patients given radiotherapy (hazard ratio 2.29; 95% confidence interval 1.03 to 5.08; P=0.026), and in those in whom GH and IGF-I concentrations were never normal (P<0.001). CONCLUSIONS: This acromegaly registry offers a realistic overview of the epidemiological characteristics, treatment outcome and morbidity of acromegaly in Spain. As active disease and treatment with radiotherapy are associated with an increase in mortality, efforts to control the disease early are desirable.     

Does washing medical devices before and after use decrease bacterial contamination?: An in vitro study

Surface treatment of medical devices may be a way of avoiding the need for replacement of these devices and the comorbidities associated with infection. The aim of this study was to evaluate whether pre- and postcontamination washing of 2 prostheses with different textures can decrease bacterial contamination.The following microorganisms were evaluated: Staphylococcus aureus, Staphylococcus epidermidis, Proteus mirabilis and Enterococcus faecalis. Silicone and expanded polytetrafluoroethylene vascular prostheses were used and divided into 3 groups: prostheses contaminated; prostheses contaminated and treated before contamination; and prostheses contaminated and treated after contamination. Treatments were performed with antibiotic solution, chlorhexidine and lidocaine. After one week of incubation, the prostheses were sown in culture medium, which was incubated for 48 hours. The area of colony formation was evaluated by fractal dimension, an image analysis tool.The antibiotic solution inhibited the growth of S epidermidis and chlorhexidine decrease in 53% the colonization density for S aureus in for both prostheses in the pre-washing. In postcontamination washing, the antibiotic solution inhibited the growth of all bacteria evaluated; there was a 60% decrease in the colonization density of S aureus and absence of colonization for E faecalis with chlorhexidine; and lidocaine inhibited the growth of S aureus in both prostheses.Antibiotic solution showed the highest efficiency in inhibiting bacterial growth, especially for S epidermidis, in both washings. Lidocaine was able to reduce colonization by S aureus in post-contamination washing, showing that it can be used as an alternative adjuvant treatment in these cases.