Energy recommendations for normal weight,overweight and obese children and adolescents: are different equations necessary?

In 2002/2005, separate energy requirement equations were generated by the Institute of Medicine's (IOM) Dietary Reference Intake process for normal weight and overweight/obese children and adolescents. The current paper questions the theoretical rationale of having two sets of equations (based solely on body-weight classification): when body weight is considered, overweight and obese children and adolescents do not seem to differ from their normal weight counterparts in energy expended for basal metabolism or physical activity tasks. However, energy needs for weight maintenance among overweight/obese girls were consistently higher when predicted using the equations for overweight/obese individuals compared with those developed for normal weight individuals. In contrast, among overweight/obese boys, they were consistently lower . Although the differences are within the variability of the estimates, even theoretical support for a higher energy intake (as occurs in girls) seems unwise because of the potential contribution to a higher body mass in children who are already at risk. It is the opinion of the authors that the IOM revisit the use of two separate equations and generate one set that is appropriate for all children and adolescents.     

Hyperemic Islets: A Possible Explanation for Poor Yields in Human and Porcine Islet Isolation

When studying histological characteristics of human and porcine pancreata in relation to islet isolation, we encountered a remarkably high number of hyperemic islets. The abnormalities observed in these islets ranged from a single dilated vessel through multiple widely dilated vessels to hemorrhages extending into the surrounding exocrine tissue. We determined their possible relevance for outcomes of islet isolation. This study involved a histological examination of 143 porcine pancreata (72 juvenile and 71 adult) and islet isolation from 48 adult pancreata. Human pancreata obtained from 71 multiple organ donors yielded islet isolation in 24 cases. To determine their endocrine content, tissue samples were stained with Aldehyde Fuchsin. The presence of hyperemic islets was scored semiquantitatively with pancreata allotted to categories based on the severity. In humans and pigs we observed hyperemic islets in 48% of pancreata, but only 4.0 ± 2.4% of the islets were hyperemic. In both humans and pigs, significantly higher endocrine content was found in the most severely affected pancreata. When the higher endocrine content was taken into account and isolation results were expressed as ratios of yield and content, we observed significantly lower yields in the most affected pancreata in pigs with a trend toward lower yields in humans. A substantial proportion of human and porcine pancreata contain hyperemic islets. Although the results in humans are preliminary, our data suggest that this phenomenon may contribute to the unpredictable, highly variable islet yields in pigs and humans.     

Upper Gastrointestinal Bleeding During the First Month After Renal Transplantation in the Mycophenolate Mofetil Era

Upper gastrointestinal (GI) bleeding remains a significant cause of mortality and morbidity among renal transplant recipients. We retrospectively analyzed the records of patients who received renal transplantations between January 2001 and July 2007 using mycophenolate mofetil (MMF) in their immunosuppressive regimens. The following data were recorded for those subjects with upper GI bleeding during the first month after transplantation (group B, cases): age, sex, acute rejection episodes, pretransplant upper GI endoscopic findings, Helicobacter positivity, and cytomegalovirus (CMV) seropositivity. The same parameters were studied among a group of patients, who did not have a history of upper GI bleeding (group A, controls). A statistical analysis was performed to ascertain potential risk factors. Among 523 patients (311 females, 212 males) of age range 7 to 58 years, 27 (5.2%) had upper GI bleeding: 13 males and 14 females of mean age 44 ± 12 years. The most frequent endoscopic finding was erosive gastritis (n = 13; 48.1%) followed by duodenal ulcers. Binary logistic regression analysis comparing the 2 groups showed that acute rejection episodes (P = .015) and active CMV infection (P = .046) were the most prominent risk factors for upper GI bleeding during the first month after renal transplantation.     

Prior diabetes mellitus is associated with increased morbidity in cystic fibrosis patients undergoing bilateral lung transplantation: an ‘orphan’ area? A retrospective case–control study

Background: The aim of this study was to determine whether pre-existing diabetes mellitus increases the risk of rejection, infection and/or death in cystic fibrosis patients undergoing bilateral sequential single-lung transplantation.
Methods: A retrospective audit of 25 consecutive patients with cystic fibrosis who underwent bilateral sequential single-lung transplantation between 1 January 2003 and 31 December 2005 at a tertiary referral hospital was carried out.
Results: Although 32% patients had diabetes diagnosed before lung transplantation, 92% had random blood glucose levels ≥11.1 mmol/L requiring insulin during admission. Patients with pre-existing diabetes had increased infection-related (3.9 vs 1.2, P = 0.01) and putative rejection-related (1.4 vs 0.5, P = 0.04) hospital admissions post-transplantation compared with those without diabetes pre-transplant. During the period of observation, four of eight patients with a prior diagnosis of diabetes died compared with none of 17 patients without prior diabetes ( P = 0.0055).
Conclusion: Almost all cystic fibrosis patients develop hyperglycaemia after lung transplantation, but patients with prior diabetes have more complication-related admissions to hospital and a higher mortality rate.     

Evaluation of Patient-Reported Outcome in Subjects Treated Medically for Acute Pancreatitis: A Follow-Up Study

Aims: To explore the quality of life in patients treated medically during the acute phase of pancreatitis as well as at 2 and 12 months after discharge from the hospital. Patients: 40 patients were studied. The etiology of the pancreatitis was biliary causes in 31 patients and non-biliary causes in 9; mild disease was present in 29 patients and severe disease in 11. 30 patients completed the two surveys at 2 and 12 months after hospital discharge. Methods: The SF-12 and EORTC QLQ-C30 questionnaires were used for the purpose of the study. Results: The two physical and mental component summaries of SF-12, all the domains of EORTC QLQ-C30 (except for physical functioning and cognitive functioning) and some symptom scales of EORTC QLQ-C30 (fatigue, nausea/ vomiting, pain, and constipation) were significantly impaired during the acute phase of pancreatitis. There was a significant improvement in the SF-12 physical component summary, and global health, role functioning, social functioning, nausea/vomiting, pain, dyspnea, and financial difficulties (EORTC QLQ-C30) at 2 months after discharge as compared to the basal evaluation. Similar results were found after 12 months except for the mental component score at 12-month evaluation, which was significantly impaired in acute pancreatitis patients in comparison to the norms. The physical functioning of the EORTC QLQ-C30 at basal evaluation was significantly impaired in patients with severe pancreatitis in comparison to patients with mild pancreatitis. Conclusions: Two different patterns can be recognized in the quality of life of patients with acute pancreatitis: physical impairment is immediately present followed by mental impairment which appears progressively in the follow-up period.     

Needle electromyography

Physiologic assessment of diseases of the motor unit from the anterior horn cells to the muscles relies on a combination of needle electromyography (EMG) and nerve conduction studies (NCS). Both require a unique combination of knowledge of peripheral nervous system anatomy, physiology, pathophysiology, diseases, techniques, and electricity is necessary. Successful, high‐quality, reproducible EMG depends on the skills of a clinician in patient interaction during the physical insertion and movement of the needle while recording the electrical signals. These must be combined with the skill of analyzing electric signals recorded from muscle by auditory pattern recognition and semiquantitation. 10 , 52 This monograph reviews the techniques of needle EMG and waveform analysis and describes the types of EMG waveforms recorded during needle EMG. © 2009 Wiley Periodicals, Inc. Muscle Nerve 39: 244–270, 2009     

Cost and workforce implications of subjecting all physicians to aviation industry work hour restrictions: A response

In recent years, the surgical profession has attempted to incorporate into clinical practice certain techniques that the airline industry has used to improve safety. These mechanisms have proven to be valuable components of our efforts to ensure that surgical patients receive safe, high-quality care. However, as the authors of “Cost and workforce implications of subjecting all physicians to aviation industry work hour restrictions” note, it would be a mistake to extend aviation's work-hour restrictions to medicine, particularly to resident training programs.     

Comparison of effects and plasma concentrations of opioids between elderly and middle-aged patients after cardiac surgery

Background: In elderly patients, opioids may cause prominent postoperative sedation and respiratory depression. We evaluated the influence of age on the effects of opioids and plasma concentrations of fentanyl and oxycodone in cardiac surgery patients.
Methods: Thirty (≥75 years, gender M9/F21) and 20 (≤60 years, gender M20/F0) patients scheduled to undergo cardiac surgery. A standard anesthesia with fentanyl as an opioid was used. Fentanyl plasma concentrations were measured at the end of surgery and 2 h later. After tracheal extubation, when the pain intensity was at least moderate, blood samples for fentanyl and oxycodone plasma concentration measurements were taken. Thereafter, oxycodone hydrochloride 0.05 mg/kg i.v. was administered. After 15 and 45 min, pain intensity, sedation and oxycodone plasma concentration were determined. This test protocol was repeated twice.
Results: The elderly had a higher plasma concentration of fentanyl at the end of surgery than younger patients (5.7±2.2 vs. 3.8±1.2 ng/ml, P =0.001). The plasma concentrations of oxycodone were comparable between the groups. The interval between the second and the third oxycodone dose was longer in the elderly patients ( P =0.036). Pain intensity on the verbal rating scale was lower at the 45-min assessment point after all three oxycodone test doses ( P =0.008) and sedation scores were significantly higher after the third dose in the elderly patients ( P =0.035).
Conclusions: In elderly patients, the plasma concentration of fentanyl was higher but plasma levels of oxycodone were at a similar level compared with middle-aged patients. However, the elderly patients had less pain and were more sedated after doses of oxycodone.