[Comprehensive nutrition therapy in hospitals - Wishful thinking or reality? A survey-based cross-sectional study of the nutritional therapy in hospitals of Baden-Württemberg]

INTRODUCTION

Malnutrition is widespread in German hospitals, has a negative impact on therapeutic success and quality of life, and it leads to increasing costs. An individualized nutritional support by nutritional professionals in accordance with current guidelines was shown to reduce mortality of malnourished inpatients. Ideally, nutritional support is conducted by an interdisciplinary nutrition support team. Current data on the nutritional therapy in German hospitals is missing.

METHODS

In order to ascertain the current status of nutritional support in hospitals in the federal state of Baden-Württemberg, clinic managements of all hospitals in Baden-Württemberg received an online questionnaire. Affiliated hospitals, specialist hospitals, as well as hospitals with less than 50 beds were excluded from the analysis.

RESULTS

The response rate was 84% (n = 94). The presence of a nutrition support team was reported by 34% of the hospitals. Twelve percent of the hospitals meet the structural characteristic of the OPS Code 8-98j Ernährungsmedizinische Komplexbehandlung, which means that their nutrition support team includes a physician. A validated nutritional risk screening is performed in 72% of the hospitals. Only 40% of the hospitals report that this is performed throughout every department. Nutrition support teams are more often concerned with malnutrition, enteral and parenteral nutrition as compared to nutritionists who are not organized in a team. Moreover, nutrition support teams have a wider range of tasks and more often a physician as a team member. Also, nutritional risk screenings are more often applied in hospitals with nutrition support teams.

DISCUSSION

Compared with a nationwide survey from 2004, there are markedly more nutrition support teams available in hospitals in Baden-Württemberg. When compared internationally, however, the rate of nutrition support teams is still low. In addition, there is no comprehensive nutritional care available. High-quality nutritional support is more often found in hospitals with nutrition support teams.

CONCLUSION

There is still a great potential of improving clinical nutritional care in hospitals in Baden-Württemberg. Moreover, an increase in nutrition support teams, also comprising medical members, should be achieved. Therefore, legal regulations and a sufficient refinancing are indispensable.

[Laboratory and calorimetric monitoring of medical nutrition therapy in intensive and intermediate care units : Second position paper of the Section Metabolism and Nutrition of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI)]

This second position paper of the Section Metabolism and Nutrition of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) provides recommendations on the laboratory monitoring of macro- and micronutrient intake as well as the use of indirect calorimetry in the context of medical nutrition therapy of critically ill adult patients. In addition, recommendations are given for disease-related or individual (level determination) substitution and (high-dose) pharmacotherapy of vitamins and trace elements.

Changes in serum omega fatty acids on a Mediterranean diet intervention in patients with gingivitis: An exploratory study

BACKGROUND

Omega-6 and omega-3 polyunsaturated fatty acids (PUFAs) are precursors of pro- and anti-inflammatory lipid mediators. Serum PUFA levels could influence the severity of inflammatory oral diseases, such as gingivitis.

OBJECTIVE

The study analyzed serum PUFA levels in a six-week randomized controlled trial in individuals on the Mediterranean diet (MedD), associations with the intake of specific foods, and possible correlations with oral inflammatory parameters.

METHODS

Data from 37 study participants on either a MedD (MedDG; n = 18) or a "Western diet" in the control group (CG, n = 19) were analyzed. Dental examinations and serum analyses were performed at two time points, T1 (baseline) and T2 (week 6). Serum PUFA status, adherence to the MedD, and data from a Food Frequency Questionnaire were analyzed.

RESULTS

Within the MedDG omega-6 fatty acid levels decreased significantly. In the overall sample, the proportional decrease in sites with bleeding on probing correlated weakly to moderately with the decrease in total omega-6 fatty acid level (Spearman's ρ = 0.274) and the decrease in gingival index correlated moderately with the decrease in linoleic acid level (Spearman's ρ = 0.351). Meat and fast-food consumption correlated positively with levels of various omega-6 fatty acids, whereas nut, fish, and dairy product consumption correlated positively with omega-3 levels.

CONCLUSION

Adherence to a MedD was associated with a decrease in serum omega-6 levels, which positively affected the omega-6/omega-3 ratio. The MedD associated reduction in serum omega-6 levels may be a mechanism that favorably affects gingival inflammatory parameters.

Commentary on 'Guidelines for the provision of nutrition support therapy in the adult critically ill patient: The American Society for Parenteral and Enteral Nutrition'

As authors of recent meta-analyses evaluating lipids for parenteral nutrition^1,2 and/or the ESPEN Expert Group: lipids in the intensive care unit³ we welcome the updating of the ASPEN guidelines for clinical nutrition in adult critically ill patients,⁴ but would like to remark on certain aspects that cause us concern This article is protected by copyright. All rights reserved.

Prospective Study of a Novel Risk Stratification Process for Opioid-Related Harm Reduction in Cancer Patients Seen in an Outpatient Palliative Care Clinic

Background: Oncologists and palliative specialists prescribe opioids for millions of cancer patients despite limited research on effective screening and mitigation strategies to reduce risk of opioid-related harm in that population. Objective: To evaluate the efficacy of a novel opioid risk stratification process for predicting significant aberrant behaviors (SABs) related to prescribed opioid medications. Design and Setting/Subjects: This is a prospective, longitudinal study of 319 consecutive patients referred to an outpatient palliative care clinic between 2010 and 2012, a period during which prescription opioid-related deaths began to increase in the United States. Measures: Patients completed a psychodiagnostic/substance use risk assessment with a licensed clinical psychologist or social worker at the initial palliative clinic visit. Patients were assigned to Low-, Moderate-, or High-Risk groups based on predetermined stratification criteria and were managed via an opioid harm reduction approach. The primary dependent measure was the presence of at least one SAB after the initial visit. Results: Eighteen percent of patients (n = 56) demonstrated at least one major aberrant behavior. Odds of future aberrant behavior was 15 times greater in the High-Risk versus the Low-Risk category. Five risk factors significantly enhanced our risk model: age 18 to 45 years, job instability, history of bipolar diagnosis, history of substance abuse, and theft. Conclusion: Our risk stratification process provides a useful model for predicting those at greatest risk of future aberrant behaviors and most in need of comanagement. We recommend additional studies to test our proposed streamlined risk stratification tool.

The continuous downgrading of malnutrition in the German DRG system: possible effects on the treatment of patients at risk for malnutrition

It has been internationally recognized that malnutrition is an independent risk factor for patients' clinical outcome. A new mandatory fixed price payment system based on diagnosis-related groups (G-DRG) went into effect in 2004. The aim of our study was to demonstrate the importance of carefully coding the secondary diagnosis of "malnutrition" in the G-DRG system and to highlight how the economic relevance of malnutrition in the G-DRG system has changed from 2014 to 2016. 1372 inpatients at the Berufsgenossenschaftliche Unfallklinik (Trauma Center) in Tübingen were screened for the risk of malnutrition using Nutritional Risk Screening (NRS-2002). Patient data were compared with the NRS values collected during the study and a case simulation was carried out separately for each year. We used the codes E44.0 for NRS = 3 and E43.0 for NRS > 3. The ICD codes were entered as an additional secondary diagnosis in the internal hospital accounting system DIACOS to determine possible changes in the effective weight. In 2014 the highest additional revenue by far was calculated by coding malnutrition. For the 638 patients enrolled in the study in 2014, we were able to calculate an average additional revenue per patient coded with malnourishment of €107. In 2016, we were unable to calculate any additional revenue for the 149 patients enrolled. Although it is well known that malnutrition is an independent risk factor for poor patient outcomes, nationwide screening for a risk of malnutrition when patients are admitted to a hospital is still not required. For this reason, malnutrition in German hospitals continues to be insufficiently documented. Due to the continuous downgrading of diagnosis-related severity (CCL) of malnutrition in the G-DRG system in trauma surgery patients, it is no longer possible to refinance the costs incurred by malnourished patients through the conscientious coding of malnutrition. We assume that the indirect positive effects of nutritional interventions will have to be taken into account more in the costing calculations and possibly lead to indirect cost compensation.

Clinical Nutrition in Critical Care Medicine - Guideline of the German Society for Nutritional Medicine (DGEM)

PURPOSE

Enteral and parenteral nutrition of adult critically ill patients varies in terms of the route of nutrient delivery, the amount and composition of macro- and micronutrients, and the choice of specific, immune-modulating substrates. Variations of clinical nutrition may affect clinical outcomes. The present guideline provides clinicians with updated consensus-based recommendations for clinical nutrition in adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function.

METHODS

The former guidelines of the German Society for Nutritional Medicine (DGEM) were updated according to the current instructions of the Association of the Scientific Medical Societies in Germany (AWMF) valid for a S2k-guideline. According to the S2k-guideline classification, no systematic review of the available evidence was required to make recommendations, which, therefore, do not state evidence- or recommendation grades. Nevertheless, we considered and commented the evidence from randomized-controlled trials, meta-analyses and observational studies with adequate sample size and high methodological quality (until May 2018) as well as from currently valid guidelines of other societies. The liability of each recommendation was described linguistically. Each recommendation was finally validated and consented through a Delphi process.

RESULTS

In the introduction the guideline describes a) the pathophysiological consequences of critical illness possibly affecting metabolism and nutrition of critically ill patients, b) potential definitions for different disease phases during the course of illness, and c) methodological shortcomings of clinical trials on nutrition. Then, we make 69 consented recommendations for essential, practice-relevant elements of clinical nutrition in critically ill patients. Among others, recommendations include the assessment of nutrition status, the indication for clinical nutrition, the timing and route of nutrient delivery, and the amount and composition of substrates (macro- and micronutrients); furthermore, we discuss distinctive aspects of nutrition therapy in obese critically ill patients and those treated with extracorporeal support devices.

CONCLUSION

The current guideline provides clinicians with up-to-date recommendations for enteral and parenteral nutrition of adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function. The period of validity of the guideline is approximately fixed at five years (2018-2023).

[DGEM Guideline "Clinical Nutrition in Critical Care Medicine" - short version]

PURPOSE

Variations of clinical nutrition may affect outcome of critically ill patients. Here we present the short version of the updated consenus-based guideline (S2k classification) "Clinical nutrition in critical care medicine" of the German Society for Nutritional Medicine (DGEM) in cooperation with 7 other national societies. The target population of the guideline was defined as critically ill adult patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g. mechanical ventilation) to maintain organ function.

METHODS

The former guidelines of the German Society for Nutritional Medicine (DGEM) were updated according to the current instructions of the Association of the Scientific Medical Societies in Germany (AWMF) valid for a S2k-guideline. We considered and commented the evidence from randomized-controlled trials, meta-analyses and observational studies with adequate sample size and high methodological quality (until May 2018) as well as from currently valid guidelines of international societies. The liability of each recommendation was indicated using linguistic terms. Each recommendation was finally validated and consented by a Delphi process.

RESULTS

The short version presents a summary of all 69 consented recommendations for essential, practice-relevant elements of clinical nutrition in the target population. A specific focus is the adjustment of nutrition according to the phases of critical illness, and to the individual tolerance to exogenous substrates. Among others, recommendations include the assessment of nutritional status, the indication for clinical nutrition, the timing, route, magnitude and composition of nutrition (macro- and micronutrients) as well as distinctive aspects of nutrition therapy in obese critically ill patients and those with extracorporeal support devices.

CONCLUSION

The current short version of the guideline provides a concise summary of the updated recommendations for enteral and parenteral nutrition of adult critically ill patients who suffer from at least one acute organ dysfunction requiring pharmacological and/or mechanical support. The validity of the guideline is approximately fixed at five years (2018 - 2023).

DGEM-Leitlinie: „Klinische Ernährung in der Intensivmedizin“

Fragestellung Die enterale und parenterale Ernährungstherapie kritisch kranker Patienten kann u. a. durch den Zeitpunkt des Beginns, die Wahl des Applikationswegs, die Menge und Zusammensetzung der Makro- und Mikronährstoffzufuhr sowie der Wahl spezieller, immunmodulierender Nährsubstrate variieren. Die Durchführung der Ernährungstherapie nimmt Einfluss auf den klinischen Ausgang dieser Patienten. Ziel der vorliegenden Leitlinie ist es, aktualisierte konsensbasierte Empfehlungen zur klinischen Ernährung kritisch kranker, erwachsener Patienten, die an mindestens einer akuten, medikamentös und/oder mechanisch unterstützungspflichtigen Organdysfunktion leiden, zu geben.

Methodik Die früheren Leitlinien der Deutschen Gesellschaft für Ernährungsmedizin (DGEM) wurden in Einklang mit den aktuellen Richtlinien der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF) als S2k-Leitlinie aktualisiert. Entsprechend der S2k-Klassifikation dieser Leitlinie enthalten die dargestellten Empfehlungen keine Angabe von Evidenz- und Empfehlungsgraden, da keine systematische Aufbereitung der Evidenz zugrunde gelegt wurde. Als Grundlage für die Empfehlungen wurden insbesondere die seit Erscheinen der letzten DGEM-Leitlinien Intensivmedizin publizierten randomisiert-kontrollierten Studien und Metaanalysen, Beobachtungsstudien mit angemessener Fallzahl und hoher methodologischer Qualität (bis Mai 2018) sowie aktuell gültige Leitlinien anderer Fachgesellschaften herangezogen und kommentiert. Die Empfehlungsstärke ist rein sprachlich beschrieben. Jede Empfehlung wurde mittels Delphi-Verfahren abschließend bewertet und konsentiert.

Ergebnisse Die Leitlinie beschreibt einführend die pathophysiologischen Konsequenzen einer kritischen Erkrankung, welche den Metabolismus und die Ernährbarkeit der Patienten beeinflussen können, ferner die Definitionen unterschiedlicher Erkrankungsphasen im Krankheitsverlauf und sie diskutiert methodologische Aspekte zu ernährungsmedizinischen Studien. In der Folge werden 69 konsentierte Empfehlungen zu wesentlichen, praxisrelevanten Elementen der klinischen Ernährung kritisch kranker Patienten gegeben, darunter die Beurteilung des Ernährungszustands, die Indikation für die klinische Ernährungstherapie, der Beginn und Applikationsweg der Nahrungszufuhr, die Menge und Art der zugeführten Substrate (Makro- und Mikronährstoffe) sowie ernährungstherapeutische Besonderheiten bei adipösen kritisch kranken Patienten und Patienten mit mechanischen Unterstützungssystemen.

Schlussfolgerung Mit der Leitlinie werden aktuelle Handlungsempfehlungen zur enteralen und parenteralen Ernährung erwachsener Patienten geben, die an mindestens einer akuten, medikamentös und/oder mechanisch unterstützungspflichtigen Organdysfunktion leiden. Die Gültigkeit der Leitlinie beträgt voraussichtlich 5 Jahre (2018 – 2023).

GLP-2 analog teduglutide significantly reduces need for parenteral nutrition and stool frequency in a real-life setting

BACKGROUND

To evaluate the benefits of teduglutide in a real-life setting, we analyzed the data of 14 patients with short bowel syndrome treated with teduglutide. Additionally, we studied glucagon-like peptide 2 (GLP-2) receptor expression in samples of small intestinal and colonic tissue to provide explanations for clinical observations.

METHODS

Stool frequency and consistency, sensation of thirst, parental calorie or fluid uptake and the number of days on parenteral support per week were collected for up to 2 years. Quantitative real-time polymerase chain reaction of the GLP-2 receptor in healthy controls was performed to better understand clinical response in different patient subgroups.

RESULTS

There was a significant reduction in parenteral support after 24 and 48 weeks (by 11.0 and 36.6%, respectively; p < 0.05). Further major improvements were made in several patients after over 1 year (reduction by 79.3%, p < 0.05). The proportion of patients who reduced parenteral support by at least 20% was 33.3%, 54.5% and 71.3% after 24 weeks, 48 weeks and beyond 1 year, respectively. Patients on daily parenteral support showed late but strong amelioration. The reduction of thirst was the earliest marker for response. While stool consistency increased (p < 0.01), stool frequency decreased (p < 0.05) significantly after 12 weeks. This reduction was even more pronounced in patients with colon in continuity. Supporting these clinical observations, we found a stronger physiological expression of the GLP-2 receptor in the colon than in the small intestine.

CONCLUSIONS

Patients benefit from teduglutide in a real-life setting, but in contrast to randomized, controlled studies reduction of parenteral support took longer. We identified early clinical markers of response, such as stool consistency and frequency as well as sensation of thirst. Clinical and molecular observations support the role of the colon as an important target organ of teduglutide.

Lipids in the intensive care unit: Recommendations from the ESPEN Expert Group

This article summarizes the presentations given at an ESPEN Workshop on "Lipids in the ICU" held in Tel Aviv, Israel in November 2014 and subsequent discussions and updates. Lipids are an important component of enteral and parenteral nutrition support and provide essential fatty acids, a concentrated source of calories and building blocks for cell membranes. Whilst linoleic acid-rich vegetable oil-based enteral and parenteral nutrition is still widely used, newer lipid components such as medium-chain triglycerides and olive oil are safe and well tolerated. Fish oil (FO)-enriched enteral and parenteral nutrition appears to be well tolerated and confers additional clinical benefits, particularly in surgical patients, due to its anti-inflammatory and immune-modulating effects. Whilst the evidence base is not conclusive, there appears to be a potential for FO-enriched nutrition, particularly administered peri-operatively, to reduce the rate of complications and intensive care unit (ICU) and hospital stay in surgical ICU patients. The evidence for FO-enriched nutrition in non-surgical ICU patients is less clear regarding its clinical benefits and additional, well-designed large-scale clinical trials need to be conducted in this area. The ESPEN Expert Group supports the use of olive oil and FO in nutrition support in surgical and non-surgical ICU patients but considers that further research is required to provide a more robust evidence base.

Prevalence and Distribution of Diabetes Mellitus in a Maximum Care Hospital: Urgent Need for HbA1c-Screening

OBJECTIVE

Diabetes mellitus affects almost one in 10 individuals in Germany. So far, little is known about the diabetes prevalence in maximum care hospitals. We assessed the diabetes prevalence, proportion of undiagnosed cases, the effectiveness of diabetes screening in a university hospital, the consequences for hospital stay and acquired complications.

RESEARCH DESIGN AND METHODS

Over a 4 week period we determined HbA_1c from 3 733 adult patients which were hospitalized at the university hospital of Tuebingen and had an available blood sample. Diabetes diagnosis was defined as HbA_1c≥6.5% and/or previously documented diabetes diagnosis, prediabetes was defined as HbA_1c≥5.7% and <6.5% without history of previous diabetes.

RESULTS

23.68% of the patients had prediabetes and 22.15% had diabetes with a high variation between the specialised departments (range 5-43%). The rate of unknown diabetes was 3.7%, the number needed to screen was 17 in patients older than 50 years. Patients with diabetes had a prolonged hospital stay compared to the mean length of stay for their diagnosis related group (diabetes: 1.47±0.24 days; no diabetes: -0.18±0.13 days, p=0.0133). The prevalence of hospital acquired complications was higher in diabetic patients (diabetes: 197 of 630; no diabetes: 447 of 2 459, p<0.0001).

CONCLUSIONS

Every fourth patient in the university hospital had diabetes and every second had either prediabetes or diabetes. It is also worthwhile to screen for unknown diabetes in patients over the age of 50. The high prevalence and negative consequences of diabetes require screening and intensified specialized diabetes treatment in hospitals.

Supplementation of Ω-3 Fatty Acids in Parenteral Nutrition Beneficially Alters Phospholipid Fatty Acid Pattern

BACKGROUND

The clinical safety and the uptake of omega-3 polyunsaturated fatty acids (PUFA) into the serum phospholipids and erythrocyte membranes after administration of fish-oil-supplemented parenteral nutrition (PN) was investigated in colorectal surgical patients.

METHODS

Forty patients undergoing colorectal surgery (n = 40) and with an indication for PN were enrolled in a prospective, double-blind, randomized study to receive an omega-3 PUFA-supplemented 20% lipid emulsion (Lipoplus; B. Braun Melsungen, Melsungen, Germany; test group, n = 19) for 5 days postoperatively. The control group received a standard 20% fat emulsion (Lipofundin MCT/LCT, B. Braun Melsungen, Melsungen, Germany, control group, n = 21). Clinical outcome parameters and safety were assessed by means of adverse events recording clinical parameters and hematologic analyses. The contents of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), as well as arachidonic acid (AA), in phospholipid fractions in plasma and in erythrocytes were analyzed preoperatively, on postoperative days 1, 6, and 10 using liquid gas chromatography.

RESULTS

Both fat emulsions were well tolerated, and none of the adverse events was considered to be related to treatment. Postoperative infectious complications occurred in 4 patients of the omega-3 PUFA group vs 7 patients in the control group. As compared with the control group, the omega-3 PUFA group had significantly increased levels of EPA in the membranes of the erythrocytes in postoperative day 6 (2.0% +/- 0.9% vs 0.8% +/- 0.5% fatty acid methyl esters, [FAME]) and postoperative day 10 (2.1% +/- 0.8% vs 0.9% +/- 0.7% FAME, p < .05). Also, the EPA levels in the serum phospholipids were significantly higher than in the control group on the same postoperative days (7.0% +/- 2.6% vs 1.3% +/- 0.8% and 3.6% +/- 1.0% vs 1.0% +/- 0.4% FAME, p < .05). The DHA levels in the serum phospholipids were significantly higher in the omega-3 PUFA group compared with the control on postoperative days 6 and 10 (11.8% +/- 1.9% vs 8.4% +/- 1.5% and 11.2% +/- 1.6% vs 8.5% +/- 1.4% FAME, p < .05). AA levels were not significantly different in the both groups.

CONCLUSIONS

Omega-3-fatty-acids-supplemented fat emulsions for parenteral administration are safe and very well tolerated. This study demonstrates that parenteral administration of omega-3-PUFA-enriched fat emulsions leads to increased incorporation of EPA and DHA into phospholipids in serum and erythrocytes, whereas AA levels remain unchanged. Thus, postoperative parenteral administration of omega-3-PUFA-enriched lipid emulsions could have an impact on the postoperative inflammatory response after abdominal surgery and could be used in standard postoperative care when PN is indicated.

New ionic cobalt(iii) complexes based on the N,N-bis(2-pyrazinecarboxamide)-1,2-benzene ligand: application to the formation of organic carbonates from epoxides and CO2

New cobalt(iii) complexes based onN,N-bis(2-pyrazine-carboxamide)-1,2-benzene were tested as catalysts for the coupling of propylene- and cyclohexene oxide with CO₂.

Determination of volume-dependent respiratory system mechanics in mechanically ventilated patients using the new SLICE method

In patients mechanically ventilated for severe respiratory failure, respiratory system mechanics are non-linear, i.e., volume-dependent. We present a new computer-based multipoint method for simultaneously determining volume-dependent dynamic compliance and resistance. Our method is based on continuously determined tracheal pressure (Ptrach). Tidal volume is subdivided into six volume slices of equal size. One compliance value (intrinsic PEEP considered) and one resistance value are determined for each volume slice by applying of the least-squares-fit (LSF) analysis based on the linear RC-model; we therefore call this the SLICE method. The method gives the course of dynamic compliance and resistance within the tidal volume. The method was evaluated using physical models of the respiratory system with linear and non-linear passive mechanical properties. The relative error of the method is smaller than ±5%. The method needs no special ventilatory pattern. Using data from 14 patients mechanically ventilated for adult respiratory distress syndrome (ARDS) we found a very good correspondence between the measured end-inspiratory airway pressure (Paw,Ie) and the end-inspiratory alveolar pressure (Palv,Ie) calculated from the dynamic compliance values determined with the SLICE method (Palv,Ie = 1.02 * Paw,Ie + 0.097; r2 = 0.977). The SLICE method allows continuous monitoring of non-linear pulmonary mechanics on a breath-by-breath basis at the bedside.

Hidden charge states in soft-x-ray laser-produced nanoplasmas revealed by fluorescence spectroscopy

Highly charged ions are formed in the center of composite clusters by strong free-electron laser pulses and they emit fluorescence on a femtosecond time scale before competing recombination leads to neutralization of the nanoplasma core. In contrast to mass spectrometry that detects remnants of the interaction, fluorescence in the extreme ultraviolet spectral range provides fingerprints of transient states of high energy density matter. Spectra from clusters consisting of a xenon core and a surrounding argon shell show that a small fraction of the fluorescence signal comes from multiply charged xenon ions in the cluster core. Initially, these ions are as highly charged as the ions in the outer shells of pure xenon clusters with charge states up to at least 11+.

[Parenteral nutrition strategies]

Parenteral nutrition is a fundamental part of any therapeutic concept in critically ill patients. Just recently some international prospective randomized controlled trials were investigating the correct indication, optimal timing and dosage of parenteral nutrition regimens. Despite a controversial discussion newer strategies recommend the parenteral nutrition as a very important supplemental component to an early enteral nutrition therapy.

Massive and long-lasting decrease in vitamin C plasma levels as a consequence of extracorporeal circulation

OBJECTIVE

The use of cardiopulmonary bypass (CPB) is suggested to induce oxidative stress, reflected by an imbalance between prooxidant and antioxidant substances. The majority of studies published have either focused on only one aspect (prooxidant or antioxidant side) or covered only a short observation period. Therefore, the aim of this study was to investigate the long-term effects of CPB on the balance of prooxidative markers and antioxidant substances in one single group of patients, being able to estimate the degree of oxidative stress.

METHODS

Blood samples were taken from 29 patients undergoing cardiovascular surgery beginning the day before surgery through postoperative day 6 (discharge). Plasma concentrations of vitamins C (total ascorbic acid) and E and malondialdehyde were measured by high-performance liquid chromatography. Plasma levels of ascorbyl free radical were determined using electron paramagnetic resonance spectroscopy.

RESULTS

The study showed a significant decrease in vitamin C plasma levels during CPB without any recovery of vitamin C up to the time of discharge. Furthermore, CPB induced a significant increase in malondialdehyde plasma concentrations immediately after unclamping, accompanied by a significant increase in the ascorbyl free radical to total ascorbic acid ratio. The latter stayed elevated until the end of observation.

CONCLUSIONS

Our findings indicate that the oxidative stress event after CPB can be divided into two phases: Immediately after reperfusion, a massive oxidative stress occurs, reflected by the increase in malondialdehyde. During convalescence, there must be an ongoing situation of oxidative stress, especially in the water-soluble compartment, leading to the consumption of vitamin C. Because the main antioxidant substance, vitamin C, did not increase again over the entire observation period, supplementation should be given consideration.

Nanoplasma dynamics of single large xenon clusters irradiated with superintense x-ray pulses from the linac coherent light source free-electron laser

The plasma dynamics of single mesoscopic Xe particles irradiated with intense femtosecond x-ray pulses exceeding 10(16)  W/cm2 from the Linac Coherent Light Source free-electron laser are investigated. Simultaneous recording of diffraction patterns and ion spectra allows eliminating the influence of the laser focal volume intensity and particle size distribution. The data show that for clusters illuminated with intense x-ray pulses, highly charged ionization fragments in a narrow distribution are created and that the nanoplasma recombination is efficiently suppressed.

Explosions of xenon clusters in ultraintense femtosecond x-ray pulses from the LCLS free electron laser

Explosions of large Xe clusters (<N> ~ 11,000) irradiated by femtosecond pulses of 850 eV x-ray photons focused to an intensity of up to 10(17) W/cm(2) from the Linac Coherent Light Source were investigated experimentally. Measurements of ion charge-state distributions and energy spectra exhibit strong evidence for the formation of a Xe nanoplasma in the intense x-ray pulse. This x-ray produced Xe nanoplasma is accompanied by a three-body recombination and hydrodynamic expansion. These experimental results appear to be consistent with a model in which a spherically exploding nanoplasma is formed inside the Xe cluster and where the plasma temperature is determined by photoionization heating.

Ultrafast x-ray scattering of xenon nanoparticles: imaging transient states of matter

Femtosecond x-ray laser flashes with power densities of up to 10(14) W/cm(2) at 13.7 nm wavelength were scattered by single xenon clusters in the gas phase. Similar to light scattering from atmospheric microparticles, the x-ray diffraction patterns carry information about the optical constants of the objects. However, the high flux of the x-ray laser induces severe transient changes of the electronic configuration, resulting in a tenfold increase of absorption in the developing nanoplasma. The modification in opaqueness can be correlated to strong atomic charging of the particle leading to excitation of Xe(4+). It is shown that single-shot single-particle scattering on femtosecond time scales yields insight into ultrafast processes in highly excited systems where conventional spectroscopy techniques are inherently blind.

Intensive medicine - Guidelines on Parenteral Nutrition, Chapter 14

In intensive care patients parenteral nutrition (PN) should not be carried out when adequate oral or enteral nutrition is possible. Critically ill patients without symptoms of malnutrition, who probably cannot be adequately nourished enterally for a period of <5 days, do not require full PN but should be given at least a basal supply of glucose. Critically ill patients should be nourished parenterally from the beginning of intensive care if they are unlikely to be adequately nourished orally or enterally even after 5–7 days. Critically ill and malnourished patients should, in addition to a possible partial enteral nutrition, be nourished parenterally. Energy supply should not be constant, but should be adapted to the stage, the disease has reached. Hyperalimentation should be avoided at an acute stage of disease in any case. Critically ill patients should be given, as PN, a mixture consisting of amino acids (between 0.8 and 1.5 g/kg/day), carbohydrates (around 60% of the non-protein energy) and fat (around 40% of the non-protein energy) as well as electrolytes and micronutrients.

Lipid emulsions - Guidelines on Parenteral Nutrition, Chapter 6

The infusion of lipid emulsions allows a high energy supply, facilitates the prevention of high glucose infusion rates and is indispensable for the supply with essential fatty acids. The administration of lipid emulsions is recommended within ≤7 days after starting PN (parenteral nutrition) to avoid deficiency of essential fatty acids. Low-fat PN with a high glucose intake increases the risk of hyperglycaemia. In parenterally fed patients with a tendency to hyperglycaemia, an increase in the lipid-glucose ratio should be considered. In critically ill patients the glucose infusion should not exceed 50% of energy intake. The use of lipid emulsions with a low phospholipid/triglyceride ratio is recommended and should be provided with the usual PN to prevent depletion of essential fatty acids, lower the risk of hyperglycaemia, and prevent hepatic steatosis. Biologically active vitamin E (α-tocopherol) should continuously be administered along with lipid emulsions to reduce lipid peroxidation. Parenteral lipids should provide about 25–40% of the parenteral non-protein energy supply. In certain situations (i.e. critically ill, respiratory insufficiency) a lipid intake of up to 50 or 60% of non-protein energy may be reasonable. The recommended daily dose for parenteral lipids in adults is 0.7–1.3 g triglycerides/kg body weight. Serum triglyceride concentrations should be monitored regularly with dosage reduction at levels >400 mg/dl (>4.6 mmol/l) and interruption of lipid infusion at levels >1000 mg/dl (>11.4 mmol/l). There is little evidence at this time that the choice of different available lipid emulsions affects clinical endpoints.

Energy expenditure and energy intake - Guidelines on Parenteral Nutrition, Chapter 3

The energy expenditure (24h total energy expenditure, TEE) of a healthy individual or a patient is a vital reference point for nutritional therapy to maintain body mass. TEE is usually determined by measuring resting energy expenditure (REE) by indirect calorimetry or by estimation with the help of formulae like the formula of Harris and Benedict with an accuracy of +/-20%. Further components of TEE (PAL, DIT) are estimated afterwards. TEE in intensive care patients is generally only 0-7% higher than REE, due to a low PAL and lower DIT. While diseases, like particularly sepsis, trauma and burns, cause a clinically relevant increase in REE between 40-80%, in many diseases, TEE is not markedly different from REE. A standard formula should not be used in critically ill patients, since energy expenditure changes depending on the course and the severity of disease. A clinical deterioration due to shock, severe sepsis or septic shock may lead to a drop of REE to a level only slightly (20%) above the normal REE of a healthy subject. Predominantly immobile patients should receive an energy intake between 1.0-1.2 times the determined REE, while immobile malnourished patients should receive a stepwise increased intake of 1.1-1.3 times the REE over a longer period. Critically ill patients in the acute stage of disease should be supplied equal or lower to the current TEE, energy intake should be increased stepwise up to 1.2 times (or up to 1.5 times in malnourished patients) thereafter.

[Pancreatic elastase-1 in the stool for the determination of exocrine pancreas function of postoperative patients with early enteral nutrition -- a pilot study]

BACKGROUND AND OBJECTIVE

There are only incomplete data about exocrine pancreatic function after major gastrointestinal surgery. Early enteral nutrition with high-molecular diets is increasingly administered to these patients. A knowledge of exocrine secretion of the pancreas is crucial, because pancreatic enzymes are needed for the adsorption of the high-molecular diets. To determine the exocrine pancreatic secretion the fecal elastase-1 is a sensitive method for measuring exocrine pancreatic secretion.

PATIENTS AND METHODS

In a prospective study fecal elastase-1 was measured in patients on enteral nutrition (n=12) early after major gastrointestinal operations. They were given a high molecular diet via an intraoperatively placed small-needle catheter jejunostomy, starting 12 hours after operation with a continuous infusion of 20 ml/h (1 kcal/ml),increased to 80 ml/h during the next few days. Samples from the first and second stools after beginning the enteral nutrition were taken for measuring the fecal elastase-1.

RESULTS

All patients fed enterally had no relevant feeding-associated complications and no diarrhea. The elastase-1 concentrations were normal in both the first and the second stool samples in all patients (normal stool elastase is > 200 g/g). The average elastase concentration in the first stool sample was 361,4 mg/g (median: 317 mg/g) and 454 mg/g in the second (median: 466,6 mg/g). Thus no exocrine pancreatic insufficiency was detected in any of the patients.

CONCLUSION

The results of elastase-1 in stool demonstrate that severe exocrine pancreas dysfunction is not generally present in patients on early enteral nutrition after major gastrointestinal surgery.

Open randomized phase II trial of an extracorporeal endotoxin adsorber in suspected Gram-negative sepsis

OBJECTIVE

An initial phase II trial to investigate the safety and therapeutic effect of the endotoxin adsorber system EN 500 in septic patients suffering from presumed Gram-negative infection.

DESIGN

Open, controlled, prospective, randomized, multiple-center, parallel-group clinical trial.

SETTING

Intensive care units of 31 university-affiliated and community hospitals in Europe.

PATIENTS

One hundred forty-five patients with a clinical diagnosis of severe sepsis or septic shock due to suspected Gram-negative infection.

INTERVENTIONS

Patients were randomized to receive either standard therapy alone for sepsis (n = 76) or standard therapy plus extracorporeal endotoxin adsorption (n = 67) daily for the first 4 days following study entry.

MEASUREMENTS AND MAIN RESULTS

The primary end point was the proportion of responders (defined as a decrease in Acute Physiology and Chronic Health Evaluation II score by > or =4 points from study entry to day 4). Secondary outcomes were the Sequential Organ Failure Assessment score and its components, length of intensive care unit stay, survival rate, and safety of the adsorber treatment. Patient characteristics at entry were well balanced between the two treatment groups, except for a higher Sequential Organ Failure Assessment score in the adsorber group. On all-subjects-treated analysis, 65% of the adsorber group were responders vs. 57% for the standard (p =.389). A planned interim analysis restricted further enrollment to patients with peritonitis, in whom a slightly higher proportion of responders was observed with the adsorber treatment (69%) vs. standard treatment (54%, p =.159). There were no differences in survival, but adsorption treatment in peritonitis patients was associated with trends toward a reduction in length of intensive care unit stay and a more rapid decline in plasma endotoxin concentrations. There was a significantly greater reduction in platelet count with the adsorber; however, this did not require extra treatment.

CONCLUSIONS

The endotoxin adsorber system did not result in a significantly improved primary end point in patients with presumed Gram-negative sepsis. In patients with peritonitis, the adsorber treatment likewise did not result in significantly improved Acute Physiology and Chronic Health Evaluation II scores. There were no clinically important side effects. These results provide encouragement for further study of adsorber treatment in patients with high likelihood of Gram-negative sepsis (e.g., peritonitis).

Pr�operative Nahrungskarenz

In Germany the predominant standard of preoperative care for elective surgery is fasting after midnight, with the aim of reducing the risk of pulmonary aspiration. However, for the past several years the scientific evidence supporting such a practice has been challenged. Experimental and clinical studies prove a reliable gastric emptying within 2 h suggesting that, particularly for limited intake of clear fluids up to 2 h preoperatively, there would be no increased risk for the patient. In addition, the general incidence of pulmonary aspiration during general anaesthesia (before induction, during surgery and during recovery) is extremely low, has a good prognosis and is more a consequence of insufficient airway protection and/or inadequate anaesthetic depth rather than due to the patient's fasting state. Therefore, primarily to decrease perioperative discomfort for patients, several national anaesthesia societies have changed their guidelines for preoperative fasting. They recommend a more liberal policy regarding per os intake of both liquid and solid food, with consideration of certain conditions and contraindications. The following article reviews the literature and gives an overview of the scientific background on which the national guidelines are based. The intention of this review is to propose recommendations for preoperative fasting regarding clear fluids for Germany as well.

[Venous bypass: gold standard with excellent results]

Since 1974 we have performed 1104 in situ vein bypasses for the reconstruction of femoropopliteal or femorotibial occlusions. The venous valves were made incompetent by using our Insitucut. An intraoperative completion angiography is mandatory. The primary cumulative patency rate is 93.5% at one year and 64.9% at five years. The permeability is depending on the quality of the outflow tract. The patency of femoropopliteal in situ bypasses with a three vessel runoff is 82.2% at five years, whereas bypasses with a single vessel runoff show a patency of 56%. The own results are comparable with the results of reversed and non-reversed vein bypasses given in the literature.

Lipid emulsions in parenteral nutrition

Lipid emulsions containing a physical mixture of medium and long chain triglycerides (MCT/LCT) are a well-proven concept in parenteral nutrition of critically ill patients. Having a demonstrably higher utilization rate, MCT/LCT emulsions do not impair liver function, produce less immune and no reticuloendothelial system function compromise, and do not interfere with pulmonary hemodynamics or gas exchange. A reduced content of n-6 polyunsaturated fatty acids can also be obtained by using newer preparations based on structured triglycerides or olive oil. Further studies are necessary in order to investigate these new lipid emulsions versus the physical mixture of MCT/LCT. A promising substrate in the development of lipid emulsions can be seen in fish oils. With regard to current literature, fish oils have a beneficial influence on the pathophysiological response to endotoxins and exert important modulations on eicosanoid and cytokine biology. Furthermore their intravenous use may improve organ perfusion in different critical situations.

Delayed derecruitment after removal of PEEP in patients with acute lung injury

BACKGROUND

A step decrease in positive end-expiratory airway pressure (PEEP) is not followed by an instantaneous loss of the PEEP-induced increase in end-expiratory lung volume (EELV). Rather, the reduction of EELV is delayed, while adverse PEEP effects on hemodynamics are immediately attenuated upon the drop in airway pressure. Step PEEP increments were applied to the lungs of patients with acute lung injury. It was investigated retrospectively whether enlargement of end-expiratory lung volume and changes in lung mechanics persist 45 min after removal of the PEEP increment.

METHODS

In 14 patients with acute lung injury (LIS score 2.7) EELV and volume-dependent dynamic compliance of the respiratory system (Cdyn,rs) were determined 45 min after removal of an additional PEEP increment (0.64 kPa added to baseline PEEP of 1.0 kPa).

RESULTS

Nine patients kept an EELV gain of 13% (SD 7) and showed improved Cdyn,rs. In 5 patients, EELV was reduced (by 9% (SD 6)) and Cdyn,rs unchanged after removal of the PEEP increment compared to baseline.

CONCLUSION

A subgroup of patients with acute lung injury, the characteristics of which remain to be defined, benefit from prolonged recruitment effects up to 45 min after removal of a PEEP increment, while sequelae of continuously increased airway pressures are minimised.

Pylephlebitis: a case report and review of outcome in the antibiotic era

Pylephlebitis or septic thrombophlebitis of the portal vein, a precursor of hepatic abscesses, is an extremely rare and frequently fatal complication of diverticulitis. The following report describes a patient presenting with pylephlebitis and complicated diverticulitis. Diagnosis was confirmed by computed tomography. The patient had a favorable outcome with medical and surgical therapy, prompting us to evaluate historical treatment of pylephlebitis.

[Fructose vs. glucose in total parenteral nutrition in critically ill patients]

Parenteral nutrition required following surgery or injury should not only meet post-aggression caloric requirements but also match the specific metabolic needs so as not to worsen the metabolic disruptions already present in this situation. The primary objective of parenteral nutrition is body protein maintenance or restoration by reduction of protein catabolism or promotion of protein synthesis or both. Whether all parenteral energy donors, ie., glucose, fructose, other polyols, and lipid emulsions, are equally capable of achieving this objective continues to be a controversial issue. The objective of the present study was to answer the following questions: (1) Do glucose and fructose differ in their effects on the metabolic changes seen following surgery or injury, the changes in glucose metabolism in particular? (2) Can the observation of poorer glucose utilization in the presence of lipids be confirmed in ICU patients?

PATIENTS, MATERIALS AND METHODS

A prospective, randomized clinical trial has been conducted in 20 aseptic surgical ICU patients to generate an objective database along these lines by performing a detailed analysis of the metabolic responses to different parenteral nutrition protocols. The effects of a glucose solution+lipid emulsion regimen vs fructose solution+lipid emulsion regimen on a number of carbohydrate and lipid metabolism variables were evaluated for an isocaloric (carbohydrates: 0.25 g/kg body weight/h; lipids: 0.166g/kg body weight/h) and isonitrogenous (amino acids: 0.0625 g/kg body weight/h) total nutrient supply over a 10-h study period.

RESULTS

A significantly smaller rise in blood glucose concentrations (increase from baseline: glucose+lipids P<0.001 vs fructose+lipids n.s.) suggested that fructose had a small effect, if any at all, on glucose metabolism. Serum insulin activity showed significant differences as a function of carbohydrate regimen, i.e. infusion of fructose instead of glucose produced a less pronounced increase in insulin activity (increase from baseline: glucose+lipids P<0.001 vs fructose+lipids P<0.01). Impairment of glucose utilization by concomitant administration of lipids was observed neither in patients who first received glucose nor in those who first received fructose.

CONCLUSIONS

As demonstrated, parenteral fructose, unlike parenteral glucose, has a significantly less adverse impact than glucose on the glucose balance, which is disrupted initially in the post-aggression state. In addition, the less pronounced increase in insulin activity during fructose infusion than during glucose infusion can be assumed to facilitate mobilization of endogenous lipid stores and lipid oxidation. Earlier workers pointed out that any rise in free fatty acid and ketone body concentrations in the serum produces inhibition of muscular glucose uptake and oxidation, and of glycolysis. These findings were recorded in a rat model and could not be confirmed in our post-aggression state patients receiving lipid doses commensurate with the usual clinical infusion rates. The serious complications that can result from hereditary fructose intolerance are completely avoidable if a careful patient history is taken before the first parenteral use of fructose. If the patient or family members and close friends, are simply asked whether he/she can tolerate fruit and sweet dishes, hereditary fructose intolerance can be ruled out beyond all reasonable doubt. Only in the extremely rare situations in which it is not possible to question either the patient or any significant other, a test dose will have to be administered to exclude fructose intolerance. The benefits of fructose-specific metabolic effects reported in the literature and corroborated by the results of out own study suggest that fructose is an important nutrient that contributes to metabolic stabilization, especially in the post-aggression phase and in septic patients. Hyperglycaemic states are largely prevented and fewer patients require ex